"C^^i. 


Y\i<^ 


dalis^s  af  ^hijatrians  anb  Bar^anB 


Srfj^r^nrF  Ktbrarg 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/surgerypracticalOOmans 


SURGERY 


A    PRACTICAL  TREATISE 


Press  Notices  of  First  Edition 

OF 

MOULLIN'S   SURGERY. 


From    THE     AMERICAN     JOURNAL    OF     MEDICAL    SCIENCES, 
Philadelphia. 

"  The  aim  to  make  this  valuable  treatise  practical  by  giving  special 
attention  to  'questions  of  treatment  has  been  admirably  carried  out.  Many 
a  reader  will  consult  the  work  with  a  feeling  of  satisfaction  that  his  wants 
have  been  understood,  and  that  they  have  been  intelligently  met.  He  w-ill 
not  look  in  vain  for  details,  without  proper  attention  to  which  he  well  knows 
that  the  highest  success  is  impossible." 

MEDICAL  RECORD,  New  York. 

"  From  such  a  standpoint  it  goes  without  saying  that  the  writer's  attitude 
is  a  conservative  one.  He  is,  however,  free  from  hesitancy,  and  shows  a 
keen  appreciation  of  the  rapid  strides  of  surgical  art  in  the  last  decade.  No 
less  than  two  hundred  of  the  illustrations  were  drawn  expressly  for  this 
work.  It  has  all  the  conciseness  of  Druitt's  well-known  work,  and  the  ad- 
vantage of  a  somewhat  more  extensive  description  of  certain  conditions 
occurring  in  practical  work.  The  book  is  creditable  alike  to  author,  assist- 
ants, and  publishers." 

THE  PHYSICIAN  AND   SURGEON,  Ann  Arbor,   Mich. 

"The  spirit  of  the  work  is  eminently  clinical  and  practical,  and  the 
author,  in  avoiding  controversial  matters,  has  endeavored  to  direct  special 
attention  to  treatment.  The  work  is  profusely  illustrated  and  appears  well 
up  to  date  in  recording  the  achievements  of  modern  surgery.  This  is  well 
shown  in  the  chapter  dealing  with  intestinal  surgery." 

From  THE  LANCET  CLINIC,  Cincinnati. 

"  We  have  carefully  examined  this  work,  and  can  truthfully  say  that  it 
is  the  best  of  the  condensed  works  on  surgery  in  the  English  language.  It 
is  based  upon  modern  ideas,  it  teaches  modern  surgery,  and  gives  a  very 
intelligent  description  of  the  subjects  treated.  The  title  of  the  book  calls 
attention  to  the  fact  that  the  subject  of  treatment  has  been  made  of  primary 
importance,  and  the  book  fully  justifies  the  announcement.  *     *     *     * 

"  In  conclusion,  we  feel  that  strict  justice  compels  us  to  say  that  we 
know  of  no  work  on  surgery  that  can  be  as  highly  recommended  to  students 
as  the  volume  before  us.  For  practitioners  (surgical)  the  book  forms  a 
valuable  condensation  of  modern  surgical  thought,  and  should  be  in  their 
possession  as  a  book  to  be  consulted  frequently." 


Handsome  Cloth,  $7.00;    Leather,   Raised   Bands,   $8.00; 

Half   Russia,  Crushed,   Marble  Edges,   $9.00. 

(These  prices  are  absolutely  7iet.) 

P.  BLAKISTON,  SON  &  CO.,  Philadelphia. 


SURGERY 


A  PRACTICAL  TREATISE 
WITH  SPECIAL  REFERENCE  TO  TREATMENT 

BY 

C.  W.  MANSELL  MOULLIN,  MA,  M.D.  OXON. 

FELLOW   OF  THE    ROYAL   COLLEGE  OF   SURGEONS;     SURGEON   AND    LECTURER   ON    PHYSIOLOGY   TO 

THE    LONDON    HOSPITAL;     FORMERLY   RADCLIFFE  TRAVELING   FELLOW  AND 

FELLOW    OF    PEMBROKE    COLLEGE,    OXFORD,    ENGLAND 

ASSISTED   BY 

VARIOUS  WRITERS  ON  SPECIAL  SUBJECTS 

WITH 

SIX  HUNDRED   ILLUSTRATIONS 

MANY   OF  WHICH   ARE    PRINTED    IN    COLORS,  ABOUT  TWO    HUNDRED 
HAVING  BEEN  MADE  FROM  SPECIAL  DRAWINGS 


SECOND    AMERICAN    EDITION 

REVISED  AND  EDITED  BY 

JOHN   B.  HAMILTON,  M.D.,  LL.D. 

PROFESSOR   OF  THE  PRINCIPLES    OF   SURGERY   AND   CLINICAL   SURGERY,  RUSH   MEDICAL   COLLEGE, 
CHICAGO;     PROFESSOR    OF    SURGERY,    CHICAGO    POLYCLINIC;     SURGEON,    FORMERLY   SUPER- 
VISING  SURGEON-GENERAL,  U.  S.  MARINE    HOSPITAL   SERVICE;    SURGEON   TO    PRESBY- 
TERIAN   HOSPITAL;     CONSULTING    SURGEON   TO    ST.   JOSRPH'S    HOSPITAL  AND 
CENTRAL     FREE    DISPENSARY,    CHICAGO;     SECRETARY-GENERAL    OF 
THE     NINTH      INTERNATIONAL     MEDICAL     CONGRESS,     ETC. 


PHILADELPHIA 
P.    BLAKISTON,   SON   &   CO 

I0I2     WALNUT     STREET 
1893 


Copyright,  1S93,  p.y  P.  Blakistox,  Son  &;  Co. 


Press  cf  V/m   F.  Feu.  &  Co 
1220-24  SiNSOM  St., 

PHII-AOELPHIA. 


AUTHOR'S    PREFACE  TO   FIRST   EDITION. 


Modern  Surgery  has  advanced  with  such  rapid  strides,  and  in  so  many  differ- 
ent directions,  that  it  is  ahiiost  impossible,  within  the  space  of  a  single  volume, 
to  give  more  than  an  epitome  of  its  main  principles.  I  have  heretofore  touched 
but  lightly  upon  controversial  matters,  and  have  endeavored  to  make  this  book  a 
practical  one,  in  the  hope  that  it  may  be  of  greater  service  to  students  and  gen- 
eral practitioners.  With  this  object,  I  have  given  special  attention  to  the  question 
of  Treatment;  and  I  have  included  under  the  head  of  each  organ  a  brief  descrip- 
tion of  the  malformations  to  which  it  is  liable,  and  the  various  operations  that 
may  be  performed  upon  it,  instead  of  relegating  them  to  chapters  by  themselves. 
The  General  Pathology  of  Surgical  Diseases  is  dealt  with  in  Part  I ;  that  of  Inju- 
ries in  Part  II.  In  Part  III  the  Diseases  and  Injuries  of  Special  Structures  and 
Organs  are  considered  more  fully.  Throughout,  I  have  endeavored  to  enforce 
the  idea  that  the  chief  aim  and  object  of  Surgery  at  the  present  day  is  to  assist 
the  tissues  in  every  possible  way  in  their  struggle  against  disease. 

Through  the  kindness  of  the  publishers,  I  have  been  enabled  to  make  use  of 
many  illustrations  from  Bryant's  "  Practice  of  Surgery,"  Fergusson's  "  Surgery," 
and  Astley  Cooper's  work  on  "Fractures  and  Dislocations."  I  am  indebted  to 
the  Clinical  Society  and  to  Mr.  Morrant  Baker  for  Figs.  245,  246,  247,  illus- 
trating Charcot's  disease  ;  to  Mr.  Bowlby  for  Figs.  50  and  54;  to  Mr.  Greig 
Smith  for  several  illustrations  of  the  various  methods  of  suturing  the  intestine; 
and  to  Mr.  Nettleship  for  others  in  connection  with  ophthalmic  surgery. 
Messrs.  Krohne  and  Sesemann,  Arnold,  Weiss,  Maw,  and  Schall  have  also 
kindly  allowed  me  to  make  use  of  various  cuts  from  their  catalogues.     The  rest 

V 


vi  AUTHOR'S  PREFACE  TO  FIRST  EDITION. 

of  the  illustrations,  nearly  two  hundred  in  number,  were  (with  four  exceptions) 
drawn  from  original  specimens  by  my  brother,  Dr.  J.  A.  Maxsell  Moullix  (to 
whom  I  am  indebted  for  the  article  on  Diseases  of  the  Female  Generative  Organs) 
or  myself. 

I  have  also  to  express  my  thanks  to  Mr.  J-  Hutchixsox,  junior,  for  his  chap- 
ters on  Diseases  of  the  Skin  and  Eye  ;  to  Mr.  T.  Mark  Hovell,  for  that  on 
Diseases  of  the  Ear  and  Larynx  ;  and  to  Mr.  F.  S.  Eve  for  that  on  Tumors. 

C.   W.   MANSELL  MOULLIX. 


EDITOR'S    PREFACE. 


Moullin's  Text-book  on  Surgery  was  introduced  into  this  country  two  years 
ago,  and  its  favorable  reception  by  the  Profession  soon  caused  the  exhaustion  of 
the  edition. 

Its  wide  scope,  its  clear  expression,  and  its  excellent  illustrations  made  it  a 
favorite  ;  and  these  characteristics  have  been  preserved  in  the  American  edition 
now  offered.  The  work  has  undergone  thorough  revision  wherever  necessary,  and 
many  new  illustrations  from  the  most  recent  Foreign  and  Domestic  Monographs 
have  been  added,  and  such  changes  in  the  text  have  been  made  as  recent  changes 
in  Theory  and  Practice  required.  Some  rearrangement  has  been  made  of  the 
text,  and  a  brief  chapter  on  the  outlines  of  Military  Surgery  has  been  added. 
To  make  room  for  the  new  matter  and  new  illustrations,  without  materially  in- 
creasing the  bulk  of  the  book,  certain  portions  of  the  former  chapters  on  diseases 
of  the  skin,  diseases  of  the  eye,  diseases  of  the  ear  and  larynx  as  were  not  strictly 
Surgical,  have  been  omitted.  Among  other  additions,  the  chapter  on  amputations 
has  been  enlarged  by  the  addition  of  a  number  of  new  illustrations,  and  Surgical 
Bacteriology  has  been  newly  illustrated  by  colored  engravings  from  recent 
monographs. 

The  additions  made  by  the  Editor  are  enclosed  in  brackets. 

The  Editor  feels  sure  that  this  excellent  work  of  Moullin  in  its  American 
dress  will  continue  to  enjoy  the  popularity  in  this  country  which  the  first  edition 
so  well  merited  and  received. 

Thanks  are  due  Passed  Assistant  Surgeon  Wertenbaker,  M.  H.  S.,  and  Dr.  D. 

Bevan,  of  Jefferson  Medical  College,  Philadelphia,  for  a  number  of  carefully  made 

drawings  that  increase  the  value  of  the  book  ;  and  to  Drs.  W.  A.  Wells  and  W. 

M.  Barton  for  assistance  in  preparing  the  index. 

JOHN  B.   HAMILTON. 
Rush  Medical  College,  Chicago,  III., 
April,  i8gj. 


Vll 


CONTENTS. 


PART 


GENERAL    PATHOLOGY  OF  SURGICAL    DISEASES. 


CHAPTER    I. 

PAGE 

INJURY   AND   REPAIR     ....  25 

Injlani  m  a/ion — 

Sympttjms  of  Inflammation 30 

Varieties  of  Inflammation 34 

Treatment  of  Inflammation  .    •     ...  35 

Chronic  Inflammation 38 


CHAPTER   II. 

DISEASES    DUE    TO    NON-INFECTIVE   ORGANISMS. 

Septic  Fever 42 

Sapraemia 43 


CHAPTER   III. 

DISEASES    DUE   TO    INFECTIVE   ORGANISMS. 

Non-specific — 

Suppuration 45 

Abscess 46 

Varieties  of 49 

Treatment  of 51 

Hectic      55 

Albuminoid  degeneration 55 

Sinus  and  fistula 56 

Ulceration 58 

Gangrene 59 

Phagedena 69 

Hospital  gangrene      69 

Phlegmonous  inflammation 70 

Treatment 73 

Pyaemia 74 

Treatment 77 


CHAPTER   IV. 

DISEASES    DUE   TO    INFECTIVE   ORGANISMS. 

2.  Specific — 

Erysipelas 79 

Treatment 81 


PAGE 

Septic  infection  or  true  septicemia  .  .  82 
Anthrax 84 

Treatment 86 

Glanders 87 

Treatment 89 

Actinomycosis 89 

Treatment ,  ...    90 

Tuberculosis 91 

Treatment 95 

Syphilis,  chancroid,  or  soft  chancre,  etc.    95 

Treatment 97 

Acquired  syphilis 98 

Secondary  period I.02 

Tertiary  syphilis 103 

Congenital  syphilis 109 

Treatment 1 1 1 

Leprosy 116 

Treatment 117 

Tetanus 118 

Treatment I2i 

Rabies 121 

Treatment 123 


CHAPTER    V. 

TUMORS. 

By  Frederick  S.  Eve,  f.r.c.s. 

Cysts 125 

Fibromata 130 

I-ipomata 132 

Myxomata 1 33 

Enchondromata 134 

Osteomata 135 

Myoma 136 

Myo-fibromata 137 

Angeioma 137 

Lymphangeiomata 138 

Neuroma 138 

Sarcomata 138 

Papillomata 143 

Adenomata 144 

Carcinoma 144 


CONTENTS. 


PART   II. 


GENERAL    PATHOLOGY  OF  INJURIES. 


CHAPTER   I. 

THE   GENERAL   EFFECTS    OF    INJURY. 

PAGE 

Shock 149 

Treatment '5' 

Delirium  tremens ^S^ 

Treatment 152 

Traumatic  delirium I53 

Traumatic  fever '54 


CHAPTER   H. 

THE   LOCAL  EFFECTS   OF   INJURY. 

Subcutaneous  injuries '55 

Signs  of  contusion ^S" 

Wounds '57 

Repair  of  wounds '5^ 

Cicatrization '59 

Skin-grafting '60 

Complications  of  repair '62 

Treatment  of  wounds '64 


Special  kinds  of  wounds J  74 

Cicatrices '75 


CHAPTER    HI. 

Burns  and  Scalds i79 

Constitutional  symptoms 180 

Treatment l8l 


CHAPTER    IV. 

Minor  Surgery — 

Sterilization  of  the  hands,  clothing,  in- 
struments, etc 184 

The  patient 185 

The  anaesthetic 185 

Local  anaesthesia 185 

General  anaesthesia 186 

Bandaging '88 


PART   III. 


DISEASES  AND   INJURIES  OF  SPECIAL    STRUCTURES. 


CHAPTER   I. 
surgical  diseases  of  the  skin. 

PAGE 

Lupus 189 

Treatment '9' 

Lupus  erythematosus '9^ 

Boils  and  carbuncles '9^ 

Treatment '93 

Ulcers,  syphilitic,  chronic,  tubercular,  trau- 
matic, maligant ^93 

Nisvi 197 

Warts '98 

Corns 198 

Horns '99 

Diseases  of  the  Nails,  treatment I99 


CHAPTER   II. 

injuries  and  diseases  OF  blood-vessels. 

1.  Injuries  of  vessels,  Symptojtis,  Trealment, 

etc 201 

Injuries  of  arteries,  hemorrhage,  aneu- 
rism, treatment,  etc 205 

Injuries  of  veins 218 

2.  Diseases  of  vessels 220 

Angeioma 220 


Haemophilia 222 

Diseases  of  arteries ■    ■  222 

"  veins 227 

Thrombosis 229 

Embolism 232 

Phlebitis 233 

Aneurysm 235 

Idiopathic  or  spontaneous  aneurysm  .  235 

Treatment 241 

Traumatic  aneurysm 248 

Special  aneurysms  with  treatment  ,    .  248 

Opei-ations  on  arteries 261 

General  rules  for  ligature 261 

Special  ligatures  .  262 


CHAPTER   III. 

injuries  and  diseases  of  lymphatics. 

Injuries  of  lymphatics 281 

Diseases  of  lymphatics  with  treatment     .    .281 

Lymphangitis 281 

Lymphadenitis 282 

Lymphatic  glandular  tumors     ....  286 

Lymphangeiectasis 289 

Lymphangeioma     ....•.•••  289 


CONTENTS. 


CHAPTER    IV. 

INJURIKS    AND    DISEASES    OF    NERVES. 

PAGE 

Injuries  of  nerves,  -ivith  treatmenf,  ....  292 

Dise(jses  of  nerves,    "  "  ....  299 

Neuritis 299 

Neuraiijia 301 

Operations  on  nerves 302 

Nerve  stretching 302 

Neurectomy 304 

Neuromata 305 


CHAPTER   V. 

INJURIES  AND  DISEASES    OF    MUSCLES,  TENDONS, 
ETC. 

Injuries  of  muscles,  etc. 

Sprains  and  contusions 306 

Rupture 307 

Dislocations 308 

Diseases  of  muscles,  etc.,  with  treatment 

Atrophy 309 

Functional  disorders 310 

Contracture 311 

Myositis 311 

Teno-synovitis 312 

Ganglion      315 

Dupuylren's  contraction 317 

Bursa; 319 


CHAPTER    VI. 
INJURIES   AND   DISEASES  OF  BONES  AND   JOINTS. 

1.  Malformations  and  deformities,  with  treat- 
ment. 

Disproportionate  growth 322 

Congenital  dislocations 322 

Club-hand 324 

Webbed  fingers  and  toes 324 

Talipes 325 

Flat  foot 336 

Deformities  of  the  toes 338 

Genu  valgum .  341 

Rickety  deformities 342 

2.  Injuries  of  bones,  with  treatment. 

Fractures 345 

Repair  of  fractures 349 

Imperfect  repair 354 

Symptoms  and  diagnosis 361 

Complications  of  fractures 363 

Treatment  of  fractures 369 

Fracture  of  the  bones  of  the  face  .    .    .  381 

"  clavicle 385 

•'  scapula 390 

"  humerus 392 

"  radius 403 

"  ulna 408 

"  carpus  and  hand   .    .       410 

"  pelvis 411 

"  femur 413 

"  patella 429 

"  tibia  and  fibula      .    .    .  435 

"  bones  of  foot     ....  443 


PAGE 

Diseases  of  bone,  with  treatment. 

Atrophy 444 

Hypertrophy 444 

Intiammation 444 

Acute 445 

Chronic 446 

Caries 448 

Simple  traumatic 450 

Phosphorus  necrosis 432 

Mercurial  necrosis 453 

Acute  suppurative  osteitis      ....  453 

Acute  epiphysitis 462 

Septic  osteomyelitis 462 

Exanthematous  necrosis     ....  464 

Syphilitic  osteitis 464 

Rheumatic  osteitis 471 

Tubercular  osteitis 472 

Rickets 474 

Acute  rickets 479 

Osteitis  deformans 480 

Osteomalacia 483 

Tumors  of  bone 484 

Osteoma 484 

Enchondroma 486 

Fibroma 487 

Sarcoma 487 

Central  sarcomata 488 

Periosteal  sarcomata 489 

Cysts 491 

Carcinoma 491 

Injuries  of  joints,  with  treatment. 

Wounds  of  joints 492 

Subcutaneous     injuries,    sprains     and 

contusions 495 

Dislocations,  general  pathology,  symp- 
toms, diagnosis,  treatment      ....  497 
Dislocation  of  the  lower  jaw    ....  504 

"  clavicle 506 

"  scapula 508 

"  humerus 508 

"  elbow  joint   .    .    .    .519 

"  wrist  joint     ....  524 

"  thumb 525 

"  hip  joint 527 

patella 535 

"  knee      536 

"  semilunar  cartilages.  537 

"  ankle 540 

"  astragalus      ....  543 

Subastragalar  dislocation 544 

Diseases  of  joints,  with  treatment. 

Pathology 545 

Etiology   •    •    • 547 

Mode  of  examination 548 

Synovitis,  acute  and  chronic     ....  549 

Arthritis 554 

Suppurative  arthritis 559 

Pysemic  arthritis 563 

Puerperal  arthritis 564 

Exanthematic  arthritis 564 

Urethral  arthritis 564 

Gouty  arthritis 566 

Rheumatic  arthritis 5^9 

Osteo  arthritis 569 

Charcot's  disea'^e 577 

Tubercular  arthritis 580 

Senile  tuberculosis 585 

Diseases  of  special  joints  with  treat- 
ment      588 

Diseases  of  the  hip  joint 588 


CONTENTS. 


PAGE 

Diseases  of  the  sacro-iliac  joint    .    .  603 
"  knee  joint     ....  605 

"  ankle 61 1 

"  shoulder 612 

"  elbow 612 

"  wrist 613 

Foreign  bodies  in  joints 614 

Ankylosis 616 

6.   Excision  of  joints 619 

Excision   of  joints   of  the   upper   ex- 
tremity       620 

Excision    of  joints   of  the    lower   ex- 
tremity       625 


CHAPTER    VII. 

INJURIES    AND    DISEASES    OF   THE   HEAD. 

Malformations 630 

Injuries  of  the  head 

Injuries  of  the  scalp 631 

Fracture  of  the  skull 634 

Injuries  of  the  brain 640 

Intracranial  hemorrhage 648 

Injuries  of  nerves 650 

Traumatic  epilepsy     .    .  ....  654 

"  insanity 654 

Diseases  of  the  head. 

Diseases  of  the  scalp 655 

Erysipelas 655 

Suppuration 655 

Tumors  and  horns 656 

Diseases  of  the  skull 657 

Hypertrophy 657 

Rickets 657 

Inflammation 658 

Tumors 659 

Diseases  of  the  brain  and  meninges  .    .  660 

Inflammation 660 

Suppuration 664 

Hernia  cerebri 672 

Tumors 673 

Trephining 677 

Cerebral  localization 678 


CHAPTER   VIII. 

INJURIES    AND    DISEASES    OF   THE    HACK. 

1.  Malformations,  with  treatment. 

Spina  bifida 680 

Congenital  sacral  tumors 684 

2.  Injuries  of  the  back,  wit  It  treatment. 

Sprains  and  wrenches 685 

Fractures  and  dislocations 687 

Injuries  of  the  spinal  cord 697 

3.  Diseases  of  the  back. 

Disease  of  the  spinal  column     .    .    .    .701 

Osteitis 701 

Tubercular  osteitis 701 

Suppuration  and  spinal  caries    .    .  709 

Curvature  of  the  spine 710 

Inflammation   of  the   spinal    cord   and 

meninges 71S 

Tumors  of  the  cord 720 

Trephining 721 


CHAPTER    IX. 

INJURIES   AND    DISEASES    OF   THE   EYE, 
By  Jonathan  Hutchinson,  Jun.,  f.k.c.s. 

PAGB 

Methods  of  examination 722 

Injuries  of  the  eye 726 

Diseases  of  the  eye. 

Diseases  of  the  conjunctiva 728 

"  cornea 729 

"  iris 729 

Cataract 731 

Glaucoma 733 

Diseases  of  the  choroid 734 

Diseases  of  the  eyelids,  etc 735 

Operations  on  the  eye 738 


CH.APTER    X. 

INJURIES    AND   DISEASES   OF   THE   FACE   AND 

NOSE. 

Malformations  :  Harelip,  etc 742 

Injuries  of  the  face 745 

Wounds 745 

Fracture 745 

Foreign  bodies  in  nose 745 

Division  of  parotid  duct 745 

Diseases  of  the  face. 

Inflammatory  affections 746 

Tumors  of  the  face 748 

Diseases  of  the  nose,  malformations,  and 

deformities 751 

Epistaxis      751 

Inflammatory  affections 753 

Tumors 755 


CHAPTER    XI. 

INJURIES    AND    DISEASES   OF   THE   MOUTH    AND 
JAWS. 

Alalformations  :  Cleft  palate,  etc 759 

Injuries  of  the  mouth  and  fauces     ....  762 
Diseases  of  the  mouth  and  fauces. 

Inflammatory  affections 762 

Periostitis  and  osteitis 765 

Diseases  of  the  antrum 767 

Closure  of  the  jaws    .    , 768 

Tumors  of  the  mouth  and  jaws    .    .    .  770 
Operations  upon  the  jaws      774 


CHAPTER   XII. 

INJURIES   AND    DISEASES    OF   THE   TONGUE, 

SALIVARY   GLANDS    .\ND    TONSILS, 

WITH   TREATMENT. 

Malformations  :  Congenital  affections,  ma- 
croglossia,  etc 778 

Diseases  of  the  tongue  : 

Glossitis 779 

Leukoplakia 781 

Tumors  of  the  tongue 784 

Operations  on  the  tongue 787 

Operations  on  the  lingual  nerve     .    .    .  790 

Diseases  of  the  tonsils 79^ 

Diseases  of  the  saliva fy  glands 794 


CONTENTS. 


xiu 


CHAPTER   XIII. 

SURGICAL   DISEASES   OF  THE   EAR    AND 

LARYNX,   WITH   TREATMENT. 

By  T.  Mark  Hovell,  m.  d. 

PAGE 

Diseases  of  the  ear  : 

Examination  of  the  ear 797 

Diseases  of  the  external  ear 799 

"  middle  ear 8oi 

"  internal  ear 802 

Syphilitic  affections 803 

Diseases  of  the  larynx  : 

Examination  of  the  larynx 803 

Inflammation  of  the  larynx 804 

Tumors  of  the  larynx 809 

Disorders  of  sensation 811 

Muscular  paralysis  and  spasm    .    .  811-813 

CHAPTER    XIV. 

INJURIES    AND    DISEASES    OF   THE   NECK    AND 
THROAT. 

MaIfortnatio7ts  :  Branchial  fistula,  etc.     .    .814 

Injuries  of  the  neck  : 

Wounds 814 

Fracture  of  hyoid  bone,  and  cartilages 

of  larynx 817 

Foreign  bodies  in  air  passages  ....  818 
Scald  of  the  glottis 821 

Diseases  of  the  neck  : 

Inflammatory  affections 823 

Torticollis 824 

Tumors  of  the  neck 826 

General  operations  on  the  air  passages  .  828 

Intubation  of  larynx 833 

Excision  of  larynx 835 


CHAPTER   XV. 

DISEASES    OF   THE   THYROID. 

Inflammation  of  the  thyroid 838 

Simple  enlargement,  or  goitre    ....  839 
Malignant  disease 844 

CHAPTER   XVI. 

INJURIES    AND    DISEASES    OF    THE    PHARYNX 
AND    (ESOPHAGUS. 

Malformations 845 

Injuries  of  the  oesophagus 845 

Foreign  bodies  in  the  oesophagus      ....  846 

Diseases  of  the  cesophagus 847 

Tumors 848 

Stricture 849 


CHAPTER   XVII. 

INJURIES   AND    DISEASES    OF   THE    CHEST. 

Injuries  of  the  chest  wall 853 

Fracture  of  the  ribs 853 

Injuries  of  the  sternum 855 

Non- penetrating  wounds 855 

Injuries  of  the  thoracic  viscera 856 

Diseases  of  the  chest  wall 864 

Operations  upon  the  thorax 864 


CHAPTER    XVIII. 

INJURIES    AND    DISEASES   OF   THE   ABDOMEN, 
WITH    TREATMENT. 

1.  Injuries  of  the  abdomen.  pace 

Contusions 870 

Wounds 872 

2.  Surgical  affections  of  the  stomach  : 

Operations  on  the  stomach 874 

3.  Hernia 877 

Anatomy 878 

Trusses 8S0 

Irreducible  hernia 882 

Obstructed  hernia 883 

Inflamed  hernia 884 

Strangulated  hernia 884 

Special  hernicTe  : 

Inguinal  hernia 896 

Femoral  hernia 905 

Umbilical  hernia 907 

Ventral  hernia 909 

Obturator  hernia 9°9 

4.  Intestinal  obstruction  : 

Acute  intestinal  obstruction 91 1 

Chronic  intestinal  obstruction     .    .    .    .922 

5.  Perityphlitis  and  peritonitis 931 

6     Operations  on  the  intestines. 

Enterostomy 93^ 

Colo'.omy 937 

Lumbar  colotomy 937)  94° 

Inguinal  or  laparo-colotomy 939 

Enterectomy 941 

Colectomy 945 

Cfficectomy 946 

Intestinal  anastomosis 946 

Artificial  anus  and  frecal  fistula     .    .    .  947 
7.  Surgical  affections  of  the  liver  and  pancreas. 

Abscess  of  the  liver, 949 

Hydatid  disease 95° 

Diseases  of  gall  bladder 951 

Operations  on  gall  bladder              .    .    .  953 
Diseases  of  the  pancreas 954 

CHAPTER   XIX. 

INJURIES    AND    DISEASES   OF   THE    RECTUM, 
WITH    TREATMENT. 

Malformations 955 

Exaviination  of  the  rectum      956 

Diseases  and  injuries  of  the  rectum. 

Hemorrhoids 95^ 

Prolapse       9^6 

Polypus 969 

Pruritus 97° 

Proctitis 970 

Periproctitis 973 

Fissure 974 

Fistula 976 

Stricture 980 

Malignant  disease 983 

Villous  tumor 9^^ 

CHAPTER    XX. 

INJURIES    AND    DISEASES    OF   THE   KIDNEY, 
WITH    TREATMENT. 

Malformations       988 

Movable  and  floating  kidney       989 

Injuries  of  the  kidney. 

Contusions  and  lacerations 990 


CONTENTS. 


Diseases  of  the  kidney. 

Suppression  of  urine 992 

Hydronephrosis 994 

Tumors  of  the  kidney  .  ....     996 

Renal  calculus 998 

Nephritis 1003 

Pyelitis  and  pyelonephritis 1006 

Perinephritis      loio 

Renal  fistula 101 1 

Methods  for  differentiating  the  secre- 
tion of  the  kidneys  ......  loii 

Operations  upon  the  kidneys. 

Puncture 1012 

Nephrotomy 1012 

Nephrolithotomy  1012 

Nephrectomy 1014 

Surgical  aspect  of  the  mine 1015 


CHAPTER   XXI. 

INJURIES    AND    DISEASES    OF   THE   BLADDER, 
WITH   TREATMENT. 

Malformations      1024 

Injuries  of  the  bladder 1026 

Diseases  of  the  bladder. 

Atony 1029 

Irritability      1030 

Incontinence 1031 

Retention 1032 

Tapping  the  bladdi  r lojS 

Cystitis 1036 

Calculus 1041 

Table  of  general  characters  of  calculi .  1043 

Lithotrity 1047 

Lithotomy      1052 

Tumors .  1064 

Electrical  illumination  of  bladder  .    .  1067 
Foreign  bodies 107 1 


CHAPTER    XXII. 

DISEASES    OF   THE   PROSTATE,    WITH 
TREATMENT. 

Enlargement      1072 

Malignant  disease 1083 

Inflammation 1083 

Pfostatic  calculi 1087 


CHAPTER   XXIII. 

INJURIES   AND    DISEASES    OF   THE    URETHRA, 
WITH    TREATMENT. 

Injuries  of  the  urethra  : 

Rupture 1088 

Calculus 1090 

The  passage  of  catheters  and  general 

effect  of  operations 1091 

Diseases  of  the  urethra  ; 

Inflammation I095 

Stricture 1102 

Extravasation  of  urine 1 118 

Urinary  abscess I120 

"        fistula .    .  1121 

The  female  urethra 1 122 


CHAPTER   XXIV. 

INJURIES    AND    DISEASES  OK  THE  MALE  ORGANS, 
WITH    TREATMENT. 


Malformations  and  diseases  of  the  penis 

Diseases  of  the  scrotum 

Malformations  of  the  testes 

Diseases  of  the  testes. 

Neuralgia 

Atrophy 

Inflammation 

Tubercular  disease 

Hernia 

Tumors 

Castration 

Varicocele .    . 

Hydrocele 

Haematocele 


PAGE 
124 
125 
127 

128 
129 
129 

'34 
135 
137 
138 
139 
143 


CHAPTER    XXV. 

DISEASES    OF   THE   FEMALE   GENERATIVE 
ORGANS,   WITH    TREATMENT. 

By  J   A.  Mansell  Moullin,  m.d  ,  m.  r.  c.  p. 

Inflammation  of  the  ovaries  and  Fallopian 

tubes 1 1 45 

Ectopic  gestation 1146 

Tumors  of  the  ovary  and  broad  ligament  .  1 148 

Tumors  of  the  uterus II59 

Operations  about  the  vulva  and  vagina  .    .  I168 


CHAPTER   XXVI. 

DISEASES    OF   THE   BREAST,   WITH    TREATMENT. 

Malformations      I171 

Diseases  of  the  nipple I171 

Diseases  of  the  gland. 

Inflammation ii73 

Tumors 1176 

The  male  breast 1185 

Excision  of  the  breast 11 85 


CHAPTER   XXVII. 

AMPUTATIONS. 

Amputation  of  limbs  and  special  amputa- 
tions    1188 

Hip-joint  operations  (including  Senn's  new 
method) 1193 

Amputation  through  femur, 1196 

Amputation  of  knee-joint,  leg,  ankle,  foot, 
toe 1 197 

Diseases  of  stumps 1203 


CHAPTER   XXVIII. 

THE   PRINCIPLES   OF    MILITARY    SURGERY. 
By  the  Editor,  John  B    Hamilton. 

First   aid  to  the   wounded,  transportation, 
etc 1204 

Gunshot  wounds 1209 

I    Gunshot  fractures      121 2 

I    Index 1213 


LIST   OF    ILLUSTRATIONS, 


Platks. 

Intestinal  Anastomosis,  Senn's  Method, Frontispiece. 

Bandaging.     Two  jilates,  showing  twenty-seven  of  the  principal  forms,    .  Placing  pages  i86  and  1 88 

Lumbar  Hernia, Facing  page  876 

The  Handkerchief  Bandages, Facing  page  1204 

FIG.  PAGE 

1.  A  Group  of  Fibroblasts, Bryatti 30 

2.  Diapedesis, ■ Original, 31 

3.  Storaata  of  the  Capillaries, Dtiplay  and  Rectus,    ...  32 

4.  Dilatation  of  Capillaries, Original, 32 

5.  Pus  from  Acute  Abscess, After  Woodhead,     ....  47 

6.  Streptococcus  Erysipelatous, Baumgarten, 79 

7.  Blood  of  Mouse  after  Inoculation,  with  Bacillus  of  Septi- 

caemia,     After  Woodhead,      ....  83 

8.  Bacillus  Anthracis, "             "               ....  85 

9.  Fibrous  Nodule  from  a  Case  of  Actinomycosis, "             "               ....  88 

10.  Actinomycosis, "             ♦'               ....  89 

11.  Tubercle  Bacilli, "             "               ....  91 

12.  Hereditary  Syphilis,  Face  in, Bryant, no 

13.  Lipoma  of  Arm, *'           132 

14.  Diffused  Lipoma  of  Neck, '*           132 

15.  Myxoma  (microscopic  appearance), "           133 

16.  Fibroma,  Osteoma,  and  Enchondroma,   (microscopic  ap- 

pearance,              "           135 

17.  Non-striped  Myoma, After  Woodhead,     ....  136 

18.  Sarcoma  (microscopic  appearance), Bryant, 139 

19.  Adenoma          "                       "              "           ........  I43 

20.  Carcinoma,      "                      '*              "           145 

21.  Epithelioma  of  Stump, "           146 

22.  23.   Cicatrization  by  Skin-Grafting, "           161 

24.  Irrigating  Can, —           165 

25.  Button  Suture, Bryant, 169 

26.  Quilled      "           "           169 

27.  Twisted     "           "           169 

28.  Interrupted  Suture, "           170 

29.  Glover's             "           '«           170 

30.  Quilt                  "           Greig  Smith, 170 

31.  Cicatrix  of  Burn  on  Face, Bryant, 175 

32.  "                 "           Arm, Fergusson, 175 

33.  The  Same  after  Incision, "            176 

34.  Epithelioma  Growing  from  a  Cicatrix, Hamilton, 177 

35.  Lupus  (microscopic  section), Hutchinson, 190 

36.  Chronic  Onychia, Bryant, 199 

XV 


LIST  OF  ILLUSTRATIONS. 


FIG. 

37- 
38. 
39- 
40. 
41. 
42. 

43- 
44. 

45. 
47- 
48. 
49. 
50. 
51- 
52. 
53- 
54- 
55- 
56. 

57- 

58. 
59- 
60. 
61. 
62. 


Onychia  Maligna, 

Laceration  of  Internal  Coats  of  Artery, 

Petit's  Tourniquet, 

"  "  Applied  to  the  Brachial  Artery, 

«  u  i<         «       Femoral      " 

Signoroni's  Tourniquet,  , 

Acupressure, 

Effect  of  Torsion  on  an  Artery, 

46.  Aneurysmal  Varix, 

Arterio-venous  Aneurysm 

The  same  laid  open, 

Cirsoid  Aneurysm  of  Scalp, 

Syphilitic  Arteritis,      

Varicose  Veins, 

Section  through  Popliteal  Aneurysm, 

Diagrams  of  Operations  on  Aneurysms, 

Femoral  Artery  Laid  Open  after  Ligature,  .    .    .    . 

Method  of  Applying  Ligature  to  Artery, 

Aneurysm  Needle, 

Ligature  of  Common  Carotid  and  Facial  Arteries, 


Fergusson, 
Bryant,  . 
Fergusson, 


Bryant, 

Fergusson 
Bryant, 

Fergusson 

Bowlby, 

Bryant, 


Bowlby, 
Bryant, 


"  Subclavian  and  Lingual  Arteries, .    .    . 

"  Axillary  Artery, 

"  Brachial  Artery, 

"  "  "       at  Bend  of  Elbow,    . 

Lines  of  Incision  for  Brachial  and  Radial  Arteries, 


63.  Ligature  of  Radial  Artery, 


64. 

65- 
66. 
67. 
68. 

69. 

70. 
71- 
72. 

73- 
74- 
75- 
76. 

77- 
78. 

79- 
80. 
81. 
82, 
84. 
85. 
86. 
87. 
88, 
90. 
91. 


"  Radial  and  Ulnar  at  the  Wrist,      .    .    .    .        . 

Incision  for  Ligature  of  Common  Iliac  Artery, 

Ligature  of  the  External  Iliac  and  Femoral  Arteries,     .    . 

Line  of  Incision  for  Ligature  of  the  Femoral  Artery,  .    .    . 

"  "  "  Posterior  Tibial  Artery, 


Adapted  from  Sedillot  by  \ 
Bryant.  i 


Fergussoti, 

j"  Adapted  frotn  Sedillot  by  \ 
I      Bryant. 


Fergusson, 


Ligature  of  the  Posterior  Tibial  Artery, 

"  "  "  at  Ankle,    .    .    . 

Line  of  Incision  for  Ligature  of  Anterior  Tibial  Artery, 

Ligature  of  the  Anterior  Tibial  Artery, 


"  Dorsalis  Pedis  Artery,  .    .    . 

Treves'  Cervical  Splint 

Lymphoma  (microscopic), 

Serous  Cyst  of  Neck, 

False  Neuroma, 

Rider's  Bone, 

Avulsed  Thumb, 

Ruptured  Biceps, 

Nussbaum's  Appliance  for  Writer's  Cramp, 
83.  Sterno-mastoid  Induration  (microscopic). 

Compound  Palmar  Ganglion, 

Dupuytren's  Contraction, 

Semi-solid  Bursa,  laid  open,       

Supernumerary  Thumb, 

89.  Congenital  Displacement  of  1  lip,    .    .    . 

Webbed  Fingers, 

Congenital  Talipes  Varus 


r  Adapted  from  Sedillot  by  \ 
I      Bryant.  i 

Original, 

Fergusson, 

(  Adapted  from  Sedillot  by  \ 
I      Bryant.  i 


Krohne  and  Sesemann,  . 
Bryant, 


Holmes, 
Bryant, 


Bryant, 


Fergusson, 
Bryant,  . 
Fergusson, 
Bryant,  . 
Feigussou , 
Bryant,     . 


PAGB 

200 
205 
208 
208 
208 
209 
211 
212 
217 
218 
218 

221 

224 
227 
239 
243 
244 
262 
262 

264 

267 
270 
270 
271 
272 

272 

273 
274 
275 
276 
278 

278 

279 
279 

279 

280 
286 
287 
289 

305 

306 

307 
307 

3" 
312 
316 

317 
320 
322 
323 
325 
326 


LIST  OF  ILLUSTRATIONS. 


PIG 

92.  Congenital  Talipes  Valgus, Bryant, 

93.  Barwell's  Adhesive  Straps,         Sayre,   . 

94.  Morton's  Club-Foot  Stretcher, Bradford, 

95.  Bradford's       "  "  " 

96.  Tin  Splint  for  Slight  Varus — 

97.  Little's  Shoe, — 

98.  Little's  Modification  of  Scarpa's  Shoe, Bryant, 

99.  Talipes  Equinus Fergusson, 

icx>.         "       Calcaneus, " 

101.  Harwell's  Shoe " 

102.  Walsham's  Shoe, — 

103.  Lever  for  Great  Toe, — 

104.  Osteoclast  of  Rizzoli, — 

105.  Transverse  Fracture  of  Femur, Original, 

106.  Greenstick  Fracture  of  Radius " 

107.  Comminuted  Fracture  of  Clavicle, " 

108.  T-shaped  Fracture  of  Humerus,  ■ '* 

109.  Badly-United  Fracture  Laid  Open, " 

;io.   Ununited  F"racture  of  Ulna, Fergusson, 

[II.  "  "  Tibia 

[12.  Pseudarthrosis  of  Tibia,      ....  " 

113.  The  Limb  in  the  same  case, Fergusson. 

[14.  Gutta-percha  Splint  for  Lower  Jaw, Original, 

[15.  Wire  "  "         "        

[16.  Thomas's  ^lethod  of  Wiring  Jaw, " 

[1 7.  Displacement  of  Broken  Clavicle, Fergusson, 

18.  Triangular  Bandage  Applied, Original, 

[I9.  Bandage  for  Fracture  of  Clavicle, " 

120,  121,  122.  Sayre's  Bandage  for  Fracture  of  Clavicle,  ...             — 

[23.  Pick's  Bandage, Original, 

[24.  Fracture  of  Neck  of  Scapula, Fergusson, 

[25.         "  Surgical  Neck  of  Humerus, " 

[26.  Bandage  for  Fractured  Neck  of  Humerus, Original, 

127.  Line  of  Upper  Epiphysis  of  Humerus, " 

[28.   Splint  for  Fracture  of  Shaft  of  Humerus, " 

[29.  Fracture  of  Lower  end  of  Humerus, Fergusson, 

[30.  Badly-united  Fracture  of  Humenis, " 

[31,  Fracture  of  Inner  Condyle  of  Humerus, " 

[32.  Epiphysis  (lower)  of  Humerus, Original, 

[33.  Separation  of  Upper  Epiphysis  of  Radius, " 

134.  Diagram  of  Colles'  Fracture, " 

[35.  Section  through  Colles'  Fracture, Bryant, 

136.  Hand  in  Colles'  Fracture,  Fergusson, 

137.  Gordon's  Splint,       Original, 

[38.  Carr's  Splint,  ....        Bryant, 

139.  Fibrous  Union  of  Olecranon, Fergusson, 

140.  Fracture  of  Pelvis,      " 

141.  Bryant's  Triangle,       Bryant, 

[42.  Intra-articular  Fracture  of  Neck  of  Femur, Original, 

[43.  Section  through  Neck  of  Femur, " 

144.  "  "  (horizontal) '' 

145.  Impacted  Fracture  through  Base  of  Neck, " 

146.  "  "         inlra-articular, " 

147.  Separation  of  Great  Trochanter, ...  Bryant, 

148.  Liston's  Splint — 

149.  Desault's  Splint, — 


PAGE 
326 

328 
330 
330 
331 

333 
334 
335 
338 
340 
344 
345 
346 
346 
346 
352 
355 
355 
355 
356 
Z^o 
384 
385 
386 

387 
388 

389 
390 
391 
392 
393 
394 
397 
399 
400 
402 
402 

403 
404 

405 
406 
407 
407 
409 

413 

414 

415 
415 
417 
419 
419 
420 
422 
422 


xviii  LIST  OF  ILLUSTRATIONS. 

P'G-  PAGE 

150.  Mode  of  Applying  Stirrup, Original, 423 

151.  Listen's  Splint  Applied, "          423 

152.  Thomas's  Knee-splint, "         424 

153.  Badly-united  Fracture  of  Femur, Fergusson, 424 

154.  Mclntyre  Splint  Applied, Original, 425 

155.  Hodgen's  Splint  Applied, Bryant, 425 

156.  Fracture  of  Femur  in  Infancy, Original, 425 

157.  Vertical  Separation  of  Lower  Epiphysis  of  Femur  with 

Bony  Union, "          426 

158.  Fracture  of  Lower  End  of  Femur, " 426 

159.  160.   Fractured  Patella, Fergusson, 429 

161.  Section  through  Knee  after  Fracture  of  Patella,      ....       Original, 429 

162.  Outline  of  Knee  in  Fracture  of  Patella, Fergusson, 429 

163.  Bony  Union  of  Fractured  Patella, Original,  ........  430 

164.  Fibrous  Union  of  Fractured  Patella, "          430 

165.  Splint  for  Fracture  of  Patella, "          431 

166.  Malgaigne's  Hooks, — 432 

167.  Leather  Splint  for  Knee, —         433 

168.  Stocking  Splint  for  Leg, Original, 437 

169.  Bavarian  Splint, "          438 

170.  Section  through  Foot  showing  effect  of  Eversion,  ....              " 440 

171.  "  "                  "              Inversion,      ...              "          440 

172.  Vertical  Splitting  of  Tibia, "          441 

173.  Dupuytren's  Splint, Fergusson, 441 

174.  Compound  and  Comminuted  Fracture  of  Leg, —        .    .    .  * 442 

175.  Atrophy  of  Bone, Original, 444 

176.  Chronic  Traumatic  Osteitis,       , "          446 

177.  Inequality  of  Growth    Consecutive    to  Inflammation  and 

Necrosis, "          447 

178.  Chronic  Abscess  of  Bone, "          449 

179.  Chronic  Osteomyelitis, "          452 

180.  Phosphorus  Necrosis  of  Jaw, " 453 

181.  Acute  Suppurative  Osteomyelitis  of  Tibia, "          455 

182.  Chronic  Osteomyelitis  of  Lower  End  of  Femur,    ....             "          456 

183.  Section  through  Bone  after  Amputation  and  Osteomyelitis,             "          463 

184.  Tubular  Sequestrum "          463 

185.  Syphilitic  Caries  of  Skull, "          466 

186.  "        Osteosclerosis  of  skull, "          467 

187.  Parrot's  Nodes, "          468 

188.  Tubercular  Caries  of  Radius, " 473 

189.  Section  through  an  Epiphysis  in  a  Case  of  Rickets,    ...             "          475 

190.  191.  Rickety  Femur  and  Tibia "          476 

192.  Skull  from  a  Case  of  Osteitis  Deformans, "          480 

193.  Femur  from  a  Case  of  Osteitis  Deformans, "          480 

194.  Attitude  in  Osteitis  Deformans, Bryant, 481 

195.  Exostosis  of  Frontal  Sinus, "           484 

196.  Exostosis  from  Frontal  Sinus, "           484 

197.  Sub-ungual  Exostosis, "           485 

198.  Enchondroma  of  Finger, Original, 486 

199.  "                   Hand, Bryant, 486 

20Q.   Central  Sarcoma  of  Tibia, Original, 488 

201.  "                       Fibula, "          488 

202.  Periosteal  Sarcoma  of  Femur, "          489 

203.  Old  Subcoracoid  dislocation — glenoid  fossa, "          499 

204.  205.  New  Sockets  in  Old  Dislocations  of  Hip, Astley  Cooper, 500 

206.  Dislocation  of  Lower  Jaw, Fergusson, 505 


LIST   OF  ILLUSTRATIONS.  xix 

FIG.  _  PAGE 

207.  Old  Dislocation  of  Humerus, Original, 510 

208.  Subcoracoid  Dislocation "          511 

209.  "                    "             Capsule  Laid  ()|ien, "          512 

210.  ■         "  "  Showing  Effect  of  rotation  out- 

ward and  abduction "          513 

211.  Rotation  Outward  of  Arm  ill  Reduction  of  Dislocation,    .             "          513 

212.  Circumduction  of  Arm, "          514 

213.  Forced  Rotation  Inward  of  Humerus, "          515 

214.  Reduction  of  Dislocation  by  Heel  in  Axilla, Fergusson, 515 

215.  Clove-hitch, "             516 

216.  Reduction  of  Dislocation  by  Upward  Traction, "             517 

217.  Dislocation  of  Bones  of  Arm   Backward Modified  from  Astley  Cooper,  519 

218.  Unreduced  Dislocation  of  Elbow, Fergusson, 522 

219.  Subluxation  of  Radius  in  an  Infant, Original, 524 

220.  Thumlj  Forceps, Fergusson, 525 

221.  Dislocation  of  Proximal  Phalanx  of  Thumb, Original, 526 

222.  Complete  Dislocation  of  Proximal  Phalanx  of  Thumb,     .              "          526 

223.  Complex  Dislocation  of  Proximal  Phalanx  of  Thumb,      .       Original, 526 

224.  Dislocation  of  Finger, Fergusson, 527 

225.  Dorsal  Dislocation  of  Hip, Aslley  Cooper 529 

226.  Sciatic  Dislocation  of  Hip,     .    -    .- "               529 

227.  Thyroid  Dislocation  of  Hip,          "                   529 

228.  Pubic  Dislocation  of  Hip, "               .        ...  529 

229.  Dislocation  on  the  Dorsum  above  the  Tendon, Original, 530 

230.  "             "             "        below  the  Tendon, " 530 

231.  View  of  Pelvis  from  below  in  Sciatic  Dislocation,       ...              "          532 

232.  Method  of  Applying  Pulleys  in  Reduction  of  Dislocations',     Fergusson, 535 

233.  Pott's  Fracture, "             540 

234.  Dislocation  of  Foot  Backward, "             541 

235.  Subastragalar  Dislocation, Original, 544 

236.  Absorption  of  Articular  Cartilage  by  Granulations,    ...             "          547 

237.  Abscess  in  Upper  Diaphysis  of  Tibia, "          559 

238.  Exfoliation  of  Cartilage, ''          560 

239.  Degeneration  of  Cartilage  in  Osteo-arthritis, "          569 

240.  Knee  Joint,  Showing  Thickening  of  Synovial  Fold,  ...              "          569 

241.  Elbow  Joint  in  Advanced  Osteo-arthritis, ''          57° 

242.  Absorption  of  Neck  of  Femur  in  Osteo-arthritis,    ....              •'          571 

243.  Papillary  Synovitis, "          572 

244.  Rheumatoid    Arthritis  of  Shoulder    with    Absorption  of 

Biceps  Tendon, "          572 

245.  Shoulder  in  Charcot's  Disease, "          577 

246.  Hand  in  Charcot's  Disease, "          578 

247.  Elbow  in  Charcot's  Disease, "          578 

248.  249.  Knee  Joint  in  Charcot's  Disease, Clinical  Society, 579 

250.  Incipient  Tubercular  Infiltration  of  Upper  End  of  Femur,       Original, 581 

251.  Incipient  Tubercular  Infiltration  of  Upper  End  of  Tibia,                "          . 581 

252.  Sequestrum  in  Neck  of  Femur, Bryant, 588 

253.  Separation  of  Head  of  Femur, "          589 

254.  Destruction  of  Head  of  Femur, Original, 5^9 

255.  Diagnosis  of  Hip  Disease, —           591 

256.  257.  Attitude  in  Early  Hip  Disease, Modified  from  IVright,  .    .  592 

258,  259.  Tilting  of  Pelvis  and  Abduction, Original, 593 

260.  Attitude  in  Advanced  Hip  Disease, Bryant, 59^ 

261.  Bryant's  Splint, —           597 

262.  Abduction  and  Extension  in  Hip  Disease, Original, 598 

263.  Adduction  and  Extension  in  Plip  Disease, •'          59^ 


XX  LIST  OF  ILLUSTRATIONS. 


FIG. 


264.  Section   through    Trunk  and  Limb  to  Show  Position  of 

Thomas's  Splint, —         egg 

265.  Measuring  for  Thomas's  Splint, —         jgg 

266.  Thomas's  Wrenches, —         600 

267.  Method  of  Lifting  Patient  with  Thomas's  Splint  Applied, .  —        600 

268.  Thomas's  Hip  Splint  Applied, —         601 

269.  Double  Thomas's  Splint, —         601 

270.  Chronic  Disease  of  Knee  Joint,  Secondary  to  Osteitis,    .       Original, 606 

271.  Primary  Tubercular  Synovitis  of  Knee, "  607 

272.  Section   through    Knee    Joint    in    a    State   ot    Advanced 

Arthritis "  608 

273.  Thomas's  Knee  Splint  with  Patten, —         609 

274.  Thomas's  Knee  Splint  Applied, —         609 

275.  Abscess  in  Head  of  Humerus, —        612 

276.  Disease  of  Elbow  Joint, Fergusson,    ....*...     613 

277.  Section  through  Anchylosed  Elbow  Joint, Original, 618 

278.  Excision  of  Elbow  Joint —         622 

279.  Incisions  for  Excision  of  Wrist  Joint, —         623 

280.  Lister's  Splint  for  Excision  of  Wrist, —         624 

281.  Meningocele Bryant, 630 

282.  Encephalocele, "  631 

283.  Exfoliation  of  Skull  after  Injury, Original, 633 

284.  285.  Fracture  of  Vault  of  Skull,  Inside  and  Outside,    .    .  "  634 

286.  Punctured  Fracture  of  Skull, "  636 

287.  Fracture  of  Base  of  Skull, "  638 

288.  Hemorrhage  from  Middle  Meningeal  Artery, " 649 

289.  Horn  and  Sebaceous  Cysts  of  Scalp, Bryant, 656 

290.  Necrosis  of  Frontal  Bone  (Syphilitic), "  659 

291.  Section  through  Mastoid  Process  and  Lateral  Sinus,      .    .       Original, 666 

292.  Hernia  Cerebri Bryant 672 

293.  Osteoplastic  Resection, Esmarch, 676 

294.  Trephining,      Fergusson, 677 

295.  Localization  of  the  Cerebral  Convolutions, —  678 

296.  Wilson's  Cyrtometer,  in  situ Bramwell, 679 

297.  Meningomyelocele  Laid  Open, Origitial, 681 

298.  Spina  Bifida  (Diagrammatic), "  682 

299.  Cicatrix  from  a  Case  of  Spina  Bifida, Bryant, 682 

300.  301.  Congenital  Coccygeal  Tumors, "  684 

302.  Fracture  of  Spine, Original, 688 

303.  Dislocation  of  Spine,      Bryant 688 

304.  Ankylosis  of  Dorsal  Vertebrte  after  Canes, Original, 702 

305.  Tubercular  Osteitis  of  Spine, "  702 

306.  Atlo-axoid  Disease, "  706 

307.  Sayre's  Tripod, —  707 

308.  Double  Thomas's  Splint  for  Caries  of  Spine, —  707 

309.  Sayre's  Jury-mast, Bryant, 708 

310.  Lateral  Curvature  of  Spine Original, 712 

311.  Spine  from  a  Case  of  Lateral  Curvature, "  714 

312.  Transverse   Section  through  Thorax  from  a  similar  case 

(advanced) "  714 

313.  Extreme  Scoliosis, Bryant, 715 

314.  Barwell's  Sling, Original, 717 

315.  Prolapse  of  Iris "  727 

316.  Beer's  Cataract  Knife, A'ettleskip 736 

317.  Melanotic  Growth  on  Edge  of  Eyelid, Original, 737 

318.  319.  Iridectomy,      A^ettleship, 739 


LIST  OF  ILLUSTRATIONS.  xxi 

FIG.  PAGR 

320.  Double  Harelip —           742 

321.  Operation  for  Single  Harelip, —           743 

322.  "           "    Harelip  with   Unequal  Sides, —           743 

323.  "           "    Double  Harelip, —           743 

324.  Lipoma  Nasi ' Fergtisson 749 

325.  Bellocq's  Sound "             752 

326.  Nasal  Speculum —             754 

327.  Method  of  Grasping  Nasal  Polypi, Fergusson 756 

328.  Incision  for  Removal  of  Upper  Jaw, Esmarck, 758 

329.  Plan  of  Bone  Section,  for  Removal  of  Upper  Jaw,     ...             "               758 

330.  Smith's  Gag, —         760 

331.  Coleman's  Gag, —         760 

332.  Cleft  of  Soft  Palate  with  Lines  of  Incision, Fergusson 760 

333.  Smith's  Tubular  Needle, —        760 

334.  Cleft  of  Palate  with  Lateral  Incisions, Origmal, 761 

335.  Ranula, Bryant, 771 

336.  Incisions  for  Section  of  the  Superior  Maxilla, Esmarch 775 

337.  338.  Resection  of  Lower  Half  of  Jaw, "              776 

339.  Macroglossia, Fergusson, 779 

340.  Chronic  Superficial  Glossitis, Original, 781 

341.  Epithelioma  of  the  Tongue,  .    .    ; "          7^5 

342.  Tonsillotome,       —         793 

343.  Salivary  Calculus, Bryant, 795 

344.  Submaxillary  Tumor, " .  79^ 

345.  Allen's  Air-pad, —         79^ 

346.  Air-bag  for  Politzer's  Inflation, —         79^ 

347.  Brunton's  Auriscope, —         799 

348.  Ear  Forceps, —         801 

349.  Golding-Bird's  Dilator, —         821 

350.  Oildematous  Laryngitis, Original, 822 

351.  Trachea  Dilator, —         829 

352.  Parker's  Suction  Tube, —         829 

353.  Durham's  Cannula, —         830 

354.  Parker's  Cannula, —         830 

355.  Hahn's  Tampon, ....             —         831 

356.  O'Dwyer's  Intubation  Tubes,  Mouth  Gag,  etc., —         834 

357.  Gussenbauer's  Artificial  Larynx, —         837 

358.  Parenchymatous  Goitre Original, 840 

359.  Cystic  Bronchocele, "          841 

360.  Colloid  Degeneration  of  Thyroid, "          842 

361.  Cystic               "                       "             "          843 

362.  Horsehair  Probang, Bryant 846 

363.  Coin-catcher, —         846 

364.  Malignant  Stricture  of  CEsophagus, Original, 849 

365.  Ribs  United  by  Callus, "          854 

366.  Strapping  for  Chest, Bryant, 855 

367.  Diagram  Showing  Position  of  Viscera, "           871 

368.  Oblique  Inguinal  Hernia, "           878 

369.  Direct            "             "         "           878 

370.  Femoral  Hernia, "           879 

371.  Truss  for  Inguinal  Hernia, —             880 

372.  Single  Circular  Truss  for  Scrotal  Hernia, —         880 

373.  Double  Femoral  Truss, —         881 

374.  Pad  for  Irreducible  Hernia, Bryant 883 

375.  Unstrangulated  Hernia, "           885 

376.  Strangulated  Hernia, "           885 


LIST   OF  ILLUSTRATIONS. 


FIG. 


577.  Congestion  and  Hemorrhage  into  Intestine  from  Strangula- 

-  tion, Bryant, 886 

378.  Reduction  en  masse, Original, 890 

379,  380,  381.  Varieties  of  Incomplete  Reduction, "  891 

382.  Method  of  Dividing  Stricture  in  Hernia Fergusson, 893 

383.  Stricture  of  Intestine  After  Strangulation Bryant, 896 

384.  Congenital  Hernia  Complete, Original, 897 

385.  "  "      Incomplete, "  897 

3S6.  Infantile  Hernia, "  898 

387.  Incision  for  Inguinal  Hernia, Fergtisson, 900 

388.  Pad  Formed  in  MacEwen's  Operation, Original, 902 

389.  Vah-ular  Shape  of  Inguinal  Canal, After  Astley  Cooper,        .    .     902 

390.  MacEwen's  Operation  for  radical  Cure, —        903 

391.  392,  393.  Radical  Operation  for  Inguinal  Hernia,  ....      After Bassini, 904 

394.  Femoral  Hernia, Original, 905 

395.  Strangulation  of  Intestine  by  Band, "  911 

396.  Prolapse  through  Meckel's  Diverticulum "  912 

397.  Intussusception,       "  913 

398.  Malignant  Disease  of  Intestine "         924 

399.  Malignant  Stricture  (Annular), "  924 

400.  Nelaton's  Operation, Bryant, 936 

401.  Method  of  Securing  Intestine  in  Lumbar  Wound,  ....       Original, 938 

402.  Artificial  Anus  After  Lumbar  Colotomy, Bryant, .     939 

403.  Method  of  Securing  Intestine  in  Inguinal  Colotomy,  .    .    .       Original, 940 

404.  405.  Maydl's  Operation  for  Artificial  Anus, Esmarch, 941 

406.  Lembert's  Suture, Greig  Smith, 942 

407.  "  "        Tied, "  943 

408.  Greig  Smith's  Method  of  Intestinal  Suture, "  944 

409.  Entero-anastomosis, After  Senn, 947 

410.  Allingham's  Speculum, —        957 

411.  Clamp  for  Cauterizing  Hemorrhoids, —         963 

412.  "  Crushing  Hemorrhoids, —         964 

413.  Prolapse  of  Rectum, Bryant, 967 

414.  Probe  Passed  through  Anal  Fistula, "  978 

415.  Method  of  Dividing  Fistula, Fergusson, 978 

416.  Single  Median  Kidney, Original, 988 

417.  Hydronephrosis, "  994 

418.  Calculus  Encysted  in  Kidney "  1000 

419.  Calculous  and  Suppurative  Pyelitis, "  looi 

420.  Tubercular  Pyehtis, "  1007 

421.  Unnary  Deposits — Urates, Bryant, 1021 

422.  "  "  Uric  Acid "  1022 

423.  "            "            Oxalate  of  Lime, "           ........  1022 

424,425.  "  "  Phosphates, "  1022 

426.  "  "  Epithelium, "  1022 

427.  "  "  Spermatozoa  and  Epithelium "  1022 

428.  "  "  Casts, "  1023 

429.  Ectopia  Vesicae  in  the  Male, "  1024 

430.  "  "  Female,       "  1024 

431.  Methods  of  Tapping  Bladder, Fergusson 1035 

432.  Tapping  the  Bladder  through  the  Rectum, Bryant, 1036 

433.  Hypertrophied  and  Sacculated  Bladder, Original, 1037 

434.  Uric  Acid  Calculus  with  Oxalate  of  Lime, Bryant, 1042 

435.  Oxalate  of  Lime  Calculus, "  I044 

436.  Cystin  Calculus, "  I044 

437.  Enlarged  Prostate,  with  Sacculated  Bladder, Original, 1044 


LIST  OF  ILLUSTRATIONS. 


FIG. 


438.  Thompson's  Sound, —        '045 

439.  Bigelow's  Lithotiite —         '047 

440.  Thomson's  Lithotrite, —         1047 

441.  Lithotrity,  Method  of  Seizing  Calculus, —        104S 

442.  "  "  "  "  —         '049 

443.  Bigelow's  Evacuator —         I049 

444.  Evacuating  Tubes, —         1050 

445.  Lithotomy  Knives, —         J052 

446.  Clover's  Crutch —         '°53 

447.  Lithotomy  Staffs, —         1053 

448.  Incision  for  Lateral  Lithotomy, Fergusson 1054 

449.  Lithotomy  with  Curved  Staff, Bryant 1054 

450.  "  Straight  Staff, —        1055 

451.  Blunt  Gorget —        io55 

452.  Lithotomy  P'orceps —         1055 

453.  Lithotomy  Scoop  and  Director, —         1056 

454.  Buckston  Browne's  Tampon, —         io57 

455.  Angular  Staff, —         1058 

456.  Suprapubic  Lithotrity, Bardenhauer, 1061 

457.  Fibro-papilloma  of  Bladder Original, 1065 

458.  Epithelioma  of  Bladder,     .    . "  1066 

459.  Leiter's  Cystoscope, —         1067 

460.  Thompson's  Bladder  Forceps, —        1069 

461.  Dilator  for  Female  Urethra, —        1070 

462.  Cystoscope  in  Position, Duplay  and  Recliis,     .    .    .  1070 

463.  Small  Polyp  as  seen  by  Cystoscope, "                   "           ...  107 1 

464,465.  Enlargement  of  the  Prostate, Original, 1073 

466.  Section  of  Hypertrophied  Prostate, Duplay  and  Reclus,    .    .    .  1075 

467.  Watson's  Cannula  in  Position, Esmarch, 1080 

468.  Neck  of  Bladder  Seen  from  Within  in  a  Case  of  Enlarged 

Prostate, ,       Original, 1082 

469.  Prostato-vesical   Calculus Bryant, 1086 

470.  Prostatic  Calculi  with  Prolapse  of  Ureter, Original, 1086 

471.  Various  Forms  of  Catheters, —        1091 

472.  Method  of  Tying  in  Catheter, Bryant, 1094 

473.  Instrument  for  Tying  Catheter  in, —         1095 

474.  Gonococcus, Senn, 1096 

475.  Leiter's  Panelectroscope —       \\o\ 

i^jd.  Stricture  of  Urethra  with  Diseased  Bladder, Original, 1104 

477.  Otis's  Urethrameter, —         1106 

478.  Bulbous  Sound, ....  —         no? 

479.  Holt's  Dilator, —         "12 

480.  Civiale's  Urethrotome, —        11^3 

481.  Otis's  Urethrotome, —         m3 

482.  Tee  van's  Urethrotome, —         1114 

483.  Syme's  Staff, —        i"5 

484.  Wheelhouses  Operation, Original, 11 16 

485.  Grooved  Staff, Bryant 1116 

486.  Teale's  Gorget, "  "'7 

487.  Cock's  Operation, "  i"7 

488.  Division  of  Stricture  in  Paraphimosis, "  •     ■  1125 

489.  Strapping  Testicle "  '^3' 

490.  Gummatous  Disease  of  Testis, Original, 1132 

491.  Tubercular  Epididymitis, "  '^^1)1> 

492.  Hernia  Testis, Bryant, ii34 

493.  Cystic  Disease  of  Testis, "  ^'35 


LIST  OF  ILLUSTRATIONS. 


FIG. 


PAGE 


494.  Varicocele, Original, 1138 

495.  Encysted  Hydrocele  of  Cord «  1141 

496.  Spermatocele,      <«  u^i 

497.  Tapping  a  Hydrocele, Bryant, 1142 

498.  Obliteration  of  Tunica  Vaginalis, Original,.    .        1142 

499.  Tapping  the  Hydrocele, y,  Volkmann, 1142 

500.  Inflammation  and  Distention  of  Fallopian  Tubes,  .    .    .    .       Original, 1 145 

501.  Multilocular  Ovarian  Cyst, «  n^g 

502.  Dermoid  Cyst  of  Ovary, <<  i  j^g 

503.  Papillary  Cyst  of  Ovary, «  1 1^0 

504.  Uterine  Fibroids, «  1160 

505,506,507.   Ruptured  Perineum,  Operation  for,     ....    ,  "  1169,1170 

508.  Cystic  Tumor  of  Breast, Bryant, 11 78 

509.  Colloid  Scirrhus  of  Breast, Ori<^inal, 1 180 

510.  Excision  of  Breast, Estnarch 1186 

511.  Teale's  Amputation, Bryant, 1189 

512.  Carden's  Amputation, <«  ii3q 

513.  Amputation  at  Shoulder  Joint, Jacobson, 1191 

514.  Amputation  at  Shoulder  Joint, Fergusson, 1191 

515.  Amputation  at  Elbow  Joint, Jacobson, 1191 

516.  Amputation  of  Forearm, Bryant, 1 192 

517.  Amputation  of  Hand, Jacobson, I192 

518.  Amputation  of  Thumb, «  1102 

519.  Outline  Diagram  for  Amputation  of  Thumb  and  Fingers, .       Bryant 1193 

520.  Furneaux  Jordan's  Amputation  at  the  Hip, "  1 194 

521.  Amputation  at  Hip, After  Wyeth, 1194 

522.  Stephen  Smith's  Method  of  Amputating, Bryant, 1197 

523.  Stump  after  Stephen  Smith's  Amputation, <'  1 197 

524.  Amputation  through  Knee  Joint, •.    .      Erichsen, 1197 

525.  Amputation  of  Leg  by  Mixed  Method, Bryant, -.    .    .1198 

526.  Stump  left  after  Amputation  by  Mixed   Method,     ....  "  II98 

527.  Syme's  Amputation  of  Foot, Treves, II98 

528.  Roux's  Amputation  of  Foot, "  1 198 

529.  Pirogoff's  Amputation, Bryant, 1199 

530.  Stump  after  Pirogoff's  Amputation, —         1199 

531.  Incisions  for  Amputation  of  Foot, Jacobson, 1200 

532.  Stump  after  Chopart's  Amputation, Fergusson, 1200 

533.  Lines  for  Tripier's  Amputation, Bryant, 1200 

534.  Stump  after  Hey's  Amputation, Fergusson, 1201 

535.  Amputation  of  Great  Toe, "  1202 

536.  Dubreuil's  Operation  for  Removal  of  Toes, Treves, 1202 

537.  Removal  of  Metatarsal  Bone  of  Great  Toe, Fergusson, 1202 

538.  Stump  Left  after  Excision  of  Metatarsal  Bone  of  Great 

Toe, .<  1202 

539.  Esmarch's  Triangular  Bandage, Pilcher, 1205 

540.  Placing  Wounded  Man  upon  Stretcher, U.  S.  A.  Drill  Manual,     .1205 

541-544.  Bearing  the  Wounded, <*                         .  1206 

545.  The  Travois, «<                         _  1207 

546.  The  Gorgas  Cot, "                         .  1207 

547.  The  Gihon  Cot  for  Transporting  Wounded  on  Shipboard, .  "                         .1207 

548.  The  Walton  Wills  Cot, Beyer, 1 208 

549.  The  McDonald  Ambulance  Lift, "         1208 

550.  Ancient  Bullet  Forceps,  9  Figures, 1210 

551.  The  Nelaton  Bullet  Probe, 1211 

552.  Longmore's  Electric  Explorer, Porter, I2ii 

553.  American  Bullet  Forceps, 1212 


PART  I. 

GENERAL  PATHOLOGY  OF  SURGICAL  DISEASES. 


CHAPTER  I. 

INJURY  AND  REPAIR.— INFLAMMATION. 

INJURY  AND  REPAIR. 

The  immediate  effect  of  an  injury  is  to  kill  some  of  the  structures  upon 
which  the  brunt  of  the  violence  falls  and  impair  the  vitality  of  others,  the  extent 
and  severity  of  the  damage  sustained  depending  partly  upon  the  intensity  of  the 
agent,  partly  upon  the  condition  of  the  tissues.  As  soon  as  the  irritant  ceases  to 
act  repair  begins,  provided  the  violence  has  not  been  so  great  as  to  destroy  life 
altogether ;  if  it  continues,  or  if,  before  its  effects  have  died  away,  a  second  is 
inflicted,  impairing  vitality  further  still,  what  is  known  as  inflammation  follows. 
Two  things,  therefore,  have  to  be  considered  in  estimating  the  effect  produced — 
the  severity  and  persistence  of  the  irritant,  and  the  condition  of  nutrition  of  the 
tissues. 

Of  the  Various  Causes  of  Injury. 

Irritants  are  divided  into  two  classes,  the  organized  or  living,  and  the 
unorganized,  which  may  be  mechanical,  physical,  or  chemical.  The  distinction 
is  not  a  logical  one,  as  the  former  act  either  mechanically,  by  blocking  the  blood- 
vessels, or  chemically,  by  means  of  certain  poisons  they  produce ;  but  it  is  con- 
venient for  this  reason,  that  the  one  is  endowed  with  an  independent  existence, 
and  the  other  is  not. 

I.  Organized  Jrrifa/its. 

Certain  animal  parasites  (such  as  the  chigoe)  are  occasionally  met  with  living 
in  the  tissues,  but  they  are  so  rare  as  to  be  of  comparatively  little  consequence ; 
the  more  important  ones  are  microscopic,  unicellular  organisms  belonging  to  the 
class  Schizomycetes,  multiplying  by  transverse  division,  and,  in  the  case  of  the 
rod-like  forms,  by  spores  as  well. 

a.  Of  these  some  can  only  live  in  dead  material.  They  are  constantly  present 
in  the  bronchi  and  the  alimentary  canal,  they  enter  freely  with  the  food  and  the 
air ;  but  even  if  they  are  injected  into  the  blood  they  are  either  killed  [by  phago- 
cytic action  of  the  leucocytes]  or  eliminated  with  the  urine ;  they  are  non-patho- 
genic, they  do  not  of  themselves  give  rise  to  any  disease.  Such,  for  example,  are 
the  bacteria  of  putrefaction.  These  cannot  exist  in  the  tissues  so  long  as  they 
are  alive ;  but  where  they  gain  entrance  to  a  collection  of  pus  or  of  wound-dis- 
charges exposed  to  the  air  they  thrive  most  vigorously  and  form  a  chemical  poison 
which  is  the  cause  of  some  of  the  varieties  of  wound  fever.  [Rosenbach  has  cul- 
tivated a  saprophytic  spore-bearing  bacillus,  and  Hauser  has  found  several  varie- 
ties of  \he  proteiis.'] 

b.  Others  can  exist  in  the  tissues  or  in  the  blood,  but  are  unable  to  affect 
them  injuriously  unless  their  power  of  resistance  has  been  lowered  by  other  local 

3  25 


26         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

or  constitutional  causes.  Such  are  the  organisms  which  give  rise  to  the  formation 
of  pus  (staphylococcus  pyogenes  aureus,  albus,  or  citreus,  streptococcus  pyogenes, 
and  several  more)  ;  they  do  not  cause  specific  diseases,  but  according  to  the  cir- 
cumstances under  which  they  enter,  and  their  surroundings,  they  are  followed  by 
suppuration,  gangrene,  pyaemia,  noma,  phagedaena,  and  other  acute  inflammatory 
disorders. 

c.  A  third  class  again  is  specific,  being  followed  invariably  by  the  same  defi- 
nite disorder.  Some  of  these  are  attended  by  local  inflammation  (tubercle, 
syphilis,  erysipelas,  glanders,  anthrax,  etc.)  ;  others,  such  as  tetanus  and  hydro- 
phobia, give  rise  to  constitutional  symptoms  only. 

2.  Unorganized  Irritants. 

Mechanical  such  as  cuts,  bruises,  friction,  or  tension.  A  simple  incised 
wound  heals  at  once,  without  inflammation.  Certain  tissue-elements  are  killed  ;  a 
very  slight  amount  of  blood  is  extravasated  between  the  cut  edges,  but  if  there  is 
no  further  hurt  or  injury  the  natural  process  of  repair  begins  at  once.  If  the  blood 
decomposes,  if  the  wound"  is  repeatedly  rubbed,  or  if  a  suture  is  put  in  so  tightly 
as  to  cause  tension,  a  fresh  injury  is  inflicted,  the  vitality  of  the  surrounding 
tissues  is  lowered,  and  inflammation  sets  in  and  continues  until  the  irritant  is 
removed. 

Physical. — Heat  acts  in  the  same  way.  A  cautery  plunged  into  a  njevus 
leaves  a  hole  with  blackened,  charred  edges  ;  but  if  no  fresh  irritant  is  allowed  to 
appear  the  wound  is  repaired  without  inflammation.  A  burn  covered  up  thor- 
oughly from  the  air  and  protected  from  decomposition  heals  without  further 
trouble,  unless  pyogenic  or  other  organisms  gain  access  to  it  in  some  way.  In- 
tense local  cold  produces  the  same  effect.  How  a  general  chill  acts  when  it  causes 
internal  inflammation  (pneumonia,  for  example)  is  not  certain. 

Chemical. — The  same  may  be  said  of  these.  Nitric  acid  applied  to  the  skin 
forms  a  scab  under  which  repair  is  completed  without  further  destruction  or  loss 
of  tissue.  If,  however,  a  continuous  stream  of  poisonous  compounds  is  poured 
into  the  blood,  or  allowed  to  act  upon  the  tissues,  the  most  intense  fever  and  the 
most  widespread  destruction  may  follow. 

It  is  still  open  to  question  whether  the  nervous  system  can  of  itself  excite 
inflammation.  There  is  no  doubt  that  a  part  of  the  body  separated  from  the  cen- 
tral organs  is  especially  liable  to  become  inflamed  if  it  is  injured  in  any  way  :  but 
this  is  not  the  point.  It  seems  probable  that  certain  disorders — herpes  zoster, 
acute  bedsores,  and  some  forms  of  arthritis — are  the  direct  result  of  affections  of 
distant  portions  of  the  nervous  system,  and  that,  therefore,  nerve-irritation  must 
be  regarded  as  a  direct  exciting  cause ;  but  in  what  way  it  can  act  must  remain 
undefined  until  more  is  known  of  the  influence  of  the  nerves  upon  the  nutrition 
of  the  tissues  during  health. 


Of  the  Ixfluenxe  of  the  Coxditiox  of  the  Tissue.s. 

The  effect  produced  by  an  irritant  depends  not  only  upon  the  irritant  itself, 
but  upon  the  condition  of  the  tissues.  In  old  age,  where  the  arteries  are  athero- 
matous and  the  circulation  feeble,  or  after  prolonged  exposure  to  cold,  a  scratch 
or  bruise  so  trivial  that  under  other  circumstances  it  would  scarcely  have  attracted 
attention  may  lead  to  the  death  of  the  part  it  affects,  and  by  the  changes  that 
follow  prove  the  cause  of  extensive  gangrene. 

I.  The  circulation  may  be  defective.  There  may  be  a  deficient  supply  of 
blood,  or  the  part  may  be  engorged  and  congested.  Everything  that  tends  to 
prevent  a  fair  amount  of  blood  flowing  to  a  part — arterial  atheroma,  cold,  strangu- 
lation, as  in  the  case  of  a  hernia  or  Esmarch's  bandage,  if  too  long  applied — 
lowers  its  vitality  and  renders  it  less  able  to  resist  injury.  In  the  same  way,  if 
there  is  any  difficulty  to  the  return  of  blood — if,  for  example,  the  veins  are  vari- 


INJURY  AND   REPAIR.  27 

cose  and  the  tissues  congested  and  oedematoiis — the  most  reel)le  irritant  may  cause 
a  very  extensive  degree  of  inflammation. 

II.  The  ([uahty  of  the  blood  may  l)e  defective:  leucocythoemia,  Bright's 
disease,  scurvy,  or  diabetes  may  l)e  present.  It  is  probable  that  gout,  intemper- 
ance, starvation,  and  possibly  rheumatism  also  act  in  this  way. 

III.  Interference  with  the  nerves  going  to  a  part  undoubtedly  predisposes  to 
inflammation,  but  whether  this  is  a  direct  result,  or  indirect,  due  to  the  fact  that 
no  work  is  done  and  that,  consecpiently,  the  nutrition  of  the  ])art  is  carried  on 
without  energy,  is  uncertain. 

Besides  these  causes  there  are  others,  many  of  them  hereditary,  concerning 
which  it  is  impossible  to  say  more  than  that  the  tissues  themselves  are  peculiarly 
susceptible,  sometimes  to  every  kind  of  irritant,  sometimes  only  to  certain  special 
forms,  such,  for  example,  as  tubercle. 

The  Effect  of  a  Single  Injury. 

The  immediate  effect  of  an  irritant  of  more  than  the  slightest  degree  of  inten- 
sity is  to  kill  some  of  the  tissue-elements  and  lower  the  vitality  of  the  others. 
Unless  the  blood-vessels  are  ruptured,  so  that  there  is  some  extravasation,  the 
change  that  actually  takes  place  is,  for  the  most  part,  beyond  our  power  of  obser- 
vation ;  it  is  known  that  after  powerful  electric  shocks  the  corneal  corpuscles  and 
wandering  leucocytes  cease  their  movements  and  become  fixed  in  shape,  and  prob- 
ably the  same  result  is  produced  by  other  irritants  of  equal  degrees  of  intensity ; 
but  even  of  this  it  is  impossible  to  say  more  than  that  the  living  protoplasm  has 
undergone  a  process  of  coagulation.  The  interchange  of  oxygen  and  carbonic 
acid  comes  to  an  end  ;  the  plasma  ceases  to  circulate  in  the  interstices  ;  fibrin- 
ferment  is  set  free  ;  coagulation  takes  place ;  and  the  injured  part  is  converted 
into  a  semi-solid  mass  of  dead  albuminous  material,  of  itself  perfectly  inert.  If 
the  irritant  is  not  sufficient  to  produce  the  full  effect  and  kill  the  tissues,  the 
changes  are  probably  the  same  in  direction,  but  not  carried  so  far. 

The  effect  upon  the  blood-vessels  is  of  exactly  the  same  character.  At  first, 
unless  the  irritant  is  a  very  powerful  one,  there  is  a  momentary  contraction  of  the 
arterioles  and  capillaries,  but  this  is  not  constant  and  is  probably  not  important. 
As  soon  as  its  influence  fairly  reaches  the  muscular  fibres  and  the  endothelial  cells 
that  form  the  walls,  the  tonic  contraction  relaxes,  the  vessels  dilate,  and  the  part 
becomes  loaded  with  blood.  For  the  first  few  moments  the  speed  of  the  stream 
is  slightly  increased,  owing  to  the  capillaries  not  dilating  to  the  same  extent  as  the 
arterioles,  but  this  does  not  last  long.  Some  of  the  living  cells  are  killed  or 
badly  hurt ;  the  normal  relations  between  the  blood  and  the  walls  of  the  vessels 
no  longer  hold  good  ;  the  colorless  corpuscles,  which  always  have  a  tendency  to 
lie  on  the  outside  of  the  current,  accumulate  in  greater  numbers  and  cling  more 
closely  to  the  damaged  structures ;  they  stick  for  a  time  at  one  spot,  and  when 
they  do  move  seem  as  if  they  were  being  dragged  away  ;  and  many  of  them  pass 
through  the  wall  and  collect  in  the  interstices  around.  Then  the  plasma  becomes 
more  viscid ;  the  stream  becomes  slower  and  slower ;  the  red  corpuscles  in  the 
axis  oscillate  a  little,  and  finally  come  to  a  standstill.  In  other  words,  stasis  sets 
in.  The  circulation  stops  ;  the  part  is  full  of  blood,  and  after  a  time  thrombosis 
occurs,  coagulation  taking  place  in  the  vessels  as  well  as  in  the  tissues. 

The  injury  has  lowered  the  vitality  of  the  cells  that  line  the  vessels  and  form 
their  wall,  and  now  they  act  toward  the  blood  like  any  other  dead  or  dying  struc- 
ture. The  changes  are  the  same  as  in  the  tissues  ;  the  blood  ceases  to  circulate  in 
the  one,  and  the  plasma  in  the  other ;  some  of  the  cells  are  killed  ;  the  ferment  is 
set  free ;  coagulation  takes  place  ;  and  fibrin  is  formed,  only,  owing  to  the  pres- 
ence of  red  blood-corpuscles  in  the  one,  the  appearance  is  much  more  striking  and 
more  easily  recognized  than  in  the  other. 

Such  an  effect  as  this  may  be  produced  by  any  simple  kind  of  injury,  mechan- 
ical, physical,  or  chemical.     A  bruise  kills  some  of  the  subcutaneous  tissues  and 


28         GENERAL   PATHOLOGY  OF  SURGLCAL   DISEASES. 

causes  a  slight  extravasation  of  blood  ;  a  clean,  incised  wound,  the  edges  of  which 
are  at  once  brought  together  again,  does  the  same.  The  actual  cautery,  plunged, 
for  example,  into  a  noevus  chars  some  of  the  tissues  round,  and  for  the  time 
impairs  the  vitality  of  those  farther  off.  A  ligature  tied  tightly  round  the  stump 
of  an  ovarian  tumor  stops  the  circulation  through  it  mechanically  and  leads  to  the 
same  result ;  and,  on  a  larger  scale,  the  same  thing  occurs  in  one  form  of  senile 
gangrene  ;  the  tissues  are  slowly  starved  to  death,  and  the  part  gradually  becomes 
hard  and  mummified. 

The  subsequent  changes,  always  provided  no  other  irritant  is  allowed  to 
appear,  are  equally  simple. 

I.  The  tissues  that  are  killed  either  undergo  fatty  degeneration,  or  are  dried 
up,  according  to  their  position.  In  the  former  case  they  gradually  disappear, 
being  absorbed  by  the  living  structures  around  ;  in  the  latter  the  deeper  part  may 
be  absorbed,  but  all  the  hardened  structures  are  thrown  off,  a  new  layer  of  epi- 
dermis being  slowly  developed  beneath  them,  so  that  the  surface  is  once  more 
restored. 

II.  Those  around  that  are  only  slightly  injured  recover  by  degrees  and  begin 
the  process  of  repair.  For  this,  however,  the  general  nutrition  must  be  fairly 
good  ;  if  their  vitality  is  already  low,  not  only  is  the  extent  of  the  original  injury 
far  greater  than  it  otherwise  would  be,  but  they  may  not  have  sufficient  power  to 
rally,  and  then  the  area  of  destruction  spreads. 

Repair. — Repair  is  merely  an  expansion  of  the  natural  process  of  nutrition. 
All  the  interstices  of  the  tissues  are  everywhere  filled  with  plasma,  which  pours 
out  through  the  walls  of  the  blood-vessels  and  drains  off  by  the  lymphatics.  Each 
living  cell  draws  from  the  general  stock  around  it  what  it  requires  for  itself,  and 
gives  up  that  for  which  it  has  no  further  need.  When  it  is  worn  out,  or  when, 
from  injury  or  any  other  cause,  it  is  brought  to  an  untimely  end,  it  is  removed 
and  replaced,  either  by  the  development  of  fresh  ones  from  the  survivors  near,  or 
by  the  agency  of  the  leucocytes  which  wander  freel}'  through  the  channels.  The 
rapidity  of  the  current  is  regulated  by  the  amount  of  work  to  be  done.  Where 
the  activity  is  unusually  great,  and  the  amount  of  work  exceptional,  as  after  an 
injury,  the  plasma  pours  through  more  freely,  the  blood-vessels  dilate,  the  blood 
circulates  more  rapidly,  more  food  is  brought,  and  the  waste  is  removed  more 
quickly.  If,  on  the  other  hand,  a  part  of  the  body  is  kept  at  rest  and  does  no 
work,  whatever  the  cause  may  be,  the  plasma  remains  stagnant  and  the  tissues 
starve. 

If  the  injury  has  been  a  slight  one,  not  sufficient  to  kill  any  of  the  ti.ssues, 
perfect  restoration  is  the  rule.  The  red  blood-corpuscles  separate  from  each  other 
and  fall  off  into  the  circulation,  almost,  if  not  quite,  unchanged  ;  the  endothelial 
cells  recover  their  natural  tone ;  the  vessels  regain  their  calibre ;  the  plasma 
loses  its  viscid  character,  just  as  incipient  rigor  mortis  may  pass  off,  and  the 
colorless  corpuscles  cease  to  collect  against  the  wall-  or  pass  through  in  excessive 
numbers. 

If  it  has  been  more  severe,  so  that  some  of  the  tissue-elements  and  of  the  cells 
in  the  walls  of  the  vessels  are  killed  (with  or  without  extravasation),  and  the 
plasma  has  coagulated,  the  process  is  not  so  simple ;  a  certain  amount  of  new 
tissue  must  be  formed,  to  replace  that  which  is  lost.  The  injured  area  now  is 
transformed  from  a  living  part  of  the  body  into  a  mass  of  dead  and  dying  cells, 
held  together  by  a  network  of  fibrin.  The  circulation  has  ceased,  the  capillaries 
are  plugged,  and  sometimes,  owing  to  the  giving  way  of  their  walls,  the  interstices 
are  filled  with  blood.  Such  a  condition  as  this  occurs  after  every  bruise  and  on 
the  surface  of  every  wound,  even  if  the  edges  are  brought  together  at  once,  the 
lymph  forming  a  soft  but  tenacious  clot  which  helps  to  check  the  hemorrhage  and 
glue  the  parts  together  until  permanent  repair  is  effected.  This  is  carried  out 
mainly,  if  not  entirely,  by  the  leucocytes. 

Normally,  in  all  the  tissues  there  is  a  certain  proportion  of  free  corpuscles 
-wandering  in  the  plasmatic  canals,  removing  what  is  broken  down  and  perhaps 


INJURY  AND  REPAIR.  29 

replacing  it.  After  an  injury,  especially  one  of  this  severity,  these  increase 
immensely  in  number,  pouring  through  the  walls  of  the  vessels  and  spreading 
into  all  the  spaces  round.  In  the  centre  of  the  injured  area,  where  stasis  has 
occurred,  this  is  only  possible  to  a  slight  extent ;  but  all  round,  where  the  tissues 
are  only  slightly  hurt,  and  farther  away,  where  they  are  not  hurt  at  all,  but  only 
stimulated  to  increased  exertion  by  the  presence  of  injured  structures  near,  these 
leucocytes  jiour  out  in  myriads,  removing  and  replacing  what  is  dead,  and  advan- 
cing (forcing  their  way  in  reality)  farther  and  farther  toward  the  centre,  until  the 
whole  injured  area  is  transferred  into  a  mass  of  living  corpuscles. 

In  the  ca.se  of  small  extravasations,  this  transformation  is  most  conspicuous. 
At  first  there  is  merely  a  dark-colored  clot  of  fibrin  entangling  the  red  corpuscles 
and  a  few  of  the  white  ones  in  its  meshes ;  the  serum  drains  away  and  is  carried 
off  by  the  lymphatics.  Then  the  red  corpuscles  undergo  disintegration  ;  the 
coloring  matter  soaks  out  of  them  and  stains  all  the  tissues  near,  the  debris  and 
the  fibrin  remain  behind.  Soon  the  outside  of  the  clot  is  j^erforated  by  numbers 
of  living  leucocytes,  many  of  which  may  be  seen  to  contain  fragments  of  colored 
ones  in  their  interior.  Gradually  this  change  extends  farther  and  farther  toward 
the  centre,  until  by  degrees  the  whole  mass  is  consumed,  and  nothing  is  left  but 
the  leucocytes  which  have  replaced  it. 

These  changes  are  not  without  their  effect  upon  the  parts  around.  More 
work  has  to  be  done ;  a  greater  amount  of  blood  is  required,  and  consequently 
all  the  neighboring  vessels  dilate,  the  temperature  of  the  part  is  raised,  the  .skin 
is  reddened  if  it  lies  near  the  surface,  there  is  a  certain  amount  of  tenderness  on 
pressure,  and  a  certain  degree  of  swelling,  caused  not  only  by  the  extravasation, 
but  by  the  increase  in  the  quantity  of  the  blood  and  the  circulating  plasma  that 
the  part  contains.  Further,  the  quantity  of  waste  and  dead  material  to  be 
absorbed  is  larger  than  usual,  and,  as  a  consequence,  the  temperature  of  the  w^hole 
body  is  slightly  raised,  for  there  is  evidence  to  show  that  the  ferment  set  free  when 
the  tissues  undergo  disintegration  acts  upon  all  the  heat-producing  centres.  All 
the  nutritive  changes,  in  short,  are  carried  on  with  more  than  the  usual  degree  of 
energy. 

The  next  step  is  the  formation  of  fresh  blood-ve.ssels.  It  is  possible  that 
when  the  injured  area  is  exceedingly  small,  the  leucocytes  may  derive  sufficient 
nourishment  from  the  circulating  plasma  :  but  if  it  is  of  more  than  the  most 
minute  dimensions,  and  new  vessels  are  not  formed,  the  young  cells  near  the 
centre  starve  and  undergo  fatty  degeneration.  In  all  cases  they  develop  from 
pre-existing  capillaries.  Conical  processes  spring  from  the  walls,  and  grow  out 
among  the  masses  of  leucocytes,  until  they  join  other  processes  or  other  vessels. 
At  first  they  are  solid,  but  even  while  they  are  growing  a  hollow  makes  its  appear- 
ance at  the  ends,  and  gradually  spreads  farther  and  farther  until  there  is  a  minute 
central  canal  down  the  whole  length.  This  enlarges  sufficiently  to  admit  the  red 
corpuscles  ;  then  nuclei  appear  in  the  wall  ;  and  a  perfect  capillary  is  formed, 
ready  itself  to  become  the  starting-point  for  others,  until  the  mass  of  growing 
leucocytes  is  supplied  with  loops  of  vessels,  spreading  into  it  from  all  sides  and 
converging  toward  the  centre.  This  is  known  as  vascula?-  gratmlation-tissue ,  from 
the  peculiar  appearance  it  presents  when  it  is  formed  upon  the  surface  of  a  wound 
expo.sed  to  the  air ;  by  it  all  the  broken-down  tissue  and  extravasated  blood  are 
removed,  and  from  it  is  developed  the  newly  formed  tissue  which  ij?  to  replace 
the  old. 

Many  of  the  corpuscles  of  which  it  is  composed  closely  resemble  pus-corpus- 
cles, and  prol)ably,  like  them,  are  dead.  They  are  round,  motionless,  slightly 
granular,  with  a  bifid  or  trifid  nucleus,  which  becomes  more  distinct  on  the 
addition  of  acetic  acid.  These  disappear,  very  possibly  consumed  by  those 
around.  The  living  ones  are  larger,  with  clear  oval  vesicular  nuclei,  and.  from 
the  resemblance  they  bear  to  epithelial  cells,  are  sometimes  called  epithelioid. 

Organization  always  begins  near  the  normal  tissue,  where  the  effect  ot  the 
irritant   is  scarcely  felt.      The   living  cells  enlarge,   become  spindle-shaped   or 


3° 


GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 


branched,  and  range  themselves  in  bundles  alongside  or  round  the  vessels  {fibro- 
blasts) ;  then  their  borders  and  ends  become  fibrillated,  other  fibrils  make  their 
appearance  in  the  matrix  between  them,  many  of  the  nuclei  disajjpear,  others 
persist  as  small  oval  corpuscles,  and  a  little  mass  of  fibrous  cicatricial  tissue  is 
formed,  abundantly  supplied  with  vessels.  A  few  multinuclear  giant-cells  may 
generally  be  found,  formed  either  by  the  division  of  nuclei  without  proportionate 
partition  of  the  cell-body,  or  by  the  blending  and  coalescence  of  contiguous 
corpuscles.     When  the  process  is  very  chronic  and  the  vessels  few  in  number,  as. 

in  the  case  of  infection  with  tubercle,  the  tendency 
to  their  production  is  very  much  greater. 

The  process  of  organization  after  a  single  injury 
gradually  extends  through  the  whole  thickness,  begin- 
ning at  the  circumference  and  converging  toward  the 
centre,  until  the  whole  area  of  granulation-tissue  is 
transformed.  If  the  injury  was  an  open  wound,  mod- 
ifications naturally  take  place  for  the  production  of  a 
protecting  layer  of  epithelium,  but  this  will  be  dealt 
with  later.  The  newly  formed  tissue  at  first  is  highly 
vascular  ;  by  degrees,  however,  the  bundles  of  fibrils 
contract  more  and  more,  and  obliterate  the  vessels  to 
a  great  extent.  In  simple  injuries  the  amount  is 
always  small — the  minimum,  in  fact,  required  to  re- 
p  ,  r  cu   ui   .  ■  jf   move  and  replace  what  is  dead,  and   the  degree  of 

Fig.  1. — A  group  of  fibroblasts  in  dil-  \  _  '  o 

ferent  stages  of  growth,   a,  embryo  contraction    is    never   serious.      When,   on  the  other 
ing  ^^^^^^  ^j^g  tissues  have  been  extensively  destroyed  by 
suppuration,  the  quantity  may  be  so  great,  and  the 
tendency  to  contract  so  inveterate,  as  to  cause  the  most  serious  deformity. 


cell    wandering. 
Bird.) 


Thk  Effect  of  Continued  Irritation. 

A  transient  irritant,  not  sufficiently  severe  to  kill  the  tissues,  after  its  first 
effect  has  subsided,  acts  as  a  stimulus  on  all  the  structures  round  ;  they  begin  at 
once  to  act  with  greater  energy,  and  strive  their 'utmost  to  repair  the  damage  that 
has  been  done.  The  same  thing  occurs  when  the  irritant  is  a  persistent  one — the 
tissues  throughout  keep  doing  their  best  to  repair  the  injury  inflicted  on  them  ; 
but  there  is  this  great  difference,  that  in  this  case  the  irritant,  instead  of  being  a 
thing  of  the  past,  is  hard  at  work  the  whole  time,  sapping  the  vitality  of  all  the 
structures  near,  and  diminishing  their  power  of  resistance.  The  whole  time  the 
irritant  continues  there  is  a  contest  between  it,  on  the  one  hand,  and  the  tissues 
on  the  other.  These,  by  increasing  the  amount  of  the  exudation  that  pours  out 
through  the  walls  of  their  vessels,  keep  striving  to  repair  the  damage  already  done, 
and  to  check  the  progress  of  the  injurious  agent,  whatever  it  may  be ;  while  this, 
so  long  as  its  power  lasts,  is  engaged  in  destroying  the  exudation,  weakening  the 
tissues,  and  impairing  their  vitality.  The  sum  of  the  changes  produced  in  the 
conflict  is  known  as  inflammation  ;  as  soon  as  the  irritant  ceases  to  act  inflamma- 
tion ceases  and  repair  begins. 


Symptoms  of  Inflammation. 

These  are  the  same  as  those  already  described,  but  they  are  very  different  in 
degree.  Redness,  swelling,  heat,  and  pain  are  present,  as  before,  to  a  greater  or 
less  extent;  the  functional  power  of  the  part  is  lowered,  and  the  temperature  of 
the  blood  is  raised  ;  but  this  is  no  longer  Avithin  physiological  limits  :  now  the 
changes  are  pathological,  kept  up  by  an  irritant  which  is  all  the  while  at  work, 
either  impairing  the  vitality  of  the  tissues,  and  causing  inflammation,  or  killing 
them. 

In  inflammation  of  a  superficial  part  all  these  signs  are  usually  present  and 


JNFLAMMA  TION.  3 1 

eiiually  well-marked,  and  the  diagnosis  is  clear  ;  in  other  cases,  however,  especially 
when  the  part  is  deejjly  seated  and  the  irritant  of  low  intensity,  there  may  be  only 
one,  and  then  the  ditificulty  is  very  great.  In  such,  a  diagnosis  can  often  be  made 
only  by  a  process  of  exclusion,  or  by  actual  exploration. 

Redness. — The  color  may  be  brilliant,  returning  instantaneously  if  driven 
away  by  pressure,  or  livid  and  almost  purple,  as  round  the  margin  of  old  sinuses. 
In  severe  ca.ses  the  blood-vessels  give  way,  leaving  ecchymoses,  which  after  a  time 
(especially  if  they  are  rei)eated)  turn  a  dull  red-brown.  A  pigment-stain  produced 
in  this  way  lasts  for  years,  ])articularly  when  it  is  upon  the  legs.  If,  as  in  perios- 
titis of  the  femur,  the  inflamed  ]>art  is  deeply  seated,  the  color  of  the  skin 
remains  unaltered,  or  is  even  whiter  than  natural,  from  being  stretched  by  the 
effusion  beneath. 

Swelling  is  never  al)sent,  although  if  the  part  is  thickly  covered  in,  it  may 
not  be  detected.  At  first  it  is  due  simply  to  the 
distention  of  the  vessels ;  but  this  is  insignifi- 
cant in  comparison  with  the  exudation  that 
follows.  The  rapidity  with  which  it  forms  and 
the  degree  of  firmness  it  presents  to  the  touch, 
depend  upon  the  anatomical  arrangement  of  the 
tissues  and  the  character  of  the  exudation.  The 
more  open  the  tissue,  the  more  quickly  it  takes 
place  and  the  softer  it  feels.  Structures,  there- 
fore, like  the  eyelids  or  scrotum,  easily  assume  enor- 
mous dimensions.  On  the  other  hand,  when  the 
exudation  is  bound  down  beneath  a  layer  of  dense 
and  close  fibrous  tissue,  such  as  the  periosteum  or 
the  deep  cervical  fascia,  it  may  be,  for  a  time  at 
least,  as  dense  and  resistant  as  bone,  although  if 
firm  pressure  is  used,  it  wall  always  yield  a  little, 

forming  a  sharply  defined  pit  which  slowly  fills  up  ic  2.—  lape  esis. 

again. 

The  character  of  the  exudation  varies  with  the  nature  and  intensity  of  the 
irritant.  It  may  be  serous,  with  but  few  leucocytes  and  little  tendency  to  form 
fibrin — almost  the  same,  in  short,  as  that  which  is  present  in  health  ;  this  is  chiefly 
met  with  when  the  cause  is  a  distant  one — round  the  extreme  margin  of  an  ab- 
scess, for  example.  It  may  be  sero-fibrinous  ox  fibrinous,  consisting  of  little  but  a 
meshwork  of  fibrin  formed  from  the  plasma  and  enclosing  the  leucocytes  in  its 
meshes.  Or  it  may  he  sero-purulent  ox  purulent,  when,  owing  to  the  peptic  action 
of  pyogenic  micro-organisms,  no  fibrin  at  all  is  formed,  but  only  a  mass  of  albu- 
minous liquid,  with  dead  and  dying  pus-corpuscles  floating  in  it.  Distinct  exam- 
ples of  all  of  these  are  seen  in  serous  and  synovial  cavities,  but  they  are  of  frequent 
occurrence  elsewhere,  especially  in  the  meshes  of  connective  tissue. 

When  the  irritant  is  very  intense,  the  walls  of  the  capillaries  perish,  and  the 
exudation  becomes  hemorrhagic.  When,  on  the  other  hand,  it  is  slight  but  per- 
sistent, as  in  the  case  of  tubercle  and  syphilis,  masses  of  granuiafion-tissue,  with 
giant  and  epithelioid  cells,  are  developed.  Sometimes,  after  lasting  a  considerable 
time,  this  becomes  absorbed  ;  more  frequently,  according  to  the  cause,  it  either 
becomes  organized,  undergoes  degeneration  and  caseation,  or  breaks  down  into 
pus.  From  this  peculiarity  these  diseases  are  sometimes  known  as  infective 
granulomata,  granulation-tissue  being  ])roduced  in  masses  of  such  size  that  they 
reseml)le  tumors. 

Heat. — The  temperature  of  an  inflamed  part  is  nearly  always  raised  ;  the 
only  exceptions  are  the  very  chronic  cases  (and  in  these  it  is  probable  that  a  ther- 
mopile would  detect  some  slight  variation  at  one  time  or  another)  ;  and  some  of 
the  very  acute,  in  which,  owing  to  the  early  occurrence  of  stasis,  the  current  of 
blood  flowing  to  the  part  is  greatly  reduced — in  short,  in  incipient  gangrene.  It 
is  stated  to  be  due,  not  to  the  increased  local  production  of  heat,  but  to  the  in- 
creased supply  of  arterial  blood  raising  the  temperature  of  the  part  almost  to  that 


32 


GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 


of  the  interior  of  the  body.  Of  course  this  may  be  far  above  the  normah  Care 
must  be  taken,  when  estimating  the  temperature  of  any  part,  to  compare  it,  not 
with  the  normal  temperature  of  the  l)ody,  but  with  the  actual  temj^erature  of  the 
corresponding  part,  placed  under  exactly  the  same  conditions  of  clothing  and 
exposure. 

Pain. — The  severity  depends  upon  the  degree  of  tension.  In  acute  inflam- 
mation of  tough,  fibrous  structures,  or  where,  as  when  bone  is  concerned,  there  is 
great  resistance  to  expansion,  it  is  exceedingly  severe,  and  is  made  infinitely  worse 
by  anything  that  increases  the  current  of  blood  in  the  part — allowing  it  to  hang 
down,  for  example,  or  using  it  in  any  way.  Under  these  circumstances,  especially 
when  suppuration  is  imminent,  it  is  often  described  as  throbbing,  each  throb 
corresponding  to  a  beat  of  the  heart,  and  to  a  fresh  amount  of  blood  driven  into 
the  part. 

The  character  of  the  pain  depends  more  upon  the  tissue  concerned  ;  thus  bones 
and  ligaments  ache  \  the  skin  smarts  and  burns  ;  and  the  eyes  become  intolerant  of 
light.  In  very  severe  cases  the  pain  may  cease  altogether  toward  the  end,  owing 
to  the  failing  power  of  the  brain. 

Impairment  of  the  function  of  the  part  is  often  one  of  the  most  valuable 


Fig.  3. — Stomata  of  the  Capillaries.     (After 
Duplay  and  Rectus.) 


Fig.  4.— Dilatation  of  Capillaries. 


signs ;  an  inflamed  joint,  for  example,  is  held  rigid  by  the  muscles,  and  cannot  be 
moved  to  its  full  extent  in  any  direction.  In  the  same  way  absorption  and  secre- 
tion cannot  be  carried  out  if  the  mucous  membrane  of  the  bowel  is  inflamed,  and 
peristalsis  is  stopped  if  the  serous  and  muscular  coats  are  attacked.  All  work 
increases  the  amount  of  blood  in  the  part,  causes  varying  degrees  of  tension  to  fall 
upon  the  tissues,  and  makes  the  pain  and  inflammation  more  severe. 

Fever. — In  addition  to  these  local  signs,  inflammation  is  always  attended 
by  a  certain  degree  of  fever.  The  temperature  of  the  body,  w^hich  normally 
ranges  from  97.5°  to  98°  in  the  early  morning,  to  98.5°  and  even  99°  of  an 
evening,  is  raised;  the  pulse  is  quick  and  hard  ;  the  respiration  is  hurried;  the 
tongue  and  mouth  are  dry  ;  the  appetite  is  lost,  and  all  the  secretions  are  dmiin- 
ished.  The  skin  is  hot  and  parched,  the  urine  is  .scanty  and  high-colored,  and  the 
bowels  constipated.  Sleep  is  disturbed  ;  headache  is  always  present ;  delirium  is 
usual  (especially  at  night)  when  the  temperature  is  raised  more  than  three  or  four 
degrees,  and  the  loss  of  flesh  and  strength  is  rapid  and  extreme. 

The  cause  of  this  fever  is  mainly  the  increased  production  of  heat ;  in  com- 
parison the  diminished  loss  by  the  skin  from  the  absence  of  evaporation  is  altogether 
insignificant,  and  this  increase  results  from  a  greater  degree  of  activity  in  the 


INFLAMMA  TION.  33 

metaliolism  of  the  ])arenchymatons  tissues  of  the  body,  the  muscles  and  glands  in 
])arti(-ular.  So  much  is  clear  from  the  rapid  emaciation  and  loss  of  strength,  and 
from  the  increase  in  the  amount  of  carbonic  acid  and  urea  eliminated. 

The  way  in  which  this  increased  metabolism  is  brought  about  is  not  so  defi- 
nite. In  all  i)robability  the  changes  that  take  i)lace  in  the  tissues  are  under  the 
control  of  the  nervous  system  ;  it  seems  likely  that  the  sujjreme  centre  is  in  the 
corte.x  of  the  brain,  probably  in  the  parietal  region;  that  there  is  another  in  the 
medulla  oblongata  ;  and,  as  in  the  case  of  the  vaso-motor  system,  others  still — 
subsitliary  ones — in  the  spinal  cord.  Possibly  also,  carrying  the  analogy  further, 
the  tissues  themselves  are  not  altogether  devoid  "of  influence,  at  any  rate  when 
isolated  from  the  main  command.  In  fever  it  is  believed  that  normal  control 
over  the  metabolism  is  enfeebled,  and  that  the  tissue-changes  are  carried  on  at  a 
much  more  rapid  rate,  with  increased  production  of  heat  as  a  natural  consequence. 
This  undue  activity  of  the  metabolism  is,  in  some  cases,  excited  by  peripheral 
stimuli  ;  tension,  for  example  (even  such  an  ajjparently  trivial  matter  as  a  suture 
drawn  too  tightly),  is  undoubtedly  a  very  powerful  stimulus,  although  it  must  not 
be  forgotten  that  it  helps  as  well  by  promoting  the  al)sorption  of  fever-causing 
substances  from  the  tissues.  Mental  emotion  is  another,  and  i)ossibly  this  ex])lains 
some  of  the  mysterious  cases  of  local  hyperpyrexia.  By  far  the  most  powerful 
cause,  however,  is  the  absorption,  through  the  blood  or  through  the  lymphatic 
system,  of  certain  products,  which  either  weaken  the  control  of  the  nerve-centres 
that  preside  over  metabolism,  'or  stimulate  the  tissues  to  increased  change.  In 
other  words,  pyrogenous  agents,  as  they  are  called,  act  either  directly  or  reflexly 
ui)on  the  heat-regulating  centres  in  the  central  nervous  system,  impairing  their 
power  of  control ;  or  upon  the  tissues  themselves,  stimulating  them  to  increased 
activity. 

Of  substances  that  possess  this  power  there  is  no  lack.  Broken-down  blood- 
clot,  even  when  a  wound  is  subcutaneous,  is  one,  the  active  constituent  being,  so 
it  is  said,  the  fibrin-ferment.  The  products  of  putrefactive  fermentation  possess  it 
in  a  very  much  higher  degree,  causing  septic  traumatic  fever  or  sapraemia,  accord- 
ing to  the  nature  of  the  ptomaine  produced,  and  the  quantity  that  enters  the  cir- 
culation at  once.  Many  varieties  of  infective  germs  are  still  more  active,  multi- 
plying in  the  tissues  and  the  blood-stream,  and  forming  substances  which  cause 
the  most  severe  constitutional  symptoms ;  and  in  all  likelihood  the  fever  that 
accompanies  simple  inflammation  (not  due  to  putrefaction  or  to  any  infective 
germ)  is  mainly  caused  in  the  same  way,  partly  by  tension,  but  chiefly  by  absorp- 
tion through  the  lymph-stream  of  substances  produced  in  the  tissues  under  the 
action  of  various  kinds  of  irritants. 

The  character  and  severity  of  the  fever  depend  upon  the  cause.  Age  is  of 
some  influence,  as  during  childhood,  when  the  metabolism  of  the  tissues  is  most 
active,  sudden  and  severe  attacks  are  not  uncommon  after  very  slight  causes. 
Sex,  and  what  is  known  as  temperament,  may  also  have  a  certain  effect.  In  the 
chronic  forms  of  inflammation  it  is  very  slight ;  in  acute  ones  it  may  be  sthenic, 
asthenic,  or  irritative. 

In  the  sthenic  form  the  symptoms  are  acute,  the  temperature  high,  104°  or 
105°  F. ,  and  the  pulse  full,  strong,  and  bounding.  The  onset  is  usually  sudden, 
and  often  marked  by  a  shivering  fit  or  rigor,  or,  in  the  case  of  children,  by  an 
attack  of  vomiting  or  convulsions. 

The  asthenic  may  either  succeed  to  this,  or  may  commence  as  such,  quietly 
anci  insidiously.  Sometimes  it  is  attended  with  sloughing,  but  in  many  cases  the 
local  signs  are  very  slightly  marked.  From  the  first,  what  are  known  as  typhoid 
symptoms  set  in  ;  the  patient  lies  overcome  with  stupor,  or  in  a  condition  of  low 
muttering  delirium  ;  the  .skin  is  hot  and  dry ;  the  face  dusky  and  pinched,  with 
sunken  eyes  ;  there  is  sordes  on  the  lips  and  teeth  ;  and  the  tongue  is  dry  and 
brown,  or  red  and  cracked.  Diarrhoea  is  often  present,  the  motions  being  passed 
unconsciously ;  and  frequently  there  is  albuminuria.  The  pulse  is  small  and 
quick,  and  the  respiration  hurried  and  shallow,  but  the  temperature  is  rarely  very 


34         GENERAL   PATHOLOGY  OF  SURGLCAL    DLSEASES. 

much  raised,  and  it  may  even  be  sul)normal,  especially  toward  the  end.  This 
variety  is  only  met  with  where  the  patient's  health  is  utterly  broken  down  from 
intemperance  or  other  causes,  or  where  an  irritant  poison  is  absorbed  in  overpower- 
ing quantity,  as  in  septic  peritonitis  following  operation. 

Irritative  fever  is  less  well-marked  ;  one  chief  characteristic  is  the  early 
occurrence  of  delirium,  and  the  prominence  of  the  nervous  symptoms. 

The  fever  is  said  to  be  continuous  when  the  daily  variations  do  not  exceed  2° 
F.;  if  it  is  greater  than  this  it  is  called  remittent.  In  the  intermittent  form  there 
are  periods  (which  may  or  may  not  be  regular,  and  which  vary  greatly  in  dura- 
tion) during  which  the  temperature  does  not  rise  above  the  normal. 

Varieties  of  Inflammation. 

These  are  the  signs  common  to  all  forms  of  inflammation  ;  they  are  an  indica- 
tion of  the  changes  that  take  place  in  the  living  tissues  while  they  are  being  irri- 
tated by  some  cause  not  sufficiently  powerful  to  kill  them,  and  they  occur  in  all 
alike,  so  far  as  structural  conditions  allow.  In  part  they  are  the  direct  effect  of 
the  injury  lowering  the  vitality  of  the  tissues  upon  which  it  is  acting ;  in  part 
they  are  due  to  the  efforts  at  repair  made  by  the  living  (uninjured)  elements 
around ;  if  the  irritant  is  the  stronger,  destruction  progresses  more  or  less 
rapidly,  and  the  fever  is  high,  and  the  part  red,  swollen,  and  painful ;  as  its 
influence  begins  to  wane  and  the  tissues  gain  control,  this  diminishes,  and  when 
its  action  ceases,  the  fever  and  the  other  signs  disappear  altogether  ;  there  is  noth- 
ing then  to  hurt  the  tissues  further,  or  prevent  them  regaining  their  former 
activity  ;  all  pathological  changes  come  to  an  end,  and  the  natural  process  of 
repair  removes  all  trace  of  morbidity  so  far  as  is  possible. 

The  extent  of  the  changes  in  inflammation  depends  upon  the  condition  of 
the  tissues  on  the  one  hand,  and  the  intensity  of  the  cause  on  the  other.  The 
character  depends  upon  the  nature  of  the  irritant. 

A  very  trivial  injury,  for  example,  may  give  rise  to  the  most  serious  conse- 
quences if  the  nutrition  of  the  tissues  is  enfeebled  from  disease  or  intemperance  ; 
but  mechanical  irritants  can  only  cause  simple  inflammation  ;  suppuration  cannot 
occur  without  pyogenic  organisms,  and  tubercle  cannot  appear  without  its  specific 
bacillus.  The  tissues,  in  their  endeavor  to  limit  the  action  of  the  irritant, 
always  produce  the  same  exudation,  but  the  changes  this  undergoes  under  the 
influence  of  different  irritants,  and  under  different  conditions,  naturally  differ  and 
give  rise  to  different  varieties  of  disease. 

A  so-called  croupous  or  diphtheritic  exudation  is  occasionally  met  with  upon 
the  surface  of  granulating  wounds.  It  forms  a  buff-colored  rind  which  may  be 
peeled  off  easily,  leaving  a  raw  surface,  which  usually  heals  readily  if  brushed 
over  with  nitrate  of  silver  or  iodine.  Sometimes,  however,  it  is  reproduced  again 
and  again,  and  it  may  extend,  to  a  serious  degree,  especially  on  burns.  Probably 
it  is  due  to  coagulation-necrosis,  caused  by  the  action  of  certain  germs,  involving 
the  exudation  and,  in  the  diphtheritic  form,  the  tissues  themselves  sometimes  to  a 
consideraV)le  depth.  True  diphtheria  very  rarely  attacks  wounds ;  when  it  does 
it  is  usually  caused  by  direct  infection  (though,  curiously  enough,  tracheotomy- 
wounds  are  seldom  contaminated),  and  the  clinical  symptoms  and  sequelae 
resemble  those  of  the  ordinary  form,  allowance  being  made  for  the  difference  in 
locality. 

[Summary. — Inflammation  is  due  to  irritation  of  the  tissues  by  living 
organisms,  chemicals,  or  mechanical  violence ;  its  symptoms  are  redness  and 
swelling  with  heat  and  pain  (Celsus),  and  its  pathological  anatomy  shows  the 
stages  of  hyperccmia,  stasis,  and  diapedesis.] 


INFLAMMA  TION. 


Simple  Inki.ammaiion. 


35 


The  causes  are  nierhanical,  physical,  or  chemical  irritants,  sufficiently  severe 
to  injure  the  tissues  without  killing  them  outright  ;  a  suture,  for  example,  drawn 
too  tightly,  a  burn  or  scald  exposed  to  the  air,  constant  friction,  or  long-continued 
irritation  by  dust  or  smoke.  I'he  symptoms  are  those  already  described  :  red- 
ness, swelling,  heat,  and  pain,  with  imjiairment  of  function  and  fever,  varying 
according  to  the  size  and  importance  of  the  part  involved,  and  the  acuteness  of 
the  attack.  They  may  be  so  intense  as  to  endanger  life,  or  so  slight  as  to  be 
scarcely  perceptible. 

Simple  inflammation  may  end  fatally,  or  undergo  resolution,  or  become  chronic. 
The  exudation  may  become  absorbed,  organized,  or  undergo  fatty  degeneration. 
Sui)puration  is  a  complication  due  to  the  action  of  certain  micrococci. 

(rt)  Death  may  l)e  caused  by  the  intensity  of  the  fever,  by  exhaustion,  or  by 
the  organ  that  is  attacked  being  essential  to  life,  as  in  the  case  of  the  glottis  or 
the  heart. 

(J))  Resolution. — If  the  nutrition  of  the  part  is  good,  this  begins  as  soon  as 
the  cause  is  removed.  The  pain  and  fever  cease  ;  the  temperature  of  the  part, 
although  still  above  that  of  the  corresponding  one,  owing  to  the  amount  of  blood 
it  receives,  is  well  below  fever  heat ;  the  swelling  disappears,  except  so  far  as  it  is 
caused  by  the  increased  flow  of  blood  and  plasma  necessary  for  repair ;  and  the 
redness  loses  its  angry  tint,  although  the  blush  persists  for  niany  months  if  new 
vessels  have  been  formed.  The  amount  of  granulation-tissue  and  .scar-formation 
depends  upon  the  extent  of  the  disease.  It  may  be  so  little  as  to  be  practically 
imperceptible,  as  after  a  bruise  or  a  simple  incised  wound,  or  it  may  be  of  any 
extent. 

(r)  Persistenee. — If  the  cause  is  frequently  repeated,  or  if,  without  being 
too  severe,  it  continues  to  act,  the  inflammation  persists  and  is  very  liable  to 
become  chronic.  This  is  especially  likely  when  constitutional  predisposing 
causes,  such  as  gout  and  rheumatism,  are  present  ;  the  attack  commences  with 
some  slight  irritant,  such  as  would  not  be  noticed  if  the  tissues  were  healthy,  and 
the  morbid  state  of  the  nutrition  is  sufficient  to  prevent  resolution  after  the 
original  irritant  has  ceased  to  act. 

General  Principles  of  Treatment. 

Inflammation  is  the  result  of  an  injury  sufificiently  severe  to  impair  the 
vitality  of  the  tissues  without  killing  them  outright.  The  first  thing,  therefore,  is 
to  prevent,  as  far  as  possible,  the  access  of  any  irritant  (preventive,  treatment), 
and  the  next  to  remove  any  source  of  injury  that  may  be  present,  to  strengthen 
and  maintain  the  nutrition  of  the  tissues,  and  to  place  them  under  the  most 
favorable  conditions  for  resisting  and  overcoming  anything  that  affects  them 
injuriously. 

I.  Preventii'e. 

A  single  uncomplicated  injury  is  not  followed  by  inflammation  ;  the  process 
of  repair  begins  at  once,  and  if  there  is  no  other  irritant  and  the  damage  is  not 
too  extensive,  is  completed  without  the  surrounding  structures  suffering  in  the 
least.  Inflammation  is  the  result  of  continued  irritation — either  local,  such  as 
that  caused  by  the  presence  of  foreign  bodies,  by  tension,  friction,  want  of  rest, 
or  putrefaction  ;  or  constitutional,  resulting  from  some  morbid  condition  of  the 
blood  or  tissues,  as  in  gout.  The  preventive  treatment,  therefore,  except  in  so 
far  as  it  is  possible  to  improve  the  nutrition  of  the  tissues  and  place  them  in  a 
more  favorable  condition,  practically  resolves  itself  into  the  treatment  of  wounds 
and  other  injuries. 

2.  Curative. 

I.  Removal  of  the  Cause. — Foreign  bodies  must  be  removed  ;  tension 
relieved  by  dividing  sutures,  making  incisions,  and  providing  the  freest  possible 


T,6         GENERAL   PATHOLOGY  OF  SURGLCAL   DISEASES. 

drainage  ;  and  friction  prevented  by  aljsolute  rest.  Pain  must  be  allayed,  and 
any  irritant  in  contact  with  the  surface,  whether  it  is  an  over-powerful  antiseptic 
or  the  products  of  putrefaction,  either  removed  or  rendered  innocuous.  Some- 
times, when  the  inflammation  is  due  to  the  action  of  a  powerful  local  irritant,  as 
in  phagedsena,  the  surface  must  be  destroyed,  and  occasionally  certain  drugs  are 
employed  which  may  possibly  act  directly  upon  the  cause — mercury,  for  example, 
in  syphilis,  and  colchicum  in  acute  gout. 

2.  Where  the  cause  cannot  be  removed,  the  symjitoms  must  be  treated.  In 
other  words,  an  attempt  must  be  made  to  regulate  the  quantity  and  quality  of 
blood  flowing  through  the  part,  so  that  the  nutrition  of  the  affected  tissue  may  be 
maintained  as  well  as  possible. 

The  means  at  disposal  are  local  and  constitutional. 

Local  Remedies. 

Rest. — The  more  the  i)art  is  used,  the  greater  the  amount  of  blood  flowing 
to  it  and  the  greater  the  tension.  To  be  of  any  use,  however,  the  rest  must  be 
complete. 

Position. — The  effect  of  allowing  an  inflamed  limli  to  hang  down  is  well 
known.  Raising  it  assists  the  venous  and  lymphatic  circulation,  and  at  the  same 
time  lessens  the  amount  of  blood  entering  it,  by  causing  a  vaso-motor  constriction 
of  the  arteries. 

Pressure. — Uniform,  gentle,  and  ela.stic  pressure,  such  as  that  produced  by 
investing  the  part  with  many  thicknesses  of  cotton-wool,  and  then  placing  a  band- 
age over  the  whole,  is  a  most  efficient  method  for  diminishing  pain  and  tension 
even  in  cases  of  phlegmonous  inflammation.  In  a  few  instances  pressure  has  been 
applied  to  the  main  artery  of  a  limb  with  the  same  object,  and  the  femoral  has 
been  ligatured  in  cases  of  acute  inflammation  of  the  knee-joint. 

Cold  is  a  most  powerful  agent  for  checking  the  amount  of  blood  flowing 
through  a  part.  It  may  be  applied  either  by  means  of  an  ice-bag,  or  by  Leiter's 
coils  of  leaden  tubing,  arranged  to  fit  closely  round.  In  other  cases,  lead  and 
spirit  lotion  is  allowed  to  drip  slowly  over  the  part  and  evaporate,  the  surplus 
being  carried  off  by  means  of  properly  arranged  rubber  sheets  beneath.  It  checks 
protoplasmic  movement,  lowers  the  vascular  tension  by  causing  paralytic  dilatation 
of  the  walls  of  the  smaller  vessels  (at  first  there  is  a  temporary  constriction),  and 
if  applied  continuously  and  with  sufficient  vigor,  can  stop  the  circulation  alto- 
gether. In  some  cases,  as  for  instance  with  tubercle-bacilli,  it  possesses  the  power 
of  retarding  development,  but,  at  the  same  time,  when  carried  far  enough  for 
this,  there  is  great  danger  of  its  depressing  the  vitality  of  the  tissues  too.  It  may 
always  be  used  in  the  early  stages  of  inflammation,  and  very  often  throughout  in 
the  sthenic  form,  especially  when  the  local  symptoms  are  well-marked  (as,  for 
example,  in  quinsy)  with  a  view  of  limiting  the  hyperaemia  and,  if  suppuration 
occurs,  reducing  the  size  of  the  abscess  ;  but  in  the  asthenic  form  it  should  always 
be  avoided.  An  icebag  laid  along  the  course  of  the  main  artery  at  a  distance 
from  the  seat  of  inflammation  is  sometimes  of  considerable  value. 

Warmth  acts  in  the  opposite  way  ;  it  stimulates  amceboid  movements, 
causes  the  walls  of  the  vessels  to  dilate,  and  gives  freer  passage  to  the  blood. 
Applied  to  the  spot  itself  it  diminishes  the  tension  in  the  tissues,  and  in  the  early 
stages  may  procure  resolution  ;  but  if  suppuration  is  imminent  it  only  encourages 
it.  Advantage  is  taken  of  this  when  it  is  wished  to  make  an  abscess  point.  When 
used  over  a  more  extensive  surface,  it  diverts  a  larger  portion  of  the  blood  that 
would  otherwise  flow  through  the  inflamed  area,  and,  by  relaxing  the  tissues,  facili- 
tates the  return  through  the  veins  and  lymphatics. 

Whether  heat  or  cold  should  be  applied  locally  may  be  left,  to  some  extent, 
to  the  patient's  feelings,  but  not  altogether.  The  former  is  usually  selected,  as  it 
diminishes  tension  and  pain  more  quickly  ;  but  if  the  latter  is  continued  for  a 
little  time,  especially  when  the  inflammation  is  acute  and  .sthenic,  the  relief  is, 


INFLAMMA  TION. 


37 


generally  speaking,  nnuh  more  complete.  Whichever  is  chosen,  the  application 
must  be  continuous;  any  intermittence,  especially  in  the  case  of  cold,  makes 
matters  infinitely  worse. 

[The  late  Professor  Allen  explained  that  either  heat  or  cold,  cotitimiously 
applied,  is  a  sedative  ;  intermittently  applied,  a  stimi//ant.'\ 

Astringents  are  chiefly  used  over  the  surface  of  mucous  membranes.  Lead, 
however,  if  ajjplied  to  the  skin  for  any  length  of  time,  becomes  absorbed  (as 
shown  by  the  discoloration)  and  acts  directly  u[)on  the  cajjillaries  and  small 
vessels. 

Local  bleeding  in  acute  inflammation  is  of  the  greatest  service,  although  it 
is  very  difficult  to  explain  why.  It  cannot  be  the  amount  withdrawn,  for  this  is 
usually  altogether  insignificant.  Leeches  may  be  used  (not,  however,  over  any 
loose  tissue,  such  as  the  eyelid  or  scrotum ;  in  orchitis  they  must  be  placed  on  the 
groin)  ;  superficial  veins  may  be  punctured  ;  or  small  incisions  made  here  and 
there  in  the  axis  of  the  limb,  taking  care  to  avoid  any  important  structure.  The 
last  method  is  especially  useful  in  phlegmonous  inflammation  of  the  cellular 
tissue,  when  there  is  any  danger  of  sloughing,  to  relieve  the  tension  on  the  skin. 
The  bleeding  may  be  encouraged  afterward,  if  necessary,  by  means  of  a  warm 
bath. 

^A^et-cupping  is  rarely  practiced  now  ;  but  dry-cupping  may  be  employed 
with  benefit  in  inflammation  of  deep-seated  organs  such  as  the  kidneys.  The  air 
in  a  cupping-glass  is  rarefied  by  holding  it  like  a  bell  over  a  large  spirit-lamp,  or 
by  burning  a  small  quantity  of  spirit  inside,  and  then  the  mouth  is  quickly  pressed 
against  the  skin,  taking  care  not  to  burn  the  patient.  As  the  air  condenses,  the 
tissues  rise  up  in  a  convex  dome,  partly  filling  the  cup,  the  cutaneous  vessels 
become  distended,  and  many  of  the  smaller  ones  rupture. 

Counter-irritants. — Rubefacients,  blisters,  Scott's  dressing,  and  the  actual 
cautery  are  chiefly  of  use  in  the  chronic  forms.  Li  all  probability  they  act  re- 
flexly  upon  the  deeper  vessels,  as  the  mere  local  dilatation  and  exudation  can  have 
but  little  influence.  Belladonna  (the  extract  mixed  in  varying  proportions  with 
glycerine)  is  sometimes  applied  with  benefit  over  very  large  areas.  There  is  no 
fear  of  too  great  absorption  through  the  skin,  but  abraded  surfaces  must  be  avoided. 
It  cau.ses  a  slight  temporary  constriction,  but  this  is  soon  succeeded  by  a  more 
permanent  dilatation,  lowering  the  tension  and  relieving  the  pain. 

Constitutional  Measures. 

Diet  is  of  great  importance.  The  waste  in  all  forms  of  inflammation  is  very 
rapid,  and  at  the  same  time  the  appetite  and  the  power  of  digestion  are  very  much 
impaired.  Solid  food  is  out  of  the  question  in  acute  cases.  Light  diet,  milk, 
beef-tea,  arrowroot,  and  other  farinaceous  foods,  jelly,  milk-puddings,  and  the  like, 
are  sufficient  in  cases  of  sthenic  inflammation  of  short  duration.  If,  however,  the 
attack  is  of  long  duration,  or  if,  as  in  erysipelas,  the  area  involved  is  extensive, 
the  strongest  meat -jelly,  eggs  beaten  up  with  milk,  brandy,  and  tgg  mixture,  pep- 
tonized foods,  and  similar  substances  that  are  easily  absorbed,  must  be  given  in 
small  quantities  at  frequent  intervals,  even  when  the  patient  is  young  and  was 
previously  healthy.  In  older  people,  and  those  whose  health  is  broken  down, 
nourishment  is  still  more  imperative ;  and  it  is  then  that  stimulants  are  of  value, 
enabling  the  patient  to  make  the  most  of  what  is  taken  with  the  least  exertion. 
Great  care,  however,  is  required  not  to  overdo  it. 

Fluids  are  given  throughout  as  required.  Fragments  of  ice  may  be  sucked 
from  time  to  time,  to  allay  the  parched  condition  of  the  mouth,  but  it  must  be 
remembered  that  a  considerable  quantity  of  water  is  swallowed  in  this  way.  Barley 
water,  lemonade,  and  acid  fruit  drinks  are  often  very  grateful,  and,  in  moderation, 
do  no  harm. 

In  the  more  chronic  cases — in  tubercular  inflammation  of  joints,  for  instance — 
a  great  deal  may  be  done  toward  improving  the  quality  of  the  blood,  and  the  gen- 


38         GENERAL  PATHOLOGY  OF  SURGICAL   DISEASES. 

eral  nutrition,  l)y  means  of  good  food,  fresh  air,  tonics,  and  especially  cod-liver 
oil.  Sea-air  in  these  cases  is  often  of  wonderful  benefit,  enabling  the  tissues  to 
resist  the  action  of  the  irritant  until  a  less  susceptible  time  of  life  is  reached. 

Bleeding  is  rarely  practiced,  although  in  cases  of  acute  suppurative  arthritis, 
or  in  jjneumonia,  when  the  other  lung  is  becoming  engorged,  it  is  sometimes  of 
great  use,  especially  in  young  adults,  the  fever  falling  at  once.  In  children  or 
patients  past  middle  life  its  ultimate  value  is  very  doubtful,  although  it  may  appear 
to  help  in  tiding  over  a  crisis. 

Purgatives. — In  inflammation  the  bowels  are  nearly  always  constipated, 
and  their  action  is  followed  by  great  relief.  If  the  mucous  membrane  of  any  part 
of  the  alimentary  canal  is  involved,  this  is  different ;  but  in  incipient  peritonitis, 
with  effusion,  mild  purgation  has  been  strongly  advocated.  It  must  be  remem- 
bered that  the  patient,  as  a  rule,  is  taking  only  a  small  amount  of  food,  and  that 
of  such  a  nature  as  to  leave  little  residue,  so  that  the  constipation  may  be  appa- 
rent rather  than  real. 

Aconite  (one  minim  every  five  minutes  until  a  distinct  effect  is  produced 
upon  the  pulse)  and  antimony  (given  at  fretpient  intervals  until  it  causes  nausea) 
are  sometimes  given  in  young  subjects  at  the  commencement  of  an  acute  attack 
(when  the  heart  is  sound)  with  a  view  of  producing  general  vascular  depression. 
The  latter  drug  is  also  used  in  smaller  doses  during  the  course  of  the  fever,  for 
the  sake  of  its  action  upon  the  skin,  and  is  frequently  given  for  this  purpose  in 
conjunction  with  Dover's  powder.  Opium  is  often  recpiired  internally  as  well  as 
locally,  for  the  relief  of  pain  or  to  procure  sleep  ;  chloral,  bromide  of  potassium,  or 
strontium  and  sulphonal  are  chiefly  of  use  as  sedatives  or  hypnotics.  If  the  tem- 
perature is  very  high,  quinine,  antipyrin,  or  salicylic  acid  is  advisable,  and  the 
first  named  appears  to  possess  the  power  of  checking  an  incipient  rigor.  In 
hyperpyrexia  cold-sponging,  an  ice-cap  (Leiter's  coils,  arranged  so  as  to  fit  the 
head,  form  the  most  convenient  appliance,  although  a  simple  ice-bag  made  of  thin 
rubber  may  be  used)  or  even  an  ice-pack  may  be  required  ;  but  meanwhile,  and 
for  some  time  afterward,  close  watch  must  be  kept  upon  the  pulse,  as  sometimes, 
in  these  cases,  the  cardiac  muscle  fails  rather  suddenly. 

In  some  cases  of  high  temperature  alcohol  has  been  given  with  considerable 
benefit.  The  condition  of  the  pulse  and  of  the  heart  is  in  general  the  best  guide 
to  its  administration.  It  is  not  required  in  sthenic  inflammation  of  short  dura- 
tion in  young  subjects  ;  but  in  asthenic  forms  attended  with  sloughing  and  great 
depression,  especially  in  old  people,  it  must  sometimes  be  given  very  freely  to  tide 
them  over  a  critical  period.  In  smaller  quantities  it  is  of  great  service  in  assisting 
digestion  and  enabling  the  patient  to  make  the  most  of  his  food  with  the  least 
expenditure,  particularly  during  convalescence.  Carbonate  of  ammonia  in  five- 
grain  (.30)  doses  is  especially  useful  when  the  tongue  is  dry  and  brown  and  the 
pulse  is  beginning  to  fail  in  strength  and  volume.  Ether  may  be  given  at  the 
same  time.  Mercury  is  used,  and  with  benefit  under  many  different  conditions  ; 
as  a  purgative  at  the  commencement  of  an  attack  ;  as  an  alterative,  particularly 
in  children,  in  the  form  of  hyd.  c.  cret.,  or  pulv.  pil.  hydrarg.  ;  in  all  stages  of 
syphilis,  more  especially  the  early  ones ;  and  locally,  sometimes,  as  a  counter- 
irritant.  Colchicum,  alkalies,  iodide  of  potash,  salicylate  of  soda,  and  other 
drugs  are  of  benefit  in  special  cases;  and  tonics,  especially  iron,  quinine,  and 
cod-liver  oil,  are  usually  required  during  the  period  of  convalescence. 

Chronic  Inflammation. 

Acute  inflammation  may  become  chronic  merely  from  frecpient  repetition, 
even  when  the  tissues  are  healthy  and  without  jtredisposition  of  any  kind.  Each 
time,  for  example,  a  loose  cartilage  is  caught  between  the  bones  of  the  knee-joint, 
it  gives  rise  to  an  attack  of  synovitis ;  before  the  first  one  the  tissues  may  have 
been  perfectly  healthy,  and  if  it  is  the  only  one  they  may  recover  completely ;  if, 
however,  the  injury  is  constantly  being  repeated,  so  that  there  is  no  time    for 


INFLAMMATION.  39 

jierfect  rei)air,  organir  changes  are  left,  nutrition  is  jjermanently  impaired,  and 
the  synovitis  becomes  chronic. 

Constant  friction  acts  in  the  same  way  ;  the  conjunctiva,  for  instance,  l)e- 
comes  roughened  and  granular  ;  the  neck  of  a  hernia  hard  and  dense  as  cartilage  ; 
and  even  the  skin  may  be  entirely  altered  in  texture.  In  the  same  way  the 
mucous  membrane  of  the  throat,  instead  of  remaining  soft  and  flexible,  becomes 
covered  with  irregular  elevations,  and  seamed  with  superficial  cicatrices  as  a  result 
of  persistent  chemical  irritation  of  slight  intensity. 

Chronic  tension  leads  to  a  similar  result.  A  leg  in  which  the  veins  or  lym- 
phatics are  obstructed  slowly  increases  in  size,  and  becomes  affected  by  what  is 
known  as  solid  (cdema,  from  the  resistance  it  offers  when  pressed  by  the  finger. 
The  exudation  becomes  organized  ;  the  amount  of  lowly  developed  fibrous  tissue 
increases;  the  muscles  waste;  the  skin  is  thickened,  bound  down,  and  hard,  and 
at  length  a  condition  practically  equivalent  to  elephantiasis  is  produced. 

Predisposing  causes  are  of  especial  importance  in  connection  with  chronic 
inflammation.  If  they  are  strongly  marked,  an  acute  attack  is  almost  sure  to 
become  chronic,  whether  the  exciting  cause  is  repeated  or  not.  A  single  abrasion, 
for  example,  is  sufficient  in  the  case  of  a  leg  which  is  congested  from  long-stand- 
ing venous  obstruction.  The  skin  is  badly  nourished  ;  in  certain  places — ^just 
above  the  ankle,  for  example — it  is  scarcely  able  to  hold  its  own  ;  if  the  cuticle  is 
rubbed  off,  or  a  tiny  vein  gives  way,  or,  in  short,  if  there  is  the  least  injury,  such 
as  in  any  other  part  of  the  body- would  not  attract  attention,  inflammation  sets  in, 
the  already  weakened  cells  and  fibres  perish,  and  then,  because  of  the  presence  of 
these  dead  structures,  or  the  friction  of  the  clothes,  or  the  tension  due  to  the  very 
slight  addition  of  blood  to  the  part,  it  becomes  chronic.  The  least  cause  is  suffi- 
cient to  depress  the  vitality  of  the  tissues  around  and  to  prevent  resolution. 

In  gout  and  rheumatism,  which  are  among  the  most  common  causes  of 
chronic  inflammation,  the  conditions  are  much  the  same.  In  each  the  nutrition 
of  the  tissues  is  so  gravely  involved  that  a  very  trivial  cause  gives  rise  to  an  acute 
attack,  and  sometimes  the  predisposition  is  so  strong  that  an  exciting  cause  is 
scarcely  needed.  At  first  the  attacks  subside  and  recovery  is,  to  all  intents  and 
purposes,  complete.  '  After  a  time,  however,  the  reparative  power  of  the  tissues 
becomes  more  and  more  impaired,  the  natural  condition  is  never  regained,  and 
the  inflammation  becomes  chronic.  The  predisposing  causes  have  grown  so 
strong  that  they  are  not  only  able  to  originate  an  attack  with  the  very  slightest 
assistance,  but  to  maintain  it,  too. 

Symptoms. 

The  general  symptoms  are  the  same  as  in  acute  inflammation,  but  much  less 
severe.  Increased  heat  is  often  scarcely  to  be  detected  ;  the  redness  is  always 
slight,  although  brown  discoloration  from  long-standing  hypersemia  is  often  pres- 
ent, especially  upon  the  legs,  where  gravity  favors  stasis  ;  and  the  pain  more 
frequently  takes  the  form  of  a  continuous  wearying  aching,  with  every  now  and 
then  a  more  severe  spasm  ;  but  even  when  suppuration  occurs,  it  never  assumes  a 
tense,  throbbing  character.  In  the  same  way  the  fever  is  slight,  and  the  loss  of 
function  much  less  noticeable,  partly,  no  doubt,  because  other  structures  compen- 
sate for  it,  and  the  patient  has  had  time  to  become  accustomed  to  it. 

With  swelling,  however,  the  case  is  different.  Exudation  is  always  present, 
but  only  a  small  proportion  of  it  is  fluid  ;  nearly  the  whole  is  composed  of  organ- 
ized elements,  many  of  them  escaped  leucocytes,  but  many  more  developed  from 
the  living  cells  in  the  tissues  round.  Whatever  may  be  the  case  in  acute  inflam- 
mation, whether  or  no  the  tissue-elements  take  any  share  then  in  the  production 
of  the  exudation,  in  the  chronic  form  there  is  no  doubt  they  do,  and  to  a  very 
considerable  extent.  Sometimes  the  part  is  greatly  increased  in  size ;  but  not 
unfrequently,  owing  to  retrogressive  changes,  its  bulk  is  actually  diminished  ; 
either  the  exudation,  after  replacing  the  natural  structures,  itself  undergoes 
degeneration  and  disappears,  or  it  becomes  organized  into  a  lowly  developed  form 


40         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

of  cicatricial  tissue,  which  contracts,  strangling  the  natural  structures,  and  render- 
ing the  organ  it  infiltrates  hard,  dense,  irregular,  and  contracted. 

Organization  is  the  prominent  feature  of  the  chronic  inflammation  that 
occurs  in  rheumatism.  The  articular  ends  of  the  bones  are  covered  with  dense 
irregular  nodules  \  the  shafts  in  some  cases  are  immensely  thickened  and  hardened  ; 
the  fibrous  tissue  round  the  joints  is  toughened  and  rigid,  and  a  similar  change 
is  met  with  in  connection  with  the  nerves,  the  walls  of  the  arteries,  and,  in  fact, 
any  connective-tissue  structure  that  is  attacked.  In  chronic  gout  the  ultimate 
effect  upon  the  exudation  is  complicated  by  the  addition  of  deposits  of  urate  of 
soda. 

In  some  of  these  affections,  in  which  the  prominent  feature  is  an  immense 
overgrowth  of  the  connective-tissue  type,  unaccompanied  by  pain,  increased  tem- 
perature, or  fever,  it  is  exceedingly  difficult  to  draw  a  distinction  between  chronic 
inflammation  and  hyperplasia,  especially  as  the  remedies  upon  which  reliance  is 
usually  placed  here  fail  completely.  Ostitis  deformans  is  an  example,  and  some 
of  those  cases  in  which  the  lymphatic  glands  are  immensely  enlarged  without 
undergoing  any  definite  alteration  in  structure.  It  is  more  than  questionable, 
however,  whether  an  attempt  at  such  a  refinement  could  succeed.  In  either  case 
there  is  an  impairment  of  nutrition,  resulting  generally  in  increased  size,  and 
always  in  imperfect  development  of  the  part,  and  caused  by  some  morbid  condi- 
tion of  the  tissues  or  of  the  blood.  It  is  not  possible  to  say  whether  this  is  to  be 
regarded  as  the  result  of  an  irritant  injuriously  affecting  one  particular  tis.sue,  and 
acquired  during  life,  or  of  some  natural  impairment  born  with  the  individual,  and 
probably  transmitted  to  him  from  his  ancestors. 

Treatment. 

The  principles  of  treatment  in  chronic  inflammation  are  the  same  as  in  the 
acute  form,  but  the  details  vary  considerably. 

1.  Removal  of  the  Cause. — In  some  few  cases  a  definite  exciting  cau.se 
can  be  found  and  removed ;  a  sequestrum,  for  example,  may  be  lying  locked  in 
the  medullary  canal  of  a  bone,  imable  to  escape ;  or  a  band  of  lymph  may  be  left 
tying  down  the  margin  of  the  iris.  In  the  majority,  however,  the  reason,  if  not 
for  the  outbreak,  at  least  for  its  persistence,  is  to  be  found  in  the  presence  of  some 
constitutional  affection  which  does  not  admit  of  such  speedy  treatment.  Mercury, 
given  in  small  doses  and  for  a  sufficient  length  of  time,  may  possibly  act  on  the 
syphilitic  virus  as  a  specific,  destroying  it,  or  at  least  prevent  it  from  having  any 
further  influence ;  but  very  few  other  drugs  possess  this  power.  Potassium  iodide, 
though  it  will  remove  the  effects,  certainly  cannot  stop  recurrences,  and  the  .same 
ma:y  be  said  of  colchicum  in  gout,  and  the  .salicylates  and  alkalies  in  rheumatism. 
They  relieve  the  symptoms  for  the  time ;  the  exudation  disappears  and  the  pain 
diminishes ;  but  the  cause  is  too  deeply  seated  in  the  nutrition  of  the  tissues  to  be 
removed  in  this  way. 

2.  Improvement  in  Nutrition.  General. — Many  of  the  exciting  causes 
are  of  very  slight  intensity ;  and  it  often  happens  that  if  only  the  general  nutri- 
tion can  be  a  little  improved,  the  tissues  gain  strength  enough  to  deal  with  the 
irritant  themselves.  It  is  to  this  improvement,  consequent  upon  the  entire  change 
of  life  and  habits,  that  so  many  of  the  foreign  bath  resorts  owe  their  reputation  in 
gout  and  rheumatism  ;  and  the  effect  produced  does  not  subside  at  once. 

The  i^articular  line  adopted  varies,  of  course,  with  the  complaint.  With  gout 
the  diet  should  be  sparing  and  light ;  stimulants  are  better  avoided,  at  any  rate  in 
the  earlier  periods  of  the  disease ;  the  bowels  should  be  kept  fairly  open,  and  any 
accumulation  of  uric  acid  in  the  blood  prevented  as  far  as  po.ssible  by  abundance 
of  fluid,  combined  with  the  moderate  use  of  alkalies.  Chronic  rheumatism,  on 
the  other  hand,  is  chiefly  benefited  by  residence  in  warm,  dry  climates ;  woolen 
clothing  ;  nutritive  but  unstimulating  food,  and  the  prolonged  use  of  baths,  especially 
sulphur  ones,  combined  with  internal  administration.     Tonics,  particularly  cod- 


INFLAMMA  TION.  41 

liver  oil  and  iron,  are  often  of  use  at  the  same  time  to  combat  the  condition  of 
ancemia  which  is  frecjuently  present.  By  measures  of  this  kind  not  only  is  the 
immediate  attack  checked  antl  cureil,  but  the  tissues  are  so  built  up  that  they  are 
better  able  to  resist  injurious  influences  of  the  same  character  afterward,  in  spite 
of  the  general  rule  (which  is  especially  true  of  this  variety  of  inflammation)  that 
one  attack  predis])oses  to  another. 

Local. — This  must  be  guided  very  largely  by  the  temperature  of  the  part. 
Subacute  attacks,  in  which  the  heat  is  considerable  and  the  i)ain  severe,  should  be 
treated  as  if  they  were  acute  ;  but  where  the  temjicrature  is  normal,  or  almost 
normal,  those  measures  answer  best  which  maintain  an  increased  but  uniform 
supply  of  blood.  Warmth  by  itself  is  beneficial,  but  alternating  with  cold  it 
produces  a  much  greater  effect.  Pouring  water  down  from  a  height,  douche-jets, 
and  needle-baths  are  exceedingly  powerful,  and  are  chiefly  of  use  where  the 
inflammation  is  past  and  only  its  effects  remain.  The  same  may  be  said  of  fric- 
tion, rubbing,  and  massage.  Carried  out  efficiently  these  have  immense  influence 
upon  the  circulation  ;  the  lymphatic  spaces  are  emptied,  the  effete  matter  pressed 
out,  the  flow  of  plasma  through  the  tissues  quickened,  and  the  nutrition  greatly 
improved. 

Counter-irritants  are  of  the  greatest  use  in  chronic  inflammation,  both  for 
the  relief  of  deep-seated  pain  and  the  diminution  of  tension  by  the  absorption 
of  the  exudation.  Rubefacients,  vesicants,  and  even  the  actual  cautery  are 
employed,  according  to  the  depth  of  the  structure  it  is  desired  to  affect  and  the 
duration  of  the  attack.  How  they  act  is  uncertain,  but  that  the  effusion  disap- 
pears, especially  when  they  are  repeated  at  frequent  short  intervals,  there  is  no 
question.  Setons,  and  other  methods  for  causing  continued  suppuration,  are 
rarely  used  now. 

Mercury  and  iodine  are  supposed  to  possess  a  special  action  in  promoting  the 
absorption  of  the  products  of  chronic  inflammation  ;  but,  apart  from  the  results 
they  produce  as  counter-irritants,  and  in  syphilitic  affections,  it  is  doubtful  if  they 
are  not  overrated.  Potassium  iodide,  however,  has  a  very  considerable  effect  upon 
vascular  tension.  Superficial  forms  of  inflammation — on  mucous  membranes,  for 
example — ^are  sometimes  benefited  by  the  action  of  local  astringents ;  and  when 
there  is  a  considerable  degree  of  effusion,  as  in  chronic  synovitis,  pressure,  in  con- 
junction with  counter-irritation,  may  be  applied  with  great  advantage. 


42         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 


CHAPTER  II. 

DISEASES  DUE   TO  NOX-IXFECTn'E  ORGANISMS. 

Of  these  there  are  only  two — septic  fever  and  sapraemia. 

These  diseases  are  caused  by  the  absorption  from  the  surface  of  a  wound  of 
certain  poisons  produced  during  the  fermentation  or  decomposition  of  albuminous 
liquids.  Probably  they  are  ptomaines,  analogous  to  the  bodies  formed  in  the 
alimentary  canal.  If  they  enter  the  blood,  they  act  as  virulent  poisons,  the  sever- 
ity of  the  symptoms  depending  upon  the  amount  of  the  dose  :  and  they  may 
cause  a  fatal  result  within  a  few  hours.  On  the  other  hand,  they  do  not  multiply 
in  the  blood,  which  therefore  is  not  infective  if  it  is  inoculated  ;  they  are  excreted 
slowly  by  the  kidneys  (ptomaines,  probably  formed  in  the  alimentary  canal,  are 
found  in  the  urine  and  saliva),  and  if  the  patient  survives  the  iirst  effect  and  the 
dose  is  not  repeated,  the  constitutional  symptoms  gradually  subside.  There  is  no 
incubation  period,  and,  other  things  being  equal,  a  large  wound,  or  one  that 
exposes  a  large  absorbent  surface,  such  as  the  peritoneum,  is  much  more  likely  to 
be  attended  with  a  .severe  attack  than  a  small  one. 

Septic  Fever. 

Subcutaneous  injuries  in  which  decomposition  (in  the  sense  of  putrefaction) 
never  takes  place  are  often  followed  by  a  certain  degree  of  fever,  due  either  to 
tension  or  to  absorption  from  the  seat  of  injury  of  some  of  the  products  of  tissue 
destruction,  of  which  the  "  fibrin-ferment  "  is  one,  and,  perhaps,  the  most  import- 
ant. It  sets  in  very  shortly  after  the  injury,  attains  its  maximum  within  twenty- 
four  hours,  and  then,  unless  some  other  irritant  is  present  as  well,  begins  to  fall 
again.  In  addition  to  this,  however,  wounds  that  are  exposed  to  the  air  are  liable 
to  be  followed  by  another  and  more  severe  disorder  caused  by  absorption  from  the 
surface  of  the  products  of  decomposition. 

This  does  not  commence  for  some  days,  generally  two  or  three  after  the 
injury  ;  then  it  rapidly  attains  its  maximum,  persisting  for  three  or  four  more, 
and  at  the  end  of  the  fifth  or  sixth,  if  the  wound  is  thoroughly  drained,  the  tissues 
healthy  and  well  nourished,  and  no  complication  arises,  begins  to  subside  again. 
Naturally,  septic  fever  rarely  occurs  by  itself;  in  by  far  the  majority  of  cases  it 
follows  the  true  traumatic  fever  before  this  has  had  time  to  disappear,  and  in  its 
turn  is  followed  by  that  which  accompanies  suppuration. 

At  the  commencement  there  is  often  a  feeling  of  chilliness,  but  rarely  a 
distinct  rigor ;  nausea  and  vomiting  are  not  unusual ;  there  is  headache,  with 
extreme  depression  ;  the  temperature  rises  to  102°  or  103°  F.;  the  skin  is  hot  and 
dry,  the  face  flushed,  the  bowels  confined,  and  the  tongue  thickly  furred.  The 
appetite  is  completely  lost ;  the  pulse  is  full  and  rapid,  and,  especially  in  the  case 
of  children  and  people  with  an  excitable  temperament,  there  is  often  slight 
delirium  at  night.  The  edges  of  the  wound  are  red  and  swollen  ;  the  skin  for 
some  distance  around  is  exceedingly  tender  and  very  hot ;  while  the  surface,  if  it 
is  visible,  is  probably  covered  over  with  grayish-yellow  sloughs,  and  discharges  a 
thin,  turbid,  and  somewhat  offensive  fluid. 

Treatment. — The  first  thing  is  prevention.  If  it  is  too  late  for  this, 
further  decomposition  must  be  stopped,  either  by  irrigation  with  an  antiseptic, 
or,  better,  by  placing  the  part,  if  it  can  be  done,  in  an  antiseptic  bath  ;  but  I  have 
known  a  sloughing  wound  of  the  hand  remain  for  three  days  in  a  corrosive  subli- 
mate bath  (i  in  5000,  renewed  every  three  hours)  without  the  smell  being  over- 
come. 


SEPTIC  FEVER— S APR ^ MIA.  43 

In  addition  to  this,  the  absorption  must  be  stopped  as  soon  as  possible  by 
the  most  thorough  drainage  and  by  encouraging  the  wound  to  secrete.  Warm 
fomentations  and  warm  baths  are  especially  grateful ;  the  tension  is  relieved  ;  the 
throb])ing  pain  sul)sides  ;  the  blood  circulates  more  easily;  the  plasma  and  the 
leucocytes  pour  out  more  freely  through  the  walls  of  the  vessels ;  the  process  of 
destruction  ceases,  and  a  barrier  of  vascular  granulation-tissue  is  formed,  to  throw 
off  dead  cohering  fragments  and  prevent  the  absorjjtion  of  any  more  of  the  poison. 
If  the  tension  is  completely  relieved,  the  temperature  falls  to  normal ;  if,  on  the 
other  hand,  the  discharge  is  retained,  it  rises  regularly  of  an  evening,  assuming 
the  remittent  type  as  suppuration  follows,  and  gradually  passes  into  hectic. 

Constitutional  treatment  should  not  be  neglected,  but  so  long  as  the  cause 
continues  at  work,  it  can  give  but  a  very  small  measure  of  relief. 

Sai'r.f.mia. 

Sapra;mia,  or  septic  intoxication,  is  the  name  given  to  the  most  intense  variety 
of  septic  fever.  It  occurs  under  the  same  conditions  and  is  caused  in  the  same 
way — by  the  absorption  from  the  surface  of  a  wound  of  some  ptomaine  formed 
during  fermentation.  Probably  the  particular  variety  is  not  always  the  same  and 
certainly  putrefaction,  with  the  formation  of  offensive  gases,  is  not  necessary. 
Clinically,  it  is  probably  very  rarely  met  with  by  itself;  but,  like  the  preceding, 
it  is  present  as  a  complication  in  all  extensive  wounds,  especially  tho.se  in  which  a 
large  amount  of  blood  is  allowed  to  accumulate  and  undergo  decomposition 
exposed  to  the  air. 

Substances  of  a  similar  character  are  formed  in  the  decomposition  of  pre- 
served meats,  sausages,  and  the  like,  and  when  swallowed  cause  all  the  symptoms 
of  violent  irritant  poisoning — vomiting,  purging,  etc.,  followed  by  profound  col- 
lapse, coma,  and,  if  the  dose  is  sufficient,  death  within  a  very  few  hours. 

The  constitutional  symptoms  resemble  to  some  extent  those  of  septic  fever, 
but  they  are  much  more  severe.  In  most  cases,  those  especially  in  which  putrefac- 
tion is  present,  the  wound  is  acutely  inflamed  ;  but  I  have  known  it,  after  an 
amputation  through  the  knee-joint,  progress,  to  all  appearance,  as  well  as  could  be 
wished,  while  the  patient's  temperature  was  gradually  rising  higher  and  higher 
and  the  pulse  becoming  weaker  and  more  feeble.  The  only  local  sign  to  attract 
attention  was  the  presence  of  a  thin  serous  discharge  in  enormous  quantities. 
Much  more  frequently,  however,  putrefaction  is  present,  and  various  forms  of 
infective  germs  as  well. 

The  pathological  appearances  present  no  distinctive  feature  of  any  kind. 
The  blood  either  does  not  coagulate  or  else  forms  a  loose,  soft,  black  clot  which 
readily  breaks  down.  The  lining  of  the  vessels  and  the  endocardium  are  often 
stained,  and  sometimes  marked  by  actual  ecchymoses,  which  also  occur  on 
the  serous  surface  of  the  viscera,  and  at  times  in  their  interior.  The  spleen  is 
enlarged  and  softened  ;  the  liver  and  the  lungs  are  congested  ;  the  structure  of 
the  viscera,  on  section,  is  confused  and  blurred,  especially  in  the  case  of  the 
kidneys ;  and  the  mucous  membrane  of  the  alimentary  canal  is  frequently  in  a 
condition  of  acute  inflammation,  especially  if  the  poisonous  substance  has  been 
swallowed.  When  it  is  slowly  absorbed  from  the  surface  of  a  wound,  intestinal 
lesions  are  not  usually  present  in  man,  though  they  are  not  uncommon  in  the  case 
of  animals.  Decomposition  after  death,  as  in  many  other  forms  of  sei)tic  diseases, 
is  unusually  rapid. 

At  the  commencement  there  is  usually  a  rigor  or  an  attack  of  vomiting ;  the 
temperature  sometimes  rises  rapidly,  without  any  apparent  reason,  to  104°  or  105° 
F.;  sometimes,  on  the  other  hand,  especially  in  the  more  severe  cases,  it  rises  a 
little  at  the  first,  and  then  falls  again,  even  becoming  subnormal.  The  pulse  is 
quick  and  feeble,  the  respiration  hurried  and  shallow.  The  extremities  are  cold, 
while  the  trunk,  perhaps,  is  burning  hot ;  the  tongue  is  dry  and  brown,  and  the 
lips  and  teeth  covered  with  sordes.    Diarrhoea,  with  blood-stained  stools,  is  usually 


44         GENERAL   PATHOLOGY  OF  SURGICAL  DISEASES. 

present  in  artificially-produced  saprcxmia,  but  is  not  frecpient  in  man.  As  the  tem- 
perature rises  the  patient  becomes  delirious ;  the  prostration  is  extreme  ;  the  pulse 
is  almost  imperceptible  ;  the  forehead  becomes  covered  with  perspiration  ;  the 
face  grows  more  and  more  dusky,  and  at  length,  if  the  dose  is  sufficient,  or  if  it 
is  repeated,  the  patient  sinks  into  a  state  of  collapse,  and  the  heart  fails  com- 
pletely. 

Treatment. — The  local  treatment,  as  in  the  case  of  septic  fever,  consists 
simply  in  thorough  drainage,  combined  with  the  use  of  antiseptics.  If  the  wound 
is  on  one  of  the  extremities,  nothing  is  more  successful  than  a  corrosive  sublimate 
bath  (one  part  in  5000)  ;  if  this  is  impracticable,  it  should  be  thoroughly  irri- 
gated, great  care  being  taken  not  to  injure  the  surface.  The  object  is  to  prevent 
further  fermentation  and  absorption ;  if  this  can  be  accomplished,  and  the 
patient's  kidneys  are  sound,  so  that  the  poison  is  eliminated,  the  prognosis  is 
good,  in  uncomplicated  cases.  Unhappily,  sapraemia  is  usually  merely  an  addi- 
tion to  other  even  more  serious  affections. 

It  has  been  suggested  that  where  any  definite  nervous  symptoms  are  present, 
which  it  is  known  can  be  counteracted  by  the  action  of  other  alkaloids^-dilata- 
tion  of  the  pupil,  for  example — an  attempt  should  be  made  in  this  direction  ; 
but  cases  in  which  this  would  be  practical  must  be  very  rare.  After  the  acute 
symptoms  have  subsided,  the  anaemia  and  exhaustion  left  must  be  combated  by 
iron,  tonics,  and  a  nutritious  diet. 

Affections  similar  to  septic  fever  and  sapraemia  are  stated  to  have  been  caused 
by  the  injection  into  the  blood  of  pepsin,  trypsin,  and  other  unorganized 
ferments. 

[Surgical  (Traumatic)  fever  is  the  designation  applied  to  the  ephemeral  fever 
which  frequently  appears  after  a  wound  or  injury.  It  is  due  either  to  the  absorp- 
tion of  minute  debris  of  tissue  necrosis  or  to  their  oxidation. 

Intestinal  Toxemia  is  a  term  used  to  designate  a  condition  in  which  the 
ptomanies  of  putrefaction  are  absorbed  from  the  intestinal  walls,  and  thus  enter 
the  circulation.  Metastatic  abscesses  may  arise  in  this  way.  Intoxication  from 
this  source  with  pyrexia  may  be  confused  by  the  observer  with  sapraemic  and 
septicaemic  processes.] 


SUPPURATION.  45 


CHAPTER  III. 

DISEASES  DUE   TO  INFECTIVE  ORGANISMS. 

Pathogenic  organisms  are  divided  into  two  distinct  classes,  specific  and  non- 
specific. The  former  are  always  followed  by  the  same  di.sorder  under  whatever 
circumstances  they  occur,  whether  they  cause  local  and  constitutional  symptoms 
(anthrax,  syphilis,  etc.),  or  constitutional  ones  only  (hydrophobia  and  tetanus)  ; 
the  latter,  the  non-specific  ones,  according  to  the  modes  of  infection  and  the 
condition  of  the  tissues,  give  rise  to  a  variety  of  diseases — suppuration  with  its 
consequences,  hectic  and  albuminoid  degeneration,  ulceration,  gangrene,  phage- 
daena,  pysemia,  and  many  others. 

I.   NON-SPECIFIC. 
SUPPURATION. 

It  is  still  open  to  question  whether  suppuration  can  occur  from  merely 
mechanical  or  chemical  irritants,  however  persistently  they  act.  As  a  matter  of 
fact,  as  Ogston  was  the  first  to  show,  certain  forms  of  organisms — staphylococci 
or  streptococci  in  the  vast  majority  of  cases — are  invariably  present  in  acute 
abscesses,  whatever  share  they  take  in  their  cau.sation. 

They  enter  either  through  a  wound  or  through  the  mucous  membranes,  and 
travel  by  means  of  the  lymphatics  or  blood-vessels.  Some  (staphylococci  for  the 
most  part)  lead  to  circumscribed  abscesses ;  others  (streptococci)  spread  by  the 
lymphatics  and  are  followed  by  diffuse  suppuration.  If  the  tissues  are  healthy 
they  can  do  nothing — either  they  are  killed  or  discharged  in  the  urine.  (It  has 
been  suggested  that  some  are  got  rid  of  by  the  medium  of  the  parotid,  thus  offer- 
ing an  explanation  of  the  extreme  frequency  of  what  has  been  called  parotid 
bubo  after  operations  and  in  the  course  of  pyaemia ;  but  it  is  at  least  equally 
possible  that  the  organisms  enter  the  gland  through  the  duct.)  If,  however,  they 
are  arrested  in  a  part  the  nutrition  of  which  is  impaired  by  injury  of  any  kind — 
mechanical,  chemical,  or  physical — particularly  if  there  is  any  extravasated  blood  ; 
or  if,  as  in  pyaemia,  they  are  present  in  such  numbers  that  whole  districts  of 
capillaries  are  simultaneously  plugged,  further  changes  take  place  in  the  surround- 
ing tissue  and  suppuration  begins. 

The  effect  is  most  characteristic  in  cases  of  simple  inflammation.  The  blood 
in  the  centre  of  the  affected  area  has  ceased  to  move ;  in  the  rest  of  the  vessels  it 
is  circulating  very  slowly ;  the  plasma  round  the  injured  cells  has  coagulated,  and 
all  round  the  tissues  near  are  in  a  state  of  immense  activity  ;  the  vessels  are 
dilated,  the  volume  of  plasma  is  increased,  the  number  of  free  leucocytes  is 
greater  than  ever,  and  every  effort  is  being  made  by  the  developing  granulation- 
tissue  to  absorb  and  replace  the  damaged  structures.  Suddenly  a  mass  of  staphy- 
lococci is  brought  to  the  part,  either  through  a  wound  or  the  blood-stream.  In  the 
stagnant  plasma  and  among  the  injured  tissues  they  find  a  most  favorable  soil ;  the 
structures  among  which  they  lie  at  once  begin  to  lose  their  distinctness  of  outline, 
the  fibres  swell  up,  become  homogeneous  and  almost  translucent ;  the  leucocytes 
perish,  and  a  ring  of  what  is  called  coagulation-necrosis  forms  round  the  ma.ss  of 
germs  and  spreads  wider  and  Avider.  After  a  time  the  centre  becomes  licjuid,  and 
then  a  minute  abscess  is  formed,  lying  in  the  middle  of  the  inflamed  tissues. 
Many  of  these  small  foci  are  usually  situated  close  together,  and,  as  they  extend 
and  widen,  the  intervening  barriers  soon  break  down. 

Meanwhile,  the  tissues  farther  away  from  the  irritant  strive  to  protect  them- 
selves by  throwing  out  a  wall  of  lymph.    At  first,  while  the  infection  is  still  active, 


46         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

this  melts  away  as  rapidly  as  it  is  produced,  the  leucocytes  perish  and  drop  off  as 
pus,  and  the  debris  of  the  tissues  and  the  plasma  (which  is  prevented  from  coagu- 
lating by  the  ptomaines)  add  to  the  amount.  By  degrees,  however,  the  activity 
of  the  germs  decreases,  the  wall  of  living  leucocytes  grows  thicker,  new  vessels  are 
developed  from  the  dilated  ones  around,  and  at  length  a  "  pyogenic  membrane  " 
[limiting  fibrine]  is  formed  and  the  spread  of  the  suppuration  is  checked.  It  rarely 
happens,  however,  that  it  is  stayed  altogether.  Owing  to  the  extreme  hyperaemia 
in  all  the  parts  near,  the  tension  of  the  fluid  in  the  interior  is  unusually  high,  and, 
aided  by  this,  the  action  of  the  germs  remains  sufficiently  powerful  to  continue 
the  destruction  in  the  direction  of  least  resistance.  Sometimes,  owing  to  the 
presence  of  dense  sheets  of  fascia,  the  pus  spreads  laterally  for  immense  distances 
among  the  tissues ;  but  sooner  or  later  its  course  turns  toward  the  surface,  the  skin 
or  mucous  membrane,  as  the  case  may  be,  gives  way,  and  the  abscess  breaks  and 
discharges  its  contents. 

[The  law  in  regard  to  the  "  pointing  "  of  an  abscess  is  that  pus  is  forced  to 
the  surface  in  the  line  of  least  resistance.] 

When  the  nutrition  of  the  tissues  is  impaired  by  intemperance  or  prolonged 
residence  in  foul  air,  in  pyjemia,  and  during  convalescence  from  exhausting 
illness,  suppuration  sometimes  occurs  without  local  injury.  The  capillaries  are 
plugged  with  micro-organisms  at  some  small  spot,  and  the  walls  of  the  vessels 
themselves  are  the  first  to  perish  and  melt  away.  In  such  cases  as  these,  or  when 
the  streptococcus  pyogenes  gains  early  access  to  the  lymphatic  spaces  and  spreads 
through  them  before  the  tissues  can  resist,  a  pyogenic  membrane  is  never  formed ; 
the  suppuration  is  diffuse ;  the  strength  of  the  tissues  is  so  enfeebled  that  they 
disappear  before  the  invading  germs,  unable  to  protect  themselves  by  a  barrier  of 
any  kind. 

Abscess,  or  Circumscribed  Suppuration. 

Abscesses  are  acute  or  chronic,  according  to  the  intensity  of  the  symptoms 
by  which  they  are  attended  and  the  rapidity  with  which  they  spread.  The 
latter  are  probably  due  to  the  same  causes  as  the  former,  acting  under  less  favor- 
able conditions.  Those,  however,  that  result  from  the  softening  and  liquefaction 
of  masses  of  caseous  material  must  be  distinguished  ;  they  are  al\\-ays  associated 
with  the  presence  of  specific  germs,  and  for  a  long  time,  at  least  so  long  as  they 
are  chronic,  do  not  contain  true  pus.  It  must  be  admitted  that  it  is  not  always 
easy  to  draw  a  definite  line  between  them. 

Pus  from  an  acute  abscess  in  an  otherwi.se  healthy  person  is  a  thick,  creamy, 
opaque,  yellowish-white,  or  greenish  fluid,  with  an  alkaline  reaction  and  a  specific 
gravity  of  1030  to  1035.  ^^"^  color  is  due  to  the  presence  of  small  quantities  of 
altered  haemoglobin  :  when  it  is  red  and  mixed  with  blood  it  is  known  zs  sa?iious  ; 
if  it  is  thin  and  watery  it  is  called  ichorous,  and  curdy  when  mixed  with  flakes  of 
caseous  material.  Sometimes,  when  it  comes  from  a  mucous  membrane,  it  is 
known  as  muco-pus ;  it  may  be  i?ifective  from  the  presence  of  micro-organisms, 
and  sometimes  specific  when  it  conveys  the  germs  that  give  rise  to  definite  dis- 
eases. In  the  neighborhood  of  the  alimentary  canal  it  not  unfrequently  has  a 
jjeculiarly  offensive  odor,  although  there  is  no  direct  communication,  and  the 
same  thing  is  often  noticed  in  connection  with  dead  bone.  In  a  few  rare  in- 
stances its  color  is  blue,  owing  to  the  presence  of  a  special  organism  {bacillus 
pyocyaneus). 

[This  bacillus  resembles  the  blue-milk  bacillus  {bacillus  cyanogenus)  and 
belongs  to  the  semi -anaerobic  species.  According  to  Ernst,  there  are  two 
varieties  of  this  organism,  the  second  having  a  green  pigment.] 

Pus  consists  of  pus-corpuscles  mixed  with  germs,  floating  in  a  highly  albuminous 
fluid.  The  corpuscles  themselves  are,  some  of  them,  identical  with  leucocytes, 
and  these  are  alive,  capable  of  amoeboid  movements,  but  the  vast  majority  are 
dead.  They  are  round,  slightly  irregular  on  the  surface,  about  ttsimj  of  an  inch  in 
diameter,  and  granular.     The  nucleus  is  generally  bifid  or  trifid.  and  sometimes 


SUPPURA  no  N— ABSCESS.  47 

actually  di\  idcd  into  two  or  three.  The  granules  are,  many  of  them,  soluble  in 
acetic  acid,  so  that  when  this  is  added  the  outline  of  the  nucleus  becomes  more 
distinct ;  but,  after  the  i)us  has  been  some  time  in  existence,  they  chiefly  consist  of 
fat.  In  very  old  collections  fatty  degeneration  is  comjjlete,  the  corpuscles  are 
entirely  broken  uj),  and  nothing  is  left  but  a  thick,  jnitty-like,  caseous  material 
mixed  with  cholesterin  crystals.  The  germs,  for  the  most  part,  are  streptococci 
or  staphylococci.  The  fluid,  unlike  plasma,  has  no  power  of  coagulating ;  it  con- 
tains a  large  quantity  of  albumin  and  chloride  of  sodium,  with  small  amounts  of 
leucin,  tyrosin,  and  other  substances.  Lime-salts  and  phosphates  are  present  to  a 
considerable  extent,  chiefly  in  the  corjniscles. 

When  suppuration  is  very  acute,  shreds  and  sloughs,  composed  of  the  denser 
tissues,  such  as  fasciae  and  tendons,  are  usually  found  floating  in  the  pus;  their 
vitality  naturally  is  low,  and  the  inflammation  around  them  has  killed  then  en 
masse — in  other  words,  they  are  examples  of  necrosis  and  inflammatory  gangrene 
on  a  small  scale.  .  Had  they  been  of  looser  texture  and  more  vascular  they  would 


jj^ 


4^ 


Fig.  5. — Pus  from  an  acute  abscess  at  time  of  evacuation.     Dried  and  treated  with  methyl  violet.   (X  700.) 

Pus  corpuscles,  between  which  may  be  seen   the  thin  film  of  coagulated  albuminoid  material.     Pair  of  micrococci. 

Diplococcus.     Chains  of  micrococci.     Streptococci.     Sets  of  four.     Tetrads.    {^A/ter  Woodhead.) 

have  melted  away,  digested  by  the  peptonizing  action  of  the  cocci,  and  helped  to 
form  the  albuminous  fluid. 

Symptoms.  Local. — These  at  first  are  the  same  as  those  of  inflammation, 
well  marked  in  the  acute  form,  very  indistinct  in  the  chronic  ones.  Then,  as  fluid 
begins  to  make  its  appearance,  the  character  of  the  swellitig  changes.  At  the 
commencement,  if  it  is  near  the  skin,  it  is  bright  red  and  firm  to  the  touch ;  the 
surface  is  shining  and  pits  on  pressure  {inflammatory  cedema)  and  the  depression 
so  formed  is  well  defined  and  is  slow  in  filling  up  again.  By  degrees,  as  the  foci 
run  together  and  the  pus  begins  to  collect,  the  centre  becomes  softer  and  more 
dusky,  the  abscess  is  pointing ;  then  the  skin  near  the  middle,  where  it  is  most 
undermined,  bulges  out  a  little,  the  cuticle  peels  off,  suddenly  a  small,  round 
opening  makes  its  appearance,  and  the  pus  is  discharged.  In  many  cases,  shortly 
before  this  happens,  a  soft  circular  spot  with  sharply  defined  edges,  marking  infal- 
libly the  part  through  which  the  pus  will  appear,  is  felt  on  gently  passing  the 
finger  over  the  surface. 


48         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

When  the  abscess  is  of  any  size,  the  existence  of  fluid  is  detected  by  what  is 
termed  fluctuation — the  wave  felt  by  the  fingers  of  one  hand  when  [pressure  is 
made  with  the  other  upon  a  distant  part.  With  large  collections  of  fluid  this  can 
be  made  out  at  once,  the  amount  of  the  displacement  is  so  great ;  but  with  small 
ones,  especially  when  they  are  deep-seated  or  tied  down  by  unyielding  sheets  of 
fascia,  it  is  often  a  matter  of  extreme  difficulty.  At  the  same  time  it  is  impossible 
to  overrate  its  importance.  The  further  apart  the  fingers  of  the  two  hands  can  be 
placed  the  better.  The  pulps,  not  the  tips,  should  rest  upon  the  .skin ;  two  should 
be  used  if  possible,  but  in  many  instances  there  is  only  room  for  one  of  each 
hand ;  those  of  the  one  should  maintain  a  slight  but  perfectly  uniform  pressure 
upon  the  skin,  those  of  the  other  should  be  gently  but  firmly  pu.shed  down  at 
short  regular  intervals,  and  before  a  definite  opinion  is  formed  the  action  should 
be  reversed.  Of  course,  fluctuation,  even  when  the  diagnosis  is  correct,  can  only 
be  taken  as  a  proof  of  the  presence  of  fluid  ;  it  is  no  ]jroof  of  its  nature,  which 
may  or  may  not  be  inflammatory. 

In  testing  a  part  of  the  body  in  this  way  there  are  many  sources  of  fallacy. 
An  excellent  imitation  of  fluctuation  is  obtained  over  a  healthy  muscle  if  the 
hands  are  placed  side  by  side  upon  it,  so  that  the  wave  is  transverse.  Soft,  solid 
growths  are  so  perfectly  elastic  that  the  .same  sensation  is  produced  over  them, 
and,  though  the  distinction  is  of  less  importance,  as  suppuration  is  almost  sure  to 
follow,  areolar  tissue  infiltrated  with  inflammatory  oedema  often  fluctuates  dis- 
tinctly ;  fluid  is  actually  present,  but  instead  of  being  confined  in  one  central  cav- 
ity, it  is  spread  about  in  the  loosely  woven  and  softened  network  of  fibres.  In 
deep-seated  abscesses,  especially  those  which  are  tied  down  beneath  dense  sheets 
of  fascia,  as  in  acute  periostitis,  the  oedematous  swelling  in  the  looser  and  more 
superficial  tissue  is  so  great  that  this  false  sense  of  fluctuation  is  all  that  can  be  felt. 
As,  however,  in  itself  it  is  almost  diagnostic  of  the  condition  beneath,  this  is  of 
less  importance. 

In  addition  to  this,  the  character  of  the  pain  changes  as  suppuration  sets  in. 
TJu-ohhing  is  met  with  under  other  conditions,  but  it  is  seldom  or  never  absent 
when  pus  is  forming  rapidly,  especially  if  it  is  tightly  bound  down,  and  tenderness 
too  often  becomes  much  more  distinct  and  localized. 

Constitutional. — The  fever  that  attends  the  formation  and  discharge  of  pus  is 
in  many  respects  highly  characteristic. 

At  the  commencement  this  is  very  often  a  rigor  or  shivering  fit.  This 
begins  with  a  sense  of  chilliness,  or  actual  cold,  which  may  last  only  a  few 
minutes,  or  may  continue  half  an  hour.  At  the  same  time  there  is  a  feeling  of 
extreme  prostration.  The  skin  is  pale,  livid,  and  rough  ;  the  face  is  pinched  ;  the 
eyes  are  sombre  and  surrounded  by  dusky  rings  ;  the  respiration  is  hurried  and 
shallow ;  and  the  pulse  small,  frequent,  and  feeble.  Even  at  this  time  the  tem- 
perature is  higher  than  normal  ;  the  rise  begins  before  the  shivering,  continues  all 
through  it  (so  that  while  the  teeth  are  chattering  the  skin  is  scorching),  and 
through  the  period  of  dry,  burning  heat  afterward,  until  sometimes  it  reaches 
io6°  F.  As  soon  as  it  ceases,  profuse  perspiration  sets  in,  the  temperature  begins 
to  fall,  the  face  becomes  flushed,  the  involuntary  muscular  fibre  in  the  skin 
relaxes,  the  natural  texture  returns,  and  there  is  a  sensation  of  profound  relief, 
although  the  weakness  and  exhaustion  afterward  are  often  extreme.  Not  unfre- 
quently  a  herpetic  eruption  makes  its  appearance  around  the  lips  the  day  after  a 
rigor,  and  in  some  cases  spreads  over  the  lower  j^art  of  the  face. 

Typical  rigors  are  by  no  means  confined  to  the  onset  of  suppuration.  They 
occur  at  the  commencement  of  many  of  the  specific  fevers,  and  in  pneumonia  and 
pyaemia.  The  first  passage  of  an  instrument  down  the  urethra  may  cause  one,  or 
the  first  micturition  after  an  operation.  Those  who  sufter  from  ague  are  particu- 
larly susceptible  to  the  urethral  form,  but  nothing  of  the  kind  has  been  proved  in 
reference  to  others.  In  children  vomiting  and  convulsions  occur  instead,  and  in 
acute  catarrhal  inflammation,  and  sometimes  in  other  forms,  there  is  a  succession 
of  slight  chills,  la.sting  for  many  hours,  instead  of  one  definite  one.     The  ultimate 


SUFPURA  T/ON— ABSCESS.  49 

cause  is  unknown.  No  doubt,  from  the  symi)tonis,  they  are  due  to  the  action  of 
the  nervous  system,  the  medulla  oblongata  and  the  higher  centres  that  control  the 
production  of  heat  in  i)articular,  but  it  is  not  known  what  the  stimulus  is  nor 
how  it  acts.  The  suppurative  rigor  and  that  which  heralds  acute  specific  fevers 
may  be  caused  by  the  absorjjtion  of  some  poi.son  into  the  blood  ;  and  Harrison 
believes  that  this  is  true  of  urethral  ones  as  well,  the  ptomaines  present  in  the 
urine  being  al)S()rbetl  through  abrasions  of  the  mucous  mem])rane  after  micturition  ; 
but  it  is  more  probable  that  these  are  due  to  reflex  irritation,  whatever  ma)'  be  the 
cause  of  the  others. 

The  subsecpient  course  of  the  fever  in  acute  suppuration  dej^ends  upon  the 
amount  of  absorption.  In  deep-seated  inflammation  the  temperature  frequently 
continues  to  rise  until  the  wall  of  granulation-ti.ssue  is  establi.shed  ;  then  it  usually 
drops  slightly  of  a  morning  (rarely  a  degree),  rising  again  to  its  former  level  of 
an  evening.  As  soon  as  the  abscess  is  opened  and  tension  relieved,  absorption 
ceases  altogether,  the  temperature  falls  to  the  normal,  and  if  the  drainage  is  what 
it  ought  to  be,  and  decomjwsition  does  not  occur,  it  does  not  ri.se  again. 

Suppurative  fever  must  be  distinguished  from  septic  fever,  although  the  two 
often  occur  together. 

If  the  sui)purative  variety  occurs  alone,  it  pursues  the  course  already  described, 
the  severity  depending  uj^on  the  tension.  Sometimes,  therefore,  as  in  thecal 
abscess  or  whitlow,  although  the  amount  of  pus  is  very  small,  the  constitutional 
symptoms  are  exceedingly  sever.e. 

If  the  two  are  present  together  they  cause  hectic,  the  temperature  continues 
to  rise  of  an  evening  (although  it  may  be  normal  of  a  morning),  and  the  strength 
of  the  patient  fails  until,  if  the  cause  is  not  removed,  death  ensues  from  ex- 
haustion. 

If  sei)tic  fever  occurs,  suppuration  is  sure  to  follow,  unless  the  case  proves 
fatal  too  soon.  In  a  recent  wound — a  compound  fracture,  for  example — in  which 
the  planes  of  cellular  tissue  up  and  down  the  limb  are  filled  with  extravasated 
blood,  traumatic  fever  sets  in  first,  with  or  without  shock.  Then,  if  decomposition 
takes  place,  septic  fever  follows,  the  limb  becomes  red  and  swollen,  the  tempera- 
ture rises,  delirium  sets  in,  and  the  patient  may  die  from  acute  blood-poisoning 
before  there  is  time  for  suppuration.  If  he  escape  this,  the  pyogenic  organisms 
gain  access  to  the  part,  the  tissues,  injured  already  by  the  action  of  the  septic 
poison,  melt  away  as  pus,  and  in  five  or  six  days  the  fever  begins  to  assume  the 
suppurative  type.  After  a  time,  unless  the  result  is  fatal  in  the  meanwhile  from 
exhaustion  and  hectic,  the  structural  elements  around  regain  their  strength,  a 
barrier  of  granulation-ti.ssue  is  thrown  out,  the  temperature  falls  of  a  morning, 
although  it  still  continues  to  rise  in  the  evening ;  and  by  degrees,  if  no  further 
injury  is  inflicted,  the  suppurating  area  contracts,  the  absorption  of  the  products 
of  decomposing  pus  ceases,  and  the  fever  subsides. 

Varieties  of  Abscess. 

Acute  or  Phlegmonous  Abscess. — This  is  usually  taken  as  the  type  of  an 
abscess.  All  the  symptoms  are  present,  constitutional  as  well  as  local,  and  they 
are  severe  in  proportion  to  its  size  and  the  degree  of  tension.  Throbbing  pain, 
heat,  swelling,  redness,  and  fever  are  well-marked  ;  inflammatory  oedema  is  always 
present  over  it,  and  fluctuation  makes  its  appearance  at  an  early  period,  varying, 
of  course,  according  to  the  depth.  If  it  is  not  opened  it  makes  its  way  in  the 
direction  of  least  resistance,  undermines  the  skin,  and  bursts ;  the  cavity  contracts 
at  once,  and  unless  some  cause,  such  as  a  foreign  body  or  a  piece  of  dead  bone, 
keeps  up  the  irritation,  the  granulations  fall  together  as  it  collapses,  and  repair  is 
completed  in  a  very  short  time  by  their  organization. 

Metastatic  abscesses  are  a  variety  of  the  acute  form  occurring  in  connection 
with  pyaemia.  They  are  sometimes  described  separately  because  of  their  distinctly 
embolic  origin  ;  but  if  the  view^  that  suppuration  is  due  to  the  action  of  cocci, 


50         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

conveyed  to  a  distant  part  of  the  body,  sometimes,  at  least,  by  the  blood-stream, 
is  correct,  the  distinction  does  not  appear  a  material  one. 

Caseous  abscesses  are  due  to  the  breaking  down  of  old,  tubercular,  syi)hilitic, 
or,  in  rare  instances,  epitheliomatous  deposits.  They  are  most  common  in  con- 
nection with  tubercular  disease  of  the  bone,  especially  of  the  spinal  column  ;  but 
they  often  originate  in  the  lymj)hatic  glands  or  the  subcutaneous  tissues — in  any 
place,  in  short,  in  which  a  caseous  deposit  is  found.  Cocci  are  never  present  so 
long  as  they  are  chronic  ;  and  the  material  they  are  filled  with,  although  it  resem- 
bles pus  in  external  appearance,  contains  very  few  pus-corpuscles,  and  consists 
chiefly  of  broken-down  fatty  debris  mixed  with  fluid.  [In  America,  in  contra- 
distinction to  acute  abscesses,  this  form  of  abscess  is  generally  termed  "cold" 
abscess ;  it  is  still  an  open  question  whether  all  these  abscesses,  without  reserve, 
are  tubercular,  but  that  the  majority  are  tubercular  none  dispute.]  Abscesses  of 
this  description  not  unfrequently  attain  an  enormous  size  without  their  existence 
being  known.  There  is  no  pain  in  connection  with  them,  nor  any  fever  so  long 
as  they  are  chronic.  They  are  too  deep-seated  in  most  cases  to  cause  any  redness 
of  the  skin  or  swelling ;  and  it  is  not  until  they  have  lasted,  perhaps,  for  months, 
and  have  destroyed  the  tissues  around  them  for  immense  distances,  that  they  at 
length  approach  the  surface.  Even  then  the  soft  parts  over  them  show  no  sign 
of  active  inflammation.  The  skin  either  rgmains  entirely  unchanged,  or  very 
slowly  becomes  thinned,  reddened,  and  softened,  until  at  length  it  gives  way. 
The  walls  of  these  abscesses,  especially  the  older  parts,  are  usually  dense  and 
hard,  containing  few  vessels,  and  lined  with  a  layer  of  cheesy  debris ;  they  do  not 
collapse  and  cohere  like  those  of  acute  ones,  and  this  is  one  of  the  chief  diffi- 
culties in  treating  them.  The  cavity,  too,  is  often  of  the  most  irregular  shape, 
with  large  offshoots  running  in  all  directions  and  crossed  by  bands  and  septa, 
many  of  which  contain  important  vessels  and  nerves.  In  short,  they  are  so 
altogether  different  from  acute  abscesses  in  their  contents,  character,  and  behavior, 
that,  except  as  a  matter  of  convenience,  they  should  not  be  classed  with  them. 
Even  their  termination  is  different.  It  very  rarely  happens  that  acute  abscesses 
dry  up  or  disappear.  With  these  this  ending  is  not  at  all  uncommon.  The  fluid 
is  gradually  absorbed  ;  the  caseous  material  becomes  more  and  more  inspissated  ; 
and  at  length  it  undergoes  calcification,  nothing  being  left  but  a  dense,  chalk-like 
substance,  lying  in  the  centre  of  a  capsule  of  fibrous  tissue. 

Unfortunately  this  termination  cannot  be  relied  upon.  If  left,  caseous 
abscesses  for  the  most  part  only  grow  larger  and  larger,  destroying  more  and 
more,  and  becoming  more  complicated  in  shape,  until  either  they  break,  or,  from 
some  accidental  cause,  the  cocci  of  true  suppuration  gain  access  to  them,  and  they 
become  acute. 

Chronic  abscesses  that  are  not  of  tubercular  origin  are  much  more  rare,  but 
occasionally  they  are  found — in  the  breast,  for  example,  or  locked  in  the  interior 
of  a  bone.  The  irritant  that  has  caused  them  has  been  of  very  slight  intensity, 
and  the  tissue  in  which  they  lie  has  surrounded  them  with  a  capsule  so  hard  and 
dense  that  escape  is  out  of  the  question.  Sometimes  these,  especially  when  they 
occur  in  bone,  are  the  source  of  severe  pain. 

Residual  abscesses  are  akin  to  these,  although  many  of  them  probably  are 
tubercular.  Typical  ones  are  met  with  in  old  cases  of  joint-excision.  Years  after 
the  operation  an  abscess,  often  of  very  large  size,  forms  rather  rapidly  in  the 
cicatrix.  It  may  be  due  to  an  old  tubercular  focus  which  has  been  left  behind 
suddenly  waking  up  again  after  some  slight  injury  ;  or  to  the  fact  that  extensive 
masses  of  cicatricial  tissue  are  very  poorly  nourished,  and  very  prone  to  break 
down  from  trivial  causes.      The  prognosis  is  always  good. 

Cold  or  congestive  abscesses  are  usually  met  with  in  connection  with  the 
lymphatic  glands,  generally  in  the  axilla  or  the  groin.  The  patient  has  been  out 
of  health  for  some  time,  and  has  received  some  slight  scratch  or  bruise.  A  few 
days  afterward,  perhaps,  when  the  original  injury  is  well  and  forgotten,  a  certain 
degree  of  stiffness  is  felt,  and  suddenly  a  huge  swelling  is  discovered,  very  soft. 


SUP  PUR  A  TION— ABSCESS. 


51 


lliictuatinn  and  jjainless,  with  but  little  siffii  of  fever  or  inflaminatioii.  The  con- 
tents are  usually  thin  anil  rather  oily,  and  not  unfre(|uently  it  takes  a  long  time 
for  the  patient  to  recover. 

Tympanitic  ahscesses,  containing  gas  as  well  as  pus,  are  occasionally  met  with 
in  the  neighborhood  of  the  alimentary  canal,  not  necessarily  in  connection  with 
the  intestine,  though  this  is  very  commonly  the  case. 

Diffuse  suppuration  is  only  met  with  when  the  action  of  the  poison  is  very 
intense,  or  the  resistance  of  the  tissues  exceedingly  feeble,  and  is  usually  as.sociated 
with  streptococci,  as  well  as  staphylococci.  The  sym])toms  of  inflammation  may 
be  well-marked,  but  not  unfrecpiently  they  are  altogether  concealed,  the  fever 
assuming  a  tyjjhoid  or  adynamic  type,  and  the  nervous  system  being  so  over- 
powered that  pain  is  scarcely  felt. 

Diagnosis. — If  the  part  involved  is  superficial,  and  the  signs  of  inflammation 
are  distinct,  there  is  little  or  no  difticulty  ;  when  the  converse  of  this  is  the  case  it 
may  be  impossible.  The  occurrence  of  a  rigor,  the  presence  of  throbbing  pain 
and  of  inflammatory  adema,  a  softer  spot  appearing  in  the  middle  of  a  mass  of 
hardened  tissue,  and  the  sensation  of  fluctuation,  are  the  mo.st  important  diagnostic 
signs ;  but  any  of  these  may  be  absent,  or  even  all  of  them,  and  it  must  always  be 
remembered  that  fluctuation  only  indicates  the  presence  of  fluid,  and  of  itself  gives 
not  the  slightest  clue  as  to  its  nature.  In  cases  of  doubt,  and  particularly  where 
the  diagnosis  has  to  be  made  from  cysts  or  soft  solid  growths  (which  may  Ije 
attended  by  all  the  signs  of  inflammation — hectic,  local  heat,  redness,  swelling, 
and  pain),  it  is  advisable  to  make  use  of  an  exploring-needle  (grooved  .so  that 
fluid  can  escape  along  it)  or  a  long  fine  trocar  and  cannula.  Very  little  harm  can 
be  done  with  either  of  these,  if  carefully  used  ;  the  liver,  for  example,  may  be 
punctured  in  all  directions,  almost  with  impunity  ;  and  the  result  can  be  relied 
upon.  Even  in  those  cases  in  which  a  caseous  mass  prevents  the  exit  of  any 
fluid,  evidence  of  its  presence  may  generally  be  found  at  the  end  of  the  cannula 
when  it  is  withdrawn. 

Treatment. — i.  Acute  abscesses. — Preventive  measures  may  be  tried  first; 
but,  as  a  rule,  if  there  are  fair  grounds  for  suspecting  suppuration,  the  sooner  an 
incision  is  made  the  better.  In  cases  in  which  pain  is  severe  and  tension  high 
(as  in  whitlow,  acute  periostitis,  and  phlegmonous  inflammation  of  the  cellular 
tissue)  it  is  certainly  not  advisable  to  wait.      Free  incision  is  the  best  prevention. 

Incision  is  the  only  method  of  treatment.  If  the  abscess  is  i)ointing,  or  if, 
short  of  this,  there  is  one  spot  more  tender  than  another,  or  at  which  the  skin  is 
more  adherent  or  oedematous,  the  question  of  locality  is  settled.  Where  there  is 
no  indication  of  this  kind  either  the  most  dependent  part  is  selected,  or  that 
which  appears  advisable  for  anatomical  reasons.  Superficial  veins  and  nerves,  for 
example,  should  be  avoided  ;  natural  folds  of  the  skin  selected  as  far  as  possible  ; 
and,  above  all,  especial  attention  paid  to  the  depth,  position,  and  direction  of  the 
more  important  structures,  such  as  vessels  and  ducts.  If  an  incision  must  be  made 
in  their  neighborhood  it  should  be  parallel  to  them. 

No  plunge  should  be  made  in  opening  an  abscess.  The  spot  is  selected,  and 
the  scalpel  or  absce.ss-knife  introduced  perpendicularly  until  either  the  sense  of 
resistance  ceases  or,  when  the  blade  is  slightly  rotated,  the  pus  wells  up  round  it. 
Sufficient  length  is  obtained  in  cutting  outward.  Deep  abscesses,  lying  among 
important  structures,  are  opened  either  by  dissection  or  by  Hilton's  method.  If, 
for  example,  there  is  suppuration  beneath  the  deep  cervical  fascia,  and  the  position 
of  the  vessels  is  uncertain,  an  incision  half  or  three-quarters  of  an  inch  in  length 
is  made  through  the  superficial  structures,  and  a  steel  director  pushed  into  the  most 
prominent  part  of  the  swelling.  As  soon  as  it  reaches  the  fluid  a  little  escapes 
along  the  groove.  Then  a  pair  of  dressing-forceps,  with  the  blades  closed,  is 
passed  along  the  director,  and  the  wall  of  the  abscess,  and  the  structures  over  it, 
torn  as  far  as  may  be  necessary  by  separating  the  handles. 

An  abscess  should  never  be  scpieezed  ;  it  only  makes  the  granulations  bleed. 
If  the  sac  is  small  and  the  tension  high  the  contents  are  soon  forced  out  by  the 


52         GENERAL   PATHOLOGY  OF  SURGICAL    DISEASES. 

neighboring  structures ;  and  if  the  incision  is  of  proper  size  and  in  proper  posi- 
tion the  cavity  is  obliterated  ahnost  at  once.  All  that  is  required  is  an  absorbent 
dressing  to  take  up  the  excess  of  fluid  that  is  secreted  at  first,  owing  to  the  sudden 
removal  of  the  tension  from  the  vessels  in  the  newly  formed  granulation-tissue. 

When  the  absce.ss  is  deep-seated  or  complicated  in  .shape  this  is  not  enough. 
If  it  lies  beneath  a  layer  of  fa.scia,  or  if  the  surrounding  structures  have  been  much 
displaced  by  its  pressure,  the  deep  wound,  when  the  tension  is  relieved,  does  not 
correspond  to  the  superficial  one.  .  The  opening  is  valvular  and  the  contents 
cannot  escape  freely.      In  this  difficulty  a  drainage-tube  must  be  used. 

The  best  are  lengths  of  red  rubber  tubing  kept  ready  in  a  five  per  cent,  car- 
bolic solution.  The  size  selected  depends,  to  some  extent,  upon  that  of  the 
abscess  and  the  character  of  its  contents,  but,  as  a  rule,  the  larger  the  better. 
Small  ones  soon  become  blocked  and  increase  tenfold  the  danger  they  are  intended 
to  prevent.  Nothing  is  more  common  than  to  see  a  gush  of  fluid  when  they  are 
withdrawn.  The  walls  must  be  flexible,  but  firm  enough  to  maintain  the  patency 
of  the  interior,  and  openings  must  be  made  in  them  here  and  there.  The  deep 
end  is  passed  by  means  of  a  probe  or  sinus-forceps  quite  to  the  farther  limit  of 
the  sac ;  the  superficial  one  is  just  flush  with  the  skin,  and  is  provided  with  a  liga- 
ture to  secure  it  if  required.  The  wall  of  an  old  abscess  is  thick  and  rigid  ;  the 
structures  around  have  grown  accustomed  to  its  presence,  and  do  not  obliterate  the 
cavity  when  the  tension  is  relieved ;  and  for  this  reason,  unless  the  freest  possible 
exit  is  given  to  the  contents  by  means  of  a  dependent  opening  and  a  large  drain- 
age-tube, some  is  sure  to  remain  behind  and  decompose. 

In  large  abscesses  it  is  advisable  to  make  two  openings  and  pass  a  drainage- 
tube  through.  After  two  or  three  days  it  may  be  withdrawn,  and  two,  one  at 
each  opening,  substituted  for  it.  As  the  structures  around  recover  themselves  and 
become  pressed  together  the  middle  portion  of  the  sac  is  obliterated,  and  when 
the  granulation-tissue  begins  to  contract  the  tubes  are  gradually  forced  out. 

Wood-wool  or  moss,  impregnated  with  corrosive  sublimate,  is  a  most  efficient 
dressing,  but  any  other  substance  that  is  sufficiently  ab.sorbent  and  capable  of 
preventing  putrefaction  may  be  u.sed  instead.  The  dressing  should  be  thick  and 
cover  some  distance  around  ;  the  compression  helps  the  abscess  to  contract,  keeps 
the  part  at  rest,  and  maintains  an  even  temperature.  The  frequency  with  which 
it  is  changed  depends  upon  the  amount  of  discharge  ;  in  many  cases  a  single 
dressing  is  sufficient.  The  temperature,  if  the  abscess  is  drained  thoroughly,  falls 
at  once  to  normal ;  if  it  rises  above  99°,  at  any  rate  on  more  than  one  evening, 
it  is  almost  certain  that  the  exit  is  not  free. 

Metastatic,  residual,  and  cold  or  lymphatic  abscesses  present  no  peculiarities. 
Chronic  ones,  locked  in  bone,  naturally  require  special  treatment.  If  sui>puration 
is  diffuse  free  drainage  is  even  more  imperative  than  when  it  is  circumscribed  ;  it 
is  just  possible  that  relieving  the  ti.ssues  of  the  additional  irritation  of  tension  may 
turn  the  scale  in  their  favor,  and  enable  them  to  throw  out  a  protecting  barrier ; 
but  it  must  be  remembered  that  in  these  cases  there  is,  as  a  rule,  progressive 
inflammation  to  deal  with  as  well. 

2.  Caseous  Abscesses. — The  treatment  of  caseous  or  tubercular  abscesses 
requires  special  mention.  An  acute  abscess,  unless  there  is  some  complication 
present,  discharges  itself  of  all  its  contents  as  soon  as  the  tension  is  relieved,  and 
organization  begins  at  once.  In  these,  on  the  other  hand,  the  reparative  power 
of  the  tissues  is  very  feeble,  the  walls  are  dense  and  rigid,  so  that  they  do  not 
collapse,  and  the  caseous  debris,  especially  the  more  solid  part,  has  a  great  ]}ro- 
pensity  for  clinging  to  the  interior.  In  other  words,  even  when  they  are  small,  it 
is  not  easy  to  procure  free  and  efficient  drainage  ;  when  they  are  of  large  size,  as 
in  the  case  of  many  spinal  abscesses,  and  divided  into  a  series  of  successive  cham- 
bers by  septa  springing  from  the  walls,  or  provided  with  offshoots  spreading  in  all 
directions,  the  difficulty  becomes  a  very  serious  one. 

Formerly  it  was  the  practice  to  leave  abscesses  of  this  kind  alone  as  long  as 
pcssible,  more  especially   as,  in  a  certain  small  proportion,  the  caseous  material 


SUPPURATION— ABSCESS.  53 

gradually  dried  up,  and  either  became  absorbed  altogether  or  converted  into  a 
calcareous  mass.  Now,  it  is  recognized  that  the  earlier  such  an  abscess  is  emjjtied 
the  better  the  prospect  of  speedy  recovery,  and  the  less  the  risk  of  its  proving 
ultimately  a  focus  for  tubercular  dissemination. 

Many  of  them  occur  under  conditions  that  necessitate  special  treatment. 
Such,  for  example,  are  the  caseous  foci  found  in  tubercular  epididymitis  and  in 
so-called  strumous  disease  of  joints.  Others — those,  for  instance,  that  are  met 
with  in  lymphatic  glands,  or  in  the  cancellous  tissue  at  the  eijiphy.sial  ends  of  the 
long  bones — may  be  very  briefly  dismissed  ;  they  should  be  opened  as  thoroughly 
as  possible ;  the  lining  of  granulation  tissue,  covered  with  ca.seous  material  and 
infiltrated  with  tubercle,  scraped  out  with  a  Volkman's  spoon,  and  iodoform 
dusted  over  the  interior.  The  difficulty  is  in  dealing  with  the  large  ones,  which 
cannot  be  treated  in  this  fashion. 

Aspiration  is  harmless,  and  sometimes  succeeds.  The  instrument  ordinarily 
used  is  a  modification  of  Dieulafoy's,  consisting  of  an  exhausting-syringe  or  glass 
receiver,  and  a  trocar  and  cannula  so  contrived  that  the  former  can  be  withdrawn 
and  the  latter  brought  into  connection  with  the  receiver,  without  destroying  the 
vacuum.  Care  must  be  taken  that  the  instrument  is  absolutely  clean  (I  prefer  to 
have  all  cannula  boiled  in  liquor  potassae  in  a  test-tube  just  before  using ;  no  oil 
then  is  required)  ;  the  opening  should  be  valvular,  and  the  trocar  should  reach 
well  into  the  cavity  before  it  is  withdrawn,  and  the  connection  established.  No 
attempt  is  made  to  empty  the  abscess  ;  as  a  matter  of  fact,  it  cannot  be  done ;  a 
large  amount  of  the  caseous  material  clings  obstinately  to  the  wall,  and  if  it  is 
detached,  blocks  the  cannula,  and  great  care  should  be  taken  not  to  make  the 
granulations  bleed,  either  by  bringing  the  end  of  the  instrument  into  contact  with 
them,  or  reducing  the  tension  too  rapidly.  The  vacuum  should  be  maintained 
as  the  needle  is  withdrawn,  for  fear  of  its  leaving  some  of  the  caseous  debris  in  the 
wound.  As  the  abscess  is  not  emptied,  the  beneficial  effect  must  be  due  to  the  relief 
of  the  tension  ;  sometimes  absorption  and  condensation  follow  ;  much  more  fre- 
quently the  cavity  slowly  refills.  If  the  aspirator  is  used  more  than  two  or  three 
times,  the  openings  fail  to  heal ;  a  little  thin  serum  escapes  from  them,  the  mar- 
gins begin  to  ulcerate,  and  the  contents  slowly  drain  away. 

Small  abscesses  are  sometimes  emptied  in  this  way,  or  with  a  trocar  and  can- 
nula, and  then  injected  with  an  emulsion  of  iodoform  in  glycerine  (one  in  ten), 
or  a  five  per  cent,  solution  of  the  same  drug  in  ether.  The  former  is  especially 
recommended,  as,  owing  to  its  high  specific  gravity,  it  sinks  down  through  the 
caseous  debris  which  collects  upon  the  floor,  and  penetrates  to  the  granulations  ; 
but  there  is  some  risk  of  iodoform-poisoning. 

Large  abscesses — those,  for  example,  in  connection  with  disease  of  the  spine — 
must  be  opened  and  drained.  Two  incisions  are  always  advisable — one  at  the 
most  dependent  part,  the  other  as  near  the  seat  of  disease  as  practicable.  Some- 
times, when  there  are  large  outlying  pouches,  a  third  is  required.  The  interior 
should  be  explored  with  the  finger,  to  ascertain,  as  far  as  possible,  its  extent,  and 
whether  the  disease  which  has  given  rise  to  it  is  within  reach  of  treatment,  but  it 
should  not  be  scraped  out,  for  fear  of  hemorrhage,  and  of  damaging  important 
structures  running  in  the  wall,  or  across  the  cavity,  or  washed  out  with  antiseptics  ; 
then,  a  very  large  drainage-tube  should  be  inserted,  or,  if  necessary,  more  than 
one,  and  absorbent  dressings  applied.  If  the  drainage  is  thorough,  the  caseous 
material  that  clings  to  the  wall  is  thrown  off  by  the  granulations  with  the  serum 
that  exudes  from  them  ;  the  amount  of  discharge  is  reduced  to  a  few  drachms  of 
turbid  fluid,  and  gradually,  as  the  structures  around  collapse  upon  the  cavity,  all 
the  outlying  parts  close  up,  leaving  only  one  sinus,  leading,  by  as  straight  a  route 
as  possible,  down  to  the  seat  of  disease. 

When  this  is  not  feasible,  Hamilton's  method  of  irrigation  with  chloride  of 
zinc  (one  part  in  200)  may  be  adopted.  A  rubber  tube,  with  a  single  opening  in 
the  side,  is  passed  across  the  abscess-cavity  ;  one  end  is  connected  with  an  irri- 
gating can,  the  other  wath  a  receiver,  and  the  fluid  (which  is  quite  inert  as  a  germi- 


54         GENERAL   PATHOLOGY  OF  SURGLCAL   DISEASES. 

cide)  is  allowed  to  flow  through,  drop  by  drop,  the  rate  being  regulated  by  means 
of  a  stop-cock.  After  a  week,  the  openings  begin  to  leak,  and  then  the  continuous 
irrigation  can  be  dispensed  with  ;  the  cavity  throws  off  the  inner  lining  in  shreds, 
and  gradually  heals  up.  The  object  is  to  place  the  tissues  under  the  most  favorable 
conditions  for  getting  rid  of  the  noxious  material  that  lines  the  cavity. 

When  efficient  drainage  is  impossible,  so  that  there  must  be  some  residue  of 
dead,  putre.scible  fluid  in  the  cavity,  or  Hamilton's  plan  is  unsuitable.  Lister's 
method,  or  some  modification  of  it,  may  be  used.  It  aims  at  preventing  the  access 
of  the  germs  of  putrefaction,  and  if  it  is  carried  out  at  all,  must  be  done  thoroughly. 
These  micro-organisms  (unlike  those  of  suppuration,  which  can  be  conveyed  from 
one  part  of  the  body  to  another,  and  can  enter  through  the  alimentary  or  resj^ira- 
tory  tract,  and  cause  the  formation  of  pus  whenever  they  meet  with  tissues  too  feeble 
to  resist  them)  are  unable  to  act  on  living  tissues ;  they  must  have  dead  material 
at  a  certain  temperature  and  with  a  certain  amount  of  fluid — conditions  whicq 
are  perfectly  fulfilled  in  ill-drained  abscesses. 

The  skin  over  and  in  the  neighborhood  of  the  wound  is  thoroughly  cleansed 
with  an  antiseptic  (carbolic  acid,  five  percent.,  is  the  usual  one),  and,  if  neces.sary, 
shaved  and  purified  from  any  fatty  matter  that  may  adhere  to  it,  with  ether  or 
some  strong  alkali.  The  instruments,  the  hands  of  the  operator,  the  sponges,  and 
everything  that  can  possibly  come  near  the  wound,  are  treated  in  the  same  way. 
After  the  abscess  is  opened,  and  the  immediate  discharge  from  it  has  ceased,  a 
drainage-tube -is  carried  down  to  the  bottom,  and  secured  in  the  ordinary  manner, 
and  then  special  dressings  are  applied. 

The  wound  itself  is  covered  with  protective — oiled  silk  coated  with  copal 
vainish,  and  brushed  over  with  dextrin.  This  is  dipped  in  carbolic  lotion  first. 
In  the  case  of  a  recent  wound,  it  is  just  large  enough  to  overlap  the  edges  all 
round,  and  protect  the  healing  surface  from  the  irritating  effect  of  carbolic  acid. 
Over  this  is  laid  a  dressing  of  specially^prepared  gauze.  As  a  rule,  it  consists  of 
tarlatan  impregnated  with  a  mixture  of  one  part  of  carbolic  acid,  four  of  resin, 
and  four  of  paraffin  ;  but  eucalyptus,  salalembroth,  and  other  substances  are 
sometimes  used  instead.  The  dressing  next  to  the  protective  is  dipped  in  a  solu- 
tion of  carbolic  acid  (two  and  one-half  per  cent.),  because,  when  dry,  the  dis- 
infectant is  not  given  off"  readily,  and  a  particle  of  dust  that  had  escaped  the 
spray  might  come  into  contact  with  the  drainage-tube.  Over  this,  covering  the 
skin  for  a  long  distance  round,  is  the  superficial  dressing ;  eight  layers  of  gauze 
(dry,  but  prepared  in  the  same  way)  with,  beneath  the  outer  layer,  a  piece  of 
mackintosh  cloth,  so  that  the  discharge  may  diffuse  itself  over  the  whole  without 
coming  into  contact  with  the  air  at  any  one  spot.  Elastic  bandages  are  used 
round  the  edges,  especially  where,  as  in  the  groin,  there  is  likely  to  be  any  move- 
ment ;  gauze  bandages  for  the  rest.  If  the  surface  is  uneven,  or  if  a  large  amount 
of  discharge  is  expected,  loose  gauze  rolled  up  lightly  is  ]:)laced,  as  much  as  may 
be  nece.ssary,  between  the  .superficial  and  the  deep  dressings. 

The  dressing  is  changed  the  day  following  the  operation,  using  the  same  pre- 
cautions, and  taking  great  care  not  to  lift  it  up  toward  the  spray,  but  away  from 
it,  so  that  no  unpurified  air  may  enter  beneath.  Afterward  it  is  left  until  the^ 
discharge  is  apparent  somewhere  at  the  edge ;  but  never  for  more  than  a  week. 

[Another  method  of  treating  these  large  abscesses,  is  by  evacuating  the  con- 
tents through  a  cannula,  then  thoroughly  washing  the  cavity  with  warm  water, 
then  with  iodine  water,  then  injecting  iodoform  emulsion,  then  closing  the  skin 
puncture  with  iodoform  collodion.  In  washing  the  cavity  the  walls  of  the  abscess 
must  be  fully  distended  to  allow  the  fluid  to  touch  every  jiart.  The  operation 
should  be  repeated  from  time  to  time  as  occasion  may  require.] 


HECTIC— ALBUMINOID  DEGENERATION.  55 

Hkciic. 

Profuse  aiul  long-continued  siii)j)uration  is  accompanied  by  a  i)eculiar  form  of 
fever  known  as  "hectic."  'Ihe  tenii)erature  is  perfectly  regular,  but  remittent. 
In  the  morning  it  is  normal,  or  only  slightly  raised  ;  in  the  evening  it  is  102°, 
103°,  or  even  104°  F.  As  the  rise  begins,  always  at  the  same  time,  there  is  a 
sensation  of  heat  and  thirst,  sometimes  jjreceded  by  a  chill  ;  the  face  becomes 
flushed,  especially  the  cheeks,  on  which  there  is  often  a  bright  red  and  strictly 
limited  patch  ;  headache  comes  on,  with  a  feeling  of  extreme  weakness  and  de- 
pression, and  the  patient  is  restless  and  uncomfortable,  tossing  about  in  bed, 
unable  to  sleep.  Then  toward  morning  the  temperature  drops ;  there  is  profuse 
perspiration,  often  soaking  the  bed-clothes ;  and  the  patient  falls  into  a  deep 
sleep,  which  may  last  till  late  in  the  day. 

The  pulse  is  always  rapid,  becoming  softer,  smaller,  and  more  frequent  as  the 
case  goes  on.  Emaciation  is  extreme;  the  eyes  are  sunken  and  bright,  the  pupils 
dilated,  the  skin  anaemic,  and  the  tongue  very  red,  especially  at  the  tip  and 
edges.  The  urine  deposits  urates  copiously,  and  diarrhoea  is  of  common  occur- 
rence toward  the  end  ;  the  strength  fails  rapidly  ;  the  mind  begins  to  wander  ; 
the  power  of  taking  food  diminishes,  and  at  leilgth  death  ensues  from  sheer 
exhaustion. 

The  most  typical  examples  of  hectic  are  met  with  in  cases  of  empyema  or  of 
large  abscesses  connected  with  the  spine  or  hip  that  have  been  imperfectly 
drained  ;  but  it  may  follow  suppuration  in  any  part  of  the  body.  It  does  not 
occur  before  an  abscess  is  opened,  and  there  is  no  doubt  that  it  is  due  to  the  ab- 
sorption from  the  granulating  surface  of  a  substance  produced  by  the  fermentation 
(not  necessarily  putrefactive)  of  the  discharge.  The  greater  the  amount  of  dis- 
charge and  the  larger  the  absorbing  surface,  the  worse  the  fever. 

The  treatment  depends  upon  the  cause ;  if  this  can  be  removed  the  fever 
ceases ;  if  it  cannot,  the  course  may  be  delayed,  but  the  end  cannot  be  prevented. 

The  strength  must  be  supported  by  nourishing  diet,  tonics,  iron,  quinine, 
and  cod-liver  oil.  Stimulants,  especially  port  wine,  are  of  undoubted  use.  The 
diarrhoea  must  be  kept  in  check  by  astringents  and  mineral  acids.  Opium  should 
only  be  given  as  a  last  resource,  to  relieve  pain.  The  night-sweats,  which  are 
very  weakening,  can  be  checked  by  belladonna ;  and  the  formation  of  aphthous 
ulcers  in  the  mouth  and  on  the  tongue  (w'hich  are  very  injurious  from  the  pain 
they  cause  in  mastication  and  deglutition)  must  be  prevented  by  means  of  borax 
and  potassium  chlorate. 

Typical  hectic,  with  emaciation,  flush,  and  profuse  night-sweats,  is  met  with  in 
connection  with  many  varieties  of  rapidly-growing  malignant  tumors.  The  cause 
is  not  known. 

Albuminoid  Degeneration. 

This  is  one  of  the  consequences  of  prolonged  suppuration  often  associated 
with  hectic.  It  has,  however,  been  known  to  occur  independently  of  the  forma- 
tion of  pus  in  syphilis  and  malaria.  In  surgery,  at  least,  it  is  usually  met  with  in 
connection  w-ith  tuberculous  disease  of  bones  or  joints,  and  as  a  consequence  of 
empyema. 

Morbid  Anatomy. — The  liver,  spleen,  kidneys,  and  the  mucous  membrane 
of  the  intestines  are  the  parts  usually  involved.  It  begins  in  the  media  and  intima 
of  the  small  arteries  and  capillaries,  and  spreads  from  them  to  the  connective-tissue 
elements  and  the  unstriped  muscular  fibres.  The  epithelial  lining  atrophies.  The 
substance  of  the  cells  is  changed  into  a  firm,  homogeneous,  waxy  material,  which 
appears  translucent  in  thin  sections,  stains  mahogany-brown  wdth  iodine,  and  red 
w^ith  methyl-violet.  It  is  nitrogenous,  resembles  albumen  in  many  respects,  but 
resists  digestion  and  putrefaction. 

Symptoms. — The  liver  retains  its  shape  more  or  less,  but  slowly  and  steadily 
increases  in  size  until  it  may  reach  into  the  iliac  fossa.  It  is  firm,  hard,  and 
resistant ;  the  edge  can  be  felt  with  unusual  distinctness ;  there  isno  pain  or  any 


56         GENERAL  PATHOLOGY  OF  SURGICAL  DISEASES. 

apparent  derangement  of  function.  The  spleen  enlarges  in  the  same  way.  The 
kidneys  show  the  effect  by  the  alteration  in  the  urine ;  this  increa.ses  in  quantity, 
diminishes  in  density,  and  in  the  later  stages  contains  a  small  amount  of  albumen 
and  some  hyaline  casts.  The  mucous  membrane  of  the  intestine  does  not  become 
involved  until  comparatively  late,  when,  naturally,  emaciation  and  diarrhoea  soon 
become  prominent  features. 

The  aspect  of  the  patient  is  characteristic.  There  is  a  peculiar  waxy  pallor 
of  the  face  which  is  unmistakable,  and  is  of  itself  sufficient  to  establish  a  diagnosis. 
In  addition,  the  anaemic  condition  of  the  lips,  the  emaciation,  and  the  protuberant 
abdomen,  can  usually  be  recognized  at  once, 

Early  removal  of  the  cause  has  been  followed  by  complete  disappearance  of 
all  the  symptoms,  so  that,  some  years  after,  no  evidence  of  such  a  change  could 
be  detected.  If  this  is  attempted,  however,  it  must  be  done  before  the  disease  is 
too  far  advanced. 

Hemorrhage  into  an  Abscess. 

Capillary  oozing  is  very  common  ;  the  granulations  are  exceedingly  vascular, 
and  the  sudden  relief  of  tension  causes  some  of  the  thin-walled  vessels  to  give 
way ;  but  it  is  very  rarely  serious.  Usually  it  stops  at  once  on  exposure ;  if  it 
does  not,  ice  may  be  applied  locally  and  the  part  well  raised.  In  very  bad  cases 
it  may  be  necessary  to  plug  the  cavity  with  iodoform  gauze — but  this  is  very  likely 
to  be  followed  by  a  considerable  degree  of  fever. 

Venous  hemorrhage  rarely  occurs  except  from  scarlatinal  or  diphtheritic 
sloughing  in  the  neck.  In  this  case  the  cavity  should  be  thoroughly  dried,  the 
hemorrhage  being  checked  meantime  by  pressure ;  dusted  well  with  iodoform,  in 
the  hope  of  staying  the  sloughing,  and  packed  with  iodoform  wool  or  gauze ; 
but,  especially  in  the  case  of  the  internal  jugular,  the  prognosis  is  almost  hopeless. 
If  iodoform  fails  or  is  not  at  hand,  turpentine  is  probably  the  most  efficient  agent. 

Arterial  hemorrhage  may  occur  under  the  same  conditions,  from  ulceration 
into  the  carotid,  or  in  the  groin  from  the  extension  of  phagedaenic  bubo.  The 
latter  appears  to  have  been  more  common  in  days  gone  by.  Occasionally  it  is 
met  with  on  the  extremities,  from  the  pressure  of  drainage-tubes  or  of  sharp  edges 
of  bone.  Fortunately,  the  hemorrhage  is  rarely  instantaneous ;  in  nearly  every 
case  there  is  a  warning.  The  treatment  varies  according  to  the  circumstances. 
In  the  neck,  if  it  is  in  the  carotid  or  one  of  the  branches  near  the  main  trunk, 
this  must  be  ligatured  at  once.  In  the  thigh,  if  only  a  few  drops  escape,  cold 
and  pressure  may  be  applied  ;  but  a  tourniquet  unscrewed  must  be  placed  upon 
the  limb  higher  up,  and  a  nurse  or  dresser  instructed  to  watch  ;  and  if  there  is  the 
least  recurrence,  no  further  delay  is  admissible.  In  the  leg,  amputation  is  usually 
required. 

The  complication  is  a  rare  one.  I  have  on  several  occasions  seen  arteries 
lying,  exposed  and  beating,  on  the  floor  of  ulcers  without  hemorrhage  ever  occur- 
ring. As  the  inflammation  extends  into  the  coats,  the  endothelium  becomes 
affected  and  a  thrombus  forms.  Suppurating  aneurisms  are  by  no  means  always 
followed  by  hemorrhage.  If,  however,  there  is  a  foreign  body  cutting  into  the 
wall  of  the  vessel,  or  if  the  ulceration  is  phagedenic,  or  even  septic  and  diffuse, 
as  in  those  whose  health  is  broken  down  from  any  cause,  the  destruction  may 
advance  too  quickly  for  repair,  and  then  hemorrhage  follows. 

Sinus  and  Fistula. 

A  sinus  or  fistula  is  the  suppurating  track  left  by  the  imperfect  healing  of  an 
abscess.  The  distinction  between  the  two  is  not  accurately  kept.  Strictly,  the 
former  has  only  one  opening,  and  that  upon  the  skin  ;  but  so  long  as  there  is  no 
communication  with  an  internal  cavity  or  with  any  of  the  hollow  viscera  (such  as 
the  bladder),  the  number  is  not  material.  A  tubercular  abscess,  for  example,  may 
have  two  or  more,  connected  by  channels  running  in  the  subcutaneous  tissue.     In 


S/NUS  AND  FISTULA.  57 

the  same  way  a  fistula  should  have  two,  of  which  one  communicates  either  with 
the  viscera  or  with  a  ca\ity  of  some  kind  ;  the  other  may  or  may  not  be  on  the 
exterior ;  in  recto-vesical  fistula,  for  example,  both  openings  are  internal ;  in  the 
biliary  variety,  only  one ;  but  blind  fistuh\3  (which  are  identical  with  simple 
sinuses)  are  occasionally  spoken  of  in  connection  with  the  anus,  on  account  of 
the  close  resemblance  they  bear  to  complete  ones. 

Causes. — Non-closure  of  an  abscess  is  due  to  the  persistence  of  some  irri- 
tant :  tension,  as  when  the  contents  cannot  escape  freely  ;  want  of  rest,  owing  to 
the  continued  action  of  muscles — the  sphincter  ani,  for  example  ;  the  presence  of 
dead  bone,  tubercular  deposit,  or  foreign  bodies  introduced  from  without,  and  the 
existence  of  an  obstruction  to  one  of  the  natural  ducts,  as  in  stricture,  are  the 
most  common.  Occasionally  fistulas  are  caused  by  actual  loss  of  tissue  (especially 
vaginal  ones),  or  by  the  presence  of  malignant  growths. 

As  a  rule,  a  sinus  or  fistula  forms  a  narrow,  more  or  less  tortuous  canal,  lined 
with  a  kind  of  granulation-tissue  which  secretes  a  thin,  watery  pus.  Exceptionally, 
when  it  is  very  short,  as  between  the  rectum  and  the  bladder,  it  is  covered  with 
epithelium.  The  external  orifice  varies  according  to  the  cause  ;  when  it  is  due  to 
dead  bone,  there  is  usually  a  protuberant  button  of  granulations,  in  the  centre  of 
which  is  a  very  small  opening.  Tuberculous  sinuses,  on  the  other  hand,  are  sur- 
rounded by  ragged,  blue,  and  undermined  edges.  In  the  case  of  old  fistulas  the 
opening  is  not  unfrequently  depressed  and  sunken,  because  of  the  contraction  of 
the  granulation-tissue  underneath."  The  internal  orifice  is  generally  well  defined, 
although  that,  too,  may  be  concealed  beneath  a  flap  of  mucous  membrane. 

When  of  recent  formation,  the  structures  that  form  the  wall  are  soft  and 
yielding ;  but  in  old  cases,  particularly  those  in  which  the  fistula  gives  exit  to  one 
of  the  secretions,  they  become  hard,  dense,  and  cartilaginous,  so  that,  even  when 
the  cause  is  removed,  healing  is  almost  impossible  without  something  further  being 
done. 

Treatment. — In  recent  cases  it  is  sufficient  to  remove  the  cause.  Dead 
bone  must  be  withdrawn  or  scraped  away  ;  a  stricture  must  be  dilated  ;  if  there  is 
not  free  exit  for  the  secretion,  the  orifice  must  be  enlarged  with  a  drainage-tube 
or  tent,  or  by  an  incision  ;  and  if,  as  in  the  case  of  sinuses  in  the  groin,  the  con- 
tinual movement  of  the  part  prevents  healing,  pressure  may  be  applied.  Even 
those  left  by  suppurating  buboes  can  be  induced  to  close  by  the  proper  application 
of  a  truss.  In  many  cases,  of  course,  the  removal  of  the  cause  entails  a  serious 
operation.  Fistula  in  ano,  for  example,  is  originally  due  to  an  absce.ss,  but  its 
persistence  is  the  result  of  the  sphincter,  and  this  must  be  divided  before  the 
wound  can  close. 

In  others  in  which,  without  any  definite  reason  being  found,  the  wound 
refuses  to  heal,  an  attempt  may  be  made  to  stimulate  the  part,  or  even,  in  old 
cases,  to  excite  acute  suppuration.  In  those  cases  in  which  the  walls  are  very 
thick  and  dense  this  is  the  only  way.  Injection  of  tincture  of  iodine  may  be 
tried  first,  or  the  introduction  of  a  probe  coated  with  nitrate  of  silver.  If  this 
fails,  the  granulations  may  be  thoroughly  scraped  out  with  a  sharp  spoon  or 
destroyed  with  the  cautery.  Finally,  sometimes  the  only  measure  of  any  use  is 
to  lay  the  whole  open  from  one  end  to  the  other,  partly  to  place  it  at  rest,  partly 
to  destroy  the  hardened,  thickened  tissues  by  causing  acute  suppuration.  Where 
bleeding  is  feared,  this  is  sometimes  done  with  an  elastic  ligature  tied  as  tightly 
as  possible. 

Large  fistulous  openings  between  hollow  viscera,  or  between  one  of  these  and 
the  exterior,  very  often  require  extensive  and  repeated  plastic  operations. 


58         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

ULCERATION. 

Ulceration  is  the  molecular  disintegration  and  removal  of  the  superficial 
structures  of  the  body  by  the  action  of  certain  irritants,  just  as  suppuration  is  of 
the  deeper  ones.  An  ulcer  is  the  sore  formed  in  the  process,  and  in  the  same 
wav  corresponds  to  an  abscess. 

A  burn — the  actual  cautery,  for  example,  applied  to  the- skin — does  not  leave 
an  ulcer,  provided  no  other  irritant  is  allowed  to  appear.  A  portion  of  the  skin 
is  killed ;  the  surrounding  tissues  at  once  begin  to  act  with  vigor ;  lymph  pours 
out ;  new  vessels  are  formed  ;  vascular  granulation-tissue  is  produced  in  sufficient 
amount,  and  the  dead  part  is  replaced,  more  or  less  perfectly,  without  a  trace  of 
suppuration. 

If,  however,  any  further  injury  is  inflicted  on  the  part — if  the  burn  is  exposed 
to  the  air,  so  that  the  dead  tissue  decomposes,  or  if  the  surrounding  living  parts 
are  constantly  rubbed  by  the  clothes,  or  if  they  are  injured  in  any  other  way — 
inflammation  sets  in  ;  the  pyogenic  organisms  multiply,  molecular  disintegration 
begins  on  the  surface  of  the  body,  and  an  ulcer  is  produced. 

As  soon  as  the  irritant  ceases  and  the  tissues  regain  their  normal  resistance, 
vascular  granulation-tissue  is  formed  as  round  an  abscess,  destruction  comes  to  an 
end,  organization  begins,  and  the  wound  begins  to  heal.  Sometimes  this  is 
called  a  healing  ulcer,  but  the  term  is  an  inappropriate  one,  as  the  ulceration 
has  ceased. 

Causes. — The  causes  of  ulceration  are  the  same  as  those  of  suppuration, 
predisposing  and  exciting.  The  former  include  everything,  hereditary  or  acquired, 
local  or  constitutional,  that  can  in  any  way  impair  the  vitality  of  the  tissues ;  and 
these  are  of  especial  importance  when  the  process  is  chronic  :  the  latter  are  the 
same  forms  of  micrococci  that  occur  in  acute  abscesses.  They  generally  gain 
access  to  the  tissues  from  the  surface  (sometimes,  as  in  pyaemia,  through  the 
blood),  and  the  cells  and  fibres  melt  away  before  them  because  they  are  too  weak 
to  resist.  There  is  the  same  contest  between  the  irritant  and  the  power  of  repair  ; 
sometimes  one  gains  the  upper  hand,  and  sometimes  the  other,  and,  as  the  case 
mav  be,  the  ulcer  spreads  or  heals.  Not  unfrequently,  especially  on  the  leg, 
there  is  scarcely  any  progress  one  way  or  the  other  for  years.  The  irritant  has 
very  little  power,  but  the  tissues  are  so  badly  nourished  that  they  cannot  throw  it 
ofif :  and  each  winter  sees  the  ulcer  slowly  getting  larger,  especially  as  age 
advances. 

There  is  the  same  question  as  in  suppuration — whether  long-continued 
mechanical  or  chemical  irritation  can  cause  ulceration  of  itself  without  the  lique- 
fying action  of  the  micrococci  ;  but  the  discussion  is  even  more  barren,  as  they 
are  invariably  present. 

Varieties. — Simple  ulcers  may  be  compared  to  acute  abscesses,  with  this 
distinction — that  septic  germs,  causing  decomposition  of  the  discharge,  are  (unless 
steps  are  taken  to  prevent  it)  always  present  with  the  pyogenic  ones,  weakening 
the  tissues  and  preparing  the  way  for  their  action. 

Specific  74 leers  resemble,  but  less  closely,  caseous  abscesses.  These  are  due 
to  the  softening  and  disintegration  of  tubercular,  syphilitic,  and,  occasionally, 
epitheliomatous  masses  in  the  interior  of  the  body  ;  but,  except  in  certain  rare 
instances,  they  do  not  contain  true  pus  until  they  are  opened.  The  corresponding 
forms  of  ulcers  are  never  the  result  of  unmixed  disintegration  in  this  way.  In 
addition  to  the  caseation  and  liquefaction,  septic  decomposition  is  always  present, 
and  pus  as  well,  from  the  presence  of  pyogenic  micrococci. 

It  is  probable  that  the  phagedaenic  and  gangrenous  forms,  which  are  usually 
separated  from  the  rest,  are  merely  the  result  of  the  ordinary  germs,  acting  with 
greater  intensity  than  usual,  sometimes  for  anatomical  reasons,  more  frequently 
because  the  vitality  of  the  tissue  is  greatly  impaired,  or  because  there  is  some 
other  poison  (that  of  syphilis,  for  example)  at  work  as  well.  They  may  be  com- 
pared to  diff"use  suppuration  ;  the  process  of  destruction  is  too  rapid  for  the  tissues 


GANGRENE.  59 

to  throw  out  a  barrier  of  i^ranulations,  or  the  poison  is  so  intense  that   the  barrier 
already  thrown  out  clisai)i)ears. 

As  soon  as  the  tissues  are  able  to  resist  the  irritant,  the  leucocytes  cease  to 
melt  away  as  pus,  the  peptonizing  action  of  the  micrococci  becomes  feebler, 
coagulable  l)mph  is  formed,  and  new  blood-vessels  are  thrown  out.  In  other 
words,  a  layer  of  vascular  granulation-tissue  is  developed  upon  the  floor  of  the 
ulcer,  exactly  like  the  limiting  fibrin  round  an  abscess ;  and  repair  begins  at 
once,  as  in  any  other  healing  wound,  by  organization  and  contraction  beneath, 
and  organization  and  the  formation  of  an  epithelial  layer  above. 

GANGRENE. 

By  gangrene  or  mortification  is  understood  the  death  of  a  part  of  the  body. 
A  certain  size  is  implied,  in  distinction  from  ulceration,  in  which  the  destruction 
is  molecular  and  the  tissues  melt  away  imperceptibly  ;  but  small  patches  of  gan- 
grene are  often  present  on  the  floor,  or  round  the  edges,  of  spreading  ulcers,  and 
the  line  between  them  is  ill-defined.  The  term  sloi/ghing  is  used  for  the  soft 
tissues ;  tiecrosis  for  the  hard  ones — bone  and  cartilage ;  and,  in  the  latter  case, 
the  dead  portion  when  encased  in  living  bone  is  known  as  a  sequestrum.  When 
not  so  encased,  the  dead  portion  is  termed  an  exfoliiini. 

Gangrene  is  dry  or  moist  according  to  the  changes  the  part  undergoes.  In 
the  dry  form  the  color  at  first  is  pale,  or  dead  white  with  a  bluish  mottling  here 
and  there ;  the  skin  is  shriveled,  and  as  it  were  shrunken  on  the  structures 
beneath  ;  at  first,  it  has  a  peculiar  semi-translucent  look ;  but  very  soon  it  loses 
this,  becomes  opaque  and  dark,  and  then  grows  more  and  more  black  until  at 
length  the  part  becomes  hard,  dried,  and  mummified.  Putrefaction  cannot  occur 
because  there  is  no  fluid.  In  the  moist  form,  on  the  other  hand,  decomposition 
is  always  present.  The  part  is  engorged  with  blood  ;  the  haemoglobin  soaks 
through  and  stains  the  skin,  so  that  it  becomes  dark  and  livid ;  bullae  form  on  the 
surface,  filled  with  reddish  fluid  of  a  very  offensive  description  ;  the  epidermis  is 
detached  ;  ashy-gray  or  green  patches  make  their  appearance ;  the  part  becomes 
swollen,  and  crackles  under  the  finger  from  the  formation  of  putrid  gases ;  and 
the  smell  is  most  offensive. 

Which  of  the  two  forms  occurs  depends  upon  the  amoimt  of  fluid  present.* 
Dry  gangrene,  therefore,  is  chiefly  met  with  in  old  people,  with  thin,  spare  limbs, 
in  whom  the  arteries  supplying  the  part  slowly  become  blocked  with  thrombi. 
Even  in  them,  however,  a  certain  amount  of  decomposition  usually  takes  place  as 
the  line  of  separation  is  formed,  or  when  the  gangrene  involves  the  calf.  In  the 
former  case  the  necessary  amount  of  fluid  is  supplied  by  the  liquefaction  of  the 
plasma  under  the  influence  of  the  pyogenic  organisms ;  in  the  latter  it  comes 
from  the  tissue  itself. 

Causes. — The  causes  of  gangrene  are  the  same  as  those  of  inflammation, 
physical  and  mechanical  irritants,  and  infective  organisms.  The  chief  difference 
is  that  they  kill  the  tissues  outright,  either  directly  or  by  cutting  off  the  blood- 
supply,  instead  of  merely  impairing  their  vitality. 

I.  General. — These  are,  for  the  most  part,  predisposing  only,  but  sometimes 
they  are  so  powerful  that,  as  in  Raynaud's  disease  (symmetrical  gangrene),  it  is 
scarcely  possible  to  find  a  local  one.  They  include  anything  that  can  in  any 
way  impair  the  general  health  or  interfere  with  the  quantity  or  the  quality  of  the 
circulating  blood.  Cardiac  disease  of  all  kinds,  valvular  and  degenerative ;  loss 
of  blood;  exhausting  illnes.ses ;  prolonged  fevers;  Bright' s  disease;  diabetes; 
exposure ;  starvation  and  intemperance,  are  some  of  the  most  common.  The 
prolonged  use  of  ergot  is  said  to  lead  to  gangrene,  but  probably  only  when  it  is 
assisted  by  other  causes. 

[*  It  is  easy  to  see  that  the  conditioa  of  the  veins  and  lymphatics  must  determine  the  relative 
moisture  or  dryness.  When  the  lymph  channels  or  veins,  or  both,  are  occluded,  or  contracted  through 
swelling,  then  there  must  be  cedema  in  the  part.] 


6o         GENERAL   PATHOLOGY  OF  SURGLCAL   DLSEASES. 

Most  of  these  act  upon  the  tissues  directly  as  well  as  through  the  circulation. 
Whether  loss  of  nerve-power  has  much  influence,  except  in  so  far  as  it  impairs 
nutrition  from  disuse,  is  uncertain.  There  is  more  evidence  in  favor  of  nerve- 
irritation.  That  inflammation  can  be  induced  in  this  way  is  generally  admitted  ; 
and  there  are  cases  on  record  in  which  the  process  has  been  so  severe  as  to  lead  to 
gangrene  of  the  most  acute  type — sloughing  bed-sores  for  example — within  twenty- 
four  hours  after  an  injury.  Whether  this  is  due  to  trophic  nerves,  or  to  spasmodic 
vaso-motor  contraction,  brought  about  by  reflex  irritation,  is  not  known.  The 
existence  of  the  former  is  not  proved  ;  while  in  favor  of  the  latter  is  a  remarkable 
case  recorded  by  Hilton,  in  which  the  pressure  of  an  exostosis  upon  the  ulnar 
nerve  caused  gangrene  of  the  little  and  adjacent  side  of  the  ring-finger,  the 
stimulus  conveyed  by  the  sensory  fibres  to  the  nerve-centre  being  reflected  down 
the  vaso-motor  ones  to  the  vessels,  and  cutting  ofl"  the  blood-supply. 

2.  Local. — Any  kind  of  irritant  can  cause  gangrene,  the  degree  of  severity 
required  being  in  inverse  ratio  to  the  activity  of  nutrition  :  a  scratch  or  bruise  is 
sufficient  when  the  vitality  of  the  part  is  low. 

(A)  Physical  or  Mechanical  Lrr Hants. 

Some  of  these  act  upon  the  tissues  themselves  ;  others  kill  them  by  cutting 
off  the  blood-supply.  Heat  and  chemical  agents  are  examples  of  the  former, 
arterial  obstruction  of  the  latter. 

Obstruction  of  an  artery  may  be  due  to  rupture,  ligature  pressure,  thrombosis, 
embolism,  or  inflammation.  As  a  rule,  the  collateral  trunks  enlarge  sufficiently 
to  make  up  for  it ;  but  if  the  vessel  that  has  given  way  is  a  large  one,  so  that 
there  is  an  enormous  extravasation  under  high  pressure  ;  or  if  the  walls  of  the 
other  vessels  are  rigid  and  atheromatous,  so  that  they  cannot  dilate,  the  blood- 
supply  is  cut  off"  and  that  part  dies.  Venous  obstruction,  owing  to  the  freedom 
of  anastomosis,  rarely  leads  to  this ;  but  in  strangulation  by  ligature,  or  when  a 
piece  of  intestine  is  caught  in  a  narrow  canal,  the  veins  are  compressed  first,  and 
the  congestion  so  caused  gradually  blocks  the  arteries. 

(^B)  Organized  Irritants. 

These  are  the  same  micro-organisms  as  in  inflammation,  only  they  are  acting 
now  with  greater  intensit}".  In  the  one  case  they  lower  the  Wtality  of  the  tissues, 
in  the  other  they  destroy  it.  They  differ  from  physical  and  mechanical  irritants 
in  the  fact  that  their  action  is  continuous  :  they  spread  wider  and  ^\-ider,  invading 
the  tissues  farther  and  farther,  until  either  their  energy  is  spent  or  they  meet  with 
some  part  sufficiently  well-nourished  to  resist. 

Of  these  some  are  certainly  specific  (anthrax,  malignant  pustule,  glanders, 
and  possibly  a  few  more).  Others' which,  like  these,  invade  living  structures,  do 
not  give  rise  to  specific  diseases,  but  merely  to  inflammation  of  great  severity.  They 
impair  the  vitality  of  the  tissues  to  such  an  extent  that  they  slough.  This  is  the 
case  with  spreading  traumatic  gangrene  and  hospital  gangrene ;  no  specific  germ 
has  been  proved  to  exist  in  them  :  they  are  merely  the  result  of  the  ordinary 
organisms  of  suppuration  acting  under  peculiarly  favorable  conditions.  Whether 
noma,  cancnim  oris,  and  phagedaena  should  be  included  is  still  a  matter  for  ques- 
tion.     Carbuncles  and  boils  are  undoubtedly  due  to  ordinary  micrococci. 

This  form  of  gangrene  is  always  moist :  putrefaction  is  present,  as  well, 
wherever  the  slough  is  exposed  to  the  air  :  and  the  products  bathing  the  surface 
of  the  sore,  lowering  the  strength  of  the  patient  as  well  as  the  vitality  of  the 
tissues,  materially  assist  the  progress  of  the  original  cause. 

Subsequent  Course. 

As  soon  as  a  part  of  the  body  has  been  killed,  whether  by  mechanical,  phys- 
ical, or  organized  irritants,  an  attempt  is  made  to  get  rid  of  it.     The  success 


GANGRENE.  6i 

which  attends  this  (Iciifiids  upon  three  conditions:  the  nutrition  of  the  tissues, 
the  i)ersistence  of  the  orii;inal  irritant,  and  the  presence  or  not  of  any  other 
in  addition. 

1.  Win- re  the  tissues  are  Jiea/tJiy,  where  the  injury  is  not  repeated,  and  where 
no  other  irritant  is  allowed  to  intervene,  the  dead  portion  is  either  absorbed  or 
tlirow  n  off,  according  to  its  position. 

If  it  is  in  the  interior  of  the  body  it  sinij)ly  undergoes  degeneration  and  is 
tranquilly  removed.  A  portion  of  tissue  that  is  dead  acts  as  a  very  slight  irritant  on 
the  structures  around.  The  pedicle  of  an  ovarian  tumor  that  has  been  ligatured 
and  returned  into  the  abdominal  cavity  is  an  instance  ;  the  neighboring  tissues 
become  more  vascular,  leucocytes  and  plasma  pour  out  in  greater  amount,  the 
strangulated  part  gradually  becomes  invaded  by  them,  new  vessels  are  formed  and 
extend  farther  and  fiirther  into  its  substance,  and  at  length  it  comj^letely  disappears. 
In  the  same  way  a  bony  secpiestrum  of  small  size,  and  even  dead  substances  of  an 
entirely  foreign  nature,  such  as  ivory  pegs,  can  be  removed. 

If  it  is  in  the  skin,  under  the  same  conditions,  the  same  changes  occur  round 
the  buried  part,  but  the  exterior  dries  up  and  becomes  hard  and  dense.  Absorjj- 
tion,  accordingly,  is  impossible,  except  to  a  very  slight  extent ;  the  lymph  that  is 
thrown  out  by  the  living  tissues  becomes  organized  ;  the  deep  part  is  converted 
into  fibrous  tissue;  the  superficial,  where  it  is  in  contact  with  dead  material,  is 
covered  over  with  epidermis,  which  grows  in  from  the  margin,  and  at  length  the 
dried-uj)  mass  drops  off  by  itself^  leaving  a  perfectly  healed  surface  beneath.  A 
burn,  for  example,  covered  up  at  once,  may  remain  dry,  and  form  a  scab  under 
which  repair  is  completed  without  the  least  further  loss  of  tissue  or  suppuration. 
The  line  along  which  the  separation  takes  place  is  known  as  the  line  of  demarca- 
tion ;  on  the  one  side  is  the  dried-up  dead  material,  on  the  other  the  living  tissues, 
reddened,  slightly  swollen,  and  more  tender  than  usual,  because,  owing  to  the 
presence  of  an  injury,  there  is  more  than  the  ordinary  degree  of  repair  required, 
and  the  circulation  is  quicker  and  more  active. 

It  must  be  acknowledged  that  suppuration  is  rarely  absent  when  the  gangrene 
is  of  considerable  size ;  but  it  is  an  accident  and  not  essential.  The  slough,  if 
the  adjacent  tissues  are  healthy  and  uninjured,  can  be  detached  without  the  loss 
of  a  single  leucocyte. 

2.  Where  the  vitality  of  the  structures  near  is  impaired,  hut  not  very  seriously. 
At  once  this  gives  a  foothold  to  pyogenic  micrococci,  which  are  always  at  hand 
and  ready ;  suppuration  takes  place,  and,  although  the  gangrene  does  not  spread, 
the  loss  of  tissue  is  greater  than  is  accounted  for  by  the  slough  alone. 

{a)  The  general  nutrition  may  be  enfeebled  from  any  of  the  causes  already 
mentioned.  A  burn,  which,  in  a  healthy  child,  would  heal  without  suppuration, 
may  give  rise  to  extensive  ulceration  in  a  person  suffering  from  Bright's  disease  or 
diabetes. 

if)  The  local  nutrition  may  be  impaired,  owing  to  the  surrounding  parts 
having  been  affected  by  the  original  injury.  In  frostbite,  for  example,  part  of 
the  tissue  is  killed  outright,  but  the  vitality  of  the  structures  for  long  distances 
round  is  so  enfeebled  that  they  are  unable  to  resist  the  onset  of  the  micro-organ- 
isms. The  same  thing  occurs  in  bad  crushes  and  bruises  ;  large  subcutaneous 
extravasations  of  blood  are  very  prone  to  suppurate,  partly  because  of  the  tension, 
but  partly  also  because  the  tissues  round  are  injured  and  unable  to  hold  their  own. 

{c)  Other  irritants  may  make  their  appearance  and  help  to  weaken  the 
resistance  of  the  still  living  tissues.  These  may  be  of  the  same  nature  as  the 
original  one,  or  different.  Tension,  for  example,  prevents  a  slough  being  detached 
without  suppuration.  Friction  and  want  of  rest  do  the  same.  Septic  decompo- 
sition is  still  more  powerful,  the  ptomaines  it  produces  causing  the  death  of  the 
structures  they  touch  to  a  depth  that  depends  upon  the  activity  of  their  nutrition. 
If  healthy  granulation-tissue  has  already  been  formed,  the  surface  cells  merely  melt 
away  ;  but  if  the  part  is  badly  nourished  and  its  vitality  depressed,  either  from 
constitutional  causes  or  from  the  original  injury,  or  if  the  poison  can  soak  into 


62         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

the  tissues  along  the  lymphatics,  the  destruction  may  extend  for  an  unlimited 
distance. 

These  causes  lead  to  one  result :  the  tissues  around  the  slough  are  injured  ; 
their  vitality  is  lowered,  and  they  have  lost  the  ])o\ver  of  resisting  the  pyogenic 
organisms  which  gain  access  to  them.  The  lymph  that  pours  through  the  walls  of 
the  vessels  melts  away  ;  the  leucocytes  perish  and  become  pus  corpuscles ;  the 
plasma  can  no  longer  coagulate  ;  the  injured  tissues  undergo  coagulation-necrosis, 
disappear,  and  add  to  the  fluid  already  present  \  and  by  degrees  a  layer  of  pus  is 
formed,  separating  the  dead  material  from  the  living  lymph,  which,  as  the  surface 
melts  away,  is  constantly  renewed  from  the  vessels  round.  If  it  is  in  the  interior 
of  the  body,  the  slough  is  enclosed  in  an  abscess,  the  micrococci  having  made 
their  way  through  the  blood-vessels  or  lymphatics,  and  having  found  a  congenial 
soil  in  the  damaged  tissues  that  lie  around  it ;  if,  on  the  surface,  it  lies  on  the 
surface  of  an  ulcer,  and  the  pyogenic  germs  have,  in  all  probability,  reached  it 
through  the  skin. 

3.  liliere  the  vitality  of  the  tissues  is  very  seriously  depressed.  It  is  no  longer 
now  a  question  of  molecular  disintegration  or  ulceration  ;  the  surrounding  part 
perishes  en  masse  ;  the  gangrene  itself  spreads. 

The  conditions  under  which  this  occurs  may  be  cla.ssified  in  the  same  way. 

(<7)  The  general  nutrition  may  be  in  fault.  I  have  known  gangrene  extend 
from  the  foot  to  the  thigh  in  both  legs,  and  prove  fatal  within  thirty -six  hours, 
with  all  the  symptoms  of  the  most  profound  collapse,  after  two  primary  amputa- 
tions, one  on  each  foot,  performed  with  the  strictest  antiseptic  precautions.  The 
vitality  of  the  tissues,  from  the  combined  eff"ects  of  Bright's  disease,  exposure, 
intemperance,  and  the  carbolic  spray,  was  so  low  that,  uninjured,  they  were  only 
just  able  to  hold  their  own  ;  the  least  hurt  killed  them  at  once,  and  the  contact  of 
the  tissues  already  killed  was  a  sufficient  irritant  to  destroy  the  vitality  of  those 
around. 

{U)  The  tissues  may  have  been  injured  too  seriously  by  the  original  cause.  If 
amputation  is  performed  for  frostbite  before  the  part  has  thoroughly  recovered, 
the  flaps  are  sure  to  slough.  Their  vitality  is  so  low  that  they  cannot  withstand 
the  additional  hurt. 

{c)  Another  irritant  may  be  added  and  comi)lete  the  destruction.  Septic 
decomposition  is  the  usual  one.  The  ptomaines  produced  by  this,  if  they  are 
absorbed,  act  as  the  most  powerful  depressing  agents,  causing  septic  fever  or 
saprsmia.  If  the  tissues  have  already  recovered  from  the  original  hurt,  and  are 
protected  by  a  wall  of  newly  developed  vascular  granulation-tissue,  no  ill-result 
follows ;  a  slough  on  the  surface  of  a  healing  ulcer  causes  very  little  disturbance, 
unless  it  is  assisted  by  tension,  friction,  or  other  modes  of  irritation  ;  but  if  there 
has  not  jet  been  time  for  this,  or  if  the  vitality  of  the  part  is  too  depressed, 
sloughing  of  the  most  extensive  description  is  almost  sure  to  follow. 

As  the  greater  includes  the  less,  so,  if  the  gangrene  spreads,  suppuration 
always  occurs.  Only  as  the  pyogenic  micrococci  require  time  before  they  can 
produce  much  effect,  in  the  worst  form  of  spreading  gangrene,  the  tissues  perish 
too  soon. 

The  consequences  of  gangrene,  in  short,  depend  upon  the  state  of  the  part 
that  is  living.  If  the  tissues  are  healthy,  uninjured,  and  well-protected,  they 
are  easily  capable  of  resisting  such  an  irritant  as  contact  with  dead  material,  and 
set  about  repair  at  once.  If,  however,  they  are  weakened  by  constitutional  or 
local  causes,  or  if  they  are  exposed  to  further  injurious  influences,  mechanical  or 
chemical,  their  power  of  resistance  is  enfeebled,  and  according  to  the  proportion 
their  strength  bears  to  that  of  the  combined  irritants,  either  molecular  or  molar 
death  follows — suppuration  or  gangrene — and  spreads  until  it  reaches  a  part  that 
is  capable  of  successful  resistance. 


GANGRENE.  63 

Special  Forms  of  Gangrene. 

Some  of  these  are  due  to  the  action  of  infective  organisms,  others  are  not ; 
but  as  the  one  nearly  always  complicates  the  other,  it  is  not  advisable  to  consider 
them  apart. 

I.  Dry  Gancrkn'e. — The  most  typical  example  is  that  caused  by  thrombosis 
in  atheromatous  arteries,  commonly  known  as  senile. 

.It  always  begins  in  the  lower  extremities  and  can  generally  be  traced  to  some 
trivial  injury.  For  some  time  past  the  feet  and  legs  have  been  peculiarly  cold 
and  numb;  there  has  been  a  constant  sense  of  itching  and  formication;  cramp 
has  been  very  painful  in  the  calf;  then  suddenly  a  dark-red  or  purple  spot,  sur- 
rounded by  a  dusky  ring,  is  noticed,  usually  on  the  inner  side  of  the  great  toe; 
and  on  examination  it  is  found  that  the  action  of  the  heart  is  very  feeble,  that  the 
tibial  pulse  can  scarcely  be  felt,  and  that  the  arteries  are  rigid  and  hard.  As  a 
rule  it  is  the  seat  of  a  constant  burning  pain,  but  sometimes  this  is  not  noticed. 
Gradually  the  central  patch  becomes  darker,  and  encroaches  on'the  areola  around  ; 
this,  without  growing  wider  or  narrower,  slowly  spreads  farther  and  farther ;  the 
toe  becomes  shrunken,  dried,  and  hard;  and  at  length  the  foot  is  involved. 
Progress  is  rarely  uniform ;  one  toe  after  another  may  be  attacked  at  intervals. 
Just  below  the  ankle  there  is  always  a  rest,  sometimes  a  permanent  one ;  but  the 
tendency  is  for  the  disease  to  progress,  sometimes  slowly,  sometimes  quickly,  until 
exhaustion,  with  extreme  depression  and  low  wandering  delirium,  sets  in.  Post 
mortem  the  arteries  are  usually  calcareous,  rough,  and  irregular  on  the  inner  surface, 
and  blocked  or  narrowed  by  coagula,  often  as  high  as  the  popliteal. 

Arterial  embolism  usually  gives  rise  to  the  same  form  when  it  causes  gangrene, 
but,  as  a  rule,  the  collateral  circulation  enlarges  sufficiently  to  prevent  it.  Excep- 
tionally, either  because  several  trunks  are  plugged  at  the  same  time,  or  the  condi- 
tion of  the  vessels  round  is  such  that  they  cannot  dilate,  the  blood-supply  is 
altogether  cut  off.  It  frequently  occurs  after  endocarditis.  The  onset  is  sudden  : 
there  is  a  severe  attack  of  pain  in  the  course  of  an  artery,  generally  where  it 
bifurcates  or  gives  off  one  or  more  large  branches  ;  the  part  feels  dead  or  numb, 
the  temperature  falls,  the  pulse  below  disappears,  and  then  by  degrees  the  skin 
passes  through  the  same  changes.  Suppuration  usually  occurs  while  the  dead  part 
is  being  detached,  because  the  living  tissues  next  to  it  are  too  much  injured  to 
resist  the  action  of  the  pyogenic  micrococci.  A  certain  amount  of  decomposition 
may  be  present,  too,  after  this  has  taken  place  and  supplied  the  necessary  fluid, 
but  so  long  as  the  general  nutrition  is  good,  there  is  little  or  no  fever,  and  the 
death  of  the  tissues  is,  except  for  the  suppuration,  limited  to  the  original  area. 

Symmetrical gangretie  (Raynaud's  disease)  is  very  similar  to  this  in  its  local 
changes ;  but  no  lesion  of  any  kind — embolism,  thrombosis,  or  degeneration — 
has  been  found  to  account  for  it.  Possibly  it  is  due  to  arterial  spasm  arising  from 
cold,  and  rendered  persistent  by  a  hyper-sensitive  condition  of  the  vaso-motor 
centres.  It  is  usually  met  with  in  young  an?emic  subjects  suffering  from  feeble 
circulation,  and  always  attacks  the  extremities.  In  its  slighter  forms,  cold, 
grayish-blue,  ill-defined  patches  of  local  syncope  or  local  asphyxia  suddenly  make 
their  appearance  after  some  trivial  exposure,  upon  the  hands  or  feet,  or  upon  the 
pinna,  very  often  symmetrically.  After  a  time  these  may  disappear,  but  occa- 
sionally the  color  remains  pale  or  livid,  then  turns  blue  and  purple,  and  finally 
becomes  black.     In  some  instances  it  is  associated  with  haematinuria. 

Gangrene  due  to  the  direct  effect  of  intense  cold  presents  the  same  features 
(^frostbite).  The  part  is  frozen  through  ;  the  skin  remains  firm  and  white,  and 
then  passes  through  the  same  changes.  This,  of  course,  like  all  other  forms,  is 
more  likely  to  occur  when  other  causes,  such  as  old  age,  starvation,  fatigue,  or 
exhaustion,  exist ;  and  moist  cold  is  certainly  worse  than  dry.  It  rarely  happens, 
however,  in  England  that  the  temperature  falls  sufficiently  for  this.  Usually, 
frostbite  is  caused  by  the  too  early  application  of  warmth  to  a  half-frozen  surface, 
and  the  gangrene  is  moist.     Slighter  degrees  of  cold  merely  lead  to  vesication, 


64         GENERAL   PATHOLOGY  OF  SURGLCAL   DISEASES. 

like  heat,  or  superficial  gangrene  ;  and  the  slightest,  to  an  erythematous  state  in 
which  the  skin  is  deep  red  or  livid,  and  subsequently,  when  warm,  becomes  painful 
and  slightly  swollen. 

Dry  gangrene  may  also  be  caused  by  intense  heat — the  actual  cautery,  for 
example ;  but,  as  a  rule,  in  cases  of  burning,  the  tissues  for  long  distances  round 
are  injured  to  such  an  extent  that  inflammation  and  suppuration  follow.  Potassa 
fusa,  applied  as  it  used  to  be  when  it  was  desired  to  form  an  issue,  produces  the 
same  result — a  limited,  shriveled  patch  of  blackened  tissue,  unable  to  undergo 
decomposition  owing  to  the  absence  of  fluid,  and  surrounded  by  a  zone  of  sup- 
puration. 

A  very  rare  form  of  arterial  obstruction,  due  to  endarteritis  obliterans,  some- 
times leads  to  the  same  result.  I  have  known  it  occur  in  the  vessels  of  the  upper 
extremity,  so  that  when  amputation  of  the  arm  was  performed,  the  brachial  did 
not  require  ligature.  The  symptoms  resemble  tho.se  of  steadily  advancing  throm- 
bosis, attended  with  severe  pain.  Most  of  the  cases  have  occurred  after  middle 
life,  without  any  very  obvious  reason. 

All  these  forms  of  gangrene  resemble  each  other  in  being  practically  unat- 
tended by  decomposition.  A  portion  of  tissue  is  killed,  either  by  being  entirely 
deprived  of  blood,  or  by  the  action  of  some  external  agent.  It  acts  as  a  foreign 
body,  almost  inert,  so  long  as  no  other  irritant  is  allowed  to  appear.  The  sur- 
rounding tissues  are  uninjured,  and  at  once,  if  their  nutrition  is  sufficiently  good, 
commence  the  process  of  repair.  Unhappily,  in  the  senile  form  due  to  thrombosis 
(the  most  typical  and  the  most  common  of  them  all),  it  usually  happens  that  the 
clot  extends  farther  and  farther  up  the  artery,  so  that  successive  portions  of  the 
limb  become  involved  and  perish  ;  and  in  any  case  the  vitality  of  the  part  is  very 
feeble.  In  other  instances  the  blood-vessels  round  the  injured  area  dilate  ;  lymph 
pours  out  through  their  walls,  new  vessels  are  developed,  and.  by  degrees,  a  layer 
of  vascular  granulation-tissue  (forming  the  so-called  line  of  demarcation)  is 
developed  round  the  whole  of  the  buried  surface  of  the  necrosed  tissue.  If  this 
is  small  and  completely  surrounded,  it  may  be  absorbed  and  disappear  entirely  ; 
if  it  lies  on  the  surface  it  gradually  dries  up,  and  is  thrown  off  by  the  granulations 
beneath. 

Suppuration  is  not  necessary  for  this  process,  although,  unless  the  necrosed 
fragment  is  of  very  small  size,  it  is  nearlv  always  present.  The  pyogenic  organ- 
isms gain  access  either  through  the  air  or  through  the  blood-vessels  or  lymphatics. 
The  plasma  no  longer  coagulates,  the  leucocytes  near  the  infected  spot  perish  and 
form  pus-corpuscles,  and  the  walls  of  the  vessels  and  the  tissue,  already  organized, 
undergo  coagulation-necrosis  and  melt  away  in  the  fluid. 

2.  Moist  Gangrene. — This  may  commence  as  such,  or  it  may  be  dry  at 
first.  Senile  gangrene,  for  example,  is  very  often  dry  until  the  calf  is  reached  ; 
then,  owing  to  the  greater  amount  of  fluid,  decomposition  sets  in. 

Dry  gangrene  does  not  extend  unless  the  original  cause  is  repeated — unless, 
for  example,  the  thrombus  spreads  higher  up  the  artery.  Moist  gangrene,  on 
the  other  hand,  whatever  the  cause,  spreads  until  it  meets  some  structure  suffi- 
ciently well-nourished  to  hold  its  own.  The  products  of  putrefaction,  soaking 
into  the  living  tissues  near,  lower  their  power  of  resistance,  and  if  their  nutrition 
is  impaired  in  the  least  degree,  or  if  the  irritant  is  assisted  by  tension,  want  of 
rest,  or  any  other  cause,  they  must  give  way.  If  the  conditions  are  exceedingly 
unfavorable,  the  surrounding  tissues  perish  en  masse  (sloughing  phagedena  and 
hospital  gangrene)  ;  if  not  quite  so  bad,  if  their  vitality  is  merely  impaired  instead 
of  being  destroyed,  they  become  inflamed,  and  as  pyogenic  organisms  are  always 
present  in  such  circumstances,  melt  away  as  pus. 

Whether  specific  micro-organisms  are  present  in  many  of  these  cases,  as  well 
as  septic  and  pyogenic  ones,  is  uncertain,  and  the  difficulty  is  especially  great  in 
connection  with  such  disea.ses  as  cancrum  oris  and  phagedena.  None,  however, 
has  yet  been  proved,  and  in  the  absence  of  this,  it  is  more  reasonable  to  assume 
that  these  diseases,  attended  with  very  characteristic   and   extensive  destruction, 


GANGRENE.  65 

are  tlie  result  of  the  ordinary  germs,  acting  under  conditions  peculiarly  favorable 
to  them  :  overcrowding,  for  instance,  and  poisoning  by  foul  air,  in  the  case  of 
hospital  gangrene  ;  and  syphilis  in  the  case  of  phageda^na. 

The  simplest  examjjle  of  moist  gangrene  is  seen  in  a  lacerated  wound.  A 
portion  of  the  tissue  is  killed,  it  remains  for  two  or  three  days  adherent  to  the 
surface,  slowly  changing  color,  and  then  cpiietly  drops  off,  detached  from  the  part 
that  is  living  by  the  vascular  lymi)h  thrown  out.  If  it  is  very  tough  and  hard — 
tendon,  for  example,  or  bone — so  that  the  blood-vessels  are  scanty  and  unable  to 
dilate,  the  process  may  take  weeks  instead  of  days. 

Bed-sores,  due  partly  to  pressure,  partly  to  the  irritation  of  urine  and  retained 
])erspiration,  are  examples  on  a  larger  scale.  The  skin  at  first  is  reddened,  then 
fluid  collects  beneath  the  epidermis ;  this  gives  way,  exposing  the  corium  ;  and 
the  continued  irritation  and  pressure  combined  soon  cause  it  to  slough.  Decom- 
position sets  in,  and  the  poison  so  formed,  added  to  the  already  existing  causes, 
kills  the  tissues  round  until  a  part  is  reached  where  the  vitality  and  power  of 
resistance  are  sufficiently  good. 

Nearly  all  forms  of  gangrene  that  are  dry  at  first  end  in  this  way.  Even  if 
the  centre  remains  hard  and  resists  putrefaction,  suppuration  occurs  around  the 
margin,  and  the  pus  provides  a  sufficient  amount  of  fluid  for  putrefaction.  For- 
tunately, as  a  rule,  by  the  time  this  has  happened  the  tissues  around  the  slough 
have  recovered  themselves,  and  have  erected  a  barrier  of  young  and  vascular 
granulation-tissue,  which  may  lose  its  surface  as  pus,  but  nothing  deeper. 

When  a  limb  is  run  over  and  crushed,  or  when  a  large  artery  gives  way  sub- 
cutaneously  and  cuts  off  the  circulation  by  the  pressure  it  causes  {local  traumatic 
goTigrejic),  the  changes  are  the  same  at  first.  Immediately  after  the  accident  the 
limb  is  cold  and  loses  its  sensibility,  the  skin  is  even  whiter  than  natural,  and  is 
stretched  and  tense  from  the  extravasation  beneath,  and  the  pulse  cannot  be  felt. 
Then  the  color  gradually  becomes  dusky  and  livid,  especially  toward  the  lower 
part,  to  which  the  blood  gravitates ;  purple  and  green  patches  make  their  appear- 
ance ;  bullae  form,  filled  with  a  reddish  fluid  ;  the  epidermis  is  detached  from  the 
corium  beneath  ;  emphysematous  crackling  can  be  felt  here  and  there,  and  the 
odor  is  most  offensive. 

The  subsequent  course,  whether  the  gangrene  remains  local  or  begins  to 
spread,  depends  upon  the  power  of  resistance  of  the  tissues  that  are  .still  living,  to 
the  combined  irritants.  If  the  size  of  the  slough  is  small,  the  tension  low,  and 
the  condition  of  nutrition  good,  the  tissues  soon  protect  themselves,  and  a  line  of 
demarcation  gradually  forms.  If,  on  the  other  hand,  the  part  involved  is  large, 
such  as  a  limb,  and  the  tension  in  it  is  high,  the  products  of  decomposition, 
unable  to  escape,  spread  into  all  the  cellular  spaces  in  the  living  structures  near, 
and  stream  into  the  lymphatics,  poisoning  everything  they  touch,  and  causing 
intense  inflammation.  The  local  traumatic  gangrene,  assisted  by  decomposition, 
has  begun  to  spread. 

The  worst  example  of  spreadiiig  traumatic  gangrene  met  with  at  the  present 
day  is  that  which  sometimes  occurs  after  compound  (open)  fractures,  especially  those 
due  to  direct  violence.  There  is  everything  to  favor  its  occurrence  and  its  exten- 
sion ;  an  enormous  extravasation  at  a  high  temperature  ;  a  wound,  so  that  decom- 
position can  begin  at  once ;  the  opening  usually  valvular,  so  that  the  tension  from 
the  hypergemia  that  follows  must  be  high  ;  fractured,  and  often  dead,  bone,  which 
in  some  particular  way  is  exceedingly  favorable  to  decomposition  ;  and  all  the 
cellular  spaces  in  the  tissues  round  widely  open  still,  with  no  protecting  barrier  of 
lymph.  Under  conditions  such  as  these  it  is  no  wonder  that,  if  septic  decompo- 
sition occurs,  and  the  products  are  not  allowed  to  escape,  spreading  traumatic 
gangrene  of  the  worst  description  follows.  The  part  swells  more  and  more  ;  the 
skin  is  tense,  red,  and  burning  hot ;  the  loose  cellular  tissue  on  the  inner  side  of 
the  limb  and  along  the  great  vessels  is  boggy  and  oedematous,  filled  with  a  sero- 
purulent  fluid  which  rapidly  decomi^oses  and  causes  emphysematous  crackling  ;  the 
redness  keeps  spreading  farther  and  farther,  round  the  seat  of  injury  it  gradually 


66         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

becomes  dull  and  livid,  then  the  cuticle  separates,  the  tissue  becomes  soft,  and,  if 
the  patient  live  sufficiently  long,  the  whole  part  decomposes. 

As  described  above,  if  the  vitality  is  already  depressed  from  other  causes, 
constitutional  or  local  (Bright's  disease,  for  example,  or  cold),  spreading  trauma- 
tic gangrene  will  follow  even  when  the  irritant  is  comparatively  slight. 

Local  traumatic  gangrene,  unless  the  part  is  exceedingly  small  and  the  escape 
absolutely  free,  is  always  attended  with  fever.  Even  when  there  is  only  a  lacerated 
wound  with  a  few  shreds  hanging  from  it,  there  is  some  absorption,  which  dimin- 
ishes as  the  tissues  become  by  degrees  able  to  protect  themselves.  In  the  spread- 
ing form,  setting  in  at  once,  before  the  cellular  spaces,  are  closed,  with  an  immense 
amount  of  poison  and  very  high  tension,  the  absorption  is  naturally  excessive,  and 
the  constitutional  disturbance  may  prove  fatal  in  the  first  few  days.  In  some  cases 
the  temperature  rapidly  runs  up  to  104°  or  105°  F.;  the  pulse  is  full  and  quick, 
and  the  respiration  hurried  and  rapid.  In  others,  and  they  are  usually  the  worst, 
it  scarcely  rises  at  all,  the  pulse  is  small  and  feeble,  the  patient  is  delirious,  the 
face  is  dusky,  the  tongue  dry  and  brown,  and  the  symptoms  are  typhoid  from  the 
beginning.  If  the  patient  survives  the  period  of  spreading  gangrene,  and  the 
tissues  gain  the  upper  hand,  resisting  the  further  advance  of  the  irritant,  and 
throwing  out  a  wall  of  vascular  lymph,  the  fever  begins  to  fall,  especially  of  a 
morning,  and  assumes  the  remittent  type,  characteristic  of  suppuration  without 
free  exit  for  the  pus. 

Given  local  traumatic  gangrene — a  part  of  the  body,  that  is  to  say,  killed  by 
injury  of  any  kind — the  consequences,  whether  a  line  of  demarcation  forms,  or 
inflammation  and  suppuration  set  in,  or  spreading  gangrene  follows,  depend  upon 
the  vigor  of  resistance  offered  by  the  tissues,  and  the  degree  to  which  they  are 
protected  from  other  irritants.  If  they  are  healthy  constitutionally,  and  were  not 
injured  when  the  neighboring  part  was  killed,  and  are  not  injured  by  any  other 
agent  (tension,  want  of  rest,  or  decomposition),  lymph  is  thrown  out,  and  repair 
is  commenced  at  once.  If  they  fail  to  a  slight  extent  in  one  or  more  of  these 
conditions — if,  that  is  to  say,  their  vitality  is  lowered — inflammation  sets  in  and 
spreads  until  a  healthier  part,  capable  of  better  resistance,  is  reached.  If  they 
fail  seriously — if  their  vitality  is  destroyed — the  gangrene  spreads. 

Treatment. — The  general  principles  are  the  same  in  all  forms,  but  special 
measures  have  to  be  adopted  in  the  case  of  some  of  them. 

1.  Constitutional. — The  reis  always  well-marked  general  depression;  very 
often  it  is  one  of  the  predisposing  causes,  weakening  the  tissues  and  rendering 
them  more  susceptible  to  the  action  of  injurious  agents,  and  if  not  already  present 
it  always  makes  its  appearance  in  the  course  of  the  disease.  Everything,  therefore, 
must  be  done  to  husband  and  maintain  the  general  strength ;  food  must  be  nutri- 
tious but  easily  assimilated,  and  given,  therefore,  in  small  quantities  at  frequent 
intervals.  Stimulants  are  required  to  assist  digestion,  or,  if  the  heart  is  weak  and 
the  pulse  feeble,  to  maintain  the  circulation.  Opium  may  be  given  to  relieve  pain 
and  procure  sleep.  Fresh  air  is  absolutely  necessary,  particularly  if  decomposition 
is  going  on,  and  special  attention  must  be  paid  to  any  constitutional  disorder  that 
may  be  present,  such  as  Bright's  disease  or  diabetes,  ^^ery  great  care,  however, 
is  required  in  the  matter  of  food,  especially  in  the  case  of  old  people.  It  often 
happens  that  for  years  past  they  have  taken  it  in  exceedingly  small  quantities,  their 
strength  being  economized  to  the  utmost  by  rest  and  warmth,  and  any  attempt  to 
increase  it  only  defeats  its  own  end.  Under  the.se  conditions  it  is  not  uncommon 
to  find  that  comparatively  large  quantities  of  stimulants,  especially  brandy,  are 
very  well  borne;  and,  provided  the  surrounding  temperature  is  carefully  main- 
tained, enable  the  patient  to  tide  over  the  crisis. 

2.  Local,  (i)  Preventive. — Sometimes  when  the  onset  is  gradual  the  cause 
of  the  gangrene  can  be  removed  in  time.  The  constriction  may  be  divided,  for 
example,  in  the  case  of  a  strangulated  hernia  or  paraphimosis  :  the  tension 
relieved  by  timely  incision  in  phlegmonous  erysipelas  or  cellulitis,  and  the  pres- 
sure in  bed-sores  distributed  over  a  wider  area,  or  transposed   to  another  part  of 


GANGRENE.  67 

the  body  altoj^^ether.  In  many  cases,  however — especially  those  in  which  the 
blood-sui)i)ly  is  cut  olT — any  measure  of  this  kind  must  be  too  late. 

(ii)  Where  this  cannot  be  done,  an  attempt  must  be  made  to  stay  the  pro- 
gress of  the  disease  by  preventing  the  repetition  of  the  original  cause  and  the 
access  of  any  other. 

The  circulation  must  be  assisted  in  every  po.ssiblc  way.  The  part  should  be 
raised,  .so  that  veins  and  lymphatics  can  empty  themselves  with  ease ;  the  tempera- 
ture kept  perfectly  even,  and  absolute  rest  enforced.  Nothing  answers  so  well  as 
investing  the  whole  limb  in  cotton-wool,  which  may  be  impregnated  with  .some 
antiseptic  to  assist  in  checking  decomposition  ;  poultices  should  always  be  avoided, 
and  wet  fomentations,  which,  by  the  moisture  they  contain,  encourage  the  soften- 
ing of  the  epidermis.  In  some  cases  of  senile  gangrene,  in  which  there  is  no 
surrounding  inflammation,  and  the  skin  of  the  limb  is  not  tender,  gentle 
upward  friction  is  of  service,  as  it  tends  to  emjjty  the  veins  and  increase  the  flow 
through  the  neighboring  tissues. 

The  least  tension  in  any  part  must  be  relieved  at  once.  Free  incisions  are 
often  required,  not  only  to  reduce  the  pressure  upon  the  skin,  and  prevent  it 
sloughing,  but,  by  giving  exit  to  pent-up  fluids,  to  check  absorption  and  allow  the 
blood  to  circulate  more  freely.  The  wide  gaping  of  the  cuts,  the  continued  drain- 
ing from  their  edges  not  only  of  blood,  but  of  inflammatory  exudation,  and  the 
wrinkling  of  the  skin  on  the  following  day,  afford  a  very  good  explanation  of  the 
fall  in  the  temperature  and  the  diminution  in  the  fever  that  always  follow. 

[Application  of  external  heat,  by  means  of  hot-water  bags,  will  be  found 
useful,  not  only  in  treatment,  but  as  one  of  the  aids  to  prevention.] 

Decomposition  must  be  prevented.  This  may  be  accomplished  in  various 
ways.  In  many  forms  of  local  traumatic  gangrene — where,  for  example,  the 
fingers  have  been  crushed,  and  it  is  not  known  how  much  is  hopeless — prolonged 
warm  and  antiseptic  baths  are  most  beneficial.  If  the  part  is  only  small,  corro- 
sive sublimate  (one  part  in  ten  thousand)  may  be  used  for  several  hours  a  day  at 
first,  and  then,  when  the  putrefactive  odor  is  overcome,  for  an  hour  night  and 
morning.  If  the  part  is  too  large,  so  that  absorption  is  feared,  or  if  the  patient 
complains  of  pain,  boracic  acid  may  be  substituted,  but  it  is  not  so  efficacious. 
The  injured  part  is  dependent,  it  is  true,  especially  when  the  lower  extremity  is 
concerned,  but  this  disadvantage  is  fully  compensated  for  by  the  relaxation  of  all 
the  tense  and  inflamed  tissues,  by  the  regularity  of  the  temperature,  the  free 
escape  for  the  inflammatory  exudation,  and  the  impossibility  of  decomposition. 

When,  on  the  other  hand,  the  gangrene  has  a  tendency  to  become  dry, 
absorbent  dressings  and  iodoform  should  be  used.  Salicylic  wool,  wood-wool 
impregnated  with  corrosive  sublimate,  moss  treated  in  the  same  way — anything,  in 
short,  that  checks  putrefaction — succeeds  in  proportion  to  its  power  of  absorption. 
The  dressing,  however,  unless  the  gangrene  is  of  the  driest  type,  needs  changing 
frequently,  for  fear  that  a  solid  mass  of  dried  discharge  may  form  like  a  scab  over 
the  ulcerating  surface  and  keep  the  fluid  beneath  pent  up.  At  the  same  time  ten- 
sion should  be  relieved  by  suitable  measures,  gentle  compression,  elevation,  and 
even  incision,  and  sloughs  or  portions  of  dead  tissues  removed  as  soon  as  they  are 
loose.  The  greatest  care  must  be  taken,  of  course,  not  to  injure  or  irritate  in  any 
way  the  protecting  barrier  of  granulations  :  this  has  been  formed  by  tissues  that 
are  only  just  able  to  hold  their  own,  and  no  more  ;  and  the  least  damage  done  to 
them  at  once  causes  the  sloughing  to  spread  ;  but  this  is  no  reason  why  parts 
which  are  clearly  dead,  and  which  can  be  removed  without  injury  to  those  around, 
should  not  be  taken  away  as  soon  as  they  can. 

As.  the  line  of  demarcation  forms  and  gradually  grows  deeper  and  more 
defined,  the  sloughs  of  the  soft  parts  usually  separate  of  themselves,  until  at  length 
the  bone  is  left  with — hanging  around  it — tendons  and  dense  sheets  of  fascia, 
which,  owing  to  the  anatomical  condition  of  the  circulation,  are  only  detached 
after  prolonged  suppuration.  Sometimes  when  this  is  the  case  the  soft  parts  may 
be  very  gently  retracted,  lateral  incisions  being  made  to  give  more  room,  and  the 


68         GENERAL   PATHOLOGY  OF  SURGLCAL   DLSEASES. 

projecting  structures  carefully  divided  ;  otherwise  the  natural  jjrocess  of  separation 
may  take  an  immense  length  of  time  ;  but  this  should  not  be  attempted  until  the 
spreading  of  the  gangrene  is  no  longer  feared. 

(iii)  AiHputation. — In  local  traumatic  gangrene — such,  for  example,  as  results 
from  the  rupture  of  a  large  artery,  with  or  without  fracture — amputation  should  be 
performed  at  once,  sufficiently  far  above  the  seat  of  injury  to  secure  healthy  flaps. 
It  means  that  the  attempt  made  to  save  the  limb  has  failed  ;  and  if  gangrene 
begins,  it  is  certain  to  spread  as  high  as  the  seat  of  injury,  and  very  likely  not 
stop  there.      Nothing,  therefore,  is  gained  by  waiting. 

In  spreading  traumatic  gangrene  the  conditions  are  different.  If  it  is  due 
mainly,  or  even  in  part,  to  constitutional  causes,  amputation  higher  up  would  be 
followed  by  the  same  consequences.  In  some  very  rare  cases,  however,  it  is 
purely  local,  due  to  the  presence  of  a  poison  retained  under  high  tension,  usually 
decomposing,  extravasated  blood  ;  and  then  it  is  just  possible  that  amputation 
higher  up,  performed  sufficiently  early,  would  succeed  ;  but  in  such  cases  as  good 
a  result  may  be  obtained  by  free  incision,  relieving  the  tension  and  checking 
absorption. 

In  no  other  case  should  amputation  be  performed  until  the  line  of  demarca- 
tion is  well  established  ;  and  even  then,  in  the  majority,  it  is  wiser  to  wait  until 
all  the  soft  parts  have  separated  and  the  wound  so  left  is  beginning  to  cicatrize. 
Excision  of  the  projecting  end  of  the  bone,  even  with  a  certain  amount  of  soft 
tissues  round  it,  is  a  very  much  less  serious  operation  than  a  formally  planned 
amputation  ;  and,  unless  the  patient  is  being  exhausted  by  suppuration,  is  always 
to  be  preferred.  Owing  to  the  conical  shape  of  the  stump  left  by  gangrene  some- 
thing of  this  kind  is  always  required. 

[It  is  the  danger  of  the  production  of  septicaemia  that  causes  us  to  override 
this  injunction  frequently.  The  carrying  into  the  circulation  of  highly  infectious 
material  is  so  dangerous  to  the  patient,  that  early  amputation  must  be  done  in 
many  cases.] 

Special  Forms  of  Gangrene. — Senile  Gangrene. — Nutritious,  digestible 
food,  with  a  reasonable  supply  of  stimulants  ;  rest,  elevation,  and  equable  warmth, 
are  here  the  most  important  measures.  The  part  should  be  well  sprinkled  with 
iodoform,  and  then  covered  up  thickly  with  many  layers  of  cotton-wool.  Care 
must  be  taken  never  to  keep  it  exposed  for  any  length  of  time,  and  not  to  allow  hot 
w^ater  bottles  too  near.  Poultices  should  not  be  applied  under  any  circumstances. 
In  this  form  of  gangrene,  in  particular,  opium  is  of  the  greatest  value,  and  it  has 
been  said  that  recovery  or  not  may  be  foretold  from  the  way  in  which  the  patient 
stands  its  administration. 

Hutchinson  has  recently  advocated  high  amputation  (through  the  lower  third 
of  the  thigh)  in  both  the  dry  and  the  inflammatory  form  of  senile  gangrene  :  the 
limb  is  usually  small  and  wasted  at  that  point ;  the  artery  is  sound  in  Hunter's 
canal ;  the  flaps  are  well  supplied  with  blood  ;  and  old  peoi)le,  as  a  rule,  resent 
operation  very  slightly  ;  their  tissues  are  not  prone  to  inflammation.  The  alter- 
native is  to  let  the  part  alone,  confining  the  patient  practically  to  one  position  in 
bed,  until  a  line  of  demarcation  has  formed,  leaving  a  very  conical  stump,  which 
does  not  heal  of  itself,  and  Avhich  does  not  admit  of  being  interfered  with.  Prob- 
ably, in  many  cases,  in  spite  of  the  apparent  severity  of  the  operation,  such  a 
measure  is  really  advisable,  not,  of  course,  if  the  gangrene  is  limited  to  the  toes,  or 
even  to  the  front  part  of  the  foot,  but  if  it  extends  to,  or  in  the  least  degree  above, 
the  ankle.  If  it  spreads  to  the  calf,  even  the  driest  form  is  exceedingly  liable  to 
become  moist,  and  then  the  inflammation  nearly  always  proves  fatal. 

In  frostbite  the  greatest  care  must  be  taken  not  to  warm  the  part  too  soon  ;  if 
it  is  exposed  even  to  a  moderate  temperature  before  the  circulation  has  recovered, 
moist  gangrene  is  almost  sure  to  follow.  Amputation  should  never  be  performed 
until  the  line  of  demarcation  is  deeply  cut. 

In  that  form  which  is  due  to  embolism  the  same  rule  practically  holds  good, 
although  an  operation  may  be  performed  somewhat  sooner  ;  the  surrounding  tissues 


PHAGEDENA— HOSPITAL   GANGRENE.  69 

are  not  so  badly  injured.      J'he  constitutional  disturbance,  however,  in  these  cases 
is  very  rarely  severe,  and  the  risk  of  septic  absorption  very  slight. 

PHAGEDENA. 

Phagedena  is  an  exceedingly  rapid  form  of  molecular  disintegration  or  ulcera- 
tion, chiefly  met  with  at  the  present  day  in  connection  with  syphilis.  There  is, 
in  the  ordinary  variety,  no  sloughing,  swelling,  oedema,  or  extensive  redness; 
simply  the  ba.se  and  the  edges  of  the  ulcer  affected  l)y  it  become  liquid  and  melt 
away.  In  another  variety,  however,  which  is  much  more  rare,  sloughing  is  present 
as  well,  the  surrounding  tissues  becoming  swollen,  tense,  and  hard,  and  then 
gradually  turning  black.  No  specific  organism  has  ever  been  proved  to  exist,  and 
it  seems  more  reasonable  to  assume  that  the  ulceration  becomes  phagedaenic 
because  of  certain  predisposing  causes,  of  which  syphilis  is  a  very  important 
one.  Exposure  to  cold  and  wet,  privation,  and  extreme  youth  are  probably  not 
without  influence.  In  the  vast  majority  of  ca.ses  primary  syphilitic  sores  that 
become  jjhagedaenic  (sixteen  out  of  seventeen,  according  to  my  notes  on  the  sub- 
ject) are  followed  by  secondary  syphilitic  symptoms. 

Constitutional  treatment  is  of  very  great  importance.  Phagedena  may  arise 
in  connection  with  syphilis  in  people  who  are  apparently  strong  and  otherwise 
healthy ;  but  it  is  much  more  frequent  in  those  who  are  broken  down  from  long- 
continued  exposure  and  intemperance. 

When  it  is  practicable,  nothing  succeeds  so  well  as  prolonged  warm  baths 
and  iodoform  ;  the  former  during  the  daytime,  for  from  eight  to  ten  hours,  the 
latter  dusted  on  at  night.  The  ulceration  nearly  always  ceases  to  spread  at  once, 
and  the  sore  begins  to  throw  out  granulations.  If  this  cannot  be  done  iodoform 
may  be.  used  alone,  or  if  the  sore  is  in  such  a  position — on  the  ala  of  the  nose, 
for  example — that  it  is  absolutely  necessary  to  stop  the  extension  at  once,  the 
patient  should  be  placed  under  an  anaesthetic  and  the  acid  nitrate  of  mercury 
applied  freely.  The  pain,  which  lasts  for  twenty-four  hours,  may  be  controlled  to 
some  extent  by  using  a  lotion  of  cocaine,  renewing  it  frequently.  Unless  the 
existence  of  syphilis  can  be  definitely  excluded,  a  mild  mercurial  course  (Hyd.  c, 
cret.  gr.  ij,  gm.  12,  with  Dover's  powder  night  and  morning)  should  be  com- 
menced without  delay. 

HOSPITAL  GANGRENE. 

Hospital  gangrene  bears  the  same  relation  to  ordinary  traumatic  gangrene 
that  phagedcena  does  to  ulceration  ;  sometimes  it  is  known  as  sloughing  phage- 
dsena.  It  is  a  form  of  gangrene  which  breaks  out  under  certain  conditions  that 
used  to  be  of  frequent  occurrence  in  connection  with  hospitals,  and  attacks  every 
kind  of  wound,  small  as  well  as  large.  It  spreads  with  the  greatest  rapidity  and 
is  intensely  contagious.  The  surface  of  the  wound  is  covered  with  micrococci, 
which  extend  deeply  into  the  substance  of  the  tissues,  destroying  them  wherever 
they  come  in  contact  with  them.  Whether  they  are  the  ordinary  forms  of  staphy- 
lococcus and  streptococcus  working  under  peculiarly  favorable  conditions,  or 
whether  they  are  specific,  is  not  known  ;  the  former  view  is  the  more  probable,  as 
hospital  gangrene  never  occurs  except  under  certain  conditions,  and  apparently 
never  fails  to  be  produced  by  them.  Overcrowding  and  absence  of  ventilation 
will  cause  it  anywhere ;  probably  the  intensely  poi.sonous  substances  produced  in 
these  circumstances,  soaking  gradually  into  the  tissues  for  days  and  weeks  together, 
impair  their  vitality  to  such  an  extent  that  the  ordinary  germs  are  able  to  act  with 
the  most  unusual  energy  and  produce  the  most  disastrous  results.  The  general 
nutrition  is  in  the  same  condition  as  that  of  the  case  already  mentioned,  in  which 
gangrene  of  both  legs  followed  after  primary  amputation  of  the  feet,  only  the 
cause  is  a  different  one. 

[The  treatment  of  hospital   gangrene   requires  the  careful  removal  of  the 


70         GENERAL   PATHOLOGY  OF  SURGLCAL   DISEASES. 

sloughing  parts  with   the   forcei)s  and   scissors,  and   the  appUcation   of  bromine 
sohition  as  strong  as  may  be  necessary.] 

In  connection  with  this,  it  is  noteworthy  that  sloiigliing  celluHtis  of  the  most 
intense  description  occurs  in  some  cases  of  snake-bite,  and  in  some  forms  of  post- 
mortem poisoning,  and,  what  is  very  significant,  not  always  in  the  neighborhood 
of  the  wound.  In  the  former  of  these  at  least  it  is  practically  certain  that  the 
gangrene  is  due  to  the  virulence  of  an  alkaloid,  which,  though  it  is  not  sufficient 
to  kill  the  tissues  at  once,  lowers  their  vitality  to  such  an  extent  that  they  fall  an 
easy  prey  to  the  micro-organisms  that  enter  from  time  to  time  into  the  blood.  In 
the  latter — when,  for  example,  all  the  cellular  tissue  on  the  side  of  the  thorax 
becomes  gangrenous  forty-eight  hours  after  a  punctured  wound  of  the  finger — the 
same  explanation  is  highly  probable  ;  and  it  does  not  seem  unlikely  that  hospital 
gangrene  is  really  due  to  saturation  of  the  blood  with  the  scarcely  less  virulent 
poison  thrown  off  by  the  lungs  in  cases  of  overcrowding. 

PHLEGMONOUS  INFLAMMATION. 

Diffuse  inflammation  of  the  cellular  tissue  and  skin,  the  so-called  phlegmon- 
ous erysipelas,  is  another  product  of  the  ordinary  micrococci  of  suppuration  acting 
under  peculiarly  favorable  circumstances.  In  many  respects  it  resembles  true 
erysipelas,  especially  in  the  conditions  under  which  it  occurs,  but  in  its  nature  it 
is  essentially  different.  Like  erysipelas,  it  usually  spreads  from  a  wound  ;  those 
who  are  broken  down  in  health  from  intemperance,  exposure,  and  particularly 
Bright' s  disease,  are  much  more  prone  to  it  than  others  ;  and  in  a  very  large  pro- 
portion of  cases  a  streptococcus  is  found  in  connection  with  it.  But,  on  the 
other  hand,  it  is  not  infectious,  although  it  is  in  the  highest  degree  contagious  ; 
it  always  ends  in  suppuration  and  sloughing ;  it  may  follow  injuries  of  the  most 
varied  description — post-mortem  wounds,  bites  of  reptiles,  or  the  sting  of  a  wasp  ; 
it  attacks  deep-seated  parts  of  the  body,  such  as  the  pelvic  cellular  tissue,  after 
parturition  or  lithotomy  ;  and  it  is  never  accompanied  by  the  characteristic,  well- 
defined  rash  always  present  in  true  erysipelas.  The  affection  of  the  skin  is  an 
altogether  secondary  complication,  which  may  or  may  not  be  present,  according 
to  the  original  seat  of  inflammation.  Further,  the  streptococcus,  which  is 
undoubtedly  the  ordinary  S.  pyogenes,  is  not  confined  to  the  lymphatics,  as  in 
the  case  of  the  S.  erysipelatis,  but  migrates  freely  beyond  into  the  cellular  spaces, 
and  penetrates  through  the  adventitia  of  the  vessels  into  their  interior. 

Causes. — In  some  rare  cases  diffuse  inflammation  originates  without  a  wound. 
Nearly  always,  however,  an  injury  of  this  kind  is  present,  opening  up  the  submu- 
cous or  the  subcutaneous  cellular  tissue,  or  the  deeper  planes  among  the  muscles  or 
round  the  bones.  When  there  is  none,  the  germs — as  in  acute  infective  osteomy- 
elitis— gain  access  to  the  part  through  the  blood.  Occasionally  the  inflammation 
commences  some  little  distance  from  the  seat  of  infection  ;  and  exceptionally  it 
does  not  attain  any  great  degree  of  severity  until  this  is  healed. 

The  predisposing  conditions  are  general  and  local.  The  former  are  those 
already  mentioned  in  connection  with  gangrene — diabetes.  Bright' s  disease,  the 
consequences  of  exposure,  intemperance,  starvation,  and,  briefly,  everything  that 
tends  to  interfere  with  the  elimination  of  waste  product  or  impair  the  general 
nutrition.  Overcrowding  and  bad  ventilation  are  very  important  in  this  respect ; 
probably  their  influence  is  due  to  the  poisonous  substances  exhaled  from  the 
lungs,  which,  even  when  breathed  for  a  short  time,  produce  the  most  extreme 
depression. 

The  local  conditions  are  very  simple  :  imperfect  drainage,  especially  if  there 
is  a  cavity  filled  with  extravasated  blood,  is  sure  to  cause  it.  It  is  for  this  reason 
that  diffuse  inflammation  of  the  most  disastrous  character  is  so  common  after  com- 
pound fractures  or  penetrating  wounds  of  joints.  Decomposition  occurs  under 
high  tension  before  the  tissues  are  able  to  protect  themselves  in  the  least,  and  the 
products  are  driven  into  the  loose  cellular  interspaces,  poisoning  and  destroying 


PHLEGMONOUS  INFLAMMATION.  71 

everything  they  touch.  For  the  same  reason  the  coiiditioii  of  the  uterus  after 
parturition,  with  an  enormous  development  of  celhilar  and  lymphatic  tissue  in  the 
region  of  the  cervix,  renders  it  particularly  susce])til)le. 

Bruising  and  tearing  the  structures  round  in  performing  an  operation — in 
other  words,  lowering  their  vitality  and  hlling  them  with  extravasated  blood — 
greatly  increases  the  liability  to  it.  It  is  partly  owing  to  this,  partly  to  the  effect  of 
renal  disease,  that  diffuse  inflammation  of  the  pelvic  cellular  tissue  is  so  common  and 
so  fatal  after  lithotomy  when  the  calculus  is  a  large  one.  In  other  cases  it  is  due  to 
the  local  effects  of  virulent  chemical  poisons.  Diffuse  celhditis  of  the  neck,  for 
example,  may  result  from  the  sting  of  a  wasp,  and  sloughing  over  a  very  large 
surface  has  been  known  to  follow  the  bite  of  a  poisonous  snake.  Probably  the 
alkaloid  injected  into  the  tissues  lowers  their  vitality  to  such  an  extent  that  they 
are  unable  to  offer  any  resistance  to  the  micrococci,  which  are  constantly  finding 
their  way  into  the  blood.  Whether  the  extremely  fatal  form  of  diffuse  cellulitis 
which  accompanies  post-mortem  wounds  in  cases  of  puerperal  peritonitis  is  due 
to  a  similar  alkaloid,  or  whether,  on  the  other  hand,  it  is  the  result  of  septic 
infection  (infection,  that  is  to  say,  with  a  living  organism)  is  uncertain.  The 
fact  that  the  virulence  of  the  poison  diminishes  rapidly  as  putrefaction  sets  in  is 
consistent  with  either  view ;  the  exceedingly  early  occurrence  of  the  symptoms 
favors  the  former. 

Symptoms,  i.  Constitutional. — These  vary  greatly  in  severity,  in  the 
worst  forms,  such  as  those  arising  from  post-mortem  wounds,  they  are  practi- 
cally the  same  as  in  spreading  traumatic  gangrene.  They  a.ssume  a  typhoid 
character  almost  from  the  first ;  there  may  be  a  rigor  or  a  succession  of  chills  : 
the  temperature  rises  rapidly  to  105°  or  106°  F.;  the  tongue  is  dry  and  brown, 
the  skin  burning  hot,  the  face  dusky,  and  the  pulse  so  small  and  quick  that  it  is 
scarcely  possible  to  count  it.  Delirium  may  set  in,  sometimes  with  profuse 
sweating,  within  twenty-four  hours,  and  the  result  may  be  fatal,  from  the  most 
acute  form  of  septic  poisoning,  within  the  first  few  days. 

In  pelvic  cellulitis  after  parturition  or  lithotomy,  the  effect  is  almost  as  rapid, 
the  patient  sinking  into  a  semi-unconscious,  wandering  state,  with  an  irregular, 
feeble  pulse,  extremely  high  temperature,  and  the  most  profound  nervous  prostra- 
tion. When  the  cellular  tissue  of  the  limb  is  concerned,  where  the  poison  is  not 
so  intense  or  the  absorption  so  rapid,  the  symptoms  are  less  .severe,  and  usually 
assume  the  sthenic  form,  but  the  fever  continues  high  and  very  irregular  for 
days  and  weeks ;  the  emaciation  and  exhaustion  are  extreme ;  there  is  always 
the  danger  of  pneumonia  and  pleurisy,  or,  if  the  head  or  face  is  involved  (par- 
ticularly the  orbit),  of  suppurative  meningitis;  and  if  the  patient  survives  the 
period  of  sloughing  and  acute  absorption,  pyaemia  not  uncommonly  supervenes  or 
hectic  and  diarrhoea  follow,  or  the  prostration  is  so  great  that  some  comparatively 
slight  disorder  sets  in  and  proves  fatal. 

2.  Local. — These  naturally  vary  with  the  structure  of  the  part,  but  the  swell- 
ing is  always  very  great,  soft  and  oedematous  at  first,  then  becoming  hard  and 
brawny,  and  later,  as  the  cellular  tissue  sloughs,  softening  again  and  becoming 
boggy.  On  the  scalp  it  is  usually  due  to  wounds  that  open  up  the  sub-aponeurotic 
layers  ;  the  cedema  spreads  rapidly  over  the  vertex,  extending  down  to  the  eyelids 
in  front,  to  the  superior  curved  line  or  the  occipital  bone  behind,  and  the  zygoma 
on  either  side.  The  skin  is  exceedingly  tender,  but  there  is  very  little  redness  ; 
the  glands  in  the  neck  are  enlarged  and  swollen,  and  there  is  always  intense  head- 
ache and  not  unfrequently  delirium.  When  it  involves  the  orbit,  the  eyelids  are 
immensely  swollen,  the  conjunctiva  is  reddened  and  chemosed,  the  globe  is 
pushed  forward  and  fixed,  and  the  pain  is  most  intense.  If  the  symptoms  do  not 
soon  subside,  the  cornea  becomes  opaque  and  sloughs,  the  eyeball  is  completely 
disorganized,  and  there  is  very  great  danger  of  the  inflammation  extending  along 
the  veins  or  lymphatics  to  the  sinuses  of  the  cranium  or  the  meninges,  leading 
to  thrombotic  pyasmia  or  acute  meningitis. 

Diffuse  inflammation  of  the  cellular  tissue  of  the  neck   is  no  less  serious. 


72         GENERAL   PATHOLOGY  OF  SURGLCAL   DLSEASES. 

Usually  it  commences  in  the  submaxillary  region,  caused,  in  all  probability,  by 
the  absorption  of  some  poison  from  the  mouth.  The  swelling  extends  rapidly 
downward,  beneath  the  deep  cervical  fascia,  giving  rise  to  the  most  intense  pain, 
with  violent  constitutional  disturbance,  and  pressing  upon  the  veins  and  the 
trachea.  Sometimes,  even,  it  reaches  to  the  mediastinum  and  involves  the  pleura 
or  pericardium.  The  skin  is  white  and  tense,  the  swelling  exceedingly  hard  and 
very  painful,  and  any  movement  is  impossible. 

In  acute  pelvic  cellulitis  the  local  symptoms  resemble  those  of  peritonitis,  in 
which  it  often  ends,  except  that  the  boundaries  of  the  swelling  are  generally  more 
defined.  In  the  more  chronic  cases  the  uterus  is  fixed,  and  a  hard  mass  is  left 
projecting  above  the  brim  of  the  pelvis  when  deep  pressure  is  made  in  the  iliac 
fossa.  If  suppuration  follows,  the  abscess  may  point  in  the  iliac  region  above 
Poupart's  ligament,  or  it  may  present  in  Douglas's  pouch,  or  extend  into  the  thigh, 
or  the  psoas  muscle,  or  reach  even  as  high  as  the  kidney. 

In  the  case  of  the  limbs,  diffuse  inflammation  nearly  always  originates  from  a 
poisoned  wound,  a  punctured  wound  of  a  joint,  or  a  compound  fracture.  Occa- 
sionally it  occurs  in  connection  with  acute  suppurative  periostitis.  When  the 
deeper  planes  are  involved,  the  skin  is  tense,  white,  and  cedematous,  but  burning 
hot  to  the  touch  and  exceedingly  tender.  Very  often  it  is  mottled  with  dusky  red 
patches,  which  correspond  to  the  places  of  communication  with  the  deep  veins. 
The  pain  is  extreme,  of  a  tense,  throbbing  character,  and  movement  is  out  of  the 
question.  Usually  the  inflammation  extends  higher  up  the  inner  side  of  the  limb 
than  the  outer,  very  often  following  the  course  of  the  large  vessels  ;  and  the  neigh- 
boring lymphatic  glands  are  always  enlarged  and  tender.  When  the  part  affected 
is  the  subcutaneous  layer,  the  symptoms  are  for  the  most  part  the  same,  but  the 
color  is  a  deep,  dusky  red,  shading  off  imperceptibly,  not,  as  in  erysipelas,  with  a 
sharply-defined  margin.  At  first  the  skin  is  soft  and  pits  on  pressure ;  then  it 
becomes  hard  and  brawny  ;  vesicles  and  blebs  form  upon  the  surface ;  the  color 
grows  deeper  and  deeper,  in  one  or  two  places  it  becomes  almost  purple,  and  then, 
here  and  there,  it  softens  and  becomes  boggy  to  the  touch.  In  other  words,  the 
subcutaneous  cellular  tissue  has  passed  through  the  stages  of  extreme  hyperaemia 
and  exudation,  and  has  sloughed ;  in  some  places,  if  it  is  cut  into,  it  is  soft  and 
gelatinous,  distended  with  a  sero-purulent  fluid,  which  can  be  squeezed  out  of  it 
like  water  from  a  sponge  ;  in  others  it  has  practically  disappeared,  and  nothing  is 
left  but  a  sheet  of  pus,  without  any  definite  limits,  mixed  with  the  shreds  and 
sloughs  of  the  fasciae  and  the  tougher  parts  of  the  connective  tissue.  Later  still, 
if  no  incisions  are  made,  the  skin  itself  perishes,  cut  oft"  from  all  source  of  nutri- 
tion except  where  some  of  the  larger  vessels  enter  it  from  the  inter-muscular  septa 
beneath ;  here,  in  general,  a  few  islets  still  persist  in  the  middle  of  the  destruc- 
tion. In  the  worst  ca.ses,  in  which  nothing  has  been  done  to  relieve  the  tension, 
the  fasciae  and  muscles  are  bared  and  dissected  away  from  each  other,  the  joints 
are  opened,  the  bones  exposed,  and  the  limb  is  reduced  to  a  perfectly  hopeless 
condition. 

Prognosis. — The  prognosis  in  the  case  of  diffuse  inflammation  of  the  cellular 
tissue  is  always  exceedingly  grave.  If  the  head  is  involved,  portions  of  the  scalp 
may  slough,  the  pericranium  may  perish,  and  osteophlebitis,  pyaemia,  or  menin- 
gitis follow.  In  the  case  of  the  orbit  the  danger  is  even  greater,  and  at  best  the 
eye  is  almost  sure  to  be  destroyed.  The  inflammation  may  spread  from  the  cellu- 
lar tissue  of  the  neck  to  the  pleura  or  pericardium,  or  it  may  prove  fatal  from 
extending  to  the  larynx.  After  lithotomy  it  is  practically  hopeless.  Even  when 
one  of  the  limbs  only  is  concerned  the  danger  is  very  great.  Osteophlebitis, 
lymphangitis,  or  pyaemia  may  follow  at  any  time.  The  inflammation  may  spread 
to  the  neighboring  joints  and  lead  to  acute  suppurative  arthritis.  The  bones  may 
necrose,  the  great  vessels  may  be  injured,  and  even  when  all  these  more  serious 
consequences  are  escaped,  the  limb  may  be  rendered  useless  and  become  a  constant 
source  of  pain  from  the  sloughing  of  the  subcutaneous  and  inter-muscular  cellular 
tissue.     The  wounds  heal  slowlv  ;  the  cicatrices  are  adherent  to  the  muscles  or  the 


PJILEGMOXOUS  INFLAM.\rATION.  73 

bones,  so  that  they  are  constantly  breaking  down  ;  the  lymphatics  are  destroyed  ; 
solid  ftdema  sets  in  ;  and,  even  after  the  most  successful  treatment,  the  part  is  left 
stiffened,  cold,  congested,  and  jjractically  useless  for  active  movement  for  months 
and  even  for  life. 

Treatment. — In  the  most  acute  form  of  diffuse  inflammation  the  prostration 
is  so  extreme  and  the  heart  fails  so  rajjidly  that  very  little  can  be  done.  Stimu- 
lants— ammonia,  ether,  and  l)randy — must  be  given  freely  as  long  as  the  jjatient 
can  absorb  them.  Sometimes,  when  the  constitution  is  otherwise  healthy,  and  the 
effect  is  due  to  the  local  absorption  of  a  chemical  poison,  it  is  possible  to  tide  over 
the  crisis,  and  under  these  circumstances  enormous  c[uantities  may  be  given  with 
very  great  benefit;  but  this  is  of  no  avail  if  the  production  of  the  poison  con- 
tinues. In  cases  that  are  less  severe,  in  which  the  immediate  danger  is  not  so 
great,  careful  watch  must  be  kept  upon  the  pulse,  and  everything  must  be  done  to 
sujjport  the  patient's  strength.  It  must  always  be  remembered  that,  unless  it  is  the 
result  of  some  very  grave  injury,  diffuse  inflammation  rarely  occurs  except  in  those 
whose  constitutions  are  thoroughly  broken  down,  whose  strength  is  exhausted,  and 
who  have  been  accustomed  to  the  free  use  of  stimulants  for  years  past ;  but,  if 
possible,  remedies  of  this  kind  should  never  be  given  alone,  always  in  small  quan- 
tities at  a  time,  with  beef-essence,  milk,  eggs  beaten  up,  and  other  foods  that  possess 
a  more  lasting  value. 

The  local  treatment  is  no  less  important.  Everything  must  be  done  to  check 
absorption  from  the  surface  of  the  wound  and  diminish  the  tension.  Cold  is 
of  less  value  in  these  cases  than  in  other  forms  of  inflammation.  The  vitality  of 
the  part  is  already  very  feeble,  and  there  is  some  danger  of  causing  gangrene.  If 
suppuration  has  not  yet  occurred,  elevation  and  gentle  elastic  compression  with 
many  layers  of  cotton-wool  may  be  tried  ;  if,  however,  this  stage  is  already  passed, 
more  good  may  be  done  by  means  of  warm  fomentations  and  long-continued 
warm  baths,  assisted  by  thorough  drainage. 

If  the  skin  is  hard  and  brawny,  with  severe  pain  and  throbbing,  incisions 
should  be  made  without  hesitation.  It  is  no  use  waiting  until  fluctuation,  or  even 
local  softening,  can  be  detected  ;  they  should  be  made  before  this,  for  the  purpose 
of  relieving  the  tension  and  allowing  the  inflammatory  exudation  to  drain  away. 
It  is  better  to  make  them  where  the  need  is  not  absolutely  certain  than  to  leave 
them  unmade.  The  depth  to  which  they  should  be  carried  varies  naturally  with 
that  of  the  inflammation  :  in  most  cases  it  is  not  necessary  to  do  more  than  incise 
the  deep  fascise,  and,  as  a  rule,  they  should  not  be  more  than  an  inch  and  a  half 
or  two  inches  long.  In  planning  them  regard  should,  of  course,  be  paid  to  the 
position  of  important  structures  and  the  natural  folds  of  the  part.  The  hemor- 
rhage is  not  unfrequently  profuse  for  a  short  time,  but  it  can  always  be  checked 
by  the  pressure  of  some  absorbent  gauze  or  other  similar  material.  Afterward 
warm  fomentations  may  be  continued,  so  as  to  encourage  the  discharge  as  much 
as  possible. 

Other  incisions  may  be  necessary  after  the  inflammation  has  ceased  to  spread, 
for  the  purpose  of  releasing  sloughs  or  to  give  better  exit  to  the  discharges  ;  and 
then,  as  granulations  spring  up,  every  attempt  must  be  made  to  procure  cicatriza- 
tion as  soon  as  possible.  Some  contraction  is  nearly  always  left,  and  often  the 
tissues  are  extensively  matted  together,  so  that  they  remain  cold  and  cedematous, 
but  if  the  part  is  not  hopelessly  disorganized,  very  great  improvement  may  gener- 
ally be  effected  by  constantly-repeated  massage,  warm  douches,  and  shampooing. 

In  the  worst  cases,  in  which  the  joints  are  involved  or  the  skin  is  extensively 
destroyed,  amputation  may  be  required,  but  it  should  not  be  performed  until  the 
acute  symptoms  shall  have  subsided. 


74         GENERAL   PATHOLOGY  OF  SURGICAL    DISEASES. 

PY.^MIA. 

Pyaemia  is  an  infective  disorder,  caused  by  the  ordinary  pyogenic  micro- 
organisms, and  distinguished  from  the  other  affections  to  which  they  give  rise  by 
the  unusual  prominence  of  some  of  the  clinical  and  pathological  features — rigors, 
metastatic  abscesses,  and  diffuse  inflammation  of  the  serous  and  synovial  mem- 
branes in  particular.  It  is  not  a  specific  disease  ;  there  is  no  evidence  that  other 
organisms  than  the  ordinary  pyogenic  ones,  the  staphylococci  and  streptococci, 
are  ever  present.  It  is  not  even  a  disease  of  itself;  it  is  merely  the  product  of 
the  ordinary  germs  that  cause  suppuration  acting  under  peculiar  conditions.  If 
these  organisms  are  rubbed  into  the  skin  so  that  the  hair  follicles  are  affected,  they 
cause  boils;  under  other  circumstances,  where  the  subcutaneous  tissue  is  espe- 
cially dense,  they  give  rise  to  carbuncles ;  when  the  tissues  are  poisoned,  either 
by  the  products  of  septic  decomposition  or  by  the  ptomaine  of  a  snake-bite, 
diffuse  cellulitis  follows  ;  if  syphilis  is  present,  phagedaena  may  occur ;  if  the 
body  is  poisoned  by  the  inhalation  of  the  exceedingly  virulent  substance  thrown 
off  by  the  lungs,  hospital  gangrene  and  sloughing  of  the  most  extensive  character 
are  produced  ;  and  under  certain  conditions  they  give  rise  to  pyaemia. 

The  anatomical  structure  of  the  injured  part  is  one.  Pyaemia  is  especially 
liable  to  occur  in  injuries  of  parts  in  which  there  are  large  veins  unable  to  collapse 
— such,  for  example,  as  the  diploe  of  the  skull,  the  medulla  of  other  bones,  and 
tissues  infiltrated  Avith  inflammatory  deposit.  The  method  of  dissemination  is 
another,  dependent  to  some  extent  upon  this.  In  diffuse  inflammation  of  the 
cellular  tissue,  the  organisms  spread  either  by  means  of  the  lymphatics,  or  in  the 
connective-tissue  spaces ;  in  pyaemia,  the  vehicle  is  the  blood  itself.  For  this 
reason,  too,  the  infection  is  not  a  slow  and  gradual  process,  in  which  the  neigh- 
boring tissues  are  overcome  layer  by  layer  in  a  widening  circle,  but  immense 
quantities  suddenly  enter  into  the  circulation,  and  are  carried  at  once  to  a  distant 
part.  Another  condition  of  very  great  importance  is  the  presence  of  some  foreign 
material  in  the  blood-stream  to  cause  embolism.  The  usual  one  is  a  fragment 
from  some  disintegrating  blood-clot ;  but  experimentally  it  has  been  shown  that 
perfectly  inert  matter,  which  can  only  act  mechanically,  is  quite  capable  of  pro- 
ducing the  same  effect.  The  mere  presence  of  pus-microbes  in  the  circulation 
(unless  the  amount  is  so  large  that  they  of  themselves  act  as  an  embolus)  is  not 
sufficient  to  cause  pyaemia ;  but  if  particles  of  cinnabar  are  injected  at  the  same 
time,  so  that  they  become  impacted  in  the  arterioles  and  injure  the  endothelial 
lining  of  the  vessels,  characteristic  metatastic  abscesses  are  produced.  That  form 
of  pyaemia  in  which  diffuse  inflammation  only  occurs,  without  evidence  of  embol- 
ism, is  distinguished  sometimes  as  pyaemia  simplex.  In  addition  to  these  there 
are  other  conditions,  less  well  known,  which  probably  are  not  without  influence ; 
the  sudden  entry  into  the  circulation,  for  example,  of  considerable  quantities  of 
broken-down  blood-clot,  causing  fever ;  the  development,  in  connection  with  the 
inflammation  of  bone,  of  substances  which  render  the  pus  produced  under  these 
circumstances  peculiarly  offensive ;  possibly,  the  inefficient  excretion  of  the 
ptomaines  generated  in  the  alimentary  canal  when  the  kidneys  are  diseased ; 
peculiarities  of  the  patient's  constitution,  etc.  They  do  not  cause  the  pyaemia 
themselves  ;  they  merely  determine  its  outbreak  instead  of,  or  in  addition  to,  other 
forms  of  suppurative  inflammation  occasioned  by  the  same  germs. 

Defective  ventilation,  want  of  cleanliness,  the  use  of  ward  sponges,  over- 
crowding, especially  the  collection  together  of  supi)urating  wounds,  and,  briefly, 
all  the  circumstances  that  favor  the  development  of  the  other  forms  of  infective 
disease,  favor  equally  that  of  pyaemia. 

Pathology. — The  blood  generally  coagulates  well ;  as  a  rule,  there  is  a  great 
increase  in  the  number  of  white  corpuscles,  while  the  red  ones  show  signs  of 
disintegration,  breaking  up  into  molecules  and  forming  irregular  masses  without 
running  into  rouleaux.  Cocci  may  often  be  found  in  abundance,  both  free  and 
in  the  white  corpuscles. 


PYEMIA.  75 

Sonictinics  the  wound  is  ai)i)art.'iuly  healing  well,  although  a  certain  amount 
of  suppuration  is  nearly  invariable.  More  frequently  it  is  foul  and  sloughing, 
with  an  offensive  or  ichorous  discharge.  'I'he  veins  running  from  it  are  usually 
filled  with  softened  clot ;  the  infective  organisms  spread  from  the  surface  of  the 
wound  to  the  cellular  tissue  around  the  vessels  and  invade  their  walls  ;  as  the  intima 
is  approached  a  thrombus  forms,  and  spreads  farther  and  farther  along  the  interior 
in  advance  of  the  inflammation.  If  the  tissues  are  healthy,  this  j)revents  general 
infection  ;  organization  sets  in,  and  the  jjoison  is  shut  off.  If,  on  the  other  hand, 
the  nutrition  of  the  ti.ssues  is  feeble,  or  the  j)ower  of  the  germs  unusally  great,  or 
a  fresh  injury  of  any  kind  is  inflicted  upon  the  part,  degeneration  follows  instead 
of  organization  ;  the  clot  softens  and  breaks  down  ;  fragments  of  it  are  carried  off 
into  the  blood-stream  ;  and  with  them  the  cocci  which  have  gradually  worked  their 
way  through  the  wall.  When  pyaemia  starts  from  a  wound  that  is  healing  without 
suppuration,  or,  as  in  acute  suppurative  osteomyelitis,  when  there  is  no  wound  at 
all,  the  thrombosis  must  be  explained  in  another  way.  The  micro-organisms  of 
suppuration  are  of  common  occurrence  in  the  circulation — at  least,  they  can  enter 
easily  enough  ;  ordinarily  they  are  innocuous  ;  the  tissues  are  able  to  resist  their 
action  ;  if,  however,  nutrition  fails,  whether  from  constitutional  or  local  causes,  or 
the  endothelial  lining  of  the  vessels  is  injured,  at  once  they  make  good  their  hold, 
coagulation-necrosis  begins  in  the  vessels,  thrombi  are  formed,  and,  if  the  other 
conditions  are  favorable,  pyaemia  follows. 

Intravascular  infection  of  this- kind  may  occur  even  in  children  who  are  to  all 
appearance  in  perfect  health.  Probably  in  them  it  is  rendered  possible  by  some 
temporary  depressing  cause  :  want,  injury,  over-exertion,  or  exhaustion  and  fatigue. 
When  pyaemia  has  already  developed,  it  is  of  frequent  occurrence,  and  thrombosis 
in  distant  parts  of  the  body,  especially  in  places  that  have  been  bruised  or  injured, 
with  the  attendant  consequences  of  embolism  and  metastatic  abscesses,  is  one  of 
the  usual  symptoms. 

Infection  with  pyogenic  micrococci  (whether  they  come  through  the  walls  of 
the  vessels  at  the  seat  of  injury,  or  enter  in  other  ways),  with  its  attendant  throm- 
bosis, leads  to  two  kinds  of  abscess,  one  arising  in  connection  with  the  veins  and 
capillaries,  the  other  embolic. 

a.  Of  these,  the  former  may  begin  either  in  the  neighljorhood  of  the  wound, 
or  in  some  distant  part  to  which  the  micro-organisms  circulating  in  the  blood  have 
been  carried,  and  in  which  they  have  been  arrested.  In  either  case,  the  process 
and  the  consequences  are  the  same.  Thrombosis  sets  in  ;  a  ring  of  coagulation- 
necrosis  forms  round  the  germs  ;  liquefaction  follows ;  the  clot,  and  then  the  walls 
of  the  vessels  and  the  surrounding  tissues,  break  down  and  melt  away ;  and  in  a 
very  short  space  of  time  an  irregular  cavity  is  formed,  filled  with  a  thin  oily 
pus,  colored  in  general  from  the  mixture  of  a  small  quantity  of  haemoglobin,  and 
surrounded  by  tissues  that  are  undergoing  disintegration  as  rapidly  as  they  .can. 
The  suppuration  is  always  diffuse ;  there  is  no  evidence  of  organization,  and  no 
sign  of  limitation  anywhere.  The  connective  tissue  between  the  muscles  melts 
away,  leaving  them  literally  dissected  out  by  the  pus  ;  the  synovial  cavity  of  a  joint, 
or  a  tendon  sheath,  is  filled  within  a  i^^x  hours ;  or  one  of  the  serous  sacs  is 
involved  in  the  same  way.  In  other  words,  there  is  diffuse  inflammation  of  the 
cellular  tissue,  followed  by  suppuration  and  sloughing,  as  in  the  worst  form  of  the 
so-called  phlegmonous  erysipelas. 

b.  Embolic  absces.ses  occur  in  a  different  way.  The  thrombi  in  the  veins, 
softened  by  the  action  of  the  micrococci,  break  clown  ;  loose  particles  are  carried 
off  in  the  blood-stream,  and  pa.ssing  through  the  heart  are  driven  into  the  vessels 
of  the  lungs.  The  smaller  ones  may  pass  through  these,  and  then  later  be  stopped 
elsewhere — in  the  liver,  for  example  ;  the  larger  ones  are  arrested  at  the  bifurcation 
of  a  vessel,  and  give  rise  to  embolic  abscesses. 

The  effect  of  a  non-infective  embolus  depends  upon  the  arrangement  of  the 
blood-vessels.  If  the  collateral  circulation  through  the  part  is  good,  no  ill-result 
follows  other  than  the  obliteration  of  a  short  segment  of  the  vessel.      If  the  blood- 


76         GENERAL   PATHOLOGY  OF  SURGLCAL   DLSEASES. 

supply  is  entirely  cut  off,  local  an?emia  and  gradual  disintegration  ensue;  but  if,  as 
in  the  case  of  the  lungs,  there  is  a  condition  intermediate  between  these  two,  the 
blood  pours  in  from  all  sides,  without  strength  sufficient  to  force  its  way  out ;  the 
part  becomes  more  and  more  congested  ;  the  walls  of  the  vessels  give  way ;  the 
blood  is  extravasated  into  the  tissues,  and  at  length,  when  coagulation  supervenes, 
the  whole  area  is  converted  into  a  solid  conical  block.  This  is  known  as  hemor- 
rhagic infarction.  It  is  common  in  the  lungs  and  spleen,  the  base  of  the  cone 
lying  toward  the  serous  surface;  but  it  never  occurs  in  the  liver  or  the  subcuta- 
neous tissue. 

When  the  embolus  is  infective  from  the  presence  of  jjyogenic  micro-organisms, 
the  same  result  ensues,  but  almost  at  once  coagulation-necrosis  follows,  the  central 
portion  becomes  liquid,  and  in  a  very  short  time  the  whole  area  of  the  infection, 
and  the  tissues  for  some  distance  round,  are  converted  into  pus.  The  change  is 
so  rapid  as  to  resemble  gangrene  rather  than  ordinary  suppuration. 

The  pathological  appearances  in  a  fatal  case  of  pyaemia  consist,  therefore, 
with  the  exception  of  the  changes  in  the  veins,  almost  entirely  of  abscesses  and 
suppuration,  sometimes  diffuse,  sometimes  embolic.  Only  one  organ  may  be 
affected,  or  several ;  the  abscesses  may  be  all  visceral,  or  all  superficial.  In  some 
cases  only  one  tissue  is  affected  ;  in  acute  suppurative  periostitis,  for  example,  the 
lesions  may  be  limited  to  the  bones ;  in  some  forms  of  chronic  pyaemia  to  the 
subcutaneous  tissues ;  in  others — those  especially  that  occur  after  the  acute 
exanthemata — to  the  joints.  Pericarditis,  due  to  infective  embolism  of  the  coro- 
nary artery,  is  exceptionally  frequent  in  suppurative  osteomyelitis,  pleurisy  in 
otitis ;  and  abscesses  in  the  liver  when  the  urinary  organs  are  involved ;  but, 
except  in  this  last-mentioned  case,  no  satisfactory  explanation  for  such  coinci- 
dences is  forthcoming. 

Symptoms. — No  wound  is  exempt ;  it  may  occur  without  one,  but  it  rarely 
breaks  out  without  distinct  evidence  of  suppuration,  or,  at  least,  of  the  presence 
of  pyogenic  germs.  Sloughing  wounds,  and  those  which  are  foul  from  the 
presence  of  septic  discharges  soaking  into  and  poisoning  all  the  tissues  round, 
are  naturally  more  liable  than  those  covered  with  healthy  granulations  ;  and  septic 
fever  and  sapraemia  are  nearly  always  present  as  well. 

It  may  begin  insidiously,  the  temperature  becoming  more  and  more  irregular 
and  the  patient  failing  distinctly,  without  its  being  possible  to  say  that  pyaemia 
has  set  in  ;  or  all  of  a  sudden  an  intense  rigor  may  commence  without  warning, 
and  the  temperature  rise  at  once  five  or  six  degrees.  After  this  it  may  fall  again, 
but  the  characteristic  feature  is  its  extreme  irregularity  ;  rigors  may  occur  every 
day,  sometimes  with  such  even  intervals  as  to  suggest  ague ;  two  or  three  may  be 
present  in  the  twenty-four  hours  ;  or  there  may  not  be  one  for  a  week  ;  but,  as  a 
rule,  the  temperature  is  always  suggestive  of  them,  sudden  and  rapid  rises 
occurring  here  and  there  without  external  causes. 

The  pulse  and  respiration  vary  with  the  temperature,  gradually  becoming 
more  rapid  and  powerless  as  the  patient  fails  in  strength  ;  any  sudden  change  in 
either  by  itself  is  suggestive  of  fresh  local  trouble.  The  expression  of  the  face  is 
always  peculiarly  anxious,  especially  as  each  rigor  comes  on.  The  conjunctiva  is 
often  distinctly  jaundiced,  and  the  color  is  earthy,  if  not  yellow.  The  tongue  is 
red  and  smooth  at  first,  later  covered  over  with  brown  crusts ;  herpes  is  often 
present,  leaving  painful  cracks  and  fissures  in  the  lips  ;  the  teeth  are  covered  with 
sordes,  and  aphthous  ulcers  are  often  scattered  over  the  mucous  membranes. 
Emaciation  is  generally  exceedingly  rapid,  and  in  itself  is  highly  suggestive  ;  the 
breath,  and  sometimes  the  whole  body,  exhales  a  peculiar  offensive  mawkish 
odor;  the  skin  is  marked  by  fugitive  erythemata  of  a  dusky  red;  sometimes 
vesicles,  and  even  pustules,  form  upon  it ;  and  in  many  cases  it  is  exceedingly 
sensitive,  the  least  touch  causing  the  most  intense  pain.  Delirium  is  not  com- 
mon, unless  the  temperature  is  continuously  high,  until  the  strength  gives  way. 
Vomiting  often  occurs  with  the  rigors ;  albuminuria  is  present  in  a  very  large 
proportion  ;  but  diarrhoea  is  unusual. 


PYEMIA.  77 

111  addition  to  these  symiJtoms,  whicli  are  dependent  ujjon  tlie  c;hanges  in  the 
blood,  others  arise  from  the  local  troubles.  Any  serous  or  synovial  membrane 
may  be  affected  ;  abscesses  may  form  in  any  part  of  the  body,  deep  or  superficial ; 
the  viscera  may  be  riddled  with  them  ;  or  they  may  be  scattered  through  the  sub- 
( utaneous  tissue  ;  and  wherever  they  occur,  they  are  always  diffuse.  Many  of 
these  cannot  be  diagnosed  ;  metastatic  ab.sce.sses  in  the  lungs,  for  example,  are 
always  small,  and  cause  but  slight  physical  signs,  w-hile  the  nervous  system  is  so 
depressed  that  the  pain,  even  when  it  is  severe,  is  scarcely  felt.  Local  tender- 
ness is  always  of  very  great  significance  ;  and  in  most  cases  it  is  essential  to  insti- 
tute a  thorough  examination  of  the  patient  every  day  to  make  sure  that  no  sup- 
])urating  focus  anywhere  is  overlooked. 

Pyaemia  varies  very  greatly  in  its  intensity.  In  some  cases — when,  for 
example,  it  is  due  to  acute  osteomyelitis — it  may  prove  fatal  within  the  week, 
even  before  metastatic  abscesses  of  any  kind  have  been  able  to  make  their  appear- 
ance. In  others  pericarditis,  or  some  other  lesion  .so  grave  as  to  imperil  life,  sets 
in  ahnost  at  once.  Sometimes,  on  the  other  hand,  it  is  very  chronic,  lasting  even 
for  months,  with  occasional  rigors  and  abscesses,  which  in  these  cases  are  limited, 
or  almost  limited,  to  the  subcutaneous  tissues.  So  far  as  the  progno.sis  is  con- 
cerned, a  very  great  deal  depends  ui)on  the  locality  of  the  secondary  deposits. 
When  the  abscesses  are  superficial  or  confined  to  the  joints,  and  when  the  fever 
does  not  run  an  extreme  course,  there  is  always  the  hope  that  recovery  may  follow, 
but  at  the  expense  of  a  long  and  tedious  illness,  with  very  likely  one  or  more 
joints  crippled  and  almost  useless. 

Treatment. — When  once  pyaemia  has  developed,  it  does  not  appear  possible 
to  cut  it  short  in  any  way  ;  all  that  can  be  done  is  to  treat  the  symptoms  as  they 
arise,  and  prevent  them  from  becoming  themselves  centres  of  fresh  infection. 
Prevention,  therefore,  is  all  the  more  e.ssential — first,  to  prevent  the  poison  devel- 
oping ;  secondly,  to  prevent  its  being  absorbed. 

Where  it  is  practicable,  every  patient  before  operation  should  undergo  a 
thorough  course  of  preparation.  It  is  a  well-known  fact  that  people  in  a  robust 
state  of  health,  taking  active  exercise,  and  consuming  a  large  amount  of  food, 
are  not  nearly  such  good  subjects  for  operation  as  those  who  have  long  been 
bed-ridden.  Laid  up  suddenly,  their  bowels  become  confined,  their  liver  is  con- 
gested, the  urine  is  thick  and  high-colored,  and  a  certain  amount  of  feverishness 
sets  in. 

The  surroundings  should  receive  the  greatest  attention.  Ventilation  should 
be  perfect ;  nothing  tends  to  such  depression  as  the  constant  breathing  of  air  that 
has  been  fouled  ;  and  absolute  chemical  cleanliness  must  be  insisted  on.  Bed, 
bedding,  instruments — everything,  in  short,  that  comes  in  contact  with  the 
patient — must  be  scrupulously  clean.  Outbreaks  of  pyemia  have  been  traced  to 
the  sudden  disturbance  of  accumulations  of  dust,  but  in  the  majority  of  instances 
it  is  probable  the  actual  vehicle  of  the  poison  is  some  material  object. 

A  wound  requires  even  greater  care.  Everything  that  tends  to  irritate  the 
tissues  in  the  neighborhood — want  of  rest,  tension,  friction,  or  decomposition — 
lowers  their  power  of  resistance  and  makes  them  more  susceptible.  Where  the 
drainage  is  perfect,  so  that  the  discharges  escape  at  once,  and  the  surface  of  the 
wound  is  kept  dry,  so  that  decomposition  cannot  occur,  suppuration  may  follow, 
but  it  will  be  limited  to  the  surface,  and  there  is  little  or  no  fear  of  the  pyogenic 
micro-organisms  either  finding  their  way  into  the  cellular  tissue  and  cau.sing  diffuse 
suppuration,  or  entering  into  the  blood-stream  and  leading  to  thrombosis,  soften- 
ing, and  metastatic  abscesses. 

Ab.scesses  should  be  opened  at  once  and  thoroughly  drained.  Joints  that  are 
filled  with  pus  must  be  treated  in  the  same  way,  or  irrigated  with  a  continuous 
stream  of  water.  At  first,  the  cartilages  and  the  synovial  lining  are  unaffected, 
and  if  only  the  contents  are  evacuated  in  time,  and  no  accumulation  is  allowed, 
the  mischief  may  be  prevented  from  extending  farther,  and  a  very  useful  articula- 
tion left.     In  many  instances,  however,  either  fibrous  or  bony  ankylosis  results. 


78         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

The  same  jjlaii  has  l)een  tried  with  the  serous  membranes,  l)ut  it  is  scarcely  pos- 
sible to  hope  for  success  with  them. 

Quinine  is  of  some  use  in  controlling  the  temperature,  and  appears  to  check 
the  onset  of  the  rigors  and  diminish  their  severity,  but  not  to  the  same  extent  as 
in  the  case  of  urethral  fever.  Germicides  taken  internally  are  of  no  avail ; 
secondary  deposits  make  their  appearance  even  when  the  urine  is  almost  black 
from  the  absorption  of  carbolic  acid.  Salicylate  of  soda  and  antipyrin  may  be 
tried  ;  and  opium  is  always  of  use,  both  to  relieve  the  pain  and  anxiety  and  pro- 
cure sleep.  The  food  should,  of  course,  be  as  nutritious  as  possible,  and  the 
supply  of  stimulants  should  be  guided  by  the  condition  of  the  pulse. 

[Pain  should  be  controlled  by  an  anodyne,  and  beef-tea,  with  brandy  or 
milk  punch,  freely  administered.] 


ERYSIPELAS.  79 


CHAPTER  IV. 

DISEASES  DUE    TO  IXFECTIVE  ORG  AN  ISMS.— Continued. 
2.   SPECIFIC. 

KRYSIPELAS. 

Two  kinds  of  erysipelas  are  clinically  distinguished — simple  cutaneous  and 
phlegmonous.  In  the  latter,  however,  the  skin  is  involved  secondarily  :  the  true 
erysipelatous  rash  is  not  present,  and  there  is  no  question  that  the  inflammation  is 
due  entirely  to  the  ordinary  forms  of  micrococci. 

lCrysii)elas  is  an  acute  infective  inflammation  of  the  capillary  lymphatics, 
caused  by  the  presence  of  a  micrococcus.  The  skin  is,  generally  speaking, 
involved,  hwX.  sometimes  it  commences  on  the  mucous  and  even  on  the  serous 
surfaces. 

Cause.— A  streptococcus  can  always  1)e  found  in  the  lymphatic  spaces  at  the 
edge  of  the  extending  inflammation,  chiefly  in  the  superficial  part  of  the  corium 
and  the  subcutaneous  fatty  tissue  ;  it  is  not  present  in  the  blood-vessels.  Whether 
it  is  the  same  as  the  streptococcus  of  suppuration  (S.  pyogenes)  or  not  is  still 
doubtful.  According  to  Fehleisen,  it  is  not ;  by  itself  it  never  leads  to  the 
production  of  pus  ;  if  this  occurs,  it  is  always  the  result  of  a  mixed  infection. 
According  to  others,  however,  all  the  differences  may  be  explained  by  the  method 
or  site  of  inoculation,  the  degree  of  attenuation,  or  the  individual  power  of  resist- 
ance. Morphologically  they  cannot  be  distinguished,  although  it  is  said  the 
micrococcus  erysipelatis  is  slightly  the  larger  of  the  two. 

It  is  very  doubtful  if  the  micro-organism  can  gain  access  otherwise  than 
through  a  wound,  but  the  smallest  scratch  or  abrasion  is  enough.     Exposure  to 
draughts,  sudden  chills,  the  east  wind,  and  the  like,  which  are 
occasionally  followed  by  an  attack,  and  which  certainly  pre-        ,_      "•"•. 
dispose  to  it,  must  be  regarded  as  depressing  agents,  render-  '■'■••.    /(''"'  \ 

ing  the  tissues  more  liable  to  infection.     Erysipelas  is  occa-       ,--^...-..") "  f")     '**••. 
sionally  epidemic,  and  probably  may  be  conveyed  by  air  or       \  ;•■        (.._ 

water;  but  it  is  certainly  contagious  and  is  especially  liable  to         I  (  ""^ 

l)e  disseminated  by  dirty  hands  or  sponges.  /'  /     :|["'"' 

The  predisposing  causes  include  everything  which  can         -...^   -r* 
either  impair  the  general  health  or  weaken  the  power  of  resist-      ^  ,3    '""\    ;*'** 
ance  of  the  tissues  in  the  neighborhood  of  the  wound.   Among     f,^.    e.  — streptococcus 
the  former   are   included   Bright's   disease,  intemperance   in        Erysipelatous.    Pure 

.,  .."  ..'-..  Culture  in    Bouillon   at 

food  as  much  as  in  drink,  gout,  exposure,  and  privation.  37°  c.  stained  with 
Overcrowding,  the  continued  breathing  of  air  loaded  with  ^^";^j^t'.';X95o(^««'«- 
the  exhalations  from  other  people's  lungs,  want  of  cleanliness, 
and  general  neglect  of  ordinary  hygienic  principles  probably  act  in  the  same  w-ay  ; 
they  all  appear  to  interfere  with  the  elimination  of  waste  material  of  one  kind  or 
another,  and  so  prevent  the  perfect  nutrition  of  the  tissues.  Mechanical  irritation, 
want  of  rest,  congestion,  or  cedema,  and  the  presence  of  foul  or  decomposing 
discharges  soaking  into  the  neighborhood  of  a  wound,  affect  the  surrounding 
stnictures,  lowering  their  vitality  and  rendering  them  less  capable  of  resisting. 
Under  conditions  of  this  kind  the  tissues,  which,  so  long  as  they  are  healthy,  are 
able  to  prevent  the  entry  of  foreign  organisms  and  destroy,  sooner  or  later,  those 
that  from  some  accident  may  have  entered  in,  seem  to  lose  their  power  of  resist- 
ance altogether.  Experiments  in  illustration  of  this  have  been  performed  by 
many  observers.      Chemical  ferments,  apparently  containing  no  organic  structure 


8o         GENERAL   PATHOLOGY  OF  SURGLCAL   DISEASES. 

of  any  kind,  have  been  injected  into  the  blood,  and  in  a  very  short  time  it  has 
been  found  that  micro-organisms  were  present  in  myriads. 

One  attack  distinctly  predisposes  to  another. 

Pathology. — Micrococci,  forming  chains,  are  found  abundantly  in  the  super- 
ficial lymj)hatics  of  the  skin  where  the  rash  is  sj^reading — not  where  it  is  fading, 
nor  where  it  has  })assed  away  ;  they  are  much  more  scarce  in  the  interstices  of  the 
tissues  (though  these  anatomically  l^elong  to  the  lymphatic  system),  and  are 
scarcely  found  at  all  in  the  vessels  of  the  part.  The  other  local  changes  are 
merely  tho.se  that  are  present  in  ordinary  inflammation — dilatation  of  vessels, 
accumulation  of  inflammatory  e.xudation,  and  of  leucocytes. 

In  fatal  cases  the  blood  is  usually  said  to  be  fluid  and  uncoagulated,  staining 
the  interior  of  the  heart  and  vessels.  The  spleen  is  soft  and  diffluent,  the  kidneys 
are  engorged,  sometimes  showing  signs  of  a  catarrhal  or  interstitial  inflammation, 
and  the  lungs  are  much  congested,  the  smaller  vessel  being  plugged  with  granular 
mas.ses,  which  are  supposed  to  be  produced  by  the  disintegration  of  white  corpus- 
cles.     A  similar  change  has  been  described  in  the  ve.s.sels  of  the  brain. 

Symptoms,  i.  Constitutional. — These  usually  precede  the  local  ones  by 
some  hours,  occasionally  longer.  There  is  a  rapid  rise  of  temperature  to  102°  or 
104°  F.,  Avith  chills,  or  even  a  rigor  ;  vomiting,  epistaxis,  and,  in  children,  con- 
vulsions are  of  common  occurrence.  The  skin  is  hot  and  dry,  the  tongue  is 
coated  with  a  thick,  creamy  fur,  the  bowels  are  confined,  and  there  is  headache 
with  general  depression.  The  temperature  usually  continues  high  for  three  or 
four  days  and  then  gradually  sinks,  assuming  the  remittent  type,  but  as  it  rises 
again  with  every  local  extension  its  course  is  rarely  uniform.  In  the  worst  cases 
the  symptoms  are  of  a  tyi)hoid  character  almost  from  the  first  ;  the  eyes  are 
jaundiced,  the  skin  is  a  peculiar  dusky  yellow,  the  pulse  is  very  small,  frequent, 
and  feeble,  diarrhcea  is  often  profuse  and  sometimes  very  offensive,  albumin  is 
present  in  the  urine  (perhaps  owing  to  the  catarrhal  inflammation),  and  there  is  a 
constant,  muttering  delirium,  which  may  be  due  to  the  plugging  of  the  cerebral 
capillaries. 

2.  Local. — The  redness  nearly  always  begins  at  the  margin  of  the  wound, 
sometimes  where  the  skin  is  continuous  with  mucous  membrane,  as  at  the  angle  of 
the  eye,  or  on  the  mucous  membrane,  very  rarely  some  distance  off.  At  first  it  is 
a  bright  rose-red  ;  exceptionally,  and  only  in  severe  cases,  it  has  a  dusky  tinge. 
The  edge  is  irregular,  but  always  sharply  defined  ;  even  when  the  rash  is  advancing 
it  always  marches  by  steps,  suddenly  showing  a  well-marked  border  some  distance 
off.  The  skin  is  .swollen,  cedematous,  and  pits  on  pressure.  The  raised  margin 
can  be  felt,  it  is  so  clear.  Where  there  is  an  abundance  of  loose  cellular  ti.ssue,  as 
in  the  eyelid  or  the  scrotum,  the  swelling  becomes  enormous  in  a  very  short  space 
of  time,  but  the  pain  is  very  slight.  When,  on  the  other  hand,  the  skin  is  tightly 
bound  down,  as  over  the  nose  or  the  pinna,  the  color  is  livid,  the  swelling  slight, 
and  the  pain  intense.  Very  often  in  these  circumstances  the  epidermis  is  detached 
from  the  corium  beneath,  forming  bullae,  which  af  first  contain  clear  serum,  but 
.soon  become  full  of  pus.  As  the  inflanmiation  subsides  these  burst,  dry  up,  and 
form  scabs,  but  there  is  no  ulceration  or  destruction  of  the  cutis.  In  severe  ca.ses 
the  fluid  they  contain  is  stained  with  blood. 

The  neighboring  lymphatic  glands  are  always  swollen  and  tender  ;  very  often 
this  is  the  earliest  sign,  and  it  is  usually  ])resent  before  the  blush  shows  itself.  As 
the  disease  advances  the  redness  involves  one  area  after  another,  fading  in  the 
centre  as  it  spreads  by  the  circumference.  Sometimes  this  continues  for  two  or 
three  days  only,  sometimes  for  much  longer  periods,  until  perhaps  the  greater  part 
of  the  body  has  been  traversed.  Then  the  temi:)erature  falls  suddenly,  the  last- 
formed  reel  patch  ceases  to  spread,  the  swelling  disajjpears.  the  skin  becomes 
wrinkled  again,  and  the  i)ain  and  tenderne.ss  disapi)ear.  Desquamation  always 
follows  a  severe  attack,  and  when  the  head  is  involved,  the  hair  falls  off.  but  it 
speedily  grows  again. 

In  rare  cases  erysipelas  is  erratic,  disappearing  in  one  i)art  and  breaking  out 


ERYSIPELAS.  8i 

in  another  ;  and.  in  very  exceptional  instances,  metastatic,  suddenly  subsiding  aiid 
attacking  some  internal  organ  instead. 

Abscesses  are  uncommon,  although  occasionally  the  lymphatic  glands  break 
down  and  suppurate.  \'ery  often  a  relajjse  occurs,  sometimes  two  or  three,  but 
they  are  rarely  so  severe  as  the  original  attack.  Acute  suppurative  arthritis,  men- 
ingitis, pleurisy,  and  peritonitis  have  been  recorded  as  complications ;  and  occa- 
sionally in  erysipelas  of  the  face  the  mouth  and  fauces  become  involved,  leading 
to  erysipelatous  laryngitis  and  cedema  of  the  glottis.  Pyaemia  occasionally  follows 
it  ;  and  sometimes,  especially  after  repeated  attacks,  a  condition  of  solid  cedema 
is  left,  which  is  very  disfiguring  when  the  face  is  concerned. 

Diagnosis. — The  sudden  rise  of  temperature,  with  headache,  vomiting,  and 
constipation  ;  the  enlargement  and  tenderness  of  the  neighboring  lymphatic 
glands  ;  and  the  peculiarly  sharply-defined  margin  of  the  redness,  are  character- 
istic.    The  last  serves  to  distinguish  it  from  simjjle  lymphangitis. 

Erysipelas  commencing  in  the  mucous  membrane  of  the  fauces  resembles 
ordinary  catarrhal  pharyngitis,  but  is  infinitely  more  severe.  The  constitutional 
symptoms  are  even  more  marked  than  in  the  ordinary  cutaneous  form  ;  the  throat 
is  swollen  and  burning  hot ;  the  mucous  membrane  of  the  palate  is  thickened  and 
of  a  brilliant  red  ;  the  voice  is  lost ;  swallowing  is  exceedingly  painful ;  and  the 
glands  at  the  angles  of  the  jaw  are  enlarged  and  very  tender.  The  prostration  in 
these  cases  is  usually  extreme,  and,  in  addition  to  the  ordinary  risks,  there  is 
always  the  fear  of  the  inflammation  extending  to  the  larynx. 

Prognosis. — The  severity  of  the  initial  fever  is  no  guide.  [In  youth  and 
middle  age  recovery  is  the  rule.]  At  the  extremes  of  life ;  when  the  head,  face,  or 
chest  is  involved  ;  when  the  disease  continues  for  any  length  of  time,  and  particu- 
larly when  there  is  old-standing  nephritis,  the  prognosis  becomes  very  grave.  A 
dusky  red,  instead  of  bright  eruption,  jaundice,  delirium,  blood-stained  bull^,  and 
a  sudden  rise  in  the  pulse-rate,  without  strength,  are  very  serious  omens.  In  many 
cases  broncho-pneumonia  sets  in  and  proves  fatal ;  in  others  signs  of  congestion 
of  the  brain  ;  in  others,  again,  the  symptoms  resemble  those  of  typhoid  with  diar- 
rhoea :  or  the  i)atient  sinks  from  exhaustion,  worn  out  by  the  long-continued  fever. 

Treatment,  i .  Constitutiojial. — It  must  always  be  remembered  that,  although 
the  fever  at  the  commencement  of  an  attack  may  be  sthenic,  it  tends  very  rapidly 
to  assume  a  typhoid  character. 

A  purgative  is  nearly  always  required  at  first :  even  when  there  is  diarrhoea  it 
may  usually  be  given  with  advantage,  and  particularly  when,  from  the  patient's 
appearance  or  habits,  it  is  probable  that  the  liver  is  congested.  Afterward  the 
bowels  may  be  kept  gently  open  by  means  of  effervescent  salines.  In  the  slighter 
ca.ses  nothing  else  is  required,  though  quinine  with  mineral  acids  may  be  given  to 
stimulate  the  appetite.  In  the  more  severe  ones.  Avhere  the  tongue  is  dry  and 
brown,  and  the  pulse  is  losing  its  strength  and  fullness,  bark  and  ammonia  with 
ether  answer  better  than  anything.  If  the  temperature  is  high  quinine  or  anti- 
pyrin  may  be  given,  but  they  appear  to  have  little  effect  upon  the  disease.  Per- 
chloride  of  iron,  which,  according  to  some,  acts  as  a  specific  when  given  in  large 
and  frequent  doses,  has  in  my  hands  failed  completely.  I  have  often  noticed  a 
distinct  improvement  when  it  has  been  left  off  and  quinine  and  carbonate  of 
ammonia  substituted. 

Stimulants  are  usually  required,  especially  in  the  aged  and  in  those  who  are 
accustomed  to  them.  The  guide  to  their  administration  is  the  condition  of  the 
tongue  and  the  pulse.  They  .should  always  be  given  in  small  quantities  at  a  time, 
and,  if  possible,  with  beef-tea,  meat -jelly,  milk,  arrowroot,  or  other  food  that  can 
be  easily  absorbed.  The  object  is  to  sustain  the  action  of  the  heart  and  supply  it 
with  strength  until  the  activity  of  the  poison  begins  to  subside.  Very  often  after 
the  first  day  or  two  the  patient  will  take  liquid  food  readily,  and  then  there  is  not 
the  same  necessity. 

2.  Local. — Many  attempts  have  been  made  to  check  the  spread  of  the  micro- 
organisms in  the  tissues,  but  not  with  any  great  success.     Injections  of  carbolic 


82         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

acid  and  of  sulphocarbolate  of  soda  are  recommended.  American  surgeons  are 
said  to  have  used  bromine  vapor  and  creasote  with  advantage.  Salicylic  acid  is 
reported  to  have  succeeded  when  injected  hypodermically ;  and  many  other  germi- 
cides have  enjoyed  a  local  reputation.  In  most  cases,  however,  it  answers  better 
to  treat  the  symptoms.  Strong  antiseptics  in  particular  should  be  avoided,  as  the 
additional  injury  they  inflict  upon  the  tissues  may  cause  sloughing. 

The  burning  pain  can  be  relieved  by  excluding  the  air  and  using  gentle 
pressure.  Cold  may  be  grateful  to  the  patient,  but  care  is  required  in  employing 
it,  for  fear  of  lowering  the  vitality  of  the  part  too  far.  Oxide  of  zinc  and  starch 
are  sometimes  dusted  thickly  over  the  skin,  but  in  many  ca.ses  they  cause  intoler- 
able itching.  Extract  of  belladonna  mixed  with  glycerin,  and  covered  with  a 
thick,  soft  layer  of  cotton-wool,  is  greatly  to  be  preferred.  Three  or  four  coats  of 
lead  paint,  mixed  with  glycerin  to  prevent  its  cracking,  have  a  very  satisfactory 
effect,  partly,  no  douVjt,  owing  to  the  absorption  of  the  lead  and  its  action  upon  the 
capillaries ;  but  the  ordinary  lead  lotion  is  equally  good  if  evaporation  is  checked 
by  using  five  or  six  thicknesses  of  lint.  In  very  mild  cases  the  surface  may  be 
painted  over  Avith  a  strong  solution  of  nitrate  of  silver  in  ether,  or  with  collodion, 
or  tincture  of  iodine,  though  the  benefit  is  probably  due  to  the  mechanical  effect 
upon  the  epidermis. 

Rest,  gentle  uniform  pressure,  and  elevation,  if  the  part  will  admit  of  it,  are 
of  material  help  in  relieving  the  pain  and  inflammation.  When  the  tension  is 
extreme  it  is  sometimes  necessary  to  make  a  few  punctures  ;  for  want  of  this  I  have 
known  the  eyelids  slough,  but  such  circumstances  are  rarely  met  with  in  uncom- 
plicated erysipelas. 

[Occasionally  the  application  of  a  blister  to  the  sound  skin,  by  temporarily 
occluding  the  lymphatics,  may  prevent  the  spread.  The  tincture  of  iodine  is 
absorbed  and  is  potentially  germicidal.  Vapor  of  bromine  is  useful  in  prevent- 
ing the  spread  to  other  patients.] 

SEPTIC  INFECTION,  OR  TRUE  SEPTICEMIA. 

In  the  strict  sense  of  the  term  this  name  should  be  reserved  for  an  acute 
specific  disease  caused  by  a  micro-organism  which  multiplies  in  the  l)lood,  so  that 
the  most  minute  trace  can  communicate  it  by  inoculation,  as  in  the  case  of  anthrax. 
It  is  not  of  necessity  attended  by  septic  fever  or  sapraemia,  on  the  one  hand,  or  by 
the  local  manifestations  of  pyaemia,  thrombosis,  embolism,  or  suppuration,  on  the 
other.  The  smallest  wound  is  sufficient ;  there  is  a  short  period  of  incubation 
— eight  or  ten  hours  in  acute  cases — and  the  symptoms  steadily  increase  in  sever- 
ity. Sometimes  it  is  known  as  progressive  septicaemia  to  avoid  confusion  Avith 
sapraemia. 

That  such  a  disease  can  be  artificially  produced  l)y  pure  cultivations  in 
animals  is  beyond  doubt.  Whether  it  ever  occurs  in  man  by  itself,  so  that  it  can 
be  distinguished  from  all  other  troubles  that  are  caused  by  infective  germs,  is  open 
to  question.  It  must  be  remembered  that  after  the  injection  of  a  minute  quantity 
of  a  chemical  poison  into  the  blood,  myriads  of  micro-organisms  make  their 
appearance,  and  care  must  be  taken  not  to  mistake  effect  for  cause. 

It  is  possible  that  some  of  the  exceedingly  fatal  ca.ses  of  post-mortem  wounds 
that  occur  in  connection  with  puerperal  peritonitis  are  examples  of  septic  infec- 
tion ;  but,  on  the  other  hand,  it  is  by  no  means  improbable  that  they  are  really 
due  to  .sapraemia,  the  inoculation  of  a  virulent  poison  (as  happens  sometimes  from 
the  bites  of  venomous  reptiles)  causing  such  extreme  depression  that  the  tissues 
either  succumb  at  once,  or  are  too  much  weakened  to  withstand  the  action  of 
other  germs.      Other  exam])]es  are  fortunately  very  rare. 

Pathological  Appearances. — The  changes  found  post-mortem  are  practi- 
cally the  same  as  those  in  other  acute  specific  fevers.  Cloudy  swelling  is  universal ; 
the  brain  and  pia  mater  are  congested  .;  the  spleen  is  enlarged  ;  and  the  number 
of  white  corpuscles  in  the  blood  apparently  increased  ;  but  in  the  most  acute  cases 


SEPTIC  INFF.CTIOX,  OR    TRUE   SEPTICEMIA.  83 

there  is  nothing  more  definite.  In  those  which  have  lasted  a  little  longer,  or  in 
which  the  temperature  has  been  very  high,  petechias  may  be  found  upon  the  skin 
and  the  surface  of  the  serous  meml)ranes,  and  sometimes  these  and  the  lining 
membrane  of  the  heart  show  evidence  of  acute  inflammation.  Unless,  however, 
the  endocarditis  has  distinctly  a.ssumed  the  ulcerative  form,  embolism  does  not 
occur.  When  the  disease  has  lasted  longer  it  is  usually  complicated  by  the  jjres- 
ence  of  local  inflammation. 

Symptoms. — The  wound  itself  may  have  been  absolutely  unnoticed,  but 
usually  it  is  inflamed  and  painful,  and  sometimes  there  is  tenderness  running  tVom 
it  in  the  direction  of  the  lymphatics.  Otherwise  it  shows  no  change.  The 
general  symptoms  commence,  as  a  rule,  al)out  eight  or  twelve  hours  after  the 
injury,  with  the  most  overpowering  depression  ;  headache  is  extremely  severe  ; 
there  may  be  a  rigor  of  great  intensity,  but  very  seldom  more  than  one ;  the 
temjjerature  begins  to  rise  at  once,  the  pulse  is  small  and  feeble  from  the  first,  the 
respiration  is  hurried  and  shallow,  and  in  a  very  short  time  delirium  sets  in,  and 


^.-^'^ 


Fig.  7. — Blood  of  a  mouse  killed  by  inoculation  of  the  bacillus  of  mouse  septicaemia.  A  thin  layer  of  the  blood  has 
been  dried  on  a  cover-glass,  carefully  heated,  stained  with  a  watery  solution  of  methyl  blue  and  mounted  in 
glycerin.     (X  70o). 

White  blood  corpuscle  with  horseshoe-shaped  nucleus,  and  numerous  minute  bacilli  in  and  around  it.  Red  blood 
corpuscles.     Small  bacilli  between  corpuscles.     {After  IVoodhead.) 

stupor  and  coma  rapidly  follow.  The  central  nervous  system  from  the  first  is 
entirely  overcome.  Sometimes  there  is  a  rash  upon  the  skin  not  unlike  that  of 
scarlatina.  Lung  complications  are  of  frequent  occurrence.  Diarrhoea  may  be 
present,  and  albuminuria,  after  the  first  two  days,  is  almost  invariable.  Later,  if 
the  case  becomes  chronic,  inflammation  of  the  serous  membranes  and  of  the  endo- 
cardium may  set  in,  and  various  local  troubles,  with  saprsemia  and  suppurative 
fever,  may  make  their  appearance. 

The  diagnosis  from  saprsemia  is  practically  impossible  [except  from  the 
history  of  the  case],  although  septic  infection  is  more  probable  when  there  is  a 
distinct  incubation  period.  No  other  diseases  occurring  under  such  conditions 
ever  cause  symptoms  of  such  severity. 

Treatment  is  of  little  use.  An  attempt  should  be  made  to  limit  further 
absorption  by  the  thorough  application  of  caustics  ;  there  is  evidence  to  show  that, 
in  the  case  of  some  other  acute  specific  and  infective  disorders,  destruction  of  the 
seat  of  inoculation  is  of  considerable  benefit.      Quinine  and  antipyrin  may  be 


84         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

given  when  the  temjjerature  is  high,  and  stimulants — alcohol,  ammonia,  and  ether — 
if  the  pulse  shows  signs  of  failing.  Otherwise,  nothing  is  of  much  avail  ;  the  case 
usually  terminates  fatally  in  a  few  days  [but  it  may  be  prolonged  for  many  weeks. 
Mercurials,  in  minute  doses,  are  said  to  be  beneficial]. 

ANTHRAX. 

Anthrax,  or  malignant  pustule,  is  an  acute  infectious  disease,  caused  by  a  spe- 
cific bacillus.  Woolsorters'  disease  is  the  same  thing  under  a  different  form,  and 
so  is  the  splenic  fever  of  cattle.  The  bacillus  anthracis  is  the  largest  and  most 
easily  recognized  of  pathogenic  organisms.  It  consists  of  rods,  from  five  to  ten 
micromillimeters  in  length,  abruptly  cut  at  the  ends,  and  capable,  under  suitable 
conditions,  of  producing  spores  which  possess  the  most  extraordinary  powers  of 
resistance  ;  their  tenacity  of  life  is  so  great  that  catgut  prepared  for  ligature  in  the 
ordinary  way  and  kept  in  a  dilute  solution  of  carbolic  acid  has  shown  itself  capa- 
ble of  transmitting  the  disease.  It  can  grow  in  the  tissues,  or  in  the  blood,  or 
outside  the  body,  provided  there  is  a  sufficient  supply  of  oxygen  and  the  tempera- 
ture is  kept  up.  Naturally,  those  are  most  exposed  to  it  who  have  to  deal  with 
hides,  wool,  etc.  :  tanners,  dock  laborers,  woolsorters,  and  others,  but  it  may  occur 
in  butchers,  and  there  is  evidence  to  show  that  it  has  been  transmitted  by  flies. 

The  mode  of  entry  is  either  through  the  skin — as  in  malignant  pustule  and 
some  cases  of  malignant  oedema — or  through  the  mucous  membrane  of  the  respira- 
tory or  alimentary  tract  (woolsorters'  disease).  In  the  former  case,  characteristic 
local  changes  precede  the  clinical  symptoms ;  in  the  latter,  the  bacillus  enters  at 
once  into  the  blood-stream,  penetrating,  so  far  at  lea.st  as  the  lungs  are  concerned, 
between  the  uninjured  epithelial  cells.  Each  of  these  forms,  as  the  infection 
spreads  through  the  body,  may  be  attended  at  a  later  period  by  the  primary  lesion 
that  is  characteristic  of  the  other;  thus,  if  the  patient  lives  sufficiently  long, 
malignant  pustule  may  develop  upon  the  skin  in  a  case  of  woolsorters'  disease,  and 
secondary  intestinal  anthrax  may  show  itself  in  the  course  of  malignant  pustule. 

The  bacilli  themselves  may  be  found  in  enormous  numbers  at  the  seat  of 
infection,  in  the  inflammatory  effusion  that  is  poured  out  round  it,  and  in  the  fluid 
of  the  vesicles  that  lie  upon  it.  They  are  also  present  in  the  blood,  especially 
where,  as  in  the  spleen,  the  circulation  is  slow ;  and  they  exist  abundantly  in  the 
ecchymoses  that  are  found  in  the  mucous  membranes  and  under  the  serous  coverings 
of  the  viscera. 

The  period  of  incubation  is  very  variable — from  a  few  hours  to  ten  days,  and 
even  more — probably  depending  upon  the  dose  and  upon  the  facilities  for  general 
distribution  afforded  by  the  anatomical  structure  of  the  part.  The  mode  of  action 
is,  to  a  certain  extent,  mechanical,  but  the  chief  effect  is  due  to  the  production  of 
some  substance  Tan  albumose,  in  all  probability)  at  the  expense  of  the  tissues.  In 
patients  who  have  survived,  the  bacilli  have  been  found  in  all  the  excreta,  and  in 
one  remarkable  case,  recorded  by  Davies  Colley,  they  were  still  present  in  the 
urine  a  month  after  the  man  had  recovered  from  the  attack. 

Recently,  it  has  been  shown  by  Hankin  that  an  albumose  possessing  similar 
toxic  properties  can  be  extracted  from  a  cultivation  of  anthrax,  and,  further,  that 
minute  doses  of  the  same,  given  previously  to  inoculation,  confer  a  certain  degree 
of  immunity,  while  large  ones  only  hasten  the  result. 

Morbid  Anatomy. — The  pathological  appearances  in  the  case  of  anthrax 
are  very  similar  to  those  that  occur  in  other  forms  of  acute  blood-poisoning. 
Decomposition  is  rapid,  the  blood  does  not  coagulate,  all  the  viscera  are  congested, 
the  spleen  in  particular,  and  sometimes  the  mesenteric  glands  are  enormously  en- 
larged. There  is  a  blood-stained  effusion  in  all  the  serous  sacs,  and  hemorrhages 
are  not  unfrequently  present  in  their  walls.  Ecchymoses  are  common,  on  the 
mucous  surface  of  the  intestine,  sometimes  forming  raised  blackened  patches,  which 
are  surrounded  by  a  zone  of  gelatinous  infiltration,  similar  to  that  in  the  primary 
affection  upon  the  skin,  and  occasionally  sloughing  has  commenced  already. 


ANTHRAX.  85 

The  seat  of  infection,  if  it  is  on  the  skin,  shows  no  sign  of  suppuration  ;  all 
the  angry  redness  and  much  of  the  swelling  disappear /<7j-/-w(7/'/'<7;/ /  the  centre 
forms  a  hard,  blackened  slough  ;  round  it  the  tissues  are  filled  with  a  blood-stained 
fibrinous  effusion  ;  and  further  away  all  the  parts,  sometimes  for  long  distances, 
are  infiltrated,  cedematous,  and  dark  with  hemorrhages.  Bacilli  are  present  in 
abundance  throughout  the  whole  infected  area  and  in  the  ecchymoses. 

Symptoms. — The  constitutional  symptoms,  as  in  septic  infection,  are  those 
of  the  most  intense  depression,  whether  the  poison  enters  by  the  skin  or  the 
mucous  membrane.  In  some  cases,  especially  in  malignant  pustule  of  the  face  and 
neck,  there  is  a  delay  of  only  a  few  hours ;  in  others  more  than  a  week  may  pass  ; 
then  the  temperature  begins  to  rise  and  becomes  exceedingly  irregular ;  shivering 
sets  in,  with  general  pains  all  over  the  body  ;  the  pulse  becomes  small  and  feeble ; 
sometimes  there  is  cyanosis,  and  occasionally  severe  dyspnoea  from  oedema  of  the 
glottis.     General  cramp,  diarrhoea,  and  vomiting  are  of  frequent  occurrence;  some- 

Fig.  8. — Bacillus  anthracis  from  the  spleen  of  a  cow  tKat  succumbed  to  an  attack  of  splenic  fever.  The  specimen  was 
taken  some  time  after  the  organ  had  been  removed  from  the  carcass,  and  in  presence  of  air,  spores  had  begun  10 
form  in  the  bacilli.  Specimen  was  dried,  heated,  stained  by  Gram's  method,  with  methyl  violet  and  vesuvin, 
and  mounted  in  Canada  Balsam.     (X  700) 

The  anthrax  rods  and  filaments,  some  of  them  with  bright  points  or8pores,are  stained  with  methyl  violet.  The  cells 
of  the  splenic  pulp  are  stained  brown  by  the  vesuvin.    (After  Woodhead.) 

times  there  are  convulsions,  especially  toward  the  end  ;  or  the  patient  becomes 
delirious  and  comatose.  In  other  cases,  the  symptoms  are  typhoid  almost  from 
the  first.  Death  usually  occurs  from  heart  failure,  sometimes  rather  suddenly  ;  or 
it  may  be  caused  by  asphyxia,  especially  when  there  is  oedema  of  the  glottis  ;  or 
by  fever  and  general  exhaustion.  Broncho-pneumonia  and  enteritis  are  more 
prominent,  as  a  rule,  where  the  infection  is  internal ;  but  often  in  these  cases  the 
course  is  so  rapid,  and  the  constitutional  symptoms  so  severe,  that  the  physical 
signs  are  insignificant  in  comparison. 

The  seat  of  infection,  when  it  is  upon  the  skin — the  so-called  malignant  pus- 
tule— is  characteristic.  A  small,  red,  itching  papule  forms  first.  As  the  effusion 
increases,  this  becomes  a  vesicle,  filled  with  blood-stained  serum,  resting  upon  an 
indurated  base.  Soon  the  vesicle  breaks  or  dries  up,  leaving  a  blackened,  central 
scab,  or  slough.  The  effusion  continues  to  increase  ;  an  indurated  area,  rai.sed 
considerably  above  the  surrounding  level,  is  rapidly  developed ,;  the  surface 
becomes  a  peculiar  purple-red,  and  ring  after  ring  of  vesicles  form  upon  it  round 


86         GENERAL   PATHOLOGY  OF  SURGLCAL   DISEASES. 

the  central  slough  ;  then  the  cedema  spreads  to  the  tissues  near,  until  sometimes 
the  hard,  brawny  swelling  and  the  peculiar  dusky  redness  extend  up  the  whole 
limb,  or,  if  it  is  on  the  face  or  neck,  spread  over  the  whole  surface  of  the  upper 
part  of  the  body,  and  to  the  deeper  structures,  especially  the  larynx,  as  well. 

The  black  central  slough  continues  to  enlarge  in  most  cases  as  the  neighbor- 
ing vesicles  fall  into  it,  but  no  pus  forms.  There  is  always  a  little  depression  in 
the  middle,  probably  from  the  drying  up  of  the  effusion,  and  this  makes  the  areola 
round  appear  more  prominent  than  it  really  is.  The  intense  brawny  hardness,  the 
rapidity  and  extent  of  the  cedema,  and  the  peculiar  rings  of  vesicles  are  the  most 
striking  local  features,  though  these  last  occasionally  are  wanting.  Pain  is  always 
peculiarly  slight.  In  some  cases,  in  which  the  infection  has  taken  place,  in  all 
probability,  from  an  internal  surface,  so  that  the  organism  gains  access  to  the  blood 
at  once,  and  only  involves  the  skin  secondarily,  the  central  papule  and  vesicle  are 
wanting  :  there  is  merely  an  enormous,  brawny  cedema  of  the  subcutaneous  tis- 
sues, and  then  of  the  skin,  appearing  first  in  separate  spots  (which,  as  they  increase 
in  size,  soon  fu.se  together),  and  becoming  covered  with  irregularly  scattered 
groups  of  vesicles.  The  working  of  the  organism  is  exactly  the  same,  except  that 
it  begins  from  beneath,  and  is  widely  spread  from  the  first,  instead  of  being  super- 
ficial and  local  for  a  time.  This  variety  is  sometimes  distingui.shed  as  a  malignant 
oedema. 

Diagnosis. — There  is  no  difficulty  when  the  local  signs  are  well-marked. 
The  central  purple  depression  A\-ith  the  indurated  dusky  base,  covered  with  rings  of 
vesicles  and  surrounded  by  wide-spreading  oedema,  is  distinctive.  In  addition, 
the  peculiar  absence  of  pain  in  the  earlier  stages  of  the  disease  is  most  noteworthy, 
and  separates  it  at  once  from  ordinary  forms  of  carbuncle  or  diffuse  inflammation. 
Internal  anthrax  and  malignant  oedema  are  not  so  easy,  although  it  may  be  clear, 
from  the  extreme  constitutional  depression,  that  there  is  some  very  grave  form  of 
blood-poisoning.  Ordinary  broncho-pneumonia  or  gastro-enteritis  seldom  causes 
such  intense  prostration  and  cyanosis  :  and  the  comparatively  slight  development  of 
the  physical  signs  by  the  side  of  the  condition  of  the  patient  is  very  suggestive. 
But,  in  the  absence  of  local  e\-idence,  it  is  only  possible  to  determine  the  particular 
form  of  blood-poisoning  that  is  present  by  a  reference  to  the  occupation  and  sur- 
roundings of  the  patient,  or,  better,  by  a  microscopic  examination  of  the  blood. 
The  bacillas  is  of  such  size,  stains  so  readily,  and  is  so  distinctive  and  so  widely 
distributed,  that  it  can  scarcely  be  overlooked. 

Prognosis. — In  external  anthrax,  if  the  seat  of  inoculation  is  excised  or 
destroyed  sufficiently  early,  the  prognosis  is  fairly  good.  Recovery  has  followed 
even  when  the  patient  was  already  so  infected  that  bacilli  were  present  in  the 
sputum,  urine,  .sweat,  and  faeces  (Davies  Colley).  Apparently  the  focus  of  inflam- 
mation acts  as  a  laboratory,  from  which  the  poison  is  discharged  into  the  system. 
In  woolsorters'  disease,  where  the  stress  of  the  complaint  falls  upon  the  intestinal 
or  pulmonary  mucous  membrane,  and  when  the  face  or  neck  is  involved,  or  the 
oedema  is  widespread,  and  shows  a  tendency  to  involve  internal  organs,  such  as 
the  larynx,  there  is  much  less  hope. 

Treatment. — If  the  infection  is  local,  the  whole  thickness  of  the  skin  and 
cellular  tissue  should  be  excised,  with  an  eighth  of  an  inch  of  the  cellular  tissue 
around.  Then,  if  there  is  any  ecchymosis  or  oedema  visible  on  the  cut  surface,  the 
actual  cautery,  or  potas.sa  fusa,  should  be  applied  freely.  When  the  oedema  is  too 
extensive  for  this,  all  that  can  be  done  is  to  inject  hypodermically  all  round  it  a 
solution  of  carbolic  acid  (i  in  20),  in  the  hojje  that  it  may  soak  into  the  tissues. 
Free  incisions  at  the  same  time  should  be  made  into  the  subcutaneous  tissue,  and 
the  wounds  irrigated  with  a  similar  solution,  or  one  of  corrosive  sublimate. 

Sulphite  of  sodium,  in  ten-grain  doses,  is  said  to  be  very  successful  in  animals, 
and  should  therefore  be  given  a  fair  trial.  Quinine  has  been  recommended,  and 
also  corrosive  sublimate.  Of  course,  the  diet  should  be  good,  and,  if  necessary, 
stimulants  s^iven  freelv. 


GLANDERS.  87 

(".LANDERS. 

This  is  another  variety  of  infettive  disease,  caused  by  a  specific  germ,  the 
bacillus  Mallei.  Like  ])yi\iinia,  anthrax,  tubercle,  and,  to  a  less  extent,  syphilis, 
it  varies  very  greatly  in  different  cases,  the  severity  of  the  attack,  and  the  nature 
of  the  symptoms  being  modified  by  the  anatomical  structure  of  the  seat  of  inocu- 
lation, the  method  of  dissemination,  and  jjrobably  the  dose  of  the  poison.  It  may 
be  acute  or  chronic  ;  it  may  affect  especially  the  mucous  membrane  of  the  nose 
and  the  respiratory  tract  (glanders),  or  it  may  spread  slowly  in  the  cellular  tissue 
and  lymphatics  (farcy)  ;  and,  not  uncommonly,  after  continuing  in  the  chronic 
form  for  a  greater  or  less  length  of  time  (I  have  known  it  upward  of  a  year  in  a 
horse),  it  suddenly  becomes  acute;  but,  in  all  cases,  although  its  manifestations 
and  its  course  are  almost  as  variable  as  those  of  tubercle  or  pyaemia,  it  is  one  and 
the  same  disease,  caused  by  the  same  species  of  organism. 

The  bacillus  is  a  small  rod,  somewhat  shorter  and  thicker  than  that  of  tubercle, 
and  usually  exists  in  pairs.  It  is  not  capable  of  spontaneous  movement,  [and 
spores  have  been  proved  to  exist  by  Baumgarten  and  Rosenthal].  Usually,  it 
enters  through  wounds,  especially  at  the  corners  of  the  nails;  but,  in  all  proba- 
bility, it  posses.ses  the  power  of  infecting  the  respiratory,  if  not  the  alimentary, 
mucous  membrane.  It  may  be  transmitted  from  man  to  man,  but,  as  a  rule,  it  is 
caught  directly  from  horses,  or  a.sses.  Other  animals  show  varying  degrees  of 
susceptibility  to  it. 

Local  changes  are  usually  produced  at  the  seat  of  inoculation  ;  there  is  a 
period  of  incubation  of  some  days,  then  the  part  becomes  red  and  swollen  ;  the 
skin  breaks  down,  and  a  foul  ulcer  is  left,  spreading  at  its  edges  and  its  base,  but 
without  anything  in  itself  characteristic.  From  this  the  organism  spreads,  with 
more  or  less  rapidity,  in  the  cellular  tissue  round,  in  the  lymphatics,  or  in  the 
blood,  the  severity  of  the  symptoms  and  the  acuteness  of  the  attack  depending  to 
a  very  large  extent  upon  this.  Whenever  it  spreads  it  causes  inflammation  ;  granu- 
lation-tissue is  produced  :  and  this,  as  in  the  case  of  tubercle  and  syphilis,  under- 
goes caseation  (unless  it  is  near  a  mucous  or  cutaneous  surface,  when  it  may  break 
down  at  once),  so  that  the  yellowish-white,  cheesy  nodules  and  tubercles  (farcy- 
l)uds.  when  they  can  be  felt  from  the  exterior),  are  formed  in  various  parts. 
Suppuration  follows,  whether  through  the  action  of  the  specific  bacilli,  or  because 
of  the  presence  of  pyogenic  organisms  in  addition,  is  not  known  :  and  then 
ulcers,  abscesses,  and  diffuse  forms  of  inflammation  break  out  in  all  the  infected 
regions.  The  bacillus  exists  in  the  cheesy  masses  and  in  the  pus  ;  not  unfrequently 
it  can  be  found  in  the  blood  as  well  in  man,  but  this  does  not  seem  to  be  the  case 
with  horses. 

Symptoms. — It  is  met  with,  naturally,  chiefly  among  those  whose  occupa- 
tions render  them  liable  to  infection,  and  it  may  be  acute,  so  that  it  proves  fatal 
within  three  or  four  days,  or  chronic,  lasting  for  months,  and  possibly  ending  in 
recovery  after  a  long  and  severe  illness. 

The  constitutional  symptoms  depend  upon  the  acuteness  of  the  attack.  In 
the  worst  cases  they  resemble  those  that  are  always  present  in  intense  blood- 
poisoning — muscular  tremors,  low-muttering  delirium,  etc.,  with  high  fever,  and 
a  small,  feeble  pulse.  When  it  is  less  severe  they  depend  practically  upon  the 
number,  size,  and  situation  of  the  abscesses  and  ulcers,  and  upon  the  extent  to 
which  suppuration  and  septic  absorption  take  place.  In  the  majority  of  cases 
they  do  not  terminate  fatally  at  the  commencement  from  the  intensity  of  the 
fever ;  either  broncho-pneumonia  sets  in,  from  the  constant  inhalation  of  the  odor 
from  the  foul  and  decomposing  sloughs,  or  the  patient  sinks  at  length  from 
exhaustion,  utterly  worn  out  by  pain,  inability  to  take  food,  profuse  suppuration, 
and  fever.     The  most  chronic  cases  recover,  but  always  seriously  crippled. 

Glanders  may  commence  with  inflammation  and  ulceration  6i  the  mucous 
membrane  of  the  nose,  or  this  may  occur  later  in  the  course  of  the  disease.  In 
the  case  of  the  former,  it  is  i)robably  due  to  direct  infection.     At  first  there  is  a 


88         GENERAL   PATHOLOGY  OF  SURGLCAL  DLSEASES. 

thin,  profuse,  watery  discharge ;  this  rapidly  becomes  ijurulent  and  exceedingly 
offensive;  the  inflammation  spreads  and  becomes  more  and  more  severe;  the 
whole  of  the  mucous  membrane  of  the  nose  ulcerates  and  sloughs ;  the  bones  are 
exposed  and  bare,  already  eaten  away  in  places ;  the  eyes,  the  frontal  sinuses,  the 
antrum,  the  pharynx,  and  palate  are  rapidly  involved  ;  and  the  whole  of  the  face 
and  neck  become  swollen,  livid  red,  hot,  and  inflamed,  as  in  the  worst  form  of 
phlegmonous  erysipelas.  Such  cases  usually  prove  fatal  at  a  very  early  period  ; 
one,  that  I  have  seen,  terminated  on  the  fourth  day  from  the  commencement  of 
the  outbreak. 

In  the  chronic  variety  (farcy)  the  distribution  of  bacillus  takes  place  chiefly 
by  the  lymphatics;  nodules  form  in  the  skin,  the  subcutaneous  tissues,  along  the 
course  of  the  lymphatic  vessels,  and  then,  later,  in  the  internal  organs.      On  the 


:^N^^ 


Fig.  9. — Fibrous  nodule  from  a  case  of  actinomycosis  (from  the  tongue  of  a  cow).  Stained  in  Spiller's  blue.  (X  50.) 
f^mgus  growing  in    the   centre  of  a   follicle.      Large   endothelioid   cells   near   the   fungus.      Fibro-cellular   tissue 

away  from  the  centre  of  the  follicle,  in  which  round   cells  predominate.     More  fibrous  tissue,  still  further  from 

the  fungus,  forming  a  fibrous  capsule.     (A/ter  IVoodhead.) 

skin  they  appear  first  as  minute  papules  scattered  in  irregular  groups  ;  these  soon 
enlarge  into  pustules  ;  the  base  upon  which  they  rest  becomes  reddened,  hardened, 
and  infiltrated,  and  then  they  break,  leaving  foul,  irregular  ulcers.  In  the  sub- 
cutaneous tissue  the  same  changes  occur,  only  the  so-called  buds  usually  attain  a 
larger  size  before  supjniration  sets  in,  and  the  same  thing  is  met  with  in  the  viscera 
and  the  lymphatic  glands,  the  symptoms  naturally  varying  with  the  number,  size, 
and  situation  of  the  abscesses.  Probably,  after  a  time,  dissemination  takes  place, 
as  in  pyaemia,  by  the  blood-stream  as  well. 

Diagnosis. — Acute  glanders  can  hardly  be  taken  for  anything  else.  The 
chronic  form,  on  the  other  hand,  may  remain  uncertain  for  a  considerable  time,  a 
certain  amount  of  fever,  with  vague,  flying  pains,  being  associated  with  a  cutaneous 
eruption  and  the  formation  of  lymphatic  nodular  swellings  in  many  other  dis- 


A  CriNO  MYCOSIS.  89 

orders — syphilis.  tul)ercle,  ijyoemia,  etc.  The  steady  persistence  with  which  the 
swellings  form,  enlarge,  and  l)reak  down  in  spite  of  everything,  must  soon,  how- 
ever, attract  attention. 

Treatment. — This  is  similar  to  that  of  anthrax;  the  seat  of  inoculation 
should  be  thoroughly  cauterized,  and  if  the  mucous  membrane  of  the  nose  is 
involved,  the  whole  cavity  should  be  irrigated  with  carbolic  acid,  corrosive  subli- 
mate, dilute  sulphurous  acid,  or  perhaps  sulphite  of  sodium.  Absces.ses  must  be 
opened  and  treated  in  the  same  way,  and  the  general  strength  must  be  maintained 
as  well  as  po.ssible.  If  the  nose  is  not  infected,  great  care  should  be  taken  to 
])revent  it.  Probably  this  takes  place  in  many  ca.ses  secondarily,  and  is  due  to 
the  patient  himself  conveying  the  poison  to  the  mucous  membrane.  Recovery 
after  this  has  happened  is  very  rare. 


v:* 


Fig.  10. — Actinomycosis.     Tongue  of  cow.     Section  stained  in  Spiller's  blue.     (X  300.) 

Centre  of  mass  of  conidia  (conidiophore).      Pear-shaped  conidia.     Endothelioid  cells.     Fibrillar    tissue  near   the 

margin  of  the  follicle.     Spindle-shaped  cells,  seen  especially  near  the  margin.     {After  Woodhead.) 


ACTINOMYCOSIS. 

Actinomycosis  is  a  disease  caused  by  a  peculiar  form  of  fungus  that  attacks 
herbivorous  animals  (including  man),  gaining  access  to  the  tissues  either  through 
wounds  or  through  the  mucous  membrane  of  the  respiratory  or  alimentary  canal. 
There  is  some  evidence  to  connect  it  with  rye,  and,  perhaps,  with  barley.  An  epi- 
demic occurred  in  Seeland,  from  eating  rye  grown  on  recently-reclaimed  ground, 
and  on  two  or  three  cases  the  disease  has  distinctly  originated  in  a  wound  of  the 
mucous  membrane  of  the  mouth,  caused  by  a  grain  of  rye,  showing  that  at  least 
it  may  be  the  carrier  of  the  infection.  In  cattle  it  usually  begins  in  the  tongue 
or  the  jaws,  generally  the  lower,  and  spreads  thence  to  the  cellular  tissue  of  the 
submaxillary  and  cervical  regions. 

The  fungus  is  easily  recognized  by  its  characteristic  star-like  masses  of 
mycelium.  The  granulation-tissue  that  forms  the  tumors,  and  the  pus  in  the 
7 


90         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

abscesses  and  ulcers,  contain  myriads  of  yellow,  rounded  bodies  like  millet-seeds. 
Each  of  these  is  made  up  of  little  threads,  which  radiate,  star-like  (whence  the 
name),  from  one  common  centre,  and,  after  a  time,  enlarge  and  terminate  in  club- 
like structures  which  probably  contain  spores.  In  ca.ses  of  suppuration,  however, 
these  are  not  always  plain,  and  the  color  is  not  always  so  clear.  Nothing  is 
known  with  regard  to  its  life-history,  except  that  it  has  been  found  in  the  muscles 
of  a  pig,  and  that  water  and  dilute  saline  solutions  destroy  it  at  once. 

Infection  usually  takes  place  through  the  mouth,  either  from  a  wound  or 
through  some  carious  tooth  ;  but  the  fungus  has  been  found  in  the  tonsil  and  as 
a  primary  growth  in  the  tubular  glands  of  the  mucous  membrane  of  the  large 
intestine.  Cutaneous  wounds  are  occasionally  affected,  and,  from  the  fact  that  it 
has  been  found  abundantly  in  the  cavities  in  the  lungs  and  in  the  pus  from  medi- 
astinal abscesses,  it  is  highly  probable  that,  sometimes  at  least,  the  spores  are 
inhaled  and,  sinking  into  the  alveoli  of  the  lung,  set  up  broncho-pneumonia. 
Wherever  it  comes,  it  causes  chronic  inflammation,  which  closely  resembles  that 
caused  by  tubercle,  at  least  in  its  histological  features.  Giant-cells  develop  around 
the  fungus  ;  outside  there  is  a  meshwork  filled  with  epithelioid  cells,  and  outside 
these  again  others  resembling  leucocytes.  Caseation  soon  begins  in  the  middle, 
and  the  nodules  formed  in  this  way  continue  to  enlarge  at  the  margin  and  decay 
at  the  centre,  until,  like  tubercle,  definite  ca.seous  masses,  which  sooner  or  later 
break  down  into  pus,  are  formed  at  all  the  infected  spots.  Suppuration  is  probably 
always  due  to  the  coincidence  of  pyogenic  germs,  for  occasionally  nodules  of  very 
considerable  size  are  found  intact.  As  soon  as  it  breaks  out  the  disease  assumes  a 
much  more  rapid  course,  the  constitutional  symptoms  become  more  severe,  and 
septic  fever,  hectic,  and  very  probably  pyasmia  (the  particles  of  the  fungus  serving 
as  the  embolus),  make  their  appearance  as  well. 

Symptoms. — The  disease  at  the  beginning  is  usually  chronic.  Enlargement 
of  the  lower  jaw,  or  an  ill-defined  swelling  in  the  submaxillary  region,  or  a  reddish 
but  painless  nodule  upon  the  skin,  is  often  the  first  sign  noticed,  and  for  a  time 
there  is  nothing  to  distinguish  it  from  all  other  forms  of  slowly-growing  granula- 
tion-tumors. Wherever  it  is,  it  grows  steadily,  not  involving  blood-vessels  or 
lymphatics  at  first.  Then,  sooner  or  later,  suppuration  begins  ;  the  pain  and 
swelling  rapidly  become  much  worse,  the  size  increases,  the  skin  becomes  red  and 
glazed,  and  the  constitutional  symptoms  become  as  severe  as  those  of  infective 
cellulitis  or  diffuse  osteomyelitis.  Secondary  deposits  soon  follow,  and,  as  might 
be  expected,  no  organ  in  the  body  is  exempt,  caseous  nodules  and  abscesses  con- 
taining the  characteristic  millet-seed  bodies  having  been  found  nearly  everywhere, 
even  in  the  brain. 

Diagnosis. — The  only  certain  diagnostic  feature  is  the  presence  of  the  char- 
acteristic mycelium.  When  the  teeth  are  attacked,  the  disease  can  usually  be 
recognized  before  it  has  gone  too  far  ;  one  after  another  becomes  loose  and  carious, 
and  the  cavities  that  result  from  their  extraction  are  filled  with  ma.sses  of  granula- 
tion-tissue breaking  down  into  pus.  In  other  cases,  however,  especially  when 
there  is  merely  a  slowly-growing  subcutaneous  tumor,  there  is  nothing  at  first 
distinctive  about  it.  It  is  impossible  to  diagnose  it  from  other  diseases  that  lead 
to  the  production  of  masses  of  granulation-tissue,  and  from  sarcomata.  The 
prognosis,  especially  if  the  whole  seat  of  infection  can  be  removed  in  time,  before 
suppuration  has  occurred,  is  very  good.  In  some  cases  the  disease  has  been  very 
chronic,  lasting  for  years  ;  in  others,  however,  it  rapidly  becomes  disseminated 
all  over  the  body,  often  being  complicated  with  true  pyaemia,  and  proves  fatal, 
either  from  some  vital  organ  becoming  involved  or  from  exhaustion  and  suppu- 
ration. 

[Treatment. — While  this  edition  was  passing  through  the  press  there  was 
published  a  statement,  emanating  from  the  Agricultural  Department  at  Washington, 
to  the  effect  that  potassium  iodide  had  been  tried  and  found  very  useful  in  arresting 
the  progress  of  the  disease.] 


TUBER  CUL  OS  IS.  9 1 

TUBERCULOSIS. 

Tuberculosis  is  an  infective  disorder  caused  by  a  specific  micro-organism 
which  gains  access  to  the  body  either  through  the  skin  or  the  mucous  memljranes, 
and  gives  rise  to  characteristic  changes. 

The  bacilhis  occurs  in  the  shape  of  very  thin,  non-motile  rods,  from  two  to 
eight  micromillimeters  in  length,  and  is  found  abundantly  in  the  interior  of  the 
giant  and  epithelioitl  cells  that  constitute  what  is  known  as  a  tubercle.  It  is  not 
present,  with  rare  excei)tions,  in  caseous  debris,  or  the  liquid  material  that  fills 
caseous  abscesses,  although  this  is  intensely  infective.  The  probable  explanation 
is  that  spores,  which  are  formed  in  the  body,  and  which  have  the  appearance  of 
vacuoles  when  seen  under  the  microscope,  are  present,  but  are  not  stained  by  the 
ordinary  reagents,  and  conseciuently  are  not  recognized. 

That  this  bacillus  is  the  cause  of  tuberculosis,  and  the  only  cause,  must  be 
considered  proved  ;  it  is  always  found  in  connection  with  tubercular  deposits;  it 
does  not  occur  without  them,  and  inoculations  with  a  pure  cultivation  practically 
invariably  give  rise  to  local  or  general  manifestations  of  tuberculosis.  As,  how- 
ever, the  changes  that  occur  and  the  results  that  follow  present  an  immense  variety, 
it  is  clear  that  there  are  other  causes  modifying  its  action. 

Predisposing  Causes. — In  large  towns  and  in  large  institutions,  especially 
where  there  is  overcrow-ding,  the  tubercle-bacillus  must  be  practically  of  universal 


Fig.  II.— Tubercle  Bacilli   in  Sputa.      Stained  with  gentian  violet.     Contrast  stain  Bismarck  brown,  Weigert's 

method.     (X  45o.)     {After  Woodhead.) 

distribution  ;  yet  only  a  few  are  attacked  by  it,  and  of  those  who  are  attacked  a 
great  many  recover  from  it.  It  can  only  thrive  in  those  who  are  in  some  way 
susceptible,  whether  this  susceptibility  is  due  to  local  or  constitutional  causes. 

Heredity  is  of  some  consequence.  There  is  no  doubt  that  when  full  "allowance 
is  made  for  the  effects  of  surroundings  the  members  of  some  families  are  much 
more  subject  to  tuberculosis  than  those  of  others.  This  tendency  Avas,  at  one 
time,  known  as  scrofula,  and  certain  personal  peculiarities  were  suppo.sed  to  be 
associated  with  it ;  but  as  the  name  was  allowed  to  include  both  the  constitution 
which  indicates  a  predisposition  to  the  formation  of  tubercle,  and  the  effects  of 
the  disea.se  itself,  it  is  better  to  drop  it  altogether.  If  its  et>Tnology  is  taken  into 
consideration,  it  should  be  confined  to  those  cases  in  which,  from  the  thickening 
of  the  tissues  of  the  neck  (caused  by  the  glandular  enlargement),  the  hypertrophy 
of  the  upper  lip,  and  the  diminished  prominence  of  the  chin,  the  profile  bears 
some  resemblance  to  that  of  a  pig. 

The  general  conditions  of  life  are  probably  of  much  greater  importance. 
Everything  that  tends  to  lower  the  vitality  of  the  tissues,  overcrowding  in  particu- 
lar, uncleanliness,  bad  food,  exposure  to  cold  and  wet,  or  want  of  exercise  and 
fresh  air,  increases  the  liability.  On  the  other  hand,  the  children  of  tubercular 
parents,  even  when  they  themselves  are  already  the  subjects  of  the  disease,  may 
recover,  and,  in  many  instances,  completely  regain  their  health,  so  that  there  is 


92         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

no  evidence  of  the  disorder  but  the  scars  it  leaves,  if  they  are  removed  sufficiently 
soon  to  a  proper  climate  and  fed  sufficiently  well. 

Age,  again,  is  not  without  influence.  Tubercular  inflammation  may  occur  at 
any  time  of  life,  even  in  old  age,  but  it  is  very  much  more  common  among  the 
young  ;  and  it  is  especially  prone  to  attack  those  parts  of  the  body  which  are  at 
the  time  the  seat  of  special  functional  activity — the  lymphatic  glands  and  the 
bones  in  youth,  and  the  testes  in  adult  life. 

Every  organ  of  the  body  may  be  attacked,  although  it  is  very  much  more 
frequent  in  some  than  in  others.  True  tubercular  ulceration  is  not  common  upon 
the  skin,  independently  of  lupus  and  anatomical  tubercle,  which  are  due  to  the 
same  caase  acting  under  special  conditions.  (Lupus,  that  is  to  say,  always  gives 
rise  to  tuberculosis  when  inoculated  in  animals,  although  the  converse  has  not  been 
observed  :  and  bacilli  apparenth-  identical  have  been  found  in  anatomical  tubercle 
of  the  fingers.)  In  the  subcutaneous  tissue  it  forms  cheesy  nodules,  which  break 
down  and  leave  sinuses  lined  with  tubercular  granulations.  The  mucous  mem- 
branes of  the  respiratory,  alimentary,  and  genito-urinary  tracts  are  often  attacked 
by  it,  the  lymphoid  follicles  enlarging  and  breaking  down  .so  as  to  leave  superficial 
ulcers,  which  slowly  extend  in  depth  and  breadth  until  huge,  ragged  excavations 
are  formed.  The  serous  sacs  are  specially  favorite  seats  for  it.  The  synovial 
membranes  of  joints  may  be  converted  into  gigantic  masses  of  soft,  gelatinous 
granulation  by  it.  The  bones,  especially  in  children,  are  often  involved,  and  not 
unfrequently  the  disease,  which  asually  begins  in  the  growing  layer  between  the 
epiphysis  and  the  shaft,  spreads  from  it  to  the  joint.  The  lymphatic  glands 
naturally  rarely  escape,  while  all  the  viscera  are  more  or  less  subject  to  it ;  the 
mamma,  ovaries,  thyroid  gland,  and  the  voluntary  mascles  being  curiously  free. 

Local  predisposition  to  tubercle  maybe  acquired  as  well.  If  the  vitality  of 
any  part  of  the  body  is  impaired  by  injury,  inflammation,  over-use,  etc.,  the 
tubercle-bacilli,  supposing  they  gain  access  to  it,  have  all  the  better  chance  of 
living.  It  is  owing  to  this,  among  other  reasons,  that  it  is  so  often  localized  in 
joints,  and  that  tubercular  disease  of  the  h-mphatic  glands  of  the  neck  is  so  fre- 
quent. It  may,  of  course,  be  that  the  common  form  of  eczema  of  the  head  in 
children  which  causes  this  enlargement  is  itself  tubercular,  and  that  the  lym- 
phatic glands  are  infected  as  a  natural  consequence;  it  issaid^n  proof  of  this,  that 
tubercle-bacilli  have  been  found  among  the  epidermic  cells ;  but  it  is  scarcely 
possible  that  this  is  true  of  the  carious  teeth  and  of  the  inflamed  and  enlarged 
tonsils,  which  are  not  seldom  the  starting-point.  It  is  enough  that  some  slight 
irritation  is  excited  in  a  lymphatic  gland  by  the  quantity  or  quality  of  the  lymph 
passing  through  it ,:  if  once  the  tubercle-bacilli  gain  access  to  it — and  they  easily 
may  through  any  abrasion — they  are  able  to  grow  and  thrive  and  prove  the  focus 
for  a  fresh  dissemination. 

Other  circumstances,  which  cannot  be  called  predisposing  causes,  modify  the 
effect  of  the  bacilli  to  a  very  considerable  degree. 

The  dose  is  of  importance.  A  single  bacillus  is  probably  enough.  It  is 
taken  up  bv  a  leucocyte  :  this  wanders  some  little  distance  in  the  tissues,  and 
then,  under  the  influence  of  the  irritation,  becomes  transformed  into  a  giant-cell, 
in  which  the  bacillus  multiplies.  Clearly,  however,  the  effect  is  likely  to  be 
much  greater  and  more  rapid  when  the  infection  is  either  a  large  one  or  frequently 
repeated;  as  when  a  patient  continues  to  breathe  air  loaded  with  germs.  Asa 
rule,  infection  with  small  quantities  gives  rise  to  local  manifestations. 

The  metJiod  of  infection  is  another  point.  There  can  be  now  no  doubt  as  to  the 
possibility  of  infecting  recent  wounds.  Many  cases  have  been  recorded  in  which 
wounds  have  gradually  developed  into  tuberculous  ulcers  from  which  the  bacilli 
have  spread  along  the  lymphatics  to  the  neighboring  glands.  The  period  of  incu- 
bation is  said  to  be  about  three  weeks  ;  a  red  nodule  forms  at  the  point  of  inocula- 
tion :  it  slowly  increases  in  size:  the  centre  breaks  down,  discharging  a  minute 
caseous  mass,  and  a  typical  tubercular  ulcer  is  left,  with  raised,  reddened,  and 
irregular   edges,    sometimes    covered    with   granulations,   and    an    uneven    base, 


TUBER  CUL  OSIS.  93 

inciiiiL'd  to  bleed.  In  most  cases,  however,  the  l)a(illi  enter  the  celliihir  tissue 
directly,  either  through  inflammatory  abrasions  of  the  surface,  as  in  eczema  capitis 
and  otorrhea,  or  in  the  case  of  mucous  membranes,  even  without  this.  In  the 
lungs  it  seems  probable  that  they  may  develop  Hrst  in  the  epithelium  that  is 
heaped  up  in  the  alveoli  in  pulmonary  catarrh. 

The  dissemination  is  chiefly  regulated  by  the  anatomical  structure  0/  t/ir  part. 
The  bacilli  may  spread  slowly  in  the  surrounding  tissue,  and  the  seat  of  infection 
enlarge  continuously  without  involving  other  structures.  They  may  be  carried 
into  the  lym])hatics,  and  arrested  for  a  time,  or  even  permanently,  in  the  glands. 
They  may  get  into  the  blood-stream  and  rajjidly  spread  all  over  the  pulmonary  or 
systemic  circulation  ;  the  wall  of  a  vein  may  be  ruptured  by  some  accident,  or 
torn  in  some  operation,  or  the  tuberculous  focus  may  gradually  ulcerate  through  it 
and  burst  into  the  interior.  The  same  thing  may  occur  with  one  of  the  arteries, 
though  much  more  rarely  ;  and  finally,  if  the  lining  membrane  of  one  of  the 
serous  or  synovial  cavities  is  attacked,  the  infection  may  spread  rapidly  over  the 
whole  surface. 

The  presence  of  a  viecJianical  eiu/)o/us,  although  it  may  not  be  of  so  much 
importance  as  in  the  ca.se  of  pyogenic  micrococci,  when  in  all  probability  it  deter- 
mines the  formation  of  metastatic  abscesses,  is  certainly  of  consequence  in  connec- 
tion with  tubercular  arthritis.  It  is  not  uncommon  to  find  that  this  has  originated 
from  a  wedge-shaped  sequestrum  in  one  of  the  articular  ends  of  the  bones  ;  and 
it  is  a  fair  suggestion  that  cutting  off  the  circulation  and  lowering  the  vitality  of 
the  segment  is  of  very  considerable  a.ssistance  to  the  development  of  specific 
germs. 

As  the  action  of  jjyogenic  organisms  is  materially  assisted  by  t\\e presence  of 
septic  decomposition,  the  ptomaines  formed  by  this  soaking  into  the  tissues,  lower- 
ing their  vitality,  and  rendering  them  less  capable  of  resistance,  so  it  is  with 
tubercle-bacilli.  If  suppuration  occurs  in  connection  with  a  tuberculous  cavity, 
the  process  of  destruction  becomes  exceedingly  rapid.  On  the  one  hand  the 
pyogenic  organisms  grow  with  greatly  increased  vigor  in  the  tissues  that  have 
been  weakened  by  the  tuberculous  process ;  on  the  other,  the  risk  of  general 
dissemination  is  very  greatly  increased  by  the  possibility  of  the  walls  of  the  ve.ssels 
giving  way. 

Pathology. — Tubercle-bacilli,  wherever  they  are  implanted,  at  once  set  up 
chronic  inflammation  of  a  somewhat  special  character.  The  earlier  changes  are 
the  same  as  with  any  non-pyogenic  germ  ;  the  capillaries  dilate,  more  plasma 
pours  through,  and  the  leucocytes  collect  in  larger  numbers.  Then,  however,  an 
enormous  multinuclear  cell  develops  at  each  point  of  infection,  so  peculiar  in  its 
appearance  that  for  a  long  time  it  was  believed  to  be  a  formation  special  to 
tuberculosis. 

The  most  typical  tubercles  are  the  youngest,  those  which  are  firm  and  gray, 
standing  out  from  the  tissues  around  as  minute,  but  distinctly  circumscribed, 
masses.  Each  of  these  is  made  up  of  smaller  ones,  containing  in  their  centre  a 
giant  multinuclear  cell,  and  sending  out  in  all  directions  processes  which  branch 
and  form  a  kind  of  network.  In  the  meshes,  round  the  central  mass,  lie  other 
cells,  known  from  their  general  appearance  as  epithelioid  ;  and  these  in  their  turn 
are  surrounded  by  numbers  of  smaller  ones,  identical  with  ordinary  leucocytes. 
In  this,  however,  there  is  nothing  peculiar  but  the  regularity  of  the  arrangement. 
Structures  precisely  similar  may  be  produced  by  other  causes  than  tubercle-bacilli ; 
similar  giant-cells  can  be  found  in  any  chronic  inflammation,  especially  those 
forms  which  are  poorly  supplied  with  vessels  ;  and  they  are  surrounded  by  similar 
groups  of  epithelioid  and  lymphoid  corpuscles.  The  specific  character  is  due  to 
the  tubercle-bacilli,  which  can  be  found  in  the  central  mass,  and  in  and  between 
the  epithelioid  cells. 

The  semi-translucent,  gray,  non-vascular  nodules  formed  in  this  Avay  are 
typical  of  tuberculosis.  Sometimes,  in  the  infiltrating  form  of  growth,  they  can- 
not be  recognized  in  the  masses  of  round-celled  granulation-tissue  thrown  out  as  a 


94         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

result  of  the  continued  irritation  ;  but,  as  a  rule,  they  can  be  found  forming  a  ring 
round  the  margins  of  growing  tubercles,  invading  all  the  tissues  near,  and  spread- 
ing into  the  lymphatics. 

As  soon  as  the  nodule  is  developed  the  central  portion  begins  to  degenerate, 
probably  killed  by  the  ptomaine  excreted  by  the  bacilli.  Fatty  degeneration  and 
caseation  follow,  and  as  the  infiltration  continues  to  spread  at  the  margins  and 
decay  in  the  centre,  enormous  masses  of  what  is  soAiietimes  called  crude  or  yellow 
tubercle  are  formed,  the  centre  soft  and  cheesy,  the  margin  consisting  of  typical 
gray  nodules,  which  keep  spreading  as  the  jmrt  already  formed  degenerates. 

The  subsequent  progress  depends  partly  upon  the  relative  vigor  of  the  tissues, 
partly  upon  the  anatomical  structure  of  the  area  involved,  and  the  opportunities 
for  dissemination  afforded  the  bacilli. 

What  is  known  as  obsolescence  may  occur.  The  bacilli,  unable  to  make  head- 
way, gradually  cease  to  extend,  and  perish.  The  outer  w-all  of  leucocytes  thrown 
out  by  the  healthy  tissues  around  gains  the  upper  hand,  organization  sets  in,  and 
a  dense,  fibrous  capsule  is  formed,  shrinking  and  becoming  harder  year  by  year. 
In  the  centre  is  a  little  caseous  or  calcareous  mass,  which  may  remain  quiet  for  the 
rest  of  life,  but  which  is  always  liable  to  become  the  source  of  future  mischief. 

Liquefaction  may  take  place.  As  the  caseous  centre  increases  in  size,  espe- 
cially if  it  is  near  a  cutaneous  or  mucous  surface,  it  gradually  becomes  more  and 
more  liquid,  until  at  length  a  cavity  is  formed,  filled  with  a  fluid  which  in  external 
appearance  resembles  pus,  and  which  used  to  be  taken  for  it.  It  is  thinner,  how- 
ever, and  whiter ;  caseous  masses  float  about  in  it,  and  under  the  microscope  it 
consists  simply  of  molecular  fat,  without  a  definite  pus-corpuscle  anywhere. 
Absce.sses  formed  in  this  way  tend  slowly  to  increase  in  size  until  at  length  they 
approach  the  surface.  Their  walls  are  lined  with  granulation-tissue,  pale,  insuffi- 
ciently supplied  with  vessels,  and  containing  myriads  of  tubercle-bacilli,  and  here 
and  there  small  caseous  masses,  softening  to  add  to  the  fluid.  Outside  this,  and 
sometimes  projecting  so  as  to  form  septa  in  the  interior,  are  the  larger  vessels, 
sheets  of  fascia,  and  dense  fibrous  structures  that  resist  invasion.  Growth  takes 
place  by  the  development  of  tubercles  in  the  walls,  following  the  easiest  route, 
until  at  length  somewhere  the  subcutaneous  cellular  tissue  is  reached.  The  skin 
at  first  separates,  unaltered,  from  the  deep  fascia,  and  is  lifted  up  so  as  to  form  a 
soft,  fluctuating  swelling,  perfectly  white  and  natural  in  texture.  After  a  time, 
however,  it  shares  the  same  fate  ;  the  bacilli  invade  it  from  beneath,  tubercles 
form  in  its  deeper  layers,  the  surface  becomes  reddened,  and  at  length  the  abscess 
breaks,  leaving  a  long,  sinuous  track,  winding  in  all  directions  from  the  original 
starting-point,  and  lined  with  a  layer  of  tubercular  granulatio.ns  mixed  with 
caseous  debris. 

Obsolescence  may  occur  even  when  the  skin  has  been  reached,  and  the 
abscess  extends  from  the  dorsal  spine  to  the  thigh ;  the  fluid  disappears,  the 
tubercle-bacilli  cease  to  grow,  the  caseous  debris  becomes  more  and  more  inspis- 
sated, and  at  length  forms  a  dense,  solid  mass,  which  slowly  undergoes  cretification 
and  remains  encapsuled  in  fibrous  tissue  for  the  rest  of  life.  In  children  this  is 
not  uncommon,  as  tubercular  disease  of  joints  is  in  them  distinctly  a  disease  of  a 
certain  period. 

In  other  cases  extension  takes  place  along  the  lymphatics.  The  neighboring 
glands  enlarge,  typical  miliary  tubercles  make  their  appearance  in  the  interior, 
forming  foci,  which,  as  elsewhere,  spread  by  the  margin  while  they  decay  in  the 
centre.  The  capsule,  formed  of  dense  fibrous  tissue,  becomes  thickened  from  the 
tension,  and  resists  for  a  great  length  of  time,  but  at  last  either  it  gives  way,  so 
that  the  caseous  liquid  spreads  into  the  loose  cellular  tissue  round  and  infects  it, 
or  suppuration  occurs  (periadenitis),  and  when  the  abscess  bursts  or  is  opened  a 
caseous  gland  is  found  lying  at  the  bottom,  or  adherent  to  one  side,  covered  over 
with  granulations.  Before  this,  however,  the  mischief,  as  a  rule,  has  spread  to  the 
neighboring  glands  and  formed  a  chain,  of  which  it  is  impossible  to  find  the  end. 

Finally,  dissemination  may  take  place  through  the  blood-vessels,  and,  accord- 


SYPHILIS.  95 

ing  to  the  i)art  of  the  circulation  invol\e(l,  acute  miliary  tuberculosis  may  develoi) 
in  one  or  every  organ  in  the  body.  In  tuberculous  disease  of  the  kidney,  for 
examjile,  it  may  be  limited  to  the  lungs.  When  this  occurs,  the  constitutional 
disturbance  is  generally  so  .severe  that  the  result  ])roves  fatal  before  the  tulfercles 
have  attained  any  size  or  undergone  more  than  incipient  degeneration. 

Results. — So  long  as  the  tuberculosis  is  local,  recovery  may  be  complete, 
with  the  exception  that  the  i)ortion  of  tissue  infected  is  lost,  whether  it  is  removed 
by  operation  or  undergoes  caseation  and  degeneration  with  the  products  of  the 
inflammation.  This  may  take  ])lace  even  when  the  lymjjhatic  glands  are  involved. 
The  tuberculous  i)redisposition  appears  in  many  cases  to  ])e  of  limited  duration. 
Scrofulous  scars  are  left  in  the  neck  :  Pott's  disease  causes  permanent  deformity, 
or  hip-disease  leaves  a  limb  shortened,  distorted,  and  wasted  ;  but  as  the  period  of 
growth  ceases  and  the  lymphatic  glands  and  the  ends  of  the  bones  lose  the  func- 
tional activity  which  characterizes  them  in  youth  the  tubercular  process  sometimes 
ceases  too,  and  cicatrices,  which  remain  healthy  through  the  rest  of  life,  are  left 
to  show  the  mischief  that  has  taken  place.  The  tissues  round  recover  sufficiently 
to  throw  out  vascular  granulation-tissue,  and  this  becomes  organized. 

Death  may  occur  either  as  a  direct  result  of  the  tubercular  process,  dissemina- 
tion taking  place  and  proving  fatal  from  the  fever  that  accompanies  it,  or  from  a 
vital  part,  such  as  the  brain,  being  involved  ;  or  as  an  indirect  consecjuence  due  to 
the  hectic,  exhaustion,  amyloid  disease,  etc.,  that  follow  on  suppuration  in  con- 
nection with  caseous  foci. 

Treatment. — i.  Local. — Where  it  is  practicable,  there  is  no  doubt  that  the 
seat  of  infection  should  be  removed.  If  this  cannot  be  done,  an  attempt  may 
be  made  to  check  the  further  progress  by  the  use  of  germicides,  of  which,  perhaps, 
iodoform  is  the  most  to  be  trusted. 

On  the  other  hand,  when  the  situation  or  the  extent  of  the  growth  ])recludes 
this,  all  that  can  be  done  is  to  place  the  tissues  in  the  best  possible  ])osition  for 
dealing  with  the  germs  themselves,  and  protect  them  from  every  other  injurious 
influence.  Fortunately,  age  is  often  of  great  assistance  in  this  ;  it  seems  as  if, 
sometimes,  about  puberty  the  susceptibility  suddenly  ceased,  the  tissues  gained  the 
upper  hand,  and  repair  commenced  at  once. 

2.  Constitutional. — Fresh  air  ;  if  possible,  sea  air  ;  but  an  equable  tempera- 
ture, not  too  moist,  and  especially  free  from  cold  winds.  A  moderate  degree  of 
warmth  suits  some  ;  a  cold,  dry  climate  agrees  better  with  others,  but  no  general 
rules  can  be  laid  down  for  this.  A  thoroughly  nutritious  diet,  with  cod-liver  oil, 
iron,  and  other  tonics,  is  equally  important.  Stimulants  are  not  required  by  the 
disease,  although  often  they  materially  assist  the  digestion.  The  clothing  should 
be  light,  but  warm.  A  fair  amount  of  exercise  should  be  taken,  and,  in  short,  the 
conditions  of  existence  should  be,  as  far  as  possible,  ideal. 

SYPHILIS. 

Syphilis  is  an  infective  disease,  due  in  all  probability  to  the  action  of  a 
specific  organism.  Its  course,  its  power  of  indefinite  multiplication  in  the  body, 
and  the  fact,  not  only  that  it  is  contagious,  but  that  it  can  only  be  propagated  by 
contact,  mediate  or  immediate,  are  sufficient  proof;  but  it  must  be  remembered 
that,  in  spite  of  the  number  of  those  who  have  tried,  no  one  has  yet  succeeded  in 
pro^  ing  the  existence  of  such  a  thing  to  the  satisfaction  of  the  rest. 

In  many  respects  syphilis  differs  considerably  from  the  specific  infective  dis- 
eases already  described.  In  the  first  place,  although  it  commences  acutely,  its 
course  is  chronic  and  persistent.  Wherever  the  inoculation  takes  place  the  imme- 
diate effect  is  local  ;  then  the  lymphatics  become  in\-olved,  and  ver\'  shortly  the 
poison  is  distributed  through  the  whole  body  by  the  blood-vessels ;  but  after  this 
stage  is  past  it  remains  in  the  tissues,  either  latent  altogether  or  with  very  slight 
evidence  of  its  existence,  and  perhaps  suddenly,  after  many  years,  breaks  out  again. 
Then  it  is  not  only  propagated  by  direct  infection  to  other  individuals,  but  it  is 


96         GENERAL   PATHOLOGy    OF  SURGICAL   DISEASES. 

hereditary  ;  the  poison  can  be  transmitted  through  the  ova  and  spermatozoa,  so 
that  characteristic  lesions  make  their  appearance  in  the  child  before  or  shortly 
after  birth  ;  and  this  transmissibility  to  the  eml)ryo  is  retained  long  after  the  power 
of  infection  by  direct  contact  is  lost.  Further,  Avhile  other  specific  germs  cause, 
for  the  most  part,  some  one  definite  form  of  inflammation,  which,  though  it  may 
be  modified  by  locality,  is  yet  characteristic  of  the  cause,  syphilis  does  not  limit 
itself  in  this  way.  There  is,  it  is  true,  a  characteristic  lesion,  but  it  is  also  true 
that  there  is  no  form  of  inflammation  which  is  not  imitated,  and  imitated  some- 
times so  closely  that  the  diagnosis  can  only  be  made  by  the  result  of  treatment. 
It  must  be  acknowledged,  therefore,  that  if  the  microbic  origin  of  the  disease  is 
considered  proved,  there  is  yet  a  great  deal  that  requires  further  elucidation. 

The  difficulty  is  not  lessened  by  the  fact  that  syphilis,  or  at  least  its  initial 
lesion,  is  often  complicated  by  the  presence  of  another  trouble,  known  as  chan- 
croid, in  distinction  from  the  true  form  of  chancre ;  and  it  is  still,  to  some  extent, 
a  matter  of  discussion  what  relation  these  two  bear  to  each  other. 

Chancroid  or  Soft  Chancre. 

A  soft  chancre,  or  chancroid,  is  a  sore  developed  upon  the  genitals  as  a  result 
of  contagion,  and  is  distinguished  from  the  hard  or  true  chancre  partly  by  the 
absence  of  induration,  but  chiefly  (as  this  is  only  relative)  by  the  fact  that  it  is 
seldom  followed  by  constitutional  symptoms,  and  that  the  period  of  incubation  is 
much  shorter ;  the  one  is  always  under  a  week  and  generally  under  three  days, 
the  other  is  always  more  than  three  Aveeks  and  is  often  as  much  as  five. 

Soft  chancre  is  never  met  with  except  upon  the  genitals,  and  is  probably  due 
to  infection  from  retained  and  decomposing  purulent  discharge.  The  intensely 
irritating  character  this  possesses  may  be  judged  of  from  the  fact  that  soft  chancre 
occurring  on  a  mucous  surface  is  almost  sure  to  infect  the  opposite  side,  and  if  the 
secretion  is  pent  up,  as  in  the  case  of  phimosis,  is  almost  certain  to  become 
phagedaenic.  No  specific  germ  has  been  proved  in  connection  with  it.  It  can  be 
inoculated  times  without  number  without  conferring  the  least  degree  of  immunity. 
It  is  never  followed  by  any  other  result  than  those  which  are  so  common  after  all 
foul  and  sloughing  sores  on  parts  that  are  never  kept  at  rest,  and  constitutional 
treatment  is  of  little  or  no  avail  for  it.  There  is  a  popular  impression  that  certain 
people  are  peculiarly  liable  to  it,  which  may  reasonably  be  accounted  for  by  local 
conditions ;  it  does  not  appear  to  be  dependent  upon  syphilis,  but  it  may  be  very 
closely  imitated  by  a  true  syphilitic  chancre  on  a  person  who  has  already  suffered 
from  that  disease,  and  who  has  not  yet  passed  through  the  period  of  immunity  that 
one  attack  confers.  Under  these  circumstances,  if  there  is  a  second  infection,  the 
character  of  the  primary  sore  is  often  very  much  modified,  both  as  regards  period 
of  incubation  and  amount  of  induration  ;  and  although  it  is  a  true  infecting  sore 
it  may  present  the  appearance  of  an  ordinary  chancroid.  In  women,  in  whom 
the  hardness  is  often  slight  and  sometimes  wanting  altogether,  the  difficulty  is 
especially  great. 

Symptoms  and  Cause. — The  favorite  situation  is  on  the  mucous  surface 
of  the  prepuce,  or  just  behind  the  corona.  A  small  red  papule  is  the  first  sign  ; 
by  the  third  or  fourth  day  this  has  become  a  pustule  with  a  bright  areola,  and  in 
twenty-four  hours  more  it  breaks,  leaving  a  sore  with  angry  base  and  edges.  In 
some  few  cases  this  heals  without  any  further  ulceration ;  probably  the  infection 
has  never  really  penetrated  into  the  submucous  tissue.  More  frequently  it  con- 
tinues to  spread,  the  edges  are  sharply  cut,  perhaps  undermined ;  round  them  is  a 
bright  red  rim  of  inflammation  ;  the  base  is  grayish  or  yellow,  covered  with  a 
slough  ;  and  the  whole  thickness  of  the  mucous  membrane  is  destroyed.  The 
sore  is  usually  circular  in  shape  and  very  tender.  On  the  glans  it  may  be  perfectly 
soft,  without  sign  of  induration  ;  but  when  it  is  upon  the  skin  the  base  is  often 
infiltrated  to  such  an  extent  that  it  is  nearly  as  hard  as  a  true  infecting  chancre. 
The  margin,  however,  is  different ;  in  a  soft  sore  the  edge  of  the  induration  is 


SYPHILIS. 


97 


ill-tlefmed  ;  it  shades  off  imperceptibly  into  the  healthy  tissues  around,  and  no 
limit  can  be  made  out,  Init,  at  the  same  time,  it  must  be  recollected  that  this  is 
e<iually  true  of  a  hard  chancre  when  it  is  inflamed  ;  and  that,  owing  to  the  extreme 
mobility  of  the  skin  upon  the  penis,  any  sore  with  a  hardened  l)ase  felt  in  the 
longitudinal  direction  and  lifted  up  from  the  tissues  beneath  ajjpears  exceedingly 
well-defined.  The  secretion,  at  first,  is  thin  and  watery,  with  a  few  shreds  and 
sloughs  detached  from  the  surface  floating  in  it ;  later,  when  granulations  form,  it 
consists  of  ordinary  pus.  such  as  comes  from  any  other  sore. 

If,  owing  to  phimosis  or  balanitis,  the  secretion  is  retained  under  the  prepuce, 
so  that  it  decom])oses,  the  ulceration  is  very  much  more  severe,  and  may  become 
phageda^nic.  The  sore  increases  in  all  directions  ;  the  opi)Osite  surface  of  the 
prepuce  is  attacked  ;  the  skin  on  the  outside  is  reddened  ;  the  whole  of  the  end 
of  the  ])enis  becomes  swollen  ;  and  if  relief  is  not  speedily  given,  the  skin  sloughs, 
ulcerating  through  from  beneath,  and  the  end  of. the  glans  protrudes  through  a 
ragged  opening  on  the  dorsum.  In  the  worst  cases  the  destruction  is  even  greater  ; 
the  whole  of  the  skin  covering  the  end  may  perish,  the  glans  be  in  great  measure 
destroyed,  and  the  urethra  laid  open. 

The  inguinal  glands,  that  lie  parallel  to  Poupart's  ligament,  are  always  more 
or  less  inflamed.  In  the  slighter  cases  they  are  simply  enlarged,  swollen,  and 
tender ;  their  outline  is  indistinct,  and  if  several  on  the  same  side  are  attacked, 
they  cannot  l)e  isolated  from  each  other.  In  the  more  severe  ones  supi)uration 
occurs,  generally  commencing  in  the  loose,  cellular  tissue  around  (periadenitis), 
so  that  when  the  bubo  is  opened  the  glands  are  seen  projecting  into  the  cavity, 
surrounded  and  bathed  with  pus.  Sometimes,  however,  it  appears  to  begin  in  the 
interior  of  the  gland,  and  occasionally  in  both  places  at  the  same  time.  It  is  said 
that  when  this  happens  the  pus  from  the  interior  of  the  gland  is  infective,  while 
that  from  the  tissues  around  is  not.  Phagedaenic  and  serpiginous  buboes  are  met 
with  exceptionally  in  very  severe  cases  of  syphilis  combined  with  soft  sores,  or 
when  the  patient's  health  is  utterly  broken  down  from  want  and  exposure.  No 
constitutional  symptoms  ever  follow  a  true  soft  sore,  and  the  inflammation  of  the 
lymphatic  gland  is  merely  due  to  the  absorption  of  pyogenic  organisms,  assisted 
by  the  retention  of  decomposing  secretion  or  other  injurious  influences.* 

Diagnosis. — Herpes  preputialis  presents  the  greatest  difficulty.  This  very 
peculiar  affection  may  occur  after  every  act  of  connection  ;  it  has  even  been 
known  to  follow  nocturnal  emissions ;  and  though  it  may  be  more  severe  and 
more  common  in  those  who  have  suff'ered  from  syphilis,  it  is  certainly  met  with  in 
those  who  are  perfectly  free  from  the  disease.  If  there  is  only  one  vesicle,  or 
two  perhaps,  and  the  case  is  not  seen  until  the  epidermis  is  broken,  there  is  no 
means  of  forming  a  diagnosis. 

If,  owing  to  the  enlargement  and  swelling  of  the  prepuce,  the  existence  of  a 
sore  is  doubtful,  circumcision  must  be  performed;  and  the  need  for  this  increases 
with  the  amount  of  redness  and  inflammation.  The  co-existence  of  syphilitic 
infection  cannot  be  affirmed  or  excluded  until  the  period  of  incubation  (six  weeks 
at  least)  is  past. 

Treatment. — Local  chancre  spreads  because  of  the  poisonous  character  of 
its  discharge.  A  single  application  of  the  acid  nitrate  of  mercury  leaves,  as  soon 
as  the  slough  separates,  a  perfectly  healthy  granulating  surface.  So  severe  a 
mea.sure  as  this,  however,  is  rarely  necessary  unless  the  sore  is  phagedaenic  and  it 
is  imperative  to  stop  the  progress  at  once.  Ordinarily  speaking,  if  the  surface  is 
well  cleansed  and  dried,  and  then  dusted  over  with  iodoform,  night  and  morning, 
the  character  of  the  secretion  changes  immediately.  Phagedaena  should  be 
treated,  as  already  mentioned,  by  the  use  of  prolonged  warm  baths.  Mercury  is 
not  required  unless  the  healing  oif  the  chancre  is  unaccountably  delayed,  or  there 
is  something  else  suggestive  of  syphilis. 

[*  The  opinion  of  our  author  on  this  point  is  met  by  equally  positive  statements /if/-  contra.'\ 


gS         GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

Acquired  Syphilis. 

The  period  of  incubation  varies  from  three  to  seven  weeks  ;  at  the  end  of 
that  time  certain  local  changes  make  their  appearance  (the  hard  or  infecting 
chancre)  ;  a  few  days  later  the  lymphatics  are  involved,  and  then  very  (jiiickly 
there  is  evidence  that  the  poison  has  gained  access  to  the  blood.  Much  later, 
after  an  interval  of  months  and  years,  local  phenomena  appear  again,  due  in  all 
probability  to  the  action  of  the  poison  latent  in  the  tissues.  These  stages,  of 
course,  overlap  each  other,  and  no  hard  and  fast  line  can  be  drawn  between  them ; 
thus  the  lymphatic  tissues  and  the  blood  are  always  involved  before  the  chancre 
has  disappeared  (indeed,  there  is  evidence  to.  show  that  they  are  affected  almost 
from  the  first,  although  there  is  no  manifestation  of  it  for  some  time,  for 
excision  of  the  point  of  inoculation  after  the  third  or  fourth  day  is  of  little  or  no 
use)  and  local  changes  may  take  place  while  the  general  ones  are  still  at  their 
height ;  but  the  distinction  between  the  three  is  convenient,  and  they  are  recog- 
nized as  primary  (or  local),  secondary  (in  which  the  lymphatic  glands  and  the 
blood  are  involved),  and  tertiary,  or  local  again. 

I.  The  Primary  Symptoms. — Inoculation  may  take  place  anywhere, 
through  a  wound  or  superficial  at)rasion,  or  possibly  in  the  case  of  mucous  mem- 
branes even  without  this,  if  the  poison  is  allowed  to  remain  upon  the  surface  for 
any  length  of  time.  The  retropreputial  fold  is  the  commonest  situation  in  men, 
the  nymphge  in  women  ;  but  chancres  are  met  with  upon  the  skin  of  the  penis, 
upon  any  part  of  the- female  genitals,  and  practically  on  every  part  of  the  body; 
the  lips  not  uncommonly  ;  the  tongue  and  even  the  tonsils  ;  the  conjunctiva  ;  the 
bridge  of  the  nose;  the  nipple  (especially  in  wet  nurses  who  are  infected  .by 
children  suffering  from  hereditary  syphilis);  the  angle  of  the  finger-nails,  and  the 
web  of  the  fingers. 

In  a  genuine  inoculation  no  change  is  witnessed  for  from  three  to  six  weeks  ;  a 
transient  redness  has  been  described  during  the  first  few  days,  but  it  is  not  often 
noticed.  Then  the  part  becomes  jdusky,  slightly  elevated,  smooth  and  glazed. 
In  the  ordinary  situations  it  is  not  sensitive,  and  the  patient  may  be  in  total 
ignorance  of  its  existence,  but  I  have  known  some  instances  in  which  the  pain  was 
very  severe,  especially  when  it  occurred  upon  the  fingers.  The  characteristic 
feature  is  the  induration  ;  the  seat  of  inoculation  is  not  only  hard,  but  the  edges 
of  the  hardness  are  sharply  defined.  If  pinched  up,  it  appears  like  a  piece  of 
cartilage  let  into  the  skin.  The  exudation  in  the  meshes  of  the  cellular  ti.ssue 
is  so  abundant  that  a  certain  small  but  well-defined  area  becomes  practically 
solid. 

It  must  be  admitted,  however,  that  this  induration  varies  so  greatly  in  differ- 
ent localities  and  under  different  conditions,  that,  although  its  presence  when  it 
is  characteristic  may  be  absolutely  relied  upon,  its  absence  is  not  a  proof  of  non- 
infection.  On  the  glans,  where  the  mucous  membrane  is  thin  and  closely  adherent 
to  the  tissues  l)eneath,  it  is  very  superficial.  In  the  retropreputial  fold  it  is  often 
so  marked  that  the  diagnosis  can  be  made  from  merely  seeing  the  way  in  which 
the  hardened  and  thickened  prepuce  rolls  back  from  the  sulcus,  and  stands  up  like 
a  collar  round  it.  In  women  it  is  often  not  to  be  discovered  at  all,  and  when  the 
chancre  occurs  on  other  parts  of  the  body — the  lips  or  fingers,  for  example — it 
varies  within  very  wide  limits.  No  doubt  this  is  due  in  some  measure  to  the 
anatomy  of  the  part  inoculated — the  presence,  for  instance,  of  loose  cellular-tissue 
beneath — and  the  depth  to  which  the  inoculation  is  carried  in  each  case  ;  but  the 
extent  and  duration  are  so  variable  that  there  must  be  other  considerations  as 
well.  There  is  no  relation  of  any  kind  between  the  size,  hardness  or  number  of 
the  infecting  sores  and  the  severity  of  the  constitutional  symptoms.  Several  sores 
may  be  present  at  the  same  time,  from  multiple  inoculation,  but  the  worst  cases 
often  follow  a  single  one  that  is  scarcely  noticed. 

The  appearance  of  a  hard  chancre  is  very  variable ;  the  skin  that  covers  it 
may  remain  unbroken,  so  that  there  is  neither  secretion  nor  ulcer,  but  merely  a 


SYPHILIS. 


99 


sliyhtly  raised  ajul  hardened  spot,  pi^nieiUed  for  a  time.  This,  however,  is  ex- 
ceptional. More  fre(|uently  the  epidermis  scales  off,  exposing  the  subjacent  ti.ssue, 
which  undergoes  necrosis  and  melts  away  ;  but  whether  this  is  due  to  the  effect  of 
the  poison,  or  simply  to  i)ressure,  is  not  known.  When  this  happens  it  leaves  a 
suiierficial  sore,  which  may  or  may  not  suppurate  ;  in  many  cases  the  only  dis- 
charge is  a  thin  watery  serum  with  a  few  ei)ithelial  scales,  or  a  little  tissue  debris 
without  true  i)us  from  first  to  last.  If  a  soft  chancre  is  present  already,  the 
appearance  and  the  discharge  are  naturally  dependent  upon  this  ;  the  only  change 
at  the  end  of  the  incubation  jjcriod  is  a  sudden  hardening  at  the  base.  Chancres 
in  the  finger  usually  take  the  form  of  a  ])atch  of  small  and  rather  Horid  granula- 
tions, with  little  discharge,  and  without  any  evidence  of  cicatrization  at  the  edge. 
The  margin  is  raised  above  the  level  of  the  skin,  and  appears  steep  and  thick  from 
the  exudation  it  contains.  On  the  lips  it  is  much  the  same,  only  in  some  ca.ses 
the  infiltration  at  the  base  and  edges  is  so  great  that  it  is  slightly  cup-shaped. 

The  duration  of  the  hardening  and  rapidity  of  cicatrization  are  no  less 
variable.  If  untreated,  the  sore  is  said  to  last  six  or  nine  months,  and  leave  a 
cicatrix  depressed  according  to  the  amount  of  tissue  lost.  Very  often,  however, 
under  the  influence  of  mercury  it  vanishes  altogether  in  a  few  weeks,  and  it  is  ex- 
ce])tional  for  it  to  continue  more  than  three  months.  Its  disappearance  is  not 
complete  until  all  hardness  is  gone  from  the  cicatrix  ;  sometimes  when  a  hard 
sore  complicates  a  soft  one,  healing  takes  place  very  soon  after  commencing 
mercurial  treatment ;  but  in  spite  of  this  the  induration  of  the  base  persists  for  a 
considerable  period. 

When  the  infection  is  mixed,  the  extent  of  the  suppuration  is  sometimes  pro- 
fuse, but  there  is  no  evidence  that  it  is  ever  sufficient  to  prevent  the  development 
of  constitutional  symptoms.  The  same  may  be  said  of  phagedsena.  Relapsing 
chancres  are  occasionally  met  with.  It  is  not  uncommon  to  find,  if  the  treatment 
is  interrupted  too  soon,  that  the  induration,  which  was  beginning  to  subside, 
extends  again  ;  but,  independently  of  this,  true  relapses  occur,  sometimes  a  year 
afterward,  the  seat  of  the  original  infection  becoming  indurated  again  and  slowly 
subsiding  under  treatment  without  there  having  been  a  sign  of  its  existence  in  the 
meanwhile  ;  and  this  may  hapi)en  more  than  once. 

2.  The  Secondary  Symptoms. — The  secondary  stage  includes  the  infec- 
tion of  the  lymphatic  glands,  and  the  general  symptoms  that  follow  the  entry  of 
the  poison  into  the  circulation. 

Glandular  eiilargonent  usually  shows  itself  ten  days  or  a  fortnight  after  the 
appearance  of  the  primary  sore.  The  local  ones  are  affected  first,  the  inguinal, 
for  example,  when  the  chancre  is  on  the  penis,  the  submaxillary  when  it  is  on  the 
lip;  but  it  never  remains  limited  to  them.  From  the  beginning  the  enlargement 
is  multiple,  and  it  soon  becomes  general,  not  as  in  the  case  of  the  uncomplicated 
soft  chancre,  limited  to  one  locality  and  often  to  one  gland.  The  character  of 
the  swelling  is  also  quite  different.  Unless  the  infecting  chancre  is  inflamed,  or  a 
soft  one  is  present  as  well,  there  is  little  or  no  infiltration  of  the  periglandular 
tissue ;  the  enlargement  is  confined  to  the  glands  themselves  ;  they  swell  up, 
become  hard,  and  slightly  tender,  but  they  remain  perfectly  isolated  and  distinct, 
and  they  are  as  freely  movable  as  they  are  in  health.  The  inflammation  is  specific, 
not  simply  due  to  absorption  of  septic  or  suppurative  products. 

Whether  suppuration  occurs  in  the  first  set  of  glands  involved  depends  entirely 
upon  the  character  of  the  .sore  ;  if  it  is  foul  and  sloughing,  the  pyogenic  organisms 
will,  in  all  probability,  gain  access  through  the  lymphatics,  and,  finding  a  genial 
soil,  excite  suppuration,  whether  syphilis  is  present  or  not,  and  without  having  any 
influence  upon  it.  The  same  thing  is  true  of  phagedena  ;  an  ulcer  left  by  a  sup- 
jnirating  bubo,  occasionally  under  the  combined  effect  of  syphilis,  a  broken-down 
constitution  and  other  injurious  influences,  becomes  itself  phagedenic  ;  but  at  the 
present  day  it  is  decidedly  rare.  The  glands  once  removed,  too  far  distant  to  be 
affected  by  local  causes  of  this  character,  sometimes  attain  a  very  considerable 
size,  but  never  form  abscesses.     As  a  rule  the  enlargement  subsides  quickly  at 


loo       GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

first,  but  evidence  of  it  can  usually  be  found  so  long  as  the  secondary  period  lasts 
and  sometimes  long  afterward. 

As  soon  as  the  poison  gains  full  access  to  the  blood,  it  causes  a  train  of 
symptoms  which  may  be  compared  with  those  that  accompany  the  acute  exanthe- 
mata and  other  specific  diseases. 

There  is  a  slight  but  fairly  constant  degree  oi  fever.  The  temperature  rises 
regularly  of  an  evening,  although  of  a  morning  it  may  scarcely  be  above  normal. 
In  exceptional  ca.ses  it  is  very  severe,  especially  when  the  eruption  that  accom- 
panies it  is  varioloid,  or  there  is  considerable  glandular  enlargement,  and  it  may 
last  for  se\"eral  weeks. 

AtKsmia  and  emaciation  are  always  present,  and  sometimes  very  marked.  The 
number  of  red  blood-corpuscles  is  diminished,  and,  it  is  said,  the  proportion  of 
haemoglobin  they  contain.  With  this  there  is  usually  general  malaise ;  the  appe- 
tite is  lost,  there  is  great  mental  depression,  and,  in  short,  there  are  all  the  signs 
of  mild  blood-poisoning. 

At  the  same  time,  or  even  before  this,  a  rash  makes  its  appearance  upon  the 
skin  and  the  mucous  membranes.  This  varies  very  greatly  in  its  character  and 
severity.  In  the  mildest  cases  there  are  merely  a  few  round-,  roseolous  spots  upon 
the  chest,  abdomen,  and  flexor  surfaces  of  the  arms,  lasting  some  days,  then 
dying  away  with  a  scarcely  percejjtible  scurfiness  of  the  integiunent  and  leaving  a 
faint  yellow  stain  for  a  week  or  two.  More  frequently,  in  addition  to  the  hyper- 
gemia  there  is  a  certain  amount  of  exudation,  the  roseola  spots  are  raised,  and 
followed  by  definite  descjuamation,  or  little  papules  and  tubercles  are  formed. 
\\'hen  the  attack  is  more  severe,  the  inflammatory  changes  may  be  very  consider- 
able, and  stasis  and  actual  extravasation  take  place  as  well,  so  that  deep  stains  are 
left  for  months.  The  eruption  sometimes  resembles  psoriasis,  although  the  distri- 
bution is  not  the  .same  and  the  jjatches  are  always  small  and  not  covered  with 
silvery  scales  :  it  frequently  imitates  lichen,  and  ^especially  on  the  shoulders  and 
back  of  the  neck)  acne  ;  in  some  cases  it  resemble  variola  so  closely  that  patients 
suffering  from  syphilis  every  now  and  then  find  their  way  to  smallpox  hospitals, 
particularly  as  this  form  is  often  accompanied  by  high  fever  ;  and  toward  the  end, 
when  the  first  eruption  is  dying  out,  rupia  sometimes  occurs,  a  number  of  papules 
running  together,  ulcerating,  and  forming  on  the  surface  a  great  conical,  limpit- 
shaped  crust  of  dried-up  discharge,  which  keeps  enlarging  in  height  and  circum- 
ference, just  like  a  shell,  by  addition  to  the  margin  as  the  destruction  spreads. 

Where  the  skin  is  moist  and  in  contact  with  other  surfaces,  these  spots  are 
modified  into  mucous  patches  of  flat  condylomata.  The  epidermis  is  macerated 
away  ;  the  papillae,  already  inflamed,  are  exposed  and  irritated  more  and  more, 
and  at  length  raised  patches  are  formed,  something  like  a  mucous  surface  (whence 
the  name),  moist,  pinkish-red,  and  smooth.  They  are  met  with  in  every  part,  but 
the  favorite  places  are  between  the  nates,  inside  the  labia,  under  the  penis,  between 
it  and  the  scrotum,  in  the  axillae,  and  behind  the  ears. 

The  mucous  membranes  are  similarly  affected.  The  interior  of  the  mouth, 
the  tongue,  the  soft  palate,  and  the  larynx  are  covered  with  an  eruption  identical 
with  that  upon  the  skin.  The  epithelium  is  bluish-white  from  maceration  ;  round 
this  is  a  bright  red  rim,  gradually  fading  away,  and  in  the  centre  there  is  often  a 
small  superficial  abrasion.  On  the  tonsil  this  gives  the  appearance  of  a  deeply- 
punched-out  ulcer  ;  on  the  soft  palate  it  usually  occurs  just  at  the  margin  on  each 
side  of  the  uvula,  the  rest  of  the  surface  being  a  dusky,  brownish-red  :  and  on  the 
tongue  it  forms  a  smooth,  bald  patch.  Sometimes,  when  the  erujition  is  papular, 
raised  mucous  plaques  are  produced  instead. 

At  the  angles  of  the  mouth,  nose,  and  anus,  and  in  the  clefts  between  the 
toes,  the  eruption  assumes  a  slightly  different  form.  It  is  just  as  if  a  mucous 
patch  had  formed  in  the  angle  of  junction,  red,  moist,  and,  differing  in  this 
respect  from  those  that  occur  elsewhere,  intensely  painful.  This,  of  course,  is  due 
to  their  situation. 

In  the  lighter  forms  of  eruption  there  is  merely  hypersemia  with  scarcely  any 


SYPHILIS.  loi 

exudation.  In  those  that  are  a  h'ttle  more  severe  there  is  enough  to  cause  desijua- 
mation,  the  epidermis  either  drying  up  in  scales  or  becoming  macerated,  accord- 
ing to  its  situation.  A\'hen  the  amount  of  exudation  is  considerable,  stasis  and 
perhai)s  extravasation  occur  (as  in  the  tubercular  syphilides)  ;  some  of  the  tissues 
perish,  and  a  deep  brown,  depressed  stain  is  left,  with  an  altered  appearance  of 
the  surface,  owing  to  the  regularity  of  the  papilUu  having  been  destroyed.  In  the 
worst  cases,  when  pyogenic  organisms  as  well  gain  access  to  the  part,  as  in  rupia 
and  phageda^na,  the  loss  of  tissue  may  be  very  extensive,  causing  cicatrices  that 
cannot  be  mistaken.  'I'he  intensity  of  the  poison,  the  constitution  of  the  patient, 
the  anatomy  of  the  juirt,  and  the  conditions  under  which  it  is  placed  all  take  a 
share  in  the  result. 

The  characteristic  features  of  a  secondary  syphilitic  eru])tion  are  its  symmetr\ 
(this  is  often  perfect,  spot  for  sj^ot,  both  in  time  and  place;,  its  colo7-  (usually 
described  as  resembling  that  of  lean  ham,  and  in  most  cases  leaving  stains  behind 
it),  and  especially  its  polyniorpliism.  True  jjsoriasis  is  psoriasis  wherever  it 
occurs  and,  except  perhaps  in  the  direction  of  lichen,  never  really  resembles  any- 
thing else.  Lupus  acts  in  the  same  way,  and  so  with  variola  and  other  specific 
affections.  Syphilis,  on  the  other  hand,  may,  and  usually  does,  present  a  fairly 
good  imitation  of  half  a  dozen  of  these  at  once.  Where  the  skin  is  thin,  as  on 
the  chest  and  arms,  there  are  roseolous  spots  ;  a  scaly  eruption  is  more  frequent 
where  it  is  thicker ;  papules  are  common  round  the  roots  of  the  hair ;  acne  spots 
may  be  found  on  the  shoulders  :  little  dark-colored  tubercles  occur  upon  the  legs ; 
one  or  two  rupia  spots  may  be  present  at  the  same  time,  and  not  unfrequently  the 
ala  of  the  nose  is  rapidly  destroyed  by  a  phagedenic  imitation  of  lupus.  All 
these  are  often  present  together,  or,  what  happens  still  more  frequently,  the  milder 
varieties  come  out  first,  generally  all  over  the  body  ;  many  of  the  sj^ots  disappear, 
leaving  stains  behind  them  ;  others  steadily  get  worse,  the  amount  of  exudation  con- 
tinuing to  increa.se,  and  then  they  become  complicated  by  suppuration.  So  that 
in  this  w^ay  tubercular  syphilides,  the  varioloid  form,  and  rupia  are  scattered  among 
psoriasis  patches,  acne  spots,  and  the  stains  of  past  roseola.  The  pigmentation 
after  secondary  syphilis  is  suggestive,  but  nothing  more,  as  deep  stains  are  not 
unfrequently  left  by  true  psoriasis,  especially  upon  the  legs  and  back.  The  most 
characteristic  is  that  which  is  associated  with  rupia  scars,  where  there  is  a  dead- 
white  tissue-paper  cicatrix  in  the  middle,  and  round  it  an  irregular  circle,  often 
deeply  stained. 

Recurrent  attacks  of  roseola  are  not  at  all  uncommon,  sometimes  occurring 
with  recurrent  hardening  of  the  primary  sore.  It  does  not  follow  either  that  the 
same  part  of  the  body  is  involved  (it  may  be  present  on  the  hands  in  one  attack 
and  not  in  the  other,  for  example),  or  that  the  eruption  presents  the  same  char- 
acter. 

The  skin  eruption,  the  anaemia,  and  the  fever  are  very  rarely  absent,  suppos- 
ing secondary  symptoms  of  any  kind  are  present.  In  addition  to  these,  there  are 
other  lesions  which  are  frequent,  but  by  no  means  universal,  and  which,  though  to 
a  certain  extent  symmetrical  (showing  thereby  their  dependence  upon  the  condi- 
tion of  the  blood),  are  still  distinctly  local,  and  constitute,  as  it  were,  a  transition 
to  those  later  forms  (tertiaries)  in  which  the  tissues  only  are  concerned. 

Periostitis,  especially  of  the  superficial  portions  of  the  compact  bones  {e.  g., 
the  tibia,  ulna,  clavicle,  and  cranium),  is  one  of  the  most  common.  It  is  always 
acute,  very  painful,  and  subsides  readily  under  treatment,  without  leaving  any 
thickening,  ^"ague  so-called  rheumatic  or  osteocopic pains,  occurring  in  the  bones 
at  night,  are  probably  due  to  transient  hyperjemia  without  exudation  ;  and  in  some 
of  the  cases  in  which  there  is  severe  localized  headache  it  is  possible  there  is  a 
similar  affection  of  the  dura  mater. 

Synovitis  may  occur,  both  in  the  tendon  sheaths  and  joints,  but  it  is  more 
rare.  Alopecia  is  not  infrequent,  the  hair  of  the  scalp  often  falling  out  in  tufts,  so 
that  the  appearance  is  most  peculiar.  It  is  never  permanent.  Epididymitis  (as 
distinguished  from  the  orchitis  of  later  syphilis,  in  which  the  epididymis  is  often 


I02       GENERAL   PATHOLOGY  OF  SURGLCAL   DISEASES. 

involved)  is  occasionally  met  with.  Recently  1  have  seen  two  cases  of  secondary 
syphilitic  phlebitis,  in  one  of  which,  among  other  veins,  some  of  those  in  the 
internal  ear  were  affected,  deafness,  with  many  of  the  symptoms  of  Meniere's 
disease,  coming  on  cpiite  suddenly.      Arteritis  is  more  common  later  on. 

In  other  cases  there  is  a  great  tendency  to  the  production  of  papillomatous 
growths  almost  unattended  with  inflammation.  These  are  known  as  verrucce  or 
pointed  condylomata  ;  they  may  form  great  dentritic  masses  when  they  grow  from 
the  genitals,  or  be  merely  simple  papillae  somewhat  enlarged,  like  those  that  are  so 
frequently  met  with  upon  the  dorsum  of  the  tongue,  far  back  in  the  middle  line. 
No  distinction  can  be  drawn  between  them  and  the  ordinary  flat  mucous  patch 
with  which  they  are  often  associated. 

Finally,  although  the  two  eyes  are  rarely  affected  symmetrically  in  point  of 
time,  iritis  must  be  placed  among  the  occasional  secondary  symptoms.  Later 
affections  of  the  eye,  choroiditis,  for  example,  and  neuroretinitis,  are  sometimes 
included  as  well. 

Duration  of  the  Secondary  Period. — No  definite  limit  can  be  assigned  ; 
there  may  be  no  symptoms  at  all;  it  may  last  a  month,  or  it  may  be  continued 
for  a  couple  of  years. 

The  symptoms  are  for  the  most  part  symmetrical,  the  earlier  ones  always  so, 
because  in  all  probability  they  are  due  to  the  effect  of  the  virus  upon  the  blood 
itself.  Long  before  these  have  passed  away,  however,  the  tissues  are  involved  as 
well,  and  then  symmetrical  lesions  are  mingled  with  the  others;  later  still,  when 
the  blood  infection  has  cjuite  died  out,  in  the  so-called  tertiary  stage,  these  occur 
alone. 

Secondary  symptoms  have  a  tendency  to  get  well  of  themselves  ;  the  blood 
and  the  tissues  may  yield  at  first  to  the  effect  of  the  poison,  but  provided  the 
patient  is  in  fairly  good  health,  and  not  exposed  to  influences  of  a  too  injurious 
character,  the  lesions  subside  again,  even  without  treatment.  Later  in  the  tertiary 
period  the  tissues  seem  to  lose  this  power  and  the  morbid  changes  steadily  grow 
worse  and  worse. 

The  blood  and  the  discharges  from  the  eruptions  are  inoculable  during  the 
secondary  period.  There  is  no  authenticated  case  of  the  disease  having  been 
transmitted  in  this  way  from  any  tertiary  affection.  How  long  the  power  of 
infection  by  contact  lasts  is  naturally  uncertain  ;  it  may  be  a  few  months,  but  it  is 
rarely  more  than  two  years.  This  disappearance  froni  the  blood  is  not  due  to  any 
alteration  in  the  blood  itself — to  the  exhaustion,  for  example,  of  some  substance 
necessary  for  the  growth  of  the  poison — for  second  attacks  of  syphilis  are  by  no 
means  uncommon,  and  it  sometimes  happens  that  a  person  becomes  affected  for 
the  second  time,  and  that  the  disease  runs  a  scarcely  modified  course  while  tertiary 
symptoms  are  actually  jjresent.  It  is  no  less  true  that  the  virus  remains  the  same, 
and  is  capable  of  regaining  its  vigor  if  the  conditions  are  a  little  changed.  Direct 
transmission  to  another  individual  may  no  longer  be  possible,  but  the  ovum  can 
be  infected  through  the  spermatozoa  long  after  the  secondary  symptoms  have 
subsided,  and  shortly  after  birth  the  child  may  become  covered  with  an  eruption 
of  an  intensely  contagious  character.  Transplanted  in  this  way  to  a  fresh  soil, 
the  virus  regains  its  vigor  and  multiplies  again  indefinitely,  the  period  of  incuba- 
tion, before  it  manifests  its  influence,  depending  very  largely  upon  the  activity  of 
the  poison  in  the  parent.  The  more  recent  the  infection  in  the  latter,  the  shorter 
the  incubation  in  the  embryo,  and  the  more  disastrous  the  results.  It  would  seem, 
therefore,  that  the  virus,  when  it  leaves  the  blood  and  becomes  imbedded  in  the 
tissues,  may  either  remain  latent  for  years  (perhaps  for  life),  or  may  at  any  time 
cause  local  inflammation  of  a  progressive  character,  slowly  infecting  the  structures 
around — tertiary  symptoms,  but  that  except  under  certain  conditions  (of  which 
transmission  to  the  embryo  through  the  ova  or  spermatozoa  is  one),  it  has  lost  its 
power  of  inoculation. 

Suppuration,  like  phagedjena,  is  an  accident  in  syphilis  which  may  occur  in 
connection  with  secondary  as  well  as  tertiary  lesions.     That  it  is  not  seen  more 


SYPHILIS.  103 

frtMiuently  in  the  former  is  prol)al)ly  due  to  their  transient  character,  and  the 
small  amount  of  exudation  that  accompanies  them.  Many  of  the  slighter  forms 
of  secondary  syjjhilitic  affections,  whether  they  involve  the  skin,  the  periosteum, 
or  the  iris,  are  probably  merely  attended  with  hypertx^mia;  in  the  more  severe 
ones,  however,  especially  those  that  occur  rather  later,  the  amount  is  often  con- 
siderable ;  and  then,  especially  if  the  lesion  is  near  the  skin  or  a  mucous  surface, 
suppuration  and  ulceration  are  very  likely  to  follow.  A  syphilitic  affection  is  not 
tertiary,  because  it  leaves  a  scar.  Rupia,  which  distinctly  belongs  to  the  late 
secondary  manifestations,  leaves  perfectly  typical  cicatrices,  which  can  be  recog- 
nized throughout  the  rest  of  life,  dead-white,  circular,  with  a  rim  of  pigment 
interrupted  here  and  there,  and  as  thin  as  tissue-paper,  wrinkling  like  it  when 
pressed  together.  The  only  condition  that  can  be  mistaken  for  it  is  the  scarring 
left  by  splashes  of  molten  metal. 

Trrtiarv  Syphilis. 

The  tertiary  period  does  not  admit  of  exact  definition  any  more  than  the 
others.  It  may  begin  within  a  few  months  of  the  primary  affection,  while  the 
secondary  symptoms  are  still  present,  or  it  may  be  postponed  for  years.  There 
may  be  a  period  of  complete  immunity,  during  which  the  patient  shows  no  sign 
of  disease,  or  one  form  of  lesion  may  succeed  another  without  a  break. 

For  convenience  sake  an  intermediate  stage  is  sometimes  spoken  of,  during 
which  the  patient  is  subject  to  certain  affections  known  as  "  reminders,"  iritis  for 
example,  choroiditis,  orcliitis,  arteritis,  and  scaly  eruptions  upon  the  hands  and 
feet ;  these  are  distinguished  from  the  true  secondary  forms,  upon  the  one  hand, 
by  their  want  of  perfect  symmetry,  and  from  the  tertiaries,  upon  the  other,  by 
their  tendency  to  get  well,  more  or  less,  of  themselves  ;  but  the  definition  of  the.se 
stages  becomes  difficult  in  proportion  to  their  multiplication. 

The  history  of  acquired  syphilis  is  a  continuous  one,  although  sometimes  there 
are  long  breaks  in  it.  At  first  the  virus  infects  the  tissues  around,  producing  a 
hard  chancre.  Then  it  gains  the  lymjihatics  and  involves  the  blood  ;  during  this 
stage  it  is  inoculable,  the  lesions  are  symmetrical  and  tend  to  get  well  of  them- 
selves. Long  before  this  has  passed  it  has  begun  to  affect  the  tissues  too,  at  first 
simply  leading  to  a  transient  hyper?emia ;  then,  as  the  power  of  their  resistance 
diminishes,  causing  a  certain  degree  of  exudation  ;  and,  finally,  in  the  last  stage 
(which  when  the  vitality  ot  the  tissues  is  very  low  may  begin  almost  at  once), 
forming  great  masses  of  inflammatory  granulation-tissue  which  slowly  undergo 
caseation.  There  is  no  break  anywhere  in  the  pathological  changes  ;  they  shade 
off  imperceptibly  one  into  the  other ;  the  distinctions  are  that,  while  the  virus 
affects  the  blood  it  is  inoculable,  when  it  involves  the  tissues  only  it  is  not,  though 
it  may  regain  its  power  under  peculiar  conditions  ;  and  that  after  it  has  spread 
from  the  blood  to  the  tissues,  these  lose  the  power  of  dealing  with  it  unaided,  so 
that  the  lesions  continue  to  grow  worse. 

The  histological  changes  in  tertiary  syphilis  are  identical  with  those  that 
occur  in  the  other  form  of  chronic  infective  inflammation  ;  the  difference  is  in 
their  distribution  and  course.  Wherever  the  virus  spreads  it  lowers  the  vitality 
of  the  tissues  with  which  it  comes  in  contact,  or  kills  them;  and  at  once  those 
around  begin  to  throw  out  granulation-tissue  composed  of  leucocytes  with  epithelioid 
and  giant  cells  (a  few  only)  as  in  tubercle,  and  the  other  infective  granulomata. 
The  ultimate  effect  of  the  exudation  and  the  effect  it  produces  in  different  parts 
of  the  body  depend  upon  its  situation  and  amount.  In  some  places  it  undergoes 
organization,  becoming  converted  into  dense,  fibrous  tissue  or  bone,  as  the  case 
may  be.  This  is  most  common  where  it  is  scattered  throughout  an  organ,  not 
collected  in  one  spot,  and  is  often  partial,  some  being  absorbed.  In  a  measure, 
it  may  be  regarded  as  a  process  of  repair,  but  it  often  leads  to  the  most  disastrous 
consequences  from  the  condensation.it  entails.  In  others,  in  which  instead  of 
being  uniformly  distributed  it  is  collected  into  masses,  caseation  sets  in  as  soon  as 


I04       GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

they  attain  any  size.  Whether  this  degeneration  arises  from  the  effect  of  the  virus 
upon  the  lymph  (as  in  tubercle),  or  is  due  to  the  arteries  being  blocked  by  the 
thickening  of  their  intima,  is  not  known ;  in  any  case  the  change  is  not  one 
peculiar  to  tubercle  or  syphilis.  Masses  of  this  kind  are  known  as  gummata. 
When  first  formed  they  consist  merely  of  soft,  vascular  granulation-tissue,  and  so 
long  as  they  are  spreading  the  margin  retains  this  character.  As  they  increase  in 
size — and  they  may  reach  that  of  a  walnut  or  be  larger  still — a  certain  degree  of 
organization  sets  in  ;  and  then,  following  this,  caseation.  Three  strata,  therefore, 
can  be  distinguished — outside  a  layer  ^f  still-growing  inflammatory  exudation, 
spreading  in  the  direction  of  least  resistance,  and  therefore  very  irregular  in 
shape ;  inside  this,  partial  organization  ;  and  in  the  centre,  a  caseous  mass. 
Naturally,  the  relative  proportion  of  these  three  is  very  variable ;  in  many  cases 
the  second  is  hardly  perceptible. 

In  addition,  the  lesions  of  tertiary  syphilis  are  frequently  complicated  by 
suppuration.  The  pyogenic  organisms,  which  are  practically  of  general  dis- 
tribution, although  they  are  unable  to  produce  any  effect  so  long  as  the  tissues 
are  healthy,  live  and  thrive  when  there  is  disease,  and  hasten  the  process  of 
destruction. 

If  they  gain  access  to  a  deeply-buried  caseous  mass  (in  the  tongue,  for 
example,  or  the  subcutaneous  tissue)  not  unfrequently  the  whole  of  the  infiltrated 
part  perishes,  becoming  gangrenous  from  the  intensity  of  the  combined  effect ; 
the  skin  or  the  mucous  membrane,  as  the  case  may  be,  gives  way ;  a  circular 
opening  is  left,  with  undermined  and  steeply-cut  edges,  and  at  the  bottom  is  a 
yellow,  wash-leather-like  slough.  Similarly,  if  the  infiltration  is  in  the  substance 
of  the  skin,  various  forms  of  ulceration  follow.  It  is  this  mixture  of  organization 
and  caseation,  suppuration  and  sloughing,  while  all  the  while  the  syphilitic 
inflammatory  exudation  is  continuing  to  spread  at  the  margin,  that  causes  the 
immense  variety  of  the  lesions  characteristic  of  the  tertiary  period. 

Intermediate  Symptoms. — The  symptoms  of  the  secondary  stage  are 
acute  and  tend  to  get  well.  After  they  have  subsided  there  is  often  a  period  of 
complete  immunity  ;  but  in  many  cases,  if  inquiry  is  made,  it  will  be  found  that 
after  all  the  symptoms  that  are  really  secondary  have  disappeared,  there  have  been 
local  attacks,  somewhat  the  same  in  character,  but  more  chronic  in  their  course 
and  much  less  severe.  Their  distribution  is  not  general,  and  they  do  not  occur 
indiscriminately,  only  where  there  is  some  other  source  of  irritation  ;  there  is  a 
greater  amount  of  exudation  than  in  most  of  the  secondary  symptoms,  and  though 
they  occasionally  get  well  of  themselves,  there  is,  on  the  whole,  a  decided 
tendency  for  them  to  spread.  In  other  words,  they  form  a  transition  to  the  true 
tertiary  ones. 

The  eruption  that  occurs  on  the  palms  of  the  hands  and  the  soles  of  the  feet 
is  an  example.  In  the  secondary  stage  a  number  of  separate  spots  form  rapidly, 
become  scaly,  and  disappear  again  in  a  week  or  two.  Later,  if  they  recur  (and 
naturally  this  is  more  common  on  the  right  side  than  the  left),  their  course  is  more 
slow,  they  are  fewer  in  number,  there  is  a  greater  amount  of  exudation,  the  scales 
are  less  distinct,  and  they  have  a  tendency  to  spread  at  the  margins.  In  the  true 
tertiary  period,  if  an  eruption  breaks  out  in  this  locality,  it  is  raised,  almost  tuber- 
cular, very  chronic,  and  extends  in  widening  circles  or  parts  of  circles.  In  the 
centre,  at  the  spot  where  it  began,  it  gradually  dies  away,  leaving  a  smooth,  more 
or  less  shiny  and  pigmented  surface  ;  there  is  no  distinct  cicatrix,  merely  an 
alteration  in  the  texture  of  the  skin  ;  at  the  margins  it  steadily  advances,  and  if 
at  any  time  one  spot  becomes  isolated — if,  for  example,  the  whole  of.it  is  cured 
but  in  one  little  place — this  forms  the  focus  for  a  fresh  ring. 

The  same  thing  occurs  at  the  angles  of  the  mouth  and  nose  and  to  a  less 
extent  at  the  anus.  The  eruption  returns  again  and  again,  leaving  painful  cracks 
and  fissures,  lined  with  a  smooth,  raw,  readily-bleeding  surface.  They  are  not 
unlike  the  sores  that  occur  at  an  earlier  period  in  the  same  locality,  but  are  more 
chronic  ;  there  is  a  greater  amount  of  thickening  at  the  base,  they  tend  to  spread 


SYPHILIS. 


105 


in  circles,  or  parts  of  circles,  on  to  the  chin  and  lips,  and  they  leave  white  linear 
cicatrices  when  they  heal. 

The  tongue  shows  the  same,  esjjccially  with  smokers.  White  patches  return 
again  and  again,  until  at  length  all  the  jjapillae  are  leveled  up  by  the  exudation, 
and  a  smooth,  bare,  white  spot  is  left,  surrounded  by  a  still  extending  infdtration. 
In  other  i)arts  of  the  body  there  are  circular  cutaneous  erui}tions,  or  patches 
closely  resembling  the  lighter  forms  of  lupus,  especially  those  that  scarcely  leave 
a  scar  ;  or  sometimes  affections  of  a  still  more  serious  character — iritis,  arteritis, 
orchitis,  periostitis,  etc. 

In  many  cases,  especially  when  treatment  is  thoroughly  carried  out,  these, 
year  by  year,  grow  milder  and  milder,  until  at  length  they  cease  altogether.  On 
the  other  hand,  it  sometimes  happens  that,  after  a  variable  and  most  deceptive 
period  of  quiescence,  true  tertiary  affections  follow,  steadily  progressive  in  their 
character,  and  inevitably,  if  not  thoroughly  treated,  passing  on  from  bad  to 
worse. 

Tertiary  Symptoms. — Two  chief  varieties  can  be  distinguished,  although 
it  is  impossible  to  draw  a  definite  line  between  them.  The  one  is  characterized 
by,  at  first,  an  enormous  local  collection  of  inflammatory  deposit — a  gumma, 
which,  according  to  the  conditions  under  which  it  is  placed,  undergoes  caseation, 
absorption,  or  sloughing.  The  other,  which  is  not  so  striking,  leads  at  once  to 
organization  and  condensation  without  any  preliminary  stage. 

The  Skin. — Nodular  and  tubercular  eruptions  of  various  degrees  of  sev^erity 
are  common  upon  the  back  of  the  neck  and  shoulders,  round  the  scalp,  and  in 
the  region  of  the  nose  and  lips.  In  the  last-mentioned  locality  they  often  resem- 
ble lupus  very  closely,  but  the  little  elevations  have  not  the  gelatinous  appearance 
characteristic  of  true  lupus,  the  course  is  more  rapid,  and  if  there  is  a  cicatrix  it 
is  firm  and  white,  not  thin  and  red.  Moreover,  it  rarely  happens  that  all  the  spots 
present  the  same  characters.  The  milder  forms  subside  without  leaving  any 
definite  mark  other  than  pigmentation  ;  those  that  are  more  severe,  in  which  the 
amount  of  exudation  is  greater  and  the  natural  texture  to  some  extent  absorbed, 
cause  a  peculiar  flattened  and  smoothed  appearance  of  the  skin ;  the  worst,  in 
which  suppuration  occurs  as  well  (this  is  especially  common  upon  the  legs),  leave 
definite  cicatrices  that  vary  in  depth  according  to  the  amount  of  the  deposit. 
Wherever  the  eruption  occurs,  it  is  always  serpiginous,  healing  in  the  centre,  con- 
stantly creeping  on  at  the  margin,  so  as  to  form  rings  or  parts  of  rings,  often 
intersecting,  as  wdien  one  has  advanced  in  one  direction  and  crossed  another, 
and  the  cicatrices  naturally  follow  the  same  course.  It  is  common  to  find  a  pig- 
mented spot  from  which  the  eruption  started ;  then,  a  thin  cicatrix,  scarcely 
producing  a  definite  alteration  in  the  skin  ;  beyond  this,  typical  scar-tissue,  white, 
with  patches  of  dark  pigment  here  and  there,  and  on  the  extreme  margin  a  ring 
of  ulcers  and  nodules ;  the  eruption  starts  in  the  centre  and  gradually  increases 
in  depth  and  width  the  longer  it  lasts. 

The  Cellular  Tissue. — The  subcutaneous  and  submucous  tissues  are  especially 
liable  to  be  the  seat  of  gummata.  A  smooth,  rounded  swelling  forms  rather 
rapidly  and  w-ithout  much  pain,  the  skin  over  it  becomes  red  and  adherent,  then 
it  gives  way,  retracts  as  only  skin  can  retract  when  it  is  separated  from  its  deep 
attachments,  and  leaves  a  deep,  circular,  punched-out  hole,  with,  perhaps  at  the 
bottom,  a  slough  formed  from  the  cellular  tissue.  Round  the  knee-joint  is  a 
very  favorite  locality,  and,  combined  with  the  skin  eruption,  of  which  they  are 
merely  a  deeper  variety,  these  gummata  lead  to  characteristic  cicatrization.  Not 
unfrequently  they  extend  some  distance  down  the  leg,  and  it  has  been  said,  with 
as  much  truth  as  is  usual  in  universal  statements,  that  every  ulcer  that  begins 
between  the  middle  of  the  leg  and  the  knee  is  due  to  syphilis.  Other  joints  are 
not  so  often  attacked,  but  wherever  there  are  bursae,  gummata  and  serpiginous 
eruptions  upon  the  skin  are  always  liable  to  occur,  partly  because  of  the  amount 
of  loose  cellular  tissue,  partly  from  the  way  in  which  structures  of  this  kind  are 
exposed  to  injury.   Submucous  gummata  are  of  common  occurrence  in  the  tongue, 


io6       GENERAL   PATHOLOGY  OF  SURGLCAL   DLSEASES. 

soft  palate,  and   pharynx,   and  possibly  some  cases  of  stenosis  of  the  trachea, 
oesophagus,  and  rectum  originate  in  this  way. 

In  addition  to  these  localities,  gummata  may  occur  in  any  of  the  soft  tissues  ; 
in  the  synovial  and  peri-synovial  tissues  of  joints,  simulating  strumous  disease  ; 
in  the  membranes  of  the  brain  and  spinal  cord,  causing  epilepsy,  convulsions, 
paralysis  (especially  of  the  oculo-motor  nerves),  and  j)araplegia  ;  in  the  walls  of 
the  arteries,  leading  to  aneurism,  thrombosis,  and  even  rupture  ;  in  all  the  viscera, 
but  especially  the  testes,  liver,  and  lungs,  and  particularly  in  the  substance  of 
the  muscles.  Wherever  they  form,  they  give  rise  to  rapidly-growing  swellings, 
attended  with  a  considerable  degree  of  inflammation  and  affecting  all  the  struc- 
tures around.  Suppuration  is  chiefly  liable  to  occur  in  the  superficial  ones  and 
those  that  are  exposed  to  injury. 

The  effect  produced  by  gummatous  infiltration  of  the  tissues  does  not  dis- 
appear with  its  absorption.  Not  only  is  there  at  the  time  a  certain  amount  of 
actual  destruction  which  can  never  be  repaired,  but  even  when  all  the  syphilitic 
exudation  is  removed  without  there  having  been  a  trace  of  pus,  a  dense,  hard, 
and  contracting  cicatrix  is  left,  which  in  certain  situations  leads  to  very  .serious 
results.  A  typical  example  of  this  occurs  in  the  liver,  in  the  middle  of  which  it 
is  not  uncomirion  to  find  a  deep,  star-like  mass  of  cicatricial  tissue,  radiating  in 
all  directions  ;  and  even  worse  consequences  may  follow  when,  for  example, 
the  dura  mater  is  involved,  or  a  stricture  is  developed  in  the  trachea  or  oeso- 
phagus. 

The  Bones  and  the  Periosteum. — In  the  secondary  stage,  when  the  symptoms 
are  acute,  the  vascular  layer  of  the  periosteum  is  the  part  chiefly  affected  ;  ii  the 
attack  is  slight,  there  is  merely  hyperaemia ;  where  more  severe,  exudation  takes 
place  as  well,  stretching  the  fibrous  layer  and  forming  an  intensely  painful  node, 
generally  on  the  subcutaneous  surface  of  one  of  the  long  bones ;  in  the  tertiary 
stage,  when  the  disease  is  chronic,  the  bone  itself  is  the  part  involved.  In  this 
syphilis  merely  follows  the  ordinary  rule ;  acute  inflammation  cannot  occur  in 
compact  bone  ;  time  is  needed  for  the  necessary  histological  changes,  the  soften- 
ing and  absorption  of  the  solid  parts,  and  the  expan.sion  of  the  Haversian  systems. 

The  vault  of  the  skull  is  one  of  the  favorite  situations.  A  swelling  slowly 
forms  under  the  scalp  and  gradually  increases  until  at  length  the  soft  tissues  over 
it  become  inflamed  from  the  tension  to  which  they  are  subjected.  It  is  painful, 
especially  at  night,  but  not  in  the  same  way  as  a  secondary  node ;  and  it  is  very 
tender  on  pressure.  Then  it  breaks  down,  suppuration  follows,  the  skin  gives 
way,  and  the  bone  beneath  is  exposed,  rough,  carious,  and  often  blackened 
already.  The  syphilitic  exudation  penetrates  into  all  the  Haversian  canals,  eats 
away  their  walls  until  the  bone  becomes  porous,  and  then  undergoes  caseation, 
the  bony  trabeculae  still  left  perishing  at  the  same  time,  from  their  blood-supply 
being  cut  off.  Even  without  suppuration  extensive  areas  on  the  vault  of  the  skull 
may  be  destroyed  in  this  way.  If  pyogenic  organisms  gain  access  too,  the 
inflammation  is  much  more  severe ;  necrosis  occurs  as  well ;  and  huge  plates, 
involving  the  whole  thickness,  may  perish  from  the  frontal  or  parietal  bones, 
leaving  the  dura  mater  exposed  beneath.  Typical,  deeply  depressed  cicatrices  in 
the  frontal  region,  are  sometimes  seen,  caused  in  this  way;  and  the  pulsation  of 
the  brain  can  be  felt  through  them,  for  no  new  bone  is  ever  formed. 

Similar  changes  are  met  with  in  connection  with  other  bones.  Gummata  of 
the  hard  palate  are  exceedingly  common,  leading  to  perforation,  always  in  the 
middle  line.  Sometimes  they  are  limited  to  the  mouth  ;  more  frequently  they 
involve  the  septum,  turbinate  bones,  and  even  the  nasal  bones,  so  that  a  huge 
cavity  is  left  filled  with  necrosed  fragments  and  decomposing  pus,  and  shut  off 
almost  altogether  from  the  pharynx  by  the  adhesion  of  the  soft  palate  to  the  pos- 
terior wall.  In  the  neighborhood  of  joints  it  leads  to  still  greater  destruction  ; 
every  part  of  the  articulation  may  be  affected,  the  skin  may  be  reddened,  infil- 
trated, and  covered  with  ulcers;  the  subcutaneous  and'perisynovial  tissues  filled 
with  exudation  ;  and  the  ends  of  the  bones  and  the  periosteum  swollen,  softened, 


SYPHILIS.  107 

and  eaten  away  to  siu  li  ww  extent  that  recovery  seems  almost  hopeless.  Sometimes 
gummata  form  in  the  medullary  canal  of  one  of  the  long  bones,  leading  to  so- 
called  spontaneous  fracture.  More  frequently,  especially  in  the  case  of  the  lower 
extremity,  the  exudation  is,  in  part  at  least,  diffuse,  and  dense,  hard  masses  of  new 
bone  are  formed  ;  or  the  two  are  combined,  ulceration  and  necrosis  occurring  in 
one  spot,  and  hy])crtrophy  over  the  rest.  Symmetrical  osseous  nodes  of  immense 
size  are  not  infrecpient  on  the  inner  surface  of  the  frontal  bone;  but,  although 
the  diploe  may  comjjletely  disapjjear,  they  rarely  extend  beyond  the  mid-parietal 
region,  and  are  never  seen  upon  the  outside. 

The  cartilages  of  the  larynx,  especially  the  epiglottis,  are  frequently  attacked. 
In  some  cases  the  ulceration  begins  on  the  surface  and  extends  into  the  deeper 
structures ;  in  others,  a  gumma  forms  on  or  around  them  in  connection  with  the 
perichondrium  ;  suppuration  sets  in,  and  when  the  mucous  membrane  gives  way 
the  cartilage  is  laid  bare,  dead  and  already  partially  separated.  Very  serious 
stenosis  of  the  larynx  may  be  caused  by  the  cicatrization  that  results.  Similar 
changes  are  of  common  occurrence  upon  the  costal  cartilages,  and  even  more 
frequent  upon  the  sternum. 

Tertiary  syphilis,  when  it  affects  the  nervous  system,  does  not  so  often  give 
rise  to  the  formation  of  gummata  (although  these  may  occur  in  the  membranes 
round  the  brain  and  spinal  cord  and  lead  to  very  serious  changes)  as  to  a  peculiar 
form  of  sclerosis,  which  tends  to  spread  indefinitely.  It  is  probable  that  it  is 
always  preceded  by  effusion,  but  this  rarely  attracts  attention  before  the  conse- 
quent atrophy  has  begun  ;  wherever  it  occurs  it  is  characterized  by  a  steady  ten- 
dency to  progress  and  invade  the  structures  round,  as  surely  as  a  serpiginous 
eruption  in  the  skin,  or  a  neglected  gumma  in  a  mu.scle.  Unfortunately,  it  does 
not  respond  so  easily  to  treatment. 

The  symptoms  to  which  it  gives  rise  naturally  present  the  greatest  possible 
variety.  The  cranial  nerves  may  be  involved,  especially  those  connected  with  the 
eye.  Amaurosis  may  occur  from  atrophy  of  the  optic  nerve ;  ophthalmoplegia 
externa  from  paralysis  of  one  or  more  of  the  nerves  that  control  the  movements  ; 
or  this  may  be  combined  with  paralysis  of  accommodation  as  well,  so  that  the  pupil 
is  dilated,  the  eyelid  dropped,  and  the  eyeball  fixed,  according  to  the  nerves 
involved.  The  fifth  and  the  facial  suffer  sometimes  as  well.  General  paralysis 
may  follow  from  the  same  cause ;  probable  locomotor  ataxy  with  its  multitude  of 
complications  is  often  occasioned  by  it ;  epilepsy  and  insanity  certainly  are,  and, 
in  short,  there  is  scarcely  a  trouble  due  to  chronic  inflammation  of  the  brain  or 
spinal  cord,  or  the  nerves  issuing  from  them,  that  cannot  sometimes  be  traced 
back  to  the  influence  of  the  syphilitic  virus.  That  affections  of  this  kind  are 
always  due  to  syphilis  is  another  matter  altogether  ;  when  they  are  steadily 
progressive  it  is  very  probable  they  are,  the  virus  slowly  but  surely  extending  its 
field  in  the  nervous  system  as  upon  the  skin  ;  but  it  is  only  one  of  the  causes,  even 
if  it  is  the  commonest ;  and  the  particular  locality  and  the  special  kind  of  lesion 
are  probably  always  determined  by  other  predisposing  agencies.  Unhappily, 
although,  if  treatment  is  commenced  in  time,  the  progress  of  the  disease  may 
generally  be  checked,  its  effects,  when  it  has  once  declared  itself,  are  permanent. 

Prognosis. — Syphilis,  even  if  it  is  not  treated,  gradually  tends  to  die  out 
in  the  majority  of  cases  ;  out  of  ninety-three  watched  by  Diday,  only  four  suffered 
from  early  tertiary  symptoms,  though  twenty-nine  had  eruptions  of  various  kinds, 
periostitis,  iritis,  and  other  severe  secondary  affections  for  upward  of  two  years. 
At  the  present  day,  however,  the  course  of  the  disease  is  always  so  modified  by 
treatment  that  such  observations  are  of  little  value.  Like  measles,  smallpox,  and 
other  specific  diseases,  it  is  said  that,  when  carried  to  a  fresh  country,  it  becomes 
intensely  virulent.  On  the  other  hand,  in  other  parts  of  the  world — in  Iceland, 
for  example, — serious  effects  are  seldom  seen.  Very  much  must  depend  upon  the 
constitution  of  the  individual ;  cases  are  sometimes  met  with  in  which,  in  spite  of 
everything  that  can  be  done,  the  disease  steadily  progresses  from  bad  to  worse, 
the  most  disastrous  tertiary  symptoms  making  their  appearance  early  in  its  course. 


io8       GENERAL   PATHOLOGY  OE  SURGLCAL   DISEASES. 

As  a  rule,  in  these  there  is  a  history  of  long-continued  intemy^erance,  or  of 
Bright's  disease;  and  very  often  the  patient  is  already  past  middle  life;  but  they 
are  occasionally  met  with  in  the  young,  and  in  those  who  are  in  good  circum- 
stances. As  might  be  supposed,  if  there  is  any  tendency  to  phthisis  the  prognosis 
is  distinctly  more  grave,  pulmonary  symptoms  not  infrecpiently  making  their 
appearance  during  the  cachexia  of  the  secondary  stage,  and  running  a  rapid 
course.     Syphilis  is  rarely  directly  fatal,  unless  the  cerebral  arteries  are  affected. 

In  the  vast  majority  of  cases,  if  treatment  is  commenced  at  once,  and  carried 
out  thoroughly,  and  if  the  patient  can  and  will  give  up  a  sufficient  length  of  time 
to  it,  secondary  symptoms  are  either  avoided  altogether,  or  occur  in  a  very  mild 
form.  It  is,  however,  of  the  utmost  importance  to  begin  at  once,  as  soon  as 
there  is  a  suspicion  of  the  disease  ;  if  the  poison  is  once  allowed  to  gain  a  settle- 
ment in  the  tissues,  if,  that  is  to  say,  local  symptoms  (other  than  the  primary 
chancre)  have  made  their  appearance,  the  prospect  of  permanent  cure  becomes 
much  more  doubtful.  The  reputation  enjoyed  by  some  of  the  foreign  bath 
resorts  is  due  partly  to  the  change  in  living,  but  chiefly  to  the  fact  that  the  treat- 
ment of  the  disease  is  made  the  first  consideration  there,  everything  else  being 
subordinated  to  it. 

One  attack,  confers  only  a  limited  degree  of  immunity.  Auto-inoculation 
from  a  primary  chancre  merely  leads  to  the  formation  of  a  papule,  unless  the  sore 
is  inflamed  or  suppurating.  After  the  secondary  period  has  subsided,  a  fresh 
infection  generally  causes  the  development  of  a  modified  chancre,  which  is  not 
followed  by  any  further  symptoms ;  but  this  rule  is  by  no  means  invariable.  I 
have  known  several  instances  in  which  second  attacks  of  syphilis  have  occurred 
within  three  years,  and  more  than  one  in  which  local  cutaneous  eruptions  were 
present  at  the  time  of  the  second  infection.  In  some  of  the  cases  the  second 
attack  was  milder  than  the  first ;  in  others  it  appeared  to  be  entirely  uninfluenced 
by  it,  running  a  typical  course  ;  in  one  it  was  distinctly  much  more  severe,  and 
was  followed  by  tertiaries. 

During  the  primary  and  secondary  stages,  the  blood  and  the  secretions  from 
the  eruptions  (especially  condylomata)  are  intensely  infective,  and  the  greatest 
care  is  required  to  prevent  mediate  contagion;  many  cases  have  arisen  from 
smoking  a  pipe  that  has  been  used  by  a  syphilitic  person.  The  normal  secretions, 
however,  seem  to  be  free  from  it.  In  the  tertiary  stage,  the  virulence  appears  to 
die  out,  so  far  as  direct  inoculation  is  concerned. 

With  regard  to  hereditary  transmission  the  facts  are  not  so  clear,  and  a  dis- 
tinction must  be  drawn  between  the  likelihood  of  infection  and  the  .severity  of 
the  symptoms.  It  is  well  known  that  of  twins  the  one  may  suffer  severely,  the 
other  hardly  at  all ;  and  it  is  said  that  one  may  escape  altogether. 

Where  the  treatment  of  the  parents  is  neglected  altogether,  or  what  is  nearly 
equally  bad,  merely  carried  out  in  a  casual  way  from  time  to  time,  the  ordinary 
rule  is  for  the  earlier  children  to  suffer,  the  later  ones  to  remain  free.  Not  infre- 
quently, however,  owing,  perhaps,  to  the  fact  that  the  infected  parent  is  taking 
mercury  at  the  time,  one  or  more  of  the  children  in  the  series  escape.  Sometimes 
the  last-born  is  aff'ected  after  a  long  interval  of  freedom,  the  strength  of  the 
mother  failing  from  age,  or  from  frequently  repeated  pregnancies,  and  the  child 
suffering  in  consequence. 

It  is  generally  held  also — but  the  evidence  upon  this  point  is  much  less 
satisfactory — that  not  only  do  the  chances  of  escape  increase,  but  that  the  disease 
itself  becomes  milder  as  the  date  of  parental  infection  becomes  more  distant  ; 
and  certainly  it  is  not  uncommon  to  find  a  long  series  of  miscarriages,  then  a 
child  born  alive,  but  dying  shortly  after  birth,  and  then  several,  one  after  the 
other,  each  apparently  less  affected  than  the  one  before.  Against  this,  on  the 
other  hand,  is  the  fact  that  syphilis,  under  whatever  circumstances  it  occurs,  is 
the  same  disease.  It  varies,  beyond  all  doubt,  immensely  in  different  individuals, 
but  there  is  no  proof  that  such  a  thing  as  a  mild  inoculation  or  a  stronger  one  is 
possible.     If  a  child  is  infected  through  one  of  its  parents,  it  may  suffer  from  a 


SYPJriLIS.  109 

slight  attack  or  from  a  severe  one,  but  this  does  not  dej^end  ii])on  the  inoculation 
or  the  date  of  infection  in  the  parents,  but  upon  the  child.  ICarly  miscarriages 
may  very  probably  be  accounted  for  by  local  affections  of  the  uterus  or  placenta, 
the  slighter  severity  in  the  later  children  by  the  improvement  in  the  general 
health  of  the  parents,  and  the  occasional  intensity  in  one  of  the  last-born  by  the 
failing  power  of  the  mother,  and  the  consequent  feeble  development  and  nutrition 
of  the  child. 

'I'he  child  may  be  affected  either  through  the  father  or  the  mother  or  through 
both.  It  is  generally  believed  that  when  the  mother  is  diseased  the  child  suffers 
more  severely,  and,  no  doubt,  death  of  the  f(jetus  before  birth  is  commonly  due 
to  some  affection  of  the  uterus  or  i)lacenta  ;  Init,  excei)t  upon  this  point,  there  is 
no  direct  evidence  one  way  or  the  other.  The  ordinary  infection  is  through  the 
father  ;  the  mother  may  show  no  sign  of  the  disease,  but,  as  was  first  pointed  out 
by  Colles,  it  is  impossible  to  believe  that  she  escapes.  An  infected  child  is  almost 
certain  to  transmit  the  disease  to  a  wet-nurse,  never  to  its  own  mother. 

If  the  lather's  attack  is  recent,  the  disease  is  communicated  directly  to  the 
mother  and  the  foetus  is  exceedingly  likely  to  die  in  utero  from  some  local  lesion. 
If  the  secondary  stage  (and  with  it  the  ])eriod  of  direct  inoculability)  is  jjast,  the 
ovum  may,  or  may  not,  be  rendered  syphilitic  by  the  spermatozoa.  I'he  only 
explanation  of  the  fact  that  the  mother  is  not  infected  by  the  child  after  birth,  is 
that  she  has  been  already  rendered  syphilitic  through  the  medium  of  the  ftjetus 
before  birth.  When  this  occurs,  the  mother  does  not  suffer  from  secondary 
symptoms  :  the  poi.sori,  beyond  all  doubt,  is  modified  by  the  conditions  under 
which  it  is  acting  (the  length  of  the  incubation  period  in  the  embryo  is  proof), 
and  transmitted  in  this  way  does  not  appear  to  cause  them ;  but  tertiary  lesions 
may  follow  later,  for  it  is  not  uncommon  to  meet  with  them  in  women  in  whom 
the  most  careful  inquiry  fails  to  reveal  any  evidence  of  secondaries. 

The  child,  there  is  no  doubt,  may  become  infected  through  the  mother  alone. 
If  syphilis  is  acquired  during  the  earlier  part  of  pregnancy,  the  ftjetus  is  affected 
and  suffers  from  the  ordinary  effects  of  the  congenital  disease,  just  as  if  the  virus 
had  been  communicated  through  the  ovum  or  spermatozoa.  In  the  later  months 
there  is  a  possibility  that  the  child  may  escape. 

Congenital  Syphilis. 

The  symptoms  of  congenital  syphilis  may  make  their  appearance  before  birth 
or  shortly  after  it,  from  three  or  four  weeks  to  six  months.  In  the  former  case 
the  child  is  nearly  always  born  dead.  It  is  quite  the  exception  to  find  any 
evidence  of  the  disease  upon  a  child  born  alive. 

1.  Before  Birth. — It  is  probable  that  in  a  large  proportion  of  the  cases  the 
death  of  the  foetus  is  due  to  disease  of  the  uterus  or  placenta,  the  foetus  itself 
showing  no  definite  sign.  In  a  few,  however,  suppuration  has  been  found  in 
connection  with  the  viscera;  gummata  are  occasionally  present,  and  certain 
changes  which  are  admittedly  syphilitic  have  been  recorded  in  the  bones. 

2.  After  Birth. — As  a  rule,  the  child  is  born  without  the  least '  evidence  of 
any  taint,  healthy  and  well-nourished,  and  no  sign  of  the  disease  makes  its 
appearance  for  some  weeks.  Exceptionally,  Pemphigus  breaks  out  within  a  day 
or  two  and  nearly  always  proves  fatal. 

A  few  weeks  after  birth  the  child  begins  to  waste  and  grow  pale.  Its  nose 
becomes  stuffed  up,  so  that  it  cannot  take  the  breast  for  any  length  of  time  with- 
out letting  go  ;  a  thin,  watery  discharge  runs  from  it,  the  breathing  becomes 
obstructed  (whence  the  popular  name,  smiffles),  and  a  ?-ash,  similar  to  that  which 
occurs  in  the  secondary  stage  of  the  acquired  form,  makes  its  appearance  more 
or  less  all  over  the  body.  The  favorite  situations  are  the  mucous  membrane  of 
the  nose,  mouth,  and  anus ;  the  skin  over  the  buttocks,  owing  to  the  generally 
moist  and  heated  condition  in  which  that  part  is  kept ;  and  the  palms  of  the 
hands  and  the  soles  of  the  feet.      On  exposed   surfaces  it  is  for  the  most  part 


no       GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 


roseolous  in  character,  not  bright,  but  a  dull,  coppery  red  ;  where  the  epidermis 
is  thicker  it  forms  circular,  scaly  rings  (miscalled  psoriasis)  ;  between  the  nates 
and  in  other  parts  it  assumes  the  form  of  condylomata,  and  in  the  mouth  and  at 
the  anus  it  resembles,  and  is  often  associated  with,  thrush.  At  the  angles  of  the 
mouth  and  nose  it  leaves  deej)  fissures  and  cicatrices,  and  between  the  toes  it 
forms  rhagades ;  in  other  words,  it  exactly  resembles  the  secondary  eruption  of 
the  acquired  form,  modified  by  the  peculiar  condition  of  a  baby's  skin. 

The  peculiar  color  and  polymorphic  character  of  the  eruption,  the  wasting 
and  aged  look  on  the  countenance,  the  coincidence  of  snuffles,  and  the  symmet- 
rical character  of  the  affection,  render  the  diagnosis  easy  when  all  are  present 
together.  It  is  very  difficult,  however,  in  some  cases.  Wasting  is  sometimes 
absent,  the  child  remaining  bright  and  well-nourished  throughout  the  attack. 
Coryza  is  often  present  without  syphilis,  and,  owing  to  the  small  size  of  the  nasal 
passage  and  the  thickness  of  the  mucous  membrane,  may  lead  to  distinct  snuffles ; 
while  eczema  and  intertrigo  are  frequently  symmetrical,  and  in  some  children  are 
dull  red  instead  of  bright. 

In  severe  cases  the  bones  are  affected  as  well.  Craniotabes,  wasting  of  the 
occipital  and  posterior  parietal  segments  of  the  skull,  so  that  in  parts  where  the 
convolutions  are  prominent  the  bone  completely  disappears,  is  probably  more 
often  due  to  rickets  than  syphilis,  but  there  are  other  affections  which  are  definite. 
Parrof  s  nodes,  periosteal  swellings  around  the  anterior  fontanelle,  one  on  each 
side,  in  front  and  behind,  so  that  the  situation  of  the  fontanelle  itself  is  marked 
by  a  cruciform  sulcus,  are  characteristic.  Similar  affections  on  the  shafts  of  the 
long  bones  are  equally  definite,  though  they  are  more  imcommon.  Infantile 
pseudo-paralysis  cannot  be  mistaken  ;  a  soft,  tender  swelling  forms  around  one  or 
more  of  the  joints,  especially  the  elbow,  and  the  child  becomes  entirely  unable 
to  move  the  limb.  The  lower  end  of  the  humerus  is  in  a  state  of  gelatiniform 
degeneration,  the  cartilage  is  enormously  thickened,  and  forms  a  soft,  translucent 
layer  between  the  epiphysis  and  the  shaft,  .so  that  a  sensation  of  yielding,  and 
even  of  soft  crepitus,  is  present  when  the  part  is  handled.  Similar  degeneration 
occurs,  exceptionally,  in  the  cranium. 

Bone  lesions  of  this  description  make  their  appearance,  for  the  most  part, 
within  the  first  three  months ;  after  six  they  are  much  more  rare.  At  the  same 
time,  guminata  are  occasionally  met  with  in  the  viscera,  but  rarely,  or  never,  in 
the  subcutaneous  tissues. 

After  the  first  year,  until  the  commencement  of  puberty,  there  is  a  period  of 
almost  perfect  freedom.     I  have  met  with  one  or  two  cases  of  condylomata  and 

of  small  gummata  in  children  five  or  six  years  old, 
and  choroiditis  is  occasionally  found  (or,  rather,  the 
results  of  it,  for  it  may  have  occurred  at  an  ear- 
lier period),  but  with  the  exception  of  these  it  is 
the  rule  for  there  to  be  no  manifestations  of  any 
kind. 

Signs  of  old  mischief  are  common,  and  persist 
more  or  less  distinctly  throughout  life  (Fig.  1 2).  The 
bridge  of  the  nose  is  flattened  and  wide,  owing  in  all 
probability  to  the  inflammation  of  the  mucous  mem- 
brane in  infancy  having  spread  to  the  periosteum 
and  interfered  with  its  proper  development.  The 
angles  of  the  mouth  are  marked  with  radiating  scars, 
and  here  and  there  upon  the  lips  are  little  dead- 
white  cicatrices.  The  permanent  teeth,  especially 
the  upper  incisors,  are  notched  in  a  most  peculiar 
manner.  The  cutting  edge,  instead  of  being  straight 
with  two  or  three  little  serrations,  is  concave  from  side  to  side  ;  the  whole  of  the 
tooth  is  dwarfed,  and,  especially  at  the  sides,  somewhat  beveled  off"  from  above 
downward,  so  that  it  has  a  peg-shaped  appearance.     This  change,  which  was  first 


Fig.  12. — Hereditary  Syphilis,  from  life. 


SYPHILIS.  Ill 

described  by  Hutchinson,  is  characteristic;  it  very  rarely,  if  ever,  occurs  under 
any  other  circumstances,  and  it  is  caused  by  and  is  i)roi)ortionate  to  the  stomatitis 
of  infancy.  If  this  is  severe  at  the  time  the  dental  papillae  are  developing,  they 
are  so  much  reduced  in  size  and  so  alteretl  in  shape  that  it  is  almost  im[jossible 
to  recognize  them  as  teeth  at  all.  Mercurial  teeth,  in  which  the  enamel  is 
defective  transversely  and  marked  by  horizontal  darkened  grooves  and  pits,  are 
totally  different,  but  it  is  not  uncommon  to  find  the  two  associated.  In  excep- 
tional cases,  in  which  the  stomatitis  has  been  late  or  prolonged,  a  similar  change 
is  visible  in  the  lateral  ones  as  well  ;  but  it  is  only  the  median  of  the  upper  jaw 
that  are  definite  and  characteristic. 

At  puberty  there  is  often  a  fresh  outbreak,  some  of  tlie  lesions  being  distinct- 
ive, others  resembling  those  of  the  tertiary  period. 

Of  the  former  the  most  important  are  interstitial  keratitis  ^x\<X  ostitis.  A  sym- 
metrical form  of  deafness,  quite  incurable,  is  also  met  with,  but  more  rarely.  The 
keratitis  always  attacks  both  eyes,  although  one  is  usually  in  advance  of  the  other, 
lasts  a  variable  number  of  months,  and  then  clears  up  again,  leaving,  unless  it  has 
been  very  severe,  little  permanent  defect.  The  ostitis  is  more  intractable.  It 
always  attacks  the  shafts  of  the  tibiae,  one  or  both,  although  it  may  appear  in  other 
bones  as  well.  The  shin  grows  out  first  and  becomes  tender  ;  the  leg  seems  to 
bow  forward  ;  then  the  whole  shaft  enlarges,  and  in  a  few  months,  or  two  or 
three  years,  the  bone  stands  out,  misshapen,  massive,  enormously  thickened,  and 
often  increased  in  length.  .In  the  milder  cases  the  exudation  is  diffiise  and 
becomes  organized ;  in  the  more  severe  ones  gummata  are  present  as  well, 
especially  on  the  periosteal  surface,  and  cause  superficial  sequestrse,  w^hich  separate 
with  the  most  extreme  slowness.  Possibly  this  is  due  to  the  sclerosis,  which  may 
also  account  for  the  fact  that  iodide  of  potash  is  almost  without  influence ;  it 
relieves  the  pain  for  the  moment  and  causes  the  gummata  to  diminish  in  size,  but 
it  does  little  or  nothing  more.  In  the  worst  of  all  the  inflammation  spreads  to  the 
ends  of  the  bones,  synovitis  sets  in,  and  at  length,  after  lasting  many  years,  with 
constant  attacks  of  pain,  the  limb  is  reduced  to  a  condition  resembling  an  old, 
gnarled  tree-trunk,  covered  all  over  with  cicatrices.  In  the  tibios  this  condition  is 
very  common  and  is  absolutely  distinctive  ;  in  other  bones  it  is  more  rare,  peri- 
osteal and  myelitic  gummata,  resembHng  those  of  acquired  syphilis,  occurring 
instead.  Very  often  the  effect  is  rendered  still  more  striking  by  the  peculiar 
undeveloped  condition  of  the  skeleton.  Congenital  syphilis  in  this  respect  closely 
resembles  rickets ;  not  only  do  the  bones  of  the  extremities  and  face  fail  to  grow, 
but  they  do  not  undergo  the  proportionate  development  of  adult  life ;  the  type 
remains  that  of  the  child. 

There  is  no  lesion  in  acquired  syphilis  that  is  not  also  met  with  sometimes  in 
the  hereditary  form.  The  skull  may  be  almost  destroyed  by  necrosis  ;  iritis, 
choroiditis,  and  optic  neuritis  may  occur;  ulceration  of  the  soft  palate  and  per- 
foration of  the  hard  one,  with  necrosis  of  the  septum  and  turbinate  bones,  are  not 
infrequent,  causing  the  most  fearful  ozsena.  Gummata — visceral,  subcutaneous, 
and  muscular — are  of  common  occurrence.  Skin  diseases,  however,  with  the 
exception  of  a  rapidly-spreading  form  of  lupus,  are  rare,  and  the  same  may  be 
said  of  degenerative  lesions  of  the  nervous  system.  I  have  met  with  ophthalmo- 
plegia (complete)  in  a  girl  sixteen  years  of  age,  in  whom  the  only  evidence  of 
disease,  past  or  present,  was  the  presence  of  a  few  cicatrices  at  the  angles  of  the 
mouth ;  but  probably  many  of  the  cases  of  epilepsy,  idiocy,  and  other  diseases 
of  the  nervous  system  are  merely  coincidences  ;  at  least,  there  is  no  direct  evi- 
dence to  connect  them  with  the  hereditary  taint. 

Treatment. — Excision.  There  is  some  evidence  in  favor  of  the  view  that 
early  excision  can  prevent  the  further  development  of  the  disease ;  but  it  must  be 
done  within  forty-eight  hours,  or  three  days  at  the  utmost,  and  cases  in  which  this 
is  possible  are  altogether  exceptional.  By  the  time  the  chancre  has  developed  it 
is  certainly  too  late,  and  in  this  respect  the  analogy  with  such  diseases  as  malig- 
nant inistule  fails  com])letely. 


112       GENERAL  PATHOLOGY  OF  SURGICAL   DISEASES. 

I.  General. — The  general  principles  of  treatment  are  easily  laid  down. 
Mercury  and  the  iodides  of  potash,  soda,  and  ammonia  are  the  only  drugs  that  exert 
any  direct  influence  upon  the  syphilitic  virus  and  its  effects ;  the  details  vary  very 
widely.  The  first-named  is  chiefly  in  use  in  the  earlier  stages  of  the  disease, 
although  there  are  many  cases  in  which  its  action  is  beneficial  throughout ;  it 
seems  to  act  as  a  specific,  causing  the  primary  induration  to  melt  away  much  more 
rapidly  than  it  otherwise  would ;  delaying  in  a  most  remarkable  manner  the 
appearance  of  secondary  symptoms  ;  not  unfrequently  preventing  them  altogether, 
and  rendering  the  whole  course  of  the  disease  very  much  more  mild  ;  but  it  must 
be  given  with  proper  care.  There  is  no  doubt  that,  if  used  in  an  indiscriminate 
fashion,  it  is  capable  of  producing  the  most  ghastly  results,  necrosis  of  the  bones  of 
the  face,  for  example  ;  and  also  that  certain  i)eople  are  peculiarly  susceptible  to  its 
influence.  Their  number,  however,  is  exceedingly  small ;  if  sufficient  precautions 
are  taken,  they  run  practically  no  risk,  and  the  danger  is  completely  outbalanced 
by  the  extraordinary  good  it  does  to  the  majority. 

How  mercury  should  be  given  does  not  really  seem  of  much  importance  so 
long  as  the  method  adopted  agrees  with  the  patient,  brings  him  quickly  under  the 
influence  of  the  drug,  and  is  fairly  convenient.  It  should  be  commenced  at  once, 
as  soon  as  the  diagnosis  is  made.  It  is  true  that  sometimes  of  themselves  second- 
ary symptoms  fail  to  develop  after  a  hard  chancre,  but  the  prospect  of  this  is  too 
remote,  and  there  is  some  evidence  in  favor  of  the  view  that,  possibly  because 
of  the  neglect  of  specific  treatment  in  the  earlier  stages,  cases  of  this  kind  not 
unfrequently  suffer  much  more  severely  later.  The  administration  should  be  con- 
tinued, gradually  but  steadily  increasing  the  amount,  until  the  patient  is  definitely 
brought  under  the  influence  of  the  drug — until  the  teeth  begin  to  feel  too  long, 
and  it  is  painful  to  bite  a  crust ;  beyond  this  stage  of  incipient  salivation  it 
should  never  be  carried.  The  treatment  must  be  kept  up  with  occasional  inter- 
missions until  all  the  secondary  symptoms,  and  especially  the  glandular  enlarge- 
ments, have  disappeared.  After  that  it  may  be  dropped,  although  in  most  cases 
a  short  course,  for  a  month  or  so,  is  advisable  two  or  three  times  in  the  next  two 
years. 

Salivation,  when  it  is  rapidly  induced,  sometimes  causes  local  lesions  to  dis- 
appear in  a  marvelous  manner  ;  but  it  has  little  or  no  influence  upon  the  general 
disease ;  it  compels  the  administration  to  be  suspended  at  once,  and  there  is 
some  evidence  to  show  that,  even  when  it  is  not  pushed,  as  it  was  in  days  gone  by, 
it  is  exceedingly  injurious,  tubercular  eruptions  and  rupia  making  their  appear- 
ance, afterward,  during  the  period  of  forced  inaction  that  must  follow.  The  object 
at  the  present  day  is  to  begin  very  gradually,  feeling  the  way,  as  it  were,  and  to 
keep  the  patient  under  the  influence  of  the  drug  for  a  considerable  length  of 
time,  without  ever  pushing  it  so  far  that  it  must  be  left  off.  As  soon  as  the  point 
of  incipient  tenderness  is  reached  the  dose  must  be  diminished  and  everything 
done  to  prevent  the  condition  of  the  gums  becoming  worse.  In  this  respect  patients 
differ  very  greatly  from  each  other.  Independently  of  individual  peculiarities, 
which  sometimes  are  so  strongly  marked  as  almost  to  prevent  the  drug  being  taken 
at  all,  a  great  deal  depends  upon  the  condition  of  the  teeth  and  the  mode  of  life. 
If  the  teeth  are  decayed,  or  if  there  is  a  collection  of  tartar  round  them,  tender- 
ness begins  much  earlier,  and  the  red  line  of  incipient  inflammation  is  distinct 
much  sooner  than  when  they  are  perfect ;  if,  on  the  other  hand,  they  have  been 
lost  from  any  cause,  it  is  very  difficult  to  affect  the  gums.  Hutchinson  has  also 
pointed  out  that  salivation  is  much  more  readily  induced  when  a  patient  is  con- 
fined to  bed  than  when  he  is  going  about  his  every-day  work,  and  that  it  is  dis- 
tinctly checked  by  the  use  of  tonics.  Abroad,  where  mercury  is  pushed  to  a  much 
greater  extent  than  is  usual  in  England,  especially  for  tertiary  affections,  strong 
astringent  gargles  are  used  to  check  the  tendency. 

The  simplest  and  most  convenient  method  is  by  the  mouth  in  X\v^fonn  of  pills. 
Hyd.  c.  cret.  (gr.  ij  (.12  gramme)  three  times  a  day)  hardly  ever  disagrees, 
especially  if  given  with  a  grain  of  Dover's  powder,  and  this  may  be  continued  for 


SYPHILIS. 


"3 


many  months  without  causing  the  least  disturbance,  gradually  increasing  the  fre- 
quency of  the  dose  (rather  than  the  amount)  if  the  patient  does  not  resent  it  and 
the  effect  is  not  sufficiently  rai)id.  Many  jjatients  are  decidedly  more  comfortable 
and  feel  better  while  they  are  taking  it,  very  ])robably  from  the  action  of  the  drug 
upon  their  liver.  A  grain,  or  a  grain  and  a  half  (.06  or  .09  gramme),  of  blue 
pill,  with  a  small  quantity  of  opium,  may  be  used  in  the  same  way.  Others  prefer 
calomel,  or  the  green  iodide;  but  the  latter  is  distinctly  more  inclined  to  caues 
purging. 

Inunction  is  chiefly  useful  in  those  cases  in  which,  in  spite  of  the  addition  of 
opium,  mercury  jjcrsists  in  causing  dyspepsia,  loss  of  ai)petite,  or  diarrhoea. 
Otherwise  it  does  not  possess  any  real  advantage  ;  and,  although  they  will  put  up 
with  it  abroad,  when  they  devote  themselves  entirely  to  their  own  treatment,  most 
patients  object  to  it  in  England  as  intolerably  dirty.  Twenty  to  forty  grains  (2.40 
to  4.80  grammes)  of  mercurial  ointment  are  rubbed  in,  at  first  every  other  day, 
and  then,  if  the  effect  is  not  sufficiently  rapid,  every  day  ;  the  sides  of  the  chest 
and  abdomen,  and  the  inner  surfaces  of  the  arms  and  thighs  being  the  places 
usually  selected,  owing  to  the  thinness  of  the  skin  and  the  absence  of  hair  follicles. 
Flannel  should  be  worn  afterward,  and  the  part  should  not  be  washed  for  twenty- 
four  hours.  Care  should  be  taken  to  change  the  locality  frequently,  for  fear  of 
causing  an  eczematous  eruption. 

Fumigation  with  calomel  may  be  tried  with  advantage  where  there  is  a  copious 
skin  eruption.  The  ordinary  apparatus  is  a  spirit  lamp,  with,  over  it,  a  metal 
saucer  containing  a  small  quantity  of  water  ;  and  in  the  middle  of  this  a  metal  disc 
on  which  the  calomel  (twenty  grains)  (2.40  grammes)  is  placed.  The  patient  is 
seated  on  a  chair  with  a  mackintosh,  or,  if  this  is  not  available,  a  blanket  wrapped 
round  him,  reaching  from  the  neck  to  the  floor.  When  the  lamp  is  lit,  the  water 
evaporates  first,  producing  copious  perspiration,  and  then,  as  soon  as  the  disc 
becomes  sufficiently  heated,  the  calomel  sublimes  in  the  form  of  a  fine  vapor,  and 
is  deposited  upon  the  skin  while  this  is  in  a  condition  well  prepared  to  receive  it. 
If  the  throat  is  affected  the  patient  may  take  the  opportunity  of  inhaling  some  of 
the  vapor.  Afterward,  as  soon  as  the  sublimation  is  complete,  the  patient  should 
be  wrapped  up  warmly  and  placed  in  bed  without  being  wiped. 

Hypodermic  injectioji  of  bichloride  of  mercury  (gr.  ^3)  (.02  gramme)  into 
the  substance  of  the  muscles  is  used  to  a  considerable  extent  upon  the  Continent, 
but  has  not  found  much  favor  in  England,  owing  to  the  pain  and  risk  of  suppura- 
tion. 

Diet  and  Regimen. — Whichever  plan  is  adopted,  it  is  absolutely  essential  that 
the  patient  should  exercise  the  greatest  care  in  his  manner  of  living.  Stimu- 
lants are  better  withheld  altogether  ;  old  claret  is  the  least  objectionable.  Every- 
thing that  tends  to  disturb  digestion  must  be  avoided  ;  rules  for  this,  of  course, 
vary  with  the  individual.  Clothing  should  be  warm  ;  exposure,  especially  at 
night,  carefully  guarded  against,  and  a  fair  amount  of  time  allowed  for  sleep. 
Warm  baths  should  be  taken  twice  a  week  at  night ;  but  if  the  patient  is  accus- 
tomed to  it,  there  is  no  objection  to  the  cold  bath  in  the  morning,  always  pro- 
vided the  reaction  is  good.  When  the  skin  eruption  is  of  an  obstinate  character, 
vapor  baths,  or  small  doses  of  pilocarpine,  sometimes  effect  a  rapid  improvement. 
Smoking  is.  strictly  prohibited  ;  it  is  almost  impossible  to  cure  a  tongue  or  a  throat 
that  is  constantly  being  irritated  with  hot  tobacco-smoke.  Exercise  in  the  open 
air  is  very  essential ;  and  where  the  patient's  circumstances  admit  of  it,  residence 
at  the  seaside,  or,  better  still,  a  sea  voyage,  is  of  very  great  benefit.  Rupia.  in 
particular,  frequently  resists  everything  until  the  patient  goes  to  the  sea.  It  can- 
not be  too  strongly  impressed  upon  those  suffering  from  syphilis  that  the  only 
prospect  of  cure  is^early  and  thorough  treatment,  and  that  proper  attention  to 
their  general  condition  is  quite  as  important  as  the  administration  of  mercury. 

The  iodides  are  of  little  use  at  the  commencement  of  the  disease.  It  has 
never  been  proved  that  they  exert  any  special  influence  upon  the  primary  indura- 
tion or  the  secondary  eruptions.    On  the  other  hand,  when  the  bones  are  involved, 


114       GENERAL  PATHOLOGY  OF  SURGLCAL   DISEASES. 

and  in  the  later  stages,  when  there  is  a  celhilar  exudation  of  a  chronic  character, 
rather  than  acute  hypersemia,  they  give  relief  almost  at  once.  It  is  not  claimed 
for  them,  as  it  sometimes  is  for  mercury,  that  the  yare  able  to  cure  syphilis  ;  their 
influence  is  rather  upon  the  manifestations  of  the  disease  than  the  disease  itself; 
but  in  their  proi)er  place  they  are  scarcely  less  valuable,  and,  when  mercury  cannot 
be  taken,  are  practically  the  only  drugs  to  rely  u])on.  Iodide  of  potash  is  the  one 
usually  selected,  but  the  corres])onding  salts  of  sodium  and  ammonia  are  equally 
powerful  and  possess  the  advantage  of  not  being  so  depressing  in  their  action. 

The  dose  varies  from  a  grain  to  a  drachm  (.06  to  3.60  grammes)  or  more  three 
times  a  day.  Small  ones  should  always  be  used  at  the  beginning  ;  if  they  do  not  suc- 
ceed the  amount  may  be  increased  step  by  step,  and  it  is  not  uncommon  for  a  distinct 
improvement  to  follow  each  addition,  but  the  dose  that  is  reached  in  this  way  is 
often  enormous.  A  large  one  at  first  might  be  unnecessary  and  very  possibly 
harmful.  Many  patients  are  peculiarly  affected  by  it.  It  nearly  always  brings 
on  a  profuse  watery  coryza  with  irritation  of  the  conjunctiva,  but  usually  this  sub- 
sides in  the  course  of  a  few  days,  even  if  the  drug  is  continued.  f]xceiJtionally  it 
is  severe,  not  abating  in  the  least,  and  is  associated  with  such  intense  depression 
that  i)atients  absolutely  refuse  to  take  any  iodine  at  all.  This  occurs  especially 
with  the  potash  salt,  and,  although  it  may  be  to  some  extent  obviated  by  the  addi- 
tion of  carbonate  of  ammonia,  it  is  better  in  such  cases  always  to  prescribe  the 
soda  and  ammonia  ones  instead. 

Cutaneous  eruptions  are  frequently  caused  by  the  iodides,  the  three  in  this 
respect  being  apparently  equal.  Acne  is  the  most  common,  occurring  upon  the 
usual  situations,  the  face  and  shoulders  ;  but  much  more  severe  vesicular  and  bul- 
lous eruptions  are  sometimes  met  with,  and  purpuric  spots  occasionally  make  their 
appearances  upon  the  lower  extremities.  Wasting  and  diminished  sexual  power 
are  not  uncommon  during  the  administration,  but  the  effect  is  not  a  lasting  one, 
and  cases  in  which  atrophy  of  the  testes  or  the  breasts  is  stated  to  have  followed 
are  for  the  most  part  open  to  suspicion. 

The  bichloride  of  mercury  and  iodide  of  potash  are  frequently  given  together 
(forming  a  biniodide  soluble  in  excess  of  the  potash  salt),  especially  in  the  later 
stages  of  the  disease,  when  it  is  wished  to  continue  the  use  of  the  drug  for  a  con- 
siderable length  of  time  without  risk  of  salivation. 

Other  drugs  are  of  use  in  individual  cases.  Iron  is  the  most  general.  By 
itself  it  has  little  or  no  effect  upon  the  anremia,  but  with  mercury  it  very  soon 
brings  about  a  complete  change.  Arsenic  is  sometimes  useful,  but  there  is  no 
proof  that  quinine  or  sarsaparilla  has  any  influence  upon  the  disease.  Cod-liver 
oil,  quinine,  and  other  tonics  are  frequently  required  in  the  later  stages,  but, 
according  to  Hutchinson,  they  rather  delay  the  action  of  mercury  at  the  com- 
mencement. 

2.  Local  and  Special  Treatment. — This  is  equally  important  ;  it  often  happens 
that  an  eruption  or  a  sore  which  resists  everything  internally  yields  at  once  to 
local  applications. 

Lotio  nigra,  or  a  very  weak  mercurial  ointment,  is  the  best  application  for  a 
hard  chancre.  The  ordinary  mild  forms  of  secondary  eruption  disappear  rapidly 
as  soon  as  the  effect  of  the  mercury  begins  to  make  itself  felt ;  but  the  more  severe 
ones,  particularly  in  the  later  stages,  when  there  are  local  causes  at  work,  require 
something  further. 

Sore  throat,  ulcers  in  the  tonsils,  and  roseolous  spots  on  the  mucous  membrane 
of  the  mouth,  may  be  treated  with  a  gargle  of  equal  parts  of  chlorate  of  potash 
and  lotio  nigra;  or  of  bichloride  of  mercury  (gr.  ^^  ad  5J)  (.015  to  32  grammes) 
and  bark.  Calomel  fumigation  is  useful  where  there  is  obstinate  ulceration  in  a 
specially  inaccessible  part.  The  drug  is  placed  in  a  glass  tube  drawn  out  to  a 
fine  point  at  one  end,  and  at  the  other  connected  with  an  ordinary  ball  syringe. 
The  calomel  is  vaporized  by  means  of  a  spirit  lamp,  and  a  gentle  current  of  air 
sent  through  the  tube,  so  that  a  fine  film  is  deposited  in  any  spot  that  requires  it. 

Condylomata  and  mucous  patches  must  be  kept  dry.      Equal  ])arts  of  calomel 


SYPHILIS.  115 

and  oxide  of  zinc  may  be  dusted  over  cutaneous  ones.  When  they  occur  ujjon 
the  tongue  they  can  be  painted  over  with  a  sohition  of  bichloride  (gr.  ij  ad  5J) 
(.12  to  32  grammes),  or  of  bicyanide  of  mercury  (gr.  v  ad  5J)  (.30  to  32 
grammes).  Cracks  and  painful  fissures  at  the  angles  of  the  nose  and  lips  may  be 
cured,  as  a  rule,  by  a  single  application  of  nitrate  of  silver  (solid)  ;  but  they  tend 
obstinately  to  return. 

Fhagcdcefia  and  the  spreading  form  of  syphilitic  lupus  require  iodoform  and 
continuous  warm  baths;  or,  if  they  occur  upon  the  face,  the  acid  nitrate  of 
mercury  freely  applied.  The  ])ain  is  relieved  to  some  extent  by  cocaine.  Some- 
times the  chronic  persistent  variety  requires  scraping. 

Rupia  is  the  most  difficult  of  all  the  early  syphilitic  manifestations.  It  is 
most  common  in  the  intemperate  and  tho.se  who  have  been  salivated;  but  some- 
times it  breaks  out  without  apparent  reason.  Very  small  doses  of  mercury  seem 
to  agree  with  it  best,  sometimes  in  conjunction  with  iodide ;  but  whenever  it  is 
possible  the  patient  should  be  sent  to  the  sea,  and  made  to  lead  a  perfectly  healthy 
and  temperate  life.  Iodoform  is  the  best  local  application  to  the  ulcers  as  soon 
as  the  scab  can  be  detached. 

Palmar  and  plantar  psoriasis  may  be  treated  either  with  an  ointment  of  the 
ammonio-chloride  of  mercury  (gr.  xv  ad  %)  (.90  to  32  grammes)  or  with  the 
ordinary  bhie  ointment,  a  piece  of  rubber  or  other  impervious  plaster  being  fixed 
over  the  whole  dressing,  so  as  to  ensure  the  softening  of  the  epidermis  and  the 
absorption  of  the  drug. 

Early  secondary  periostitis  disappears  in  a  day  under  the  influence  of  the 
iodide.  The  later  affections  of  bone  do  not  get  well  so  readily,  but  the  pain  can 
usually  be  relieved  at  once.  Sclerosing  ostitis  and  hyperostosis  in  hereditary 
syphilis  are  exceptions  ;  iodide  seems  scarcely  to  have  any  effect  upon  them.  If 
there  is  a  gumma  on  the  bone  the  exudation  is  absorbed,  but  the  inflammation 
seems  to  progress  unchecked  beneath.  Subcutaneous  division  of  the  periosteum 
and  linear  osteotomy  are  occasionally  resorted  to  when  the  pain  is  severe,  but 
the  benefit  is  rarely  more  than  temporary.  Mercury  is  equally  powerless,  and 
local  applications,  with  the  possible  exception  of  the  actual  cautery,  answer  no 
better.  Fortunately  the  pain  seems  gradually  to  wear  itself  out  after  a  time ;  in 
all  probability  the  tension  and  compression  of  the  nerve  filaments  at  length  cause 
atrophy  ;  but  it  may  be  years  before  this  happens. 

Gummata  and  serpiginous  ulcerations  in  the  tertiary  period  require  iodide 
freely.  Small  quantities  of  mercury  are  exceedingly  beneficial  at  the  same  time, 
either  applied  locally  in  the  form  of  black  wash,  or  given  as  the  biniodide,  inter- 
nally. This  is  particularly  useful  where  it  is  desired  to  keep  up  the  administration 
for  any  length  of  time. 

In  chronic  affections  of  the  nervous  system  it  answers  best  to  begin  with  small 
doses  of  mercury,  and  gradually  to  push  it  until  a  distinct  effect  is  produced  upon 
the  gums.  If  this  cannot  be  borne,  iodide  must  be  given  ;  but  alone  it  rarely 
succeeds  so  well.  After  a  certain  time  the  biniodide  may  be  tried  and  kept  up 
for  a  year  or  more.     Relapses  are  very  common. 

Iritis  and  neuro-retinitis  require  the  administration  of  mercury  to  be  pushed 
vigorously.  In  cases  such  as  these  it  is  necessary  to  check  the  exudation  as  soon 
as  possible. 

In  the  inherited  form  either  small  doses  of  hyd.  c.  cret.  may  be  given  night 
and  morning,  or  inunction  may  be  tried,  a  small  quantity  of  mercurial  ointment 
being  placed  inside  a  flannel  binder  sewn  around  the  body.  Iron  is  usually  very 
beneficial  at  the  same  time.  The  later  affections  that  appear  at  puberty  must  be 
treated  as  the  tertiary  ones  of  the  acquired  form  ;  but  they  are  seldom  so  tractable, 
and  usually  require  mercury  in  addition  to  the  iodide. 

If  the  attack  is  recent,  or  if  there  have  been  recent  miscarriages,  small  doses 
of  mercury  should  be  taken  during  the  whole  course  of  pregnancy.  If  the  father 
is  infected  precautions  of  a  similar  character  should  be  adopted.  Marriage  should 
on  no  account  be  sanctioned  until  at  least  two  years  have  elapsed  from  the  original 
attack  and  six  months  from  the  disappearance  of  the  last  symptom. 


ii6       GENERAL   PATHOLOGY  OF  SURGLCAL   DLSEASES. 


LEPROSY. 

Leprosy  is  a  contagious  disease,  very  chronic  in  its  course,  in  many  respects 
analogous  to  syphilis,  and  caused  by  a  specific  bacillus,  which  resembles  that  of 
tubercle  in  its  behavior  to  staining  reagents,  though  its  size  is  smaller. 

The  disease  is  very  widely  spread.  Formerly  it  was  common  in  England  and 
Scotland  ;  at  the  present  day  it  is  only  met  with  when  imported.  In  Norway, 
Iceland,  the  East  and  West  Indies,  Palestine,  and  other  countries,  it  is  of  frequent 
occurrence.  It  is  not  connected  with  diet,  climate,  syphilis,  malaria,  or  other 
diseases,  except  in  so  far  as  they  lower  the  vitality  of  the  tissues  and  weaken 
their  power  of  resistance.  Heredity  is  doubtful  ;  but  there  is  no  question  as  to 
its  being  contagious,  although  probably  individual  predisposition  varies  very 
considerably. 

Pathology. — The  essential  feature  in  all  the  lesions,  no  matter  how  much 
they  differ  in  appearance,  is  the  production  of  masses  of  granulation-tissue,  similar 
to  that  formed  in  tubercle  and  syphilis,  with  giant-cells,  round-cells,  and  all  the 
intermediate  varieties  that  occur  as  a  result  of  chronic  irritation.  The  so-called 
lepra-cells  are  merely  leucocytes,  connective-tissue  corpuscles,  or  epithelioid  cells 
from  the  interior  of  the  lymphatics  or  capillaries,  transformed  by  the  action  of 
the  bacillus  ;  every  grade  can  be  found  between  the  leucocyte  with  the  single 
germ  and  the  lepra-cell  with  myriads.  The  subsequent  development  depends 
partly  upon  the  stage  of  the  di.sease,  partly  upon  the  condition  of  the  patient,  and 
the  presence  or  not  of  other  organisms,  especially  those  that  cause  suppuration. 
The  newly-formed  granulation-tissue  is  never  very  well  supplied  with  vessels ; 
even  at  the  commencement  of  the  disease  it  wastes  away,  undergoing  caseation 
and  absorption,  or  developing  into  dense  fibroid  tissue ;  later  it  breaks  down, 
suppuration  sets  in,  and  not  unfrequently  phagedaenic  ulceration  with  immen.se 
destruction  follows.  The  changes  are  the  same  whether  it  occurs  upon  the  skin, 
in  internal  organs,  or  on  mucous  surfaces,  the  internal  complications  to  which  it 
gives  rise  not  uncommonly  proving  the  immediate  cause  of  death. 

Symptoms. — Leprosy  exists  in  two  forms,  the  tubercular  and  the  anaes- 
thetic ;  the  former  is  the  more  common  in  temperate  climates,  the  latter  in  the 
tropics,  but  there  is  no  essential  difference  between  them,  and  they  may  occur  in 
the  same  patient  as  a  mixed  form.  The  bacillus  has  only  been  proved  to  exist  in 
the  tuberculated  variety. 

Certain  vague  prodromata,  which  may  last  months  or  even  years,  are  present 
in  both.  Chills  with  occasional  attacks  of  fever,  but  very  rarely  anything  like  a 
genuine  rigor,  weakness,  drowsiness,  and  vertigo  are  the  most  common,  varying 
from  time  to  time,  and  indicating  little  more  than  a  general  failure  of  health.  The 
local  symptoms  are  characteristic. 

I.  The  tuberculated  variety. — The  skin  and  subcutaneous  tissue  usually  suffer 
first,  especially  on  the  face;  then  the  mucous  membrane  of  the  mouth,  tongue, 
and  larynx  ;   finally  it  becomes  general. 

Erythematous  patches,  little  nodules,  tubercles,  and  finally  giant  mas.ses,  the 
size  of  an  egg  and  even  larger,  make  their  appearance  in  successive  crops,  gradually 
getting  worse  and  worse,  and  each  outbreak  attended  with  a  feverish  attack.  At 
first  the  skin  only  is  involved  ;  dusky,  red,  slightly  raised  patches  of  various  size, 
associated  with  hyperaesthesia,  form  upon  the  face,  forehead,  arms  (especially  the 
extensor  surface),  and  legs.  They  are  fairly  well  defined  at  the  margin,  and  after 
lasting  some  little  time  disappear,  leaving  the  skin  where  they  were  pale,  pig- 
mented, and  atrophied.  The  hyperaesthesia  disappears  with  the  exudation,  and  is 
succeeded  by  distinct  impairment,  but  there  is  no  general  anaesthesia,  as  in  the 
other  form. 

Then,  as  the  disease  advances,  these  are  .succeeded  by  crops  of  dusky  red  or 
brown  nodules  and  tubercles,  scaly  upon  the  surface,  and  involving  the  deeper 
tissues  as  well  as  the  skin.  The  smaller  and  earlier  ones  disappear  as  before ;  the 
larger  ones,  although  they  too  may  become  absorbed,  not  unfrequently  break  down 


LEPROSY.  117 

and  suppurate,  forming  deep,  red,  and  glazed  ulcers,  which  heal  very  slowly.  By 
degrees,  as  the  tubercles  become  more  frefjuent  and  larger  and  the  surrounding 
inflammation  more  severe,  the  aspect  of  the  face  is  completely  changed.  The  eye- 
lids, nose,  lips,  and  ears  are  enormously  increased  in  size,  and  distorted  by  great 
bosses  and  masses  of  (judematous  tissue  interspersed  with  scars.  The  forehead  is 
covered  with  folds  of  thickened  hypertrophied  skin  ;  the  hands  and  arras  and  the 
trunk  are  more  or  less  deformed  in  the  same  way.  The  general  health  fails ; 
strength  and  energy  are  lost ;  sexual  power  disappears,  and  a  condition  of  complete 
prostration  follows. 

Other  symptoms  are  caused  by  similar  eruptions  upon  the  mucous  membranes. 
The  voice  becomes  altered  ;  ozaena  sets  in  from  ulceration  of  the  nose ;  diarrhfjea 
is  not  uncommon  :  jjulmonary  complaints  follow  from  the  inhalation  of  foul  and 
putrid  discharges  ;  and  the  immediate  end  is  not  unfrequently  caused  by  some  low 
type  of  inflammation  consequent  upon  phagedaenic  ulceration  of  the  mouth  and 
fauces. 

2.  The  ancEsthetic  variety  is  attended  by  similar  prodromata.  The  local  symp- 
toms, however,  are  traceable  almost  entirely  to  disease  of  the  nerves. 

Patches  of  hyperaesthesia,  with  shooting  pains  and  eruptions  of  small  bullae 
upon  the  hands,  forearms,  and  legs,  are  the  earliest  sign.  The  skin  of  the  fingers 
becomes  glossy  and  red,  and  the  muscles  waste,  corresponding  to  the  distribution 
of  one  of  the  nerves,  esj^ecially  the  ulnar  or  median,  which  can  often  be  felt 
enlarged.  Then  dry,  yellowish-white,  scurfy  spots  appear  upon  the  back  and 
shoulders  and  over  the  knees  and  elbow.  In  the  centre  of  each  sensation  is  lost ; 
round  the  margin,  which  is  often  raised  and  even  vesicular,  there  is  for  the  time 
some  degree  of  hyperaesthesia.  These  keep  increasing  in  size  and  number;  the 
area  of  anaesthesia  slowly  spreads,  mascular  wasting  becomes  more  rapid  ;.  the  joints 
become  stiff  and  contracted  ;  and  finally,  after  many  years'  duration,  the  skin 
over  the  whole  body  may  be  atrophied,  dry,  and  white  or  yellow,  according  to  the 
depth  of  complexion. 

Bullae  are  not  uncommon  here  and  there  upon  the  exposed  parts ;  pjerforating 
ulcer  may  occur  upon  the  foot ;  severe  injuries  are  often  sastained  owing  to  the 
total  absence  of  sensation,  and  dry  or  moist  gangrene  occasionally  sets  in  and 
follows  its  usual  course,  according  to  the  presence  of  septic  decomposition  or  not. 

In  addition,  the  most  extraordinary  deformities  are  caused  by  absorption  and 
wasting.  The  phalanges  of  the  fingers  may  disappear  until  the  nails  rest  upon  the 
ends  of  the  metacarpal  bones ;  the  hands  may  assume  a  peculiar  claw-like  form 
from  atrophy  of  the  interossei ;  drop-wrist  may  occur  ;  the  toes  may  disappear  ; 
and  what  with  gangrene,  wasting,  interstitial  absorption,  and  ulceration  (which, 
however,  is  rarely  so  severe  as  in  the  tuberculated  form)  the  most  extreme  degree 
of  mutilation  may  be  produced. 

The  immediate  cause  is  the  infiltration  of  the  growth  into  the  substance  of 
the  nerves,  giving  rise  at  first  to  irritation  and  hyperaesthesia,  later  to  wasting 
with  anaesthesia  and  degenerative  changes,  the  exact  locality  of  the  symptoms 
depending  in  each  case  upon  the  fibres  involved. 

Treatment. — A  certain  amount  of  improvement  is  stated  to  have  followed 
the  administration  of  Gurjun  oil  fin  lime  water,  3  grs.)  (.18  gramme)  twice  a  day 
and  Chaulmoogra  oil  (in  perles,  each  containing  three  minims),  gradually  increas- 
ing the  dose  until  the  patient's  limit  of  endurance  was  reached  ;  and  this  may  be 
combined  with  their  external  application.  For  the  rest,  all  that  can  be  done  is 
to  treat  symptoms  as  they  arise,  paying  special  attention  to  hygienic  measures 
and  trying  to  check  ulceration  as  far  as  possible.  In  the  anaesthetic  variety 
temporary  improvement  has  been  obtained  by  nerve-stretching  and  ner\'e-splitting, 
the  operation  probably  acting  by  releasing  the  fibres  from  constriction  or  pressure. 


ii8       GENERAL   PATHOLOGY  OF  SURGLCAL  DISEASES. 


TETANUS. 

Tetanus  is  a  disease  characterized  by  tonic  contraction  of  voluntary  muscles, 
either  those  belonging  to  a  single  group  of  actions  or  those  of  the  whole  body. 
It  usually  follows  a  wound,  but  as  this  may  be  of  the  most  trivial  description — z. 
mere  pin-prick,  for  instance — or  be  wanting  altogether,  it  cannot  be  regarded  as 
essential ;  and  it  may  be  acute,  proving  fatal  within  a  few  hours ;  or  chronic, 
lasting  for  days  or  weeks. 

Various  terms  are  applied  to  it,  according  to  the  muscles  involved.  It  is 
known  as  trismus  when  those  connected  with  mastication  are  rigid  (whence  the 
popular  name,  locked  jaw"),  and  trismus  tiascentium  or  neotiatonwi  when  it 
occurs  shortly  after  birth.  If  it  follows  an  injury  to  the  head  it  is  sometimes 
described  as  tetanus  hydrophobicus,  owing  to  the  spasmodic  contraction  of  the 
muscles  of  deglutition  which  is  occasionally  present ;  and  as  opistJwtonos  when 
the  head  is  thrown  back  ;  einprostiwtonos,  when  the  body  is  curved  forward  ; 
and  pleurosthotonos,  when  it  is  thrown  to  one  side.  These  terms,  however,  are 
merely  descriptive,  and  the  two  last  conditions  are  exceedingly  rare. 

Etiology. — Tetanus  is  especially  common  in  certain  races,  and  in  certain 
climates,  but  it  may  attack  any  one.  Lacerated  wounds,  those  in  which  there 
is  a  foreign  body  embedded,  and  gunshot  injuries  of  the  lower  extremities,  are 
said  to  be  more  often  followed  by  it  than  others,  and  decomposition  appears  to 
be  favorable  to  it ;  but  it  may  occur  without  an  open  wound  (as  in  simple  fractures) 
and  even  without  an  injury  of  any  kind.  Exposure  to  cold  and  wet  or  to  great 
changes  of  temperature  is  usually  stated  to  be  a  cause,  but  it  may  be  merely  a 
predisposing  one.  No  doubt  cases  frequently  occur  together,  and  at  times  well- 
marked  epidemics  of  tetanus  have  been  recorded ;  but  whether  this  is  due  to 
contagion  or  to  the  fact  that  the  patients  were  simultaneously  exposed  to  the 
influence  of  the  s-ame  agencies,  is  not  clear.  It  is  a  very  common  disease  in 
horses  and  cattle  generally,  but  dogs  seem  especially  exempt. 

There  are  two  views  with  regard  to  its  pathology  :  the  one,  that  it  is  due  to  an 
abnormal  condition  of  a  peripheral  nerve,  which  either  extends  directly  to  the 
spinal  cord  or  causes  general  reflex  spasm  ;  the  other,  that  it  is  the  product  of 
some  poison  excreted  by  a  living  organism.  Neither  can  be  considered  proved, 
and  not  improbably  there  is  an  element  of  truth  in  both. 

(a)  The  former  rests  chiefly  on  clinical  evidence.  There  is  a  certain  small  but 
undoubted  number  of  cases  in  which  a  distinct  nerve  lesion  has  been  found  (a 
foreign  body,  for  example,  pressing  on  a  nerve  or  embedded  in  it)  and  in  which  the 
symptoms  have  subsided  after  its  removal.  It  has  been  known  to  occur  even  in 
simple  fractures  from  the  pressure  of  a  displaced  fragment. 

Further,  distinct  improvement  occasionally  follows  nerve  section,  although, 
unhappily,  the  number  of  acute  cases  in  which  this  has  taken  place  is  very  small. 
The  success  that  sometimes  attends  excision  of  the  wound  or  amputation  does  not 
point  to  anything,  for  it  may  be  explained  by  the  fact  that  the  poison  is  to  some 
extent  a  local  production,  as  in  malignant  pustule. 

Sometimes  in  man,  and  to  a  much  greater  extent  in  animals,  the  tetanic  symj)- 
toms,  instead  of  beginning  as  trismus,  show  themselves  first  in  the  injured  limb, 
and  even  in  the  muscles  that  correspond  with  the  distribution  of  the  injured 
nerves — in  the  biceps,  for  example,  when  the  musculo-cutaneous  nerve  is  involved. 
This,  however,  is  capable  of  being  explained  on  either  theory. 

The  same  may  be  said  of  the  fact  that  occasionally  in  tetanus,  spasmodic 
attacks  may  be  excited  by  pressing  upon  the  trunk  of  the  nerve  that  is  believed  to 
be  affected  ;  upon  the  ulnar  nerve  at  the  elbow,  for  example,  when  the  injury 
aff'ects  the  little  finger.  This  merely  shows  that  when  the  nervous  system  is  in  the 
peculiarly  excitable  condition  produced  by  this  disease,  the  slightest  stimulus  can 
call  forth  an  entirely  disproportionate  result. 

Nor  is  it  of  much  importance  that  in  a  few  exceptional  cases  evidence  of 
nerve  irritation  (swelling,  hyperaemia,  cellular  infiltration,  etc.)  has  been   found 


TETANUS.  119 

in  the  region  of  the  wound.  If  tetanus  can  be  caused  by  mechanical  irritation  of 
a  peripheral  nerve,  it  should  be  much  more  common  than  it  is  ;  it  should  follow 
neuritis  and  ojjerations  upon  nerves;  and  sutures  and  ligatures,  which  must  often 
involve  nerve  filaments,  should  constantly  give  rise  to  it,  for  the  smallest  wound 
is  enough.  Moreover,  the  actual  number  of  ca.ses  in  which  any  evidence  of  this 
kind  has  been  found  is  exceedingly  small ;  in  the  great  majority  the  condition  of 
the  nerves  round  the  seat  of  injury  presents  nothing  abnormal ;  and  in  a  certain 
proportion  there  is  no  injury  at  all.  In  short,  it  must  be  admitted  that,  although 
it  is  at  present  impossible  to  explain  some  cases,  the  theory  that  tetanus  can  be 
caused  by  mechanical  irritation  only  is  not  proved. 

(b)  There  is  more  evidence  in  favor  of  the  other  view.  The  fact  that  the 
disease  is  distinctly  endemic  as  well  as  epidemic,  that  it  occurs  again  and  again 
in  certain  hospitals  and  in  certain  wards,  until  suddenly  there  is  some  alteration — 
some  improvement  in  the  ventilation,  perhaps — is  most  suggestive.  Of  children 
born  in  the  Rotunda  at  Dublin,  at  one  time  no  less  than  seventeen  per  cent,  used 
to  die  from  it ;  and  epidemics  on  a  smaller  scale  have  been  recorded  in  connec- 
tion with  many  other  institutions. 

The  existence  of  an  incubation  period  again  deserves  consideration.  It  is 
true  it  is  most  irregular ;  the  disease  may  break  out  within  a  {q^n  hours  after  an 
injury,  or  not  occur  for  weeks ;  but  when  the  conditions  are  the  same — in  new- 
born children,  for  example — there  is  such  uniformity  that  in  some  parts  of  the 
country  the  disease  is  known  as  "  nine-day  spasms."  Moreover,  it  is  not  a  little 
singular  that,  as  a  rule,  the  attack  is  milder,  the  course  more  chronic,  and  the 
prognosis  better,  in  proportion  to  the  length  of  time  that  has  elapsed  since  the 
receipt  of  the  injury.  Acute  cases  rarely  survive ;  chronic  ones  and  those  that 
are  not  due  to  a  wound  not  uncommonly.  It  would  almost  seem  as  if  the  short- 
ness of  the  incubation  period  and  the  virulence  of  the  poison  were  in  some  way 
connected  with  the  tissue-changes  that  occur  soon  after  the  infliction  of  a  wound. 

The  results  of  experiment  are  more  definite.  Although  there  is  a  certain 
amount  of  discrepancy,  the  balance  of  evidence  is  distinctly  in  favor  of  its  being 
due  to  a  form  of  bacillus,  living  in  moist  earth,  widely  distributed,  and  closely 
associated  with  the  bacillus  of  putrefaction,  so  that  it  is  exceedingly  difficult  to 
obtain  a  pure  cultivation.  It  is  found  chiefly  in  the  immediate  region  of  the 
wound  (a  fact  which  may  be  of  some  significance  in  connection  with  treatment)  ; 
the  blood  is  rarely  infective,  so  far,  at  least,  as  animals  are  concerned  (in  men 
this  is  not  so  certain,  especially  when  the  disease  is  acute)  ;  evidence  of  its  exist- 
ence has  been  found  in  the  spinal  cord  and  medulla  oblongata ;  and  it  can  be 
cultivated  in  proper  media,  although  with  some  difliculty. 

The  disease  has  been  produced  in  other  ways  :  by  the  hypodermic  introduc- 
tion of  earth  ;  by  using  in  the  same  way  fragments  of  tissues  and  washings  of  wounds 
from  patients  who  have  died  from  the  disease  ;  by  inoculations  with  dust  (it  is 
recorded  that  out  of  seventy  people  injured  in  a  church  during  an  earthquake  at 
Bajardo,  no  less  than  seven  were  attacked  by  tetanus,  and  that  animals  inoculated 
with  dust  from  the  same  place  suffered  in  the  same  way)  ;  by  a  culture  obtained 
from  a  splinter  of  wood  that  had  already  caused  an  attack  of  tetanus ;  and  by 
using  some  of  the  dried  discharge  from  a  pair  of  forceps  that  had  been  employed 
in  castrating  horses. 

It  is  true  that  there  is  some  discrepancy  about  the  form  of  the  bacillus ;  some 
observers  have  been  unable  to  find  it  at  all ;  some  have  succeeded  with  blood, 
others  not ;  some  have  found  it  necessary  to  make  use  of  subdural  injections, 
while  with  others  hypodermic  ones  have  answered  better ;  and  emulsions  of  the 
spinal  cord  are  according  to  some  innocuous,  according  to  others  certainly  fatal. 
For  all  that,  the  broad  facts  must  be  admitted,  that  the  disease  (or  one  so  strikingly 
like  it  that  it  cannot  be  told  from  it)  can  be  caused  almost  at  will  by  the  injection 
of  certain  substances  which  usually  contain  the  same  form  of  organisms.  In  all 
probability  it  is  really  due  to  certain  albumoses   which  have  been  extracted  from 


I20       GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

cultivations,  and  which  have  been  shown  to  be  capable  of  causing  tetanic  convul- 
sions. That  the  disease  in  animals  usually  begins  in  or  near  the  seat  of  inoculation 
is  not  really  very  much  to  the  i)oint,  for  such  cases,  though  they  may  be  rare,  are 
certainly  met  with  in  man.  [Kitasato  obtained,  by  an  ingenious  process,  a  pure 
culture  of  the  tetanus  bacillus  of  Nicolaier,  and  by  inoculation  of  animals  repro- 
duced the  disease.  Verneuil  is  of  opinion  that  contact  with  horses  is  a  necessary 
factor  in  the  causation  of  tetanus.  Larrey  long  ago  cited  instances  where  the  use 
of  soiled  straw  taken  from  a  stable  and  used  by  wounded  soldiers  as  bedding  was 
followed  by  tetanus.  The  tetanus  bacillus  is,  however,  one  of  the  most  widely 
distributed  in  nature.  Brieger  has  also  found  from  pure  cultures  of  the  tetanus 
bacillus  certain  toxalbumins — tetanin,  tetanotoxin,  spasmotoxine,  and  spasmodine 
— and  with  these  poisons  he  produced  tetanus.  It  therefore  now  seems  probable 
that  the  products  of  the  tetanus  bacilli  are  the  immediate  cause  of  the  disease.] 

The  post-mortem  appearances  in  tetanus  are  not  distinctive  in  any  way. 
[Inoculations  made  from  cadavers  dead  from  tetanus  have  reproduced  the 
disease.]  Occasionally  evidence  of  neuritis  is  found,  but  it  is  decidedly  rare  ; 
rupture  of  muscles  and  engorgement  from  asphyxia  might  be  expected.  In  one 
or  two  instances  curious  rounded  points  visible  to  the  naked  eye  have  been  found 
in  the  spinal  cord  and  medulla  oblongata  ;  they  stained  readily  with  carmine  and 
logwood,  were  apparently  homogeneous,  and  pushed  aside  the  nerve  fibres  round 
them ;  but  it  is  not  known  what  significance  is  to  be  attached  to  them.  Dilatation 
of  the  perivascular  lymphatics  in  the  brain  has  also  been  described. 

Symptoms. — Premonitory  symptoms  are  rare.  The  first  definite  sign  is 
usually  jiain  and  stiffness  about  the  muscles  of  the  jaw  and  neck  ;  the  patient  com- 
plains of  sore  throat  or  stiff  neck,  and  imagines  he  has  caught  cold.  Then  it  is 
noticed  that  the  mouth  cannot  be  opened  to  its  full  extent,  though  it  can  still  be 
closed,  and  that  mastication  and  deglutition  are  difficult.  Every  attempt  brings 
on  painful  spasms,  and  seems  to  make  the  contraction  worse.  By  degrees,  some- 
times rapid,  sometimes  slow,  the  painful  contraction  and  the  rigidity  extend  to 
other  muscles  near.  The  orbicularis  oris  may  be  contracted ;  more  frequently 
the  lips  are  drawn  apart  (risus  sardonicus),- the  neck  is  drawn  back  so  that  the 
head  bores  its  way  into  the  pillow,  the  thorax  becomes  rigid  and  the  abdomen 
hard  and  board-like ;  often  there  is  a  fearful  pain  extending  from  the  ensiform 
cartilage  backward  ;  respiration  becomes  shallow  and  rapid ;  the  forehead  is 
bathed  with  sweat ;  the  pulse  small  and  feeble ;  and  the  whole  face  expressive  of 
the  most  intense  anxiety  and  suffering. 

Gradually,  as  the  disea.se  advances,  all  the  muscles  of  the  trunk  become  hard 
and  rigid  ;  the  thighs  and  legs  are  extended  or  drawn  apart,  and  the  shoulders 
and  arms  thrown  out.  The  fingers  and  wrists  usually  escape.  Meanwhile  the 
convulsions  become  more  and  more  severe,  and  the  interval  shorter.  Paroxysmal 
attacks  with  the  most  violent  contractions  come  on  every  few  minutes,  and  with 
every  sound  or  breath  of  air  ;  the  face  is  distorted  ;  the  body  wrenched  and 
twisted  with  the  utmost  violence  into  inconceivable  positions  ;  the  limbs  jerked 
wildly  about,  until  at  length  the  muscles  themselves  give  way  or  are  ruptured. 

Consciousness  is  retained  to  the  last.  The  pain  in  the  acute  forms  is  agoniz- 
ing. Sleep  is  impossible,  except  in  short  snatches  from  sheer  exhaustion  ;  it  is 
said  that  then  there  is  slight  relaxation.  The  bowels  are  confined,  the  urine 
scanty,  and  toward  the  end  the  temperature  often  begins  to  rise,  and  it  may 
continue  after  death  until  it  reaches  112°  F.,  or  even  more.  Sometimes,  just  at 
the  end,  there  is  a  brief  lull  in  the  severity  of  the  symptoms,  but  no  hope  is  to  be 
derived  from  that.  Death  is  generally  due  to  asphyxia  or  heart-failure.  If  this 
does  not  happen,  the  exhaustion  may  be  so  extreme  as  to  prove  fatal  of  itself.  In 
chronic  cases  the  convulsions  diminish  in  intensity  until  only  a  certain  degree  of 
tonic  contraction  is  left ;  a  relapse  is  always  possible  so  long  as  the  slightest  trace 
persists. 

Prognosis. — Acute  tetanus  is  nearly  always  fatal ;  death  may  occur  in  four 


RABIES.  121 

or  five  hours.  After  the  fourth  day  the  chances  of  recovery  increase.  Idiopathic 
tetanus  and  that  which  occurs  late  after  the  infliction  of  a  wound  are  very  much 
more  hopeful. 

There  is  rarely  any  difficulty  in  the  diagnosis,  although  it  must  be  borne  in 
mind  that  a  very  severe  form  of  trismus  if  not  uncommon  when  the  wisdom-teeth 
are  coming  through.  In  any  case  of  doubt  the  interior  of  the  mouth  should  be 
thoroughly  examined  under  an  anaesthetic.  Hysteria,  cerebro-spinal  meningitis, 
attendeil  with  opisthotonos,  and  hydrophobia  occasionally  cause  a  little  hesitation. 
The  last  mentioned  is  sometimes  simulated  very  closely  when  tetanus  complicates 
injuries  of  the  head.  Strychnia-poisoning  reaches  its  maximum  in  the  first  hour, 
and  then  either  proves  fatal  or  gradually  subsides. 

Treatment. — The  wound  should  be  thoroughly  explored,  and  if  the  injury 
is  a  recent  one  and  the  attack  acute,  excised.  It  may  do  no  good,  but  there  is 
some  little  evidence  to  show  that  the  poison  (like  that  of  malignant  pustule)  is  a 
local  one,  in  a  measure  at  least ;  and  it  certainly  can  do  no  harm.  Nerve-section 
and  nerve-stretching  fail  in  acute  cases,  where  their  help  is  wanted. 

The  bowels  should  be  opened  thoroughly,  once  for  all ;  the  patient  placed  in 
a  darkened  room  and  kept  absolutely  quiet.  If  he  can  swallow,  beef-tea,  eggs, 
brandy,  and  wine  may  be  given  freely.  If  not,  nutrient  enemata  must  be  tried. 
According  to  Sir  Thomas  Watson,  wine  in  large  doses,  and  nourishing  diet,  are 
more  likely  to  succeed  than  any  drug. 

Chloral  and  bromide  of  potash  have  undoubtedly  some  influence  upon  the 
severity  of  the  spasms.  Chloroform  inhalation  has  been  tried  and  kept  up  for 
hours,  but  with  only  a  temporary  benefit,  if  any.  Curare  has  failed  completely  ; 
opium  is  of  very  little  use ;  Calabar-bean  raised  a  certain  amount  of  hope  for  a 
time  ;  but  no  drug  has  the  least  effect  upon  the  disease,  though  one  or  two  may 
alleviate  the  most  painful  of  the  symptoms. 


RABIES. 

Rabies  (or  hydrophobia,  as  it  is  called  in  man,  from  one  of  its  prominent 
symptoms)  is  a  specific  disease  resulting  from  the  inoculation  of  the  virus  from  a 
rabid  animal.  There  is  no  proof  that  it  ever  originates  de  novo  ;  it  is  always  com- 
municated, chiefly  from  dogs,  cats,  and  wolves,  although  exceptional  instances  of 
it  having  been  transmitted  from  herbivora  are  on  record  ;  and  human  saliva  and 
human  tissues  have  proved  infective  in  the  case  of  animals.  Although  the  poison 
has  not  yet  been  isolated,  there  can  be  no  doubt  that  it  is  the  product  of  a  living 
organism  ;  it  is  contained  in  the  saliva  and  in  the  blood,  but  its  most  certain  habi- 
tat is  the  central  nervous  system ;  inoculation  with  the  two  former  fail  not  unfre- 
quently  ;  with  the  latter,  very  seldom  ;  and  it  is  capable  of  indefinite  multipli- 
cation within  the  body.  Certain  people  and  certain  dogs  seem  naturally  to  possess 
immunity,  but  probably  this  is  not  so  common  as  at  first  sight  it  appears  to  be, 
many  of  the  cases  being  really  due  to  ineffective  inoculation. 

The  only  morbid  changes  that  are  found  with  any  constancy  are  in  the  low-er 
part  of  the  medulla  oblongata,  round  the  respiratory  and  deglutition  centres,  and 
sometimes  in  the  gray  substance  of  the  cord.  They  consist  chiefly  in  perivascular 
infiltration,  with  glandular  degeneration  of  the  cells  themselves.  Congestion  of 
the  brain  is  sometimes  present,  and  the  pharynx,  fauces,  and  salivary  glands  are 
in  many  instances  deeply  injected  and  stained  with  blood. 

Symptoms. — The  symptoms  of  rabies  in  dogs  differ  in  many  respects  from 
those  of  hydrophobia  in  man,  but  there  is  no  doubt  as  to  the  identity  of  the  two 
diseases. 

In  the  former  the  incubation  period  is  rarely  under  a  fortnight,  very  rarely 

over  three  months.     At  first  there  is  merely  an  alteration  in  general  behavior ; 

the  animal  is  agitated  and  restless  ;  it  may  still  be  obedient,  but  it  is  very  irritable 

toward  strangers  ;  there  is  a  constant  tendency  to  gnaw  everything  and  to  swallow 

9 


122       GENERAL   PATHOLOGY  OF  SURGLCAL   DLSEASES. 

all  sorts  of  substances  ;  in  some  cases  the  wound  a])i)ears  to  annoy  it  ;  and  the 
bark  is  peculiar  and  characteristic,  ending  in  a  long-drawn  howl.  This,  in  two  or 
three  days,  is  followed  by  the  second  or  furious  stage,  in  which  the  animal,  although 
it  appears  to  wish  to  avoid  injuring  those  it  knows,  seems  compelled  to  bite  at 
everything  and  every  one  round.  There  is  no  fear  of  water ;  a  dog  will  often 
plunge  his  head  in  and  drink  freely  ;  but  there  are  certainly  hallucinations,  com- 
ing on  at  intervals,  although  the  animal  is  conscious  and  has  not  lost  all  control 
over  itself.  The  final  stage  of  paralysis  soon  follows,  the  strength  rapidly  failing, 
often  in  the  hind  legs  first,  and  complete  prostration  setting  in.  In  other  animals 
the  symptoms  are  very  much  the  same,  varying,  of  course,  with  the  habits  and 
general  mode  of  life.  In  rabbits,  for  example,  the  first  two  stages  are  not  present, 
and  the  disease  begins  with  paralysis.  Sometimes  the  same  thing  occurs  in  dogs, 
the  .so-called  dumb-madness,  and  even  in  man. 

In  man  the  incubation  period  is  more  variable.  Without  subscribing  to 
cases  in  which  it  is  said  to  have  lasted  ten  years  and  more,  there  can  be  no  doubt 
as  to  its  having  been  as  long  as  fifteen  months.  On  the  other  hand,  it  may  be 
only  a  fortnight,  especially  when  the  bite  is  on  the  face  and  the  animal  was  a  wolf, 
or,  what  is  probably  nearly  as  bad,  a  cat.  As  might  have  been  expected,  the 
shortest  period  is  often  associated  with  severe  and  extensive  injuries.  [In  two 
cases  uncler  the  personal  observation  of  Professor  Senn  the  stage  of  incubation 
lasted  forty-two  days.]  The  wound  may  suppurate  and  appear  unhealthy,  but 
this  is  not  due  to  the  rabic  virus  ;  inoculation  wounds  jjerformed  with  due  pre- 
cautions never  give  rise  to  inflammation. 

The  stages  are  the  same  as  in  the  dog.  A  certain  degree  of  uneasiness  is  often 
noticed  about  the  scar  ;  it  may  be  red  and  irritable,  and  tingling  sensations  are 
not  unfrequently  complained  of.  This  may  last  for  two  or  three  days  before  the 
depression  begins,  or  it  may  be  absent  altogether.  The  patient  becomes  restless 
and  uneasy,  without  being  able  to  assign  a  cause ;  there  is  the  most  extreme 
depression  ;  insomnia  is  of  frequent  occurrence  ;  there  is  complete  loss  of  energy, 
and  in  many  cases  irritability  and  general  malaise.  The  second  stage  usually  sets 
in  suddenly,  with  a  feeling  of  fullness  and  constriction  about  the  throat.  There  is 
no  tonic  contraction  as  in  tetanus,  but  successive  convulsive  spasms,  of  the  most 
violent  character,  involving  particularly  the  muscles  of  deglutition  and  respiration, 
and  excited  by  the  least  breath  of  air  or  the  slightest  sound.  Sometimes  they  are 
so  severe  as  to  threaten  death  from  suffocation  ;  often  there  is  marked  opisthotonos, 
but  in  the  intervals  there  is  usually  complete  relaxation.  General  hyper^esthesia  is 
the  rule  ;  frequently  there  is  great  excitement  of  the  sexual  organs  ;  hallucinations 
are  of  common  occurrence,  and  the  patient  may  be  exceedingly  violent,  but  there 
is  rarely  anything  like  mania,  and  intervals  of  self-control  are  nearly  always  pres- 
ent from  time  to  time.  The  pulse  is  small  and  frequent ;  the  secretion  of  saliva  is 
profuse  but  viscid  ;  the  tone  of  the  voice  is  altered  ;  the  urine  is  scanty,  often  con- 
taining albumin,  and  there  is,  as  a  rule,  intense  thirst,  every  attempt  to  alleviate 
it,  or  even  the  idea  of  drinking,  bringing  on  violent  convulsions.  Gradually, 
after  lasting  perhaps  forty-eight  hours,  the  attacks  diminish  in  severity ;  if  life  is 
sufficiently  prolonged,  a  condition  of  rapidly-ascending  paralysis  sets  in  (probably, 
as  pointed  out  by  Horsley,  the  ascending  paralysis  of  Landry  was  really  hydro- 
phobia), and  the  j^atient  sinks,  retaining  consciousness  more  or  less  to  the  end. 
Death  may  occur  during  the  second  stage,  from  asphyxia  or  from  heart  failure ;  it 
rarely  hapi)ens  that  the  case  lasts  more  than  four  days  from  the  first  commence- 
ment of  the  actual  symptoms,  although  in  a  few  instances  the  jjatient  has  lingered 
for  a  week. 

Although  some  of  the  symptoms,  even  the  hydrophobia,  are  occasionally 
wanting,  there  is  rarely  any  difficulty  in  the  diagnosis.  Tetanus,  especially  that 
form  of  it  which  sometimes  follows  wound  of  the  head,  resembles  it  more  closely 
than  anything  else,  but  trismus  is  absent  in  rabies,  and  there  are  always  periods 
of  remission.      Hysteria,  hystero-epilepsy,   and  even  mania  have  been  mistaken 


RABIES.  123 

for  it,  and  there  is  a  certain  number  of  cases  on  record  in  which  all  the  symptoms 
have  been  i)resent,  and  in  which  death  has  followed,  without  its  being  possible  to 
find  any  evidence  or  any  history  of  inoculation. 

Prognosis. — The  disease,  if  left  to  itself,  is  absolutely  fatal.  No  authenti- 
cated case  of  recovery  after  the  first  symptoms  have  appeared  is  known,  at  least 
in  human  beings  ;  in  one  of  Pasteur's  experiments  a  dog  recovered,  and  subse- 
quently showed  comjjlete  immunity. 

What  proportion  of  those  who  are  bitten  by  infected  animals  suffer  from  the 
disease  is  very  difficult  to  estimate.  In  the  case  of  dog-bites  it  seems  to  be,  at  the 
lowest  estimate,  fifteen  per  cent.;  cat-bites  are  worse  ;  and  wolf-bites,  especially  on 
the  face,  far  worse  still — no  less  than  eighty  per  cent,  of  these  are  said  to  prove 
fatal.  The  length  of  the  period  of  incubation  varies  in  the  same  manner,  but 
possibly  this  may  be  accounted  for  by  the  greater  severity  of  the  injury.  Bites  on 
exposed  parts  are  more  serious  than  when  the  teeth  have  to  pass  through  se\"eral 
layers  of  clothes  first. 

Treatment. — A  tight  ligature  should  be  placed  at  once  above  the  wound, 
and  bleeding  encouraged  as  much  as  possible.  It  is  not  safe  for  any  one  else  to 
suck  the  wound,  as  the  least  abrasion  of  the  mucous  membrane  is  sufficient. 
The  sooner  the  whole  injured  surface  is  excised  or  thoroughly  cauterized  the 
better. 

No  drug  has  the  least  influence  upon  the  progress  of  the  disease,  although 
chloral  and  morphia  may  relieve  the  pain  and  diminish  the  severity  of  the  spasms. 
The  patient  must  be  kept  perfectly  quiet,  in  the  dark  ;  thirst  must  be  relieved  as  far 
as  possible  by  rectal  injections — if,  that  is  to  say,  there  is  the  ordinary  difficulty  in 
swallowing — and  any  food  that  can  be  taken  must  be  given.  Tracheotomy  is  very 
rarely  required,  and  such  remedies  as  hot  or  vapor  baths  only  serve  to  accelerate 
the  end. 

The  only  treatment  of  any  service  at  all  is  the  inoculation  plan,  discovered 
and  perfected  by  Pasteur,  and  by  which  he  has  succeeded  in  reducing  the  mor- 
tality to  1.47  per  cent,  on  the  whole  number  (2164)  ;  and  to  a  very  much  lower 
figure  still,  if  only  the  later  cases,  and  those  which  applied  for  treatment  soon 
after  the  injury,  are  reckoned. 

The  most  recent  and  complete  account  of  Pasteur's  method  is  that  given  by 
Dr.  Ruffer  at  the  Leeds  meeting  of  the  British  Medical  Association.  The  virus  is 
invariably  present  in  the  cerebro-spinal  nerve-centres.  If  the  rabbit  is  inoculated 
under  the  dura  mater  with  an  emulsion  made  from  the  medulla  of  a  rabid  dog,  the 
first  symptoms  appear  within  fifteen  days,  never  earlier  than  nine.  If  the  medulla 
of  this  rabbit  is  used  to  infect  a  second,  the  period  of  incubation  is  shortened  ;  and 
if  this  system  is  repeated  eighty  times,  at  length  what  Pasteur  terms  '•  fixed  virus  " 
is  reached,  a  poison,  that  is  to  say,  which  has  a  period  of  incubation  of  from  six 
to  seven  days,  and  always  proves  fatal  on  the  tenth. 

The  duration  of  life  of  the  rabic  organism  is  very  limited.  If  the  spinal  cord 
of  a  rabbit  that  has  died  of  hydrophobia  is  preserved  in  a  sterilized  bottle,  the 
air  of  which  is  kept  dry  by  means  of  caustic  potash,  the  organisms  gradually  die 
off,  until  after  ten  or  eleven  days  no  more  are  left  alive ;  only  the  chemical  pro- 
ducts of  their  action  are  still  there.  An  emulsion  made  from  a  cord  in  this  con- 
dition is  used  to  begin  the  treatment. 

It  has  been  proved  that  some  pathogenic  organisms,  when  growing  in  suitable 
media,  produce  chemical  substances  which,  when  injected  into  an  animal,  enable 
that  animal  to  resist  the  action  of  the  specific  organism  itself.  The  object  that 
Pasteur  had  in  view  was,  by  treating  the  patient  during  the  period  of  incubation, 
to  render  him  insusceptible  to  the  disease. 

At  first  an  attempt  was  made  to  effect  this  by  injecting  an  emulsion  of  fresh 
spinal  cord  ;  this  would  contain  living  organisms,  and  their  chemical  products 
too  ;  the  latter  would  act  at  once,  and  confer  immunity  before  the  former  had 
passed  the  incubation  stage,  but  success  was  not  certain. 

By  using  a  spinal  cord  that  has  been  kept  until  all  the  organisms  have  died 


124       GENERAL   PATHOLOGY  OF  SURGLCAL    DLSEASES. 

out,  only  the  protecting  substance  is  injected,  although  jjrobably  the  (inantity  is 
small,  and,  by  repeated  injections,  each  time  making  use  of  a  cord  that  is  one  day 
less  old  than  the  one  before  (and  therefore  contains  more  both  of  the  protecting 
substances  and  of  the  germs),  at  length  a  condition  of  complete  insusceptil)ility  is 
reached  before  the  incubation  period  of  the  original  infection  is  exhausted. 
Thus,  on  the  first  day  of  treatment  an  emulsion  from  a  spinal  cord  dried  for  four- 
teen days,  and  another  dried  for  thirteen,  is  injected  \  on  the  second  day  an 
emulsion  from  one  dried  for  twelve  days,  and  another  from  one  dried  for  eleven  ; 
on  the  third,  two  more,  one  ten  days  old  and  one  nine ;  until,  on  the  fifth  day,  a 
cord  dried  for  six  days  only  is  used.  The  treatment  is  continued  for  sixteen  days, 
each  injection  consisting  of  about  half  a  cubic  centimetre  of  spinal  cord  crushed 
in  two  cubic  centimetres  of  sterilized  beef-tea. 

For  most  cases  Pasteur  found  this  course  sufficiently  rapid  in  its  action,  but 
not  for  wolf-bites,  or  bites  upon  the  face.  For  these,  what  is  known  as  the 
intensive  method  is  employed,  the  same  in  principle  but  more  rapidly  carried  out, 
four  injections  being  made  on  the  first  day,  four  on  the  second,  and  two  on  the 
third,  so  that  on  the  fourth  day  a  cord  is  used  which  has  only  been  kept  five  days. 
Of  fifty  patients  treated  in  this  way  not  one  died. 

Dr.  Ruffer  states,  in  the  most  positive  manner,  that  no  case  is  on  record  in 
which  death  has  been  produced  by  Pasteur's  treatment. 


TUMORS—  CYSTS.  1 25 


CHAPTER  V. 

Tumors. 

By  Frederick  S.  Eve,  F.R.C.S. 

[Tumors  may  be  divided  into  two  general  classes,  neoplasvis  and  cysts,  but 
many  pathologists  only  admit  the  neoplasms.] 

Cysts  or  Cystomata. — A  cyst  may  be  broadly  defined  as  a  cavity  with  well- 
defined  walls  and  fluid  contents.  The  walls  are  composed  of  connective  tissue 
and  are  usually  lined  with  epi-  or  endo-thelium. 

A  cyst  may  be  single  or  simple.  Many  cysts  may  be  grouped  together  to  form 
a  conglomerate  cystic  tumor,  or  a  cystic  tumor  may  be  miilti-lociilar.  The  latter 
term  is  applied  when  the  mass  is  broken  up  into  numerous  cavities  or  loculi  by 
partitions,  and  this  condition  is  produced  either  by  fusion  of  adjoining  cysts  or 
by  the  growth  of  secondary  cysts  within  the  walls  of  the  primary  cavities,  as  in 
ovarian  tumors.  The  secondary  cysts  either  project  externally  (exogenous  cysts) 
or  internally  (endogenous).  A  cyst  is  said  to  be  proliferous  when  a  growth  or 
vegetation  springs  from  its  walls  into  its  cavity. 

Cysts  have  commonly  been  classified  according  to  the  nature  of  their  con- 
tents, as  :   sebaceous,  mucous,  serous,  mucoid,  and  colloid. 

A  primary  classification,  according  to  their  source,  seems  preferable,  as  fol- 
lows : — 

I.  Cysts  arising  in  normal  structures. 

II.  Cysts  arising  in  persistent  foetal  rudiments  and  misplaced  foetal  structures 
(congenital  cysts). 

III.  Cysts  formed  within  or  of  the  nature  of  tumor  formations. 

I.   CYSTS  ARISING  IN  NORMAL  STRUCTURES. 

The  first  class,  which  comprises  the  larger  number,  maybe  further  subdivided, 
on  an  anatomical  basis,  thus  : — 

{a)  Cysts  formed  by  distention  of  serous  sacs  and  synovial  membranes,  or  of 
diverticula  from  the  .same ;  and  by  distention  of  connective-tissue  interspaces 
(exudation  cysts),  /.  e.,  hydrocele,  ganglion,  and  adventitious  bursse. 

{b)  By  distention  of  mucous  membrane  canals,  /.  e. ,  hydro-salpinx,  dilatation 
of  vermiform  appendix,  etc. 

{/)  By  dilatation  of  ducts  and  glands  (retention  cysts),  /.  e.,  sebaceous  cysts, 
ranula,  spermatocele,  and  most  of  the  cysts  of  the  breast. 

(//)  By  distention  of  normally-closed  follicles  in  glands,  i.  <?.,  Graafian  follicle 
cysts  and  some  cysts  of  the  thyroid  gland. 

(^)  By  dilatation  and  cutting  off  of  portions  of  blood  and  lymphatic  vessels. 

(/)  By  encapsulation  of  extravasations  of  blood,  foreign  bodies,  and  parasites, 
/'.  €.,  arachnoid  cysts,  hsematomata,  hydatids,  etc. 

{a)  The  application  of  the  term  cyst  to  many  cavities  abnormally  di.stended 
with  fluid  is  purely  arbitrary  and  founded  on  custom.  Thus,  among  the  first  divi- 
sion, hydroceles  are  not  usually  described  as  cy.sts,  although  they  are  technically 
quite  as  much  so  as  a  dilated  bursa  patellae.  Among  other  examples  of  this  class 
is  the  common  ganglion,  which  is  formed  by  distention  of  diverticula  from  the 
tendons  of  the  dorsum  of  the  hand  and  foot.  Adventitious  bursae  result  from  sepa- 
ration of  connective-tissue  bundles  by  exudation,  the  cavity  becoming  lined  with 
endothelium. 

(/;)   Hydro-salpinx  or  distention  of  the  Fallopian  tubes  by  fluid,  and  disten- 


126       GENERAL    PATHOLOGY  OF  SURGICAL   DISEASES. 

tion  of  the  vermiform  appendix,  are  familiar  examples  of  cysts  formed  by  dilata- 
tion of  mucous  canals. 

{c)  The  cysts  resulting  from  retention  of  secretion  in  normal  ducts  and  in 
glands,  or  retentioJi  cysts,  constitute  surgically  the  most  important  group,  of  which 
the  common  wen  or  sebaceous  cyst  is  an  example. 

Sebaceous  Cysts. — The.se  are  most  common  in  middle  life,  and  their  seats  of 
predilection  are  the  scalp,  back,  shoulders,  and  face.  They  are  rounded  or  lenticu- 
lar, fairly  movable,  and  situated  immediately  beneath  the  skin,  to  which  they  are 
often  adherent.  Upon  their  surface  the  blackened  orifice  of  a  dilated  hair  follicle 
may  often  be  seen,  and  down  this  a  fine  probe  may,  in  many  cases,  be  passed  into 
the  cyst.  The  contents  are  a  yellowish  curdy  material,  either  insfjissated  or  semi- 
fluid, and  showing,  under  the  microscope,  fat  globules,  fat  crystals,  and  epithelial 
cells  undergoing  fatty  degeneration. 

Microscopically  the  walls  are  composed  of  an  external  coat  of  connective 
tissue  lined  internally  with  epithelium.  The  outer  layers  of  cells  are  elongated 
and  vertical  ;  as  the  inner  surface  is  approached  they  become  flattened,  undergo 
fatty  degeneration,  and  finally  form  laminae.  The  cysts  are  probably  formed  by 
dilatation  of  the  hair  follicle  with  sebaceous  secretion  and  eijithelium,  and  not  of 
the  sebaceous  gland  or  its  duct.  They  not  infrequently  become  inflamed  and 
suppurate,  and  occasionally  calcify  ;  they  may  also  become  the  seat  of  secondary 
growths  which  spring  Jrom  their  internal  surface,  namelj- — papillomata,  horns, 
and  epitheliomata. 

The  diagnosis  of  sebaceous  cysts  rarely  presents  any  difficulties  except  from 
dermoid  cysts.  The  latter  can  be  distinguished  by  the  fact  that  they  lie  beneath 
the  deep  fascia,  and  the  skin  is  therefore  freely  movable  over  them,  while 
sebaceous  cysts  lie  within  the  corium  and  are  therefore  attached  to  the  skin.  The 
situation  of  the  cyst,  age  of  patient,  and  other  circumstances  of  the  case  may  also 
assist  in  forming  a  diagnosis. 

Mucous  Cysts. — Retention  cysts  occur  on  mucous  membranes  from  dilatation 
of  the  follicles.  They  are  met  with  on  the  inner  surface  of  the  lip,  base  of  tongue, 
and  on  the  floor  of  the  mouth.  Dilatations  of  Bartholini's  glands  on  the  female 
vulva,  and  very  rarely  of  Covvper's  glands  in  the  male,  may  call  for  surgical  inter- 
ference. 

Ranula  should  also  be  classed  in  this  group,  it  having  been  shown  to  be  due 
to  dilatation  of  one  of  a  pair  of  mucous  glands  lying  beneath  the  mucous  mem- 
brane of  the  mouth  on  each  side  of  the  tip  of  the  tongue.  They  are  known  as 
the  glands  of  Blandini  and  Xuhn.  Ranula  presents  itself  as  a  fluctuating  swelling, 
covered  with  translucent  mucous  membrane,  which  projects  from  the  floor  of  the 
mouth  beneath  the  tip  of  the  tongue,  and  extends  backward  for  some  distance  on 
one  or  the  other  side.  The  cyst  may  attain  the  size  of  a  pigeon's  egg.  On 
opening  it  a  glairy,  fluid-like  egg-albumin  issues  from  it.  The  fluid  is  rich  in 
mucin,  but  does  not  pos-sess  the  characters  of  saliva,  since  it  does  not  give  the 
test  for  sulpho-cyanogen  and  is  incapable  of  transforming  starch  into  malto.se. 

A  cystic  dilatation  of  Wharton's  duct  itself  was  actually  demonstrated  in  a 
case  by  Richet,  but  there  can  be  no  doubt  that  the  ordinary  ranula  originates  in 
the  glands  of  Blandini  and  Xuhn.  [In  every  case  which  has  fallen  under  my 
personal  observation,  the  cyst  has  originated  by  an  obstruction  of  the  ducts  of 
Rivini  (.sub-lingual),  and  not  of  the  glands  of  Blandini.] 

Dermoid  cysts  occur  in  the  same  situation  as  ranula,  and  can  only  be  differ- 
entiated from  them  by  the  nature  of  their  contents. 

Retention  cysts  of  glandular  organs  will  be  described  in  other  parts  of  this 
work.  I  will  only  allude  to  the  fact  that  in  the  breast,  and  perhaps  in  a  less 
degree  in  the  testis  and  kidney,  they  may  be  roughly  divided  into  three  classes  : — 

1.  Involution  cysts  due  to  anomalies  of  development — illustrated  in  the 
breast. 

2.  Cysts  occurring  in  middle  life  resulting  from  sclerosis  and  chronic  inflam- 
mation ;  these  are  observed  also  in  the  breast  and  kidney. 


TUMORS -CVS  vs.  127 

3.  Involution  cysts  accomi)anyin^  the  atrophy  of  senility  in  each  particular 
organ  antl  observed  in  the  breast.  I  have  also  shown  that  spermatocele  may  be 
produced  by  the  same  i)rocess.* 

(^/)  Cysts  of  the  (iraafian  follicles  at  times  resemble  retention  cysts,  in  that 
they  are  preventetl  from  rupturing  by  adhesions,  the  result  of  jteri-ovaritis. 

(^•)  Cysts  formed  by  cutting  oft"  of  portions  of  blood-vessels  are  rare,  and 
are  found  in  connection  with  veins,  especially  the  internal  saphena  ;  one  case  has 
come  under  my  own  observation.  Virchow  records  an  example  in  connection 
with  the  internal  jugular  vein.  A  case  of  cystic  dilatation  of  the  lymphatic 
vessels  of  each  groin,  in  a  youth  aged  twenty,  has  been  described  by  Trelat.  The 
swellings  had  existed  six  years. 

(/)  Cysts  formed  around  extravasations  of  blood,  foreign  bodies,  and  para- 
sites, are  practically  of  the  same  nature,  the  encapsulation  being  due  to  the  for- 
mation and  organization  of  granulation  tissue.  In  illustration  of  the  first  I  may 
allude  to  a  very  large  and  distinctly  defined  blood-cyst  of  the  scrotum,  which  I 
described.  It  followed  a  kick  and  had  existed  sixteen  years.  Ijutlin  has  ])ointed 
out  that  many  cysts  formerly  described  as  blood-cysts  were  probably  soft  sarcomata 
into  which  profuse  extravasation  of  blood  had  occurred  (Jiemorrhagic  sarcoma). 

Proliferous  Cysts. — Many  cysts,  especially  those  of  glandular  organs  and 
mucous  membranes,  may  become  the  seat  of  solid  growths,  which  spring  from 
their  inner  surface.  They  occur  frequently  in  cysts  of  the  lacteal  ducts,  and  the 
disease  then  constitutes  the  true  sero-cxstic  disease  of  Brodie.  The  intra-cystic 
growths  are  softish  and  papillary  on  the  surface.  Under  the  microscope  they 
usually  show  i)apill?e,  between  which  gland-like  tubules,  either  rectilinear  or 
tortuous,  extend  downward  and  give  to  the  mass  the  appearance  of  an  adenoma 
with  scanty  intercellular  substance.  Such  cysts  are  usually  innocent,  but  at  times 
the  growth  is  cancerous  and  infiltrates  the  surrounding  tissues  ;  it  then  constitutes 
the  disease  described  as  villous  cancer. 

Proliferous  or  papillary  cysts  are  also  common  in  the  hilum  of  the  ovary  and 
broad  ligament.  They  have  essentially  the  same  structure,  being  composed  of 
tubular  glands  lined  with  columnar  or  cuneiform  epithelium,  and  their  surface  is 
more  or  less  distinctly  papillary.     They  secrete  mucus  freely. 

Such  papillary  and  adenomatous  intra-cystic  growths  are  homologous  to  warts 
on  the  integument. 

II.   CONGENITAL  CYSTS. 

Cysts  originating  in  persistent  rudiments  of  foetal  structures  and  congenital 
cysts. 

I.  Cysts  formed  in  the  Remains  of  the  Wolffian  Duct  and  Body  in  the 
Female. — The.se  were  first  systematically  described  by  Dr.  Coblentz  in  Virchow's 
Archil',  Bd.  5,  1881.  In  ruminants  and  some  other  mammals  the  whole  of  the 
Wolftian  body  and  duct  persists.  But  in  the  human  female  only  the  anterior  or 
sexual  portion  is  normally  present ;  it  lies  in  the  broad  ligament,  being  known  as 
the  parovarium  or  organ  of  Rosenmiiller.  It  consists  of  twelve  or  fifteen  narrow, 
vertical  tubes  about  half  an  inch  in  length,  which  radiate  upward  from  the  hilum 
of  the  ovary  to  join  a  horizontal  tube  running  nearly  parallel  with  the  Fallopian 
tube.  These  vertical  tubes  represent  the  anterior  or  sexual  segment  of  the 
Wolffian  body ;  a  few  similar  tubes  are  in  rare  instances  found  between  these  and 
the  uterus,  and  are  remnants  of  the  posterior  non-sexual  segment.  The  horizontal 
tube,  known  as  Gartner's  duct,  is  the  duct  of  the  same  organ  ;  it  pa.sses  from  the 
broad  ligament  into  the  side  wall  of  the  uterus,  down  which  it  courses  into  the 
anterior  wall  of  the  vagina,  where  it  is  usually  lost.  Wolffian  remains  also  extend 
into  the  tissue  of  the  hilum  of  the  ovary,  and  in  horizontal  sections  of  that  organ 
are  seen  as  tortuous  rods  or  columns  of  epithelium.      This  portion  of  the  gland 

*  See  "  Catalogue  of  St.  Bartliolomew's  Hospital  Museum,"  Nos.  2807  and  2808. 


128       GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

is  named  the  i)aroophoron,  while  the  ovarian  tissue  i^roper  is  s])oken  of  as  the 
oophoron. 

All  remnants  of  the  Wolffian  body  and  its  duct  give  rise,  by  distention,  to 
cysts,  and  the  great  majority  of  these,  according  to  Doran,  contain  papillary 
proliferous  growths.     They  are  conveniently  classified  as — 

{a)  Hilum  cysts,  which  spring  from  the  hilum  of  the  ovary,  and  are  distin- 
guished from  cysts  of  the  oophoron  by  having  a  layer  of  true  ovarian  tissue  si)read 
over  their  free  surface.      They  often  contain  papillary  intra-cystic  growths. 

{b)  Broad  ligament  cysts.  These  arise  from  the  normally  persistent  vertical 
tubes  or  parovarium,  and  sometimes  in  Gartner's  duct.  The  cysts  lie  between 
the  layers  of  the  broad  ligament,  which  is  usually  evenly  expanded.  The 
Fallopian  tube  courses  over  their  upper  surface,  and  is  much  stretched  if  they 
attain  a  large  size.  They  contain  a  clear,  watery  fluid,  but  sometimes  the  contents 
are  discolored  by  hemorrhages.  In  larger  cysts  an  epithelial  lining  rarely  exists, 
but  in  smaller  ones  columnar  or  columnar-ciliated  epithelium  may  be  found. 

2.  Cysts  of  Mi'iIIer'' s  Duct. — A  small  cyst,  known  as  the  hydatid  of  Morgagni, 
is  attached  to  one  of  the  fimbriae  of  the  Fallopian  tube  in  the  female  and  to  the 
head  of  the  epididymis  in  the  male.  It  represents  the  terminal  end  of  Miiller's 
duct  in  the  female  and  in  the  male,  but  is  of  no  clinical  importance. 

A  remarkable  instance  of  persistence  of  Miiller's  duct  on  one  side  in  its  whole 
length  has  been  described  by  Dr.  Ord.  The  dilated  duct  formed  an  elongated 
cyst  extending  from  the  right  kidney  to  the  sinus  prostaticus. 

3.  Cysts  from  the  UracJuis. — Among  other  rarities,  mention  may  be  made  of 
cysts  arising  in  the  persistent  urachus.  Some  are  lined  with  ciliated  columnar 
epithelium  and  others  with  hair-bearing  skin  ;  they  may  attain  a  great  size.  Cases 
have  been  observed  in  which  the  cyst  communicated  with  the  bladder,  and  this 
circumstance  has  given  rise  to  the  passage  of  hairs  with  the  urine  when  the  cyst 
was  dermoid. 

Cysts  have  also  been  known  to  develop  in  Meckel's  diverticulum,  from  the 
blocking  up  of  the  intestinal  end. 

4.  Dermoid  Cysts. — These  cysts  are  found  in  connection  both  with  skin  and 
mucous  membrane  and  in  various  internal  organs.  A  dermoid  cyst  must,  therefore, 
be  defined  as  a  cyst  lined  with  skin  or  with  mucous  membrane  and  of  congenital 
origin.  They  may  conveniently  be  divided  into  :  {a)  Dermoids  derived  from  epi- 
blast  by  enclavement.      (Ji)  Dermoids  of  internal  organs. 

{a)  The  first  group  comprises  dermoid  cysts  of  the  skin,  mouth,  rectum,  and 
nerve-centres,  and  those  situated  near  the  median  line  in  the  thoracic  and  abdom- 
inal cavities.  They  are  all  produced  by  cutting  off  of  a  portion  of  epiblast  {enclave- 
ment) during  the  process  of  closure  of  branchial  fissures  of  the  body  walls  in  the 
middle  line,  and  in  the  formation  of  the  membrane  bones  of  the  skull  and  face. 
They  also  occur  in  connection  with  the  involution  of  epiblast  to  form  the  mouth, 
genito-urinary  apertures,  rectum,  the  eye  and  ear,  and  the  brain  and  spinal  cord. 

{l>)  The  second  group  include  dermoids  of  the  ovary  and  testis,  and  perhaps 
may  be  attributed  to  exceptional  formative  powers  and  tendencies  to  variation  in 
the  structures  from  which  these  organs  arise.  But  since  the  Wolffian  duct  has 
recently  been  shown  to  be  of  epiblastic  origin,  the  possibility  suggests  itself  that 
these  cysts  may  also  be  derived  from  the  epiblast. 

Distribution. — On  the  head  and  face  they  are  more  often  situated  over  the 
lines  of  sutures.  Their  commonest  site  is  beneath  or  near  the  eyebrow,  especially 
toward  the  outer  side  ;  but  they  are  also  found  at  almost  any  part  of  the  orbital 
margin.  On  the  skull  they  are  more  often  observed  on  the  temple  near  the  fronto- 
maxillary  suture,  round  the  anterior  fontanelle  and  over  the  mastoid  process ;  but 
they  may  exist  at  any  part.  On  the  face  they  occur  over  the  middle  line  of  the 
nose,  the  fronto-nasal  suture,  and  rarely  on  the  cheek.  On  the  neck  they  are  placed 
laterally,  viz.,  over  the  parotid  gland,  near  the  angle  of  the  jaw  and  along  the 
anterior  margin  of  the  sterno-ma.stoid  at  points  corresponding  to  the  lines  of  the 
first  three  branchial  fissures.      Or  they  are  median,  being  commonest  here  beneath 


TUMORS—  C  YS  TS.  1 2  9 

the  hyoid  bone  (sub-hyoid  cyst).  Those  of  the  skull  and  orbital  margin  are 
always  deeply  placed  and  attached  to  the  i)eriosteiim.  They  often  lie  in  a  depres- 
sion in  the  bone,  which  may  even  be  jjcrforated  ;  or  the  cyst  is  placed  entirely 
within  the  skull.  In  the  College  of  Surgeons'  museum  is  a  parietal  bone  jjer- 
forated  at  its  centre  ;  from  the  aperture  a  dermoid  cyst  was  removed  and  the 
patient  died  of  meningitis. 

Some  dermoids  near  the  angle  of  the  jaw  and  along  the  sterno-mastoid  have 
deep  connections  attaching  them  to  the  styloid  process  and  sheath  of  the  carotid 
vessels. 

Cysts  formed  during  the  closure  of  the  body  walls  are  observed,  especially  near 
the  junction  of  the  first  and  second  bones  of  the  sternum  and  near  the  um])ilicus ; 
also  in  the  thoracic  and  abdominal  cavities  and  even  in  the  lung  itself.  In  con- 
nection with  the  development  of  the  central  nervous  system,  dermoids  occur  in 
the  brain  and  over  the  spine.  They  are  fairly  common  over  the  sacro-coccygeal 
region,  constituting  one  of  the  varieties  of  congenital  sacral  tumor. 

Precisely  similar  cysts  are  also  generally  distributed.  I  have  met  with  two 
over  the  scapula  and  one  near  the  breast.  They  exist  as  rarities  in  the  limbs. 
Those  of  the  digits  are  often  due  to  implantation  of  epithelium  by  wounds. 

The  dermoids  of  the  ovaries  are  situated  within  the  o5phoron  ;  those  of  the 
testicle  within  the  tunica  vaginalis,  and  sometimes  are  enfolded  by  the  parenchyma 
of  the  gland. 

Dermoids  found  in  various  parts  of  the  abdominal  cavity  are  often  of  ovarian 
origin,  having  become  separated  by  twisting  of  their  pedicles. 

Structure. — The  dermoid  cysts  included  in  group  {a)  are  usually  simple  in 
structure.  They  have  a  lining  possessing  the  microscopic  characters  of  skin,  which 
shows  the  normal  arrangement  of  the  epidermis  with  papillae.  Some  are  devoid  of 
both  hairs  and  glands  ;  others  are  furnished  with  hairs  and  sebaceous  glands,  while 
in  a  smaller  number  the  wall  also  contains  sudoriparous  ones.  The  contents  are 
fatty  matter,  of  oily,  honey-like,  or  buttery  character.  This  is  derived  from  degen- 
erated cast-off  epithelium  and  from  the  secretion  of  sebaceous  glands.  Microscop- 
ically it  shows  epithelium  and  crystals  of  margarin  and  cholesterine.  Similar  cysts 
to  these  form  a  large  proportion  of  group  (<5),  i.e.,  dermoids  of  internal  organs, 
not  apparently  connected  with  epiblast.  Cysts  of  the  same  nature  as  dermoid  are 
found  in  the  floor  of  the  mouth,  in  the  neck  and  omentum ;  they  are  lined  with 
pavement  or  with  columnar-ciliated  epithelium,  and  may  conveniently  be  described 
as  mucoid  cysts.  I  have  examined  a  sublingual  cyst  from  John  Hunter's  collection, 
of  this  nature.  Some  of  the  cysts  of  the  neck  are  covered  on  one  side  by  skin  and 
on  the  other  by  mucous  membrane,  indicating  that  the  lining  was  derived  from 
the  epithelium  on  each  side  of  a  branchial  cleft.  They  may  even  open  externally, 
like  a  persistent  branchial  cleft.  Complex  dermoid  tumors  occur  in  the  ovary, 
scrotum,  sacro-perineal  and  maxillary  regions,  in  the  thorax  and  abdomen,  and,  in 
one  instance,  in  the  orbit.  Many  of  them  are  included  in  the  group  of  congenital 
tumors  to  which  the  name  of  teratomata  has  been  given.  They  are  for  the  most 
part  cystic,  or  solid.  The  cysts  are  respectively  lined  in  varying  proportions  with 
skin  and  with  mucous  membrane.  Those  having  an  integumental  covering  present 
the  ordinary  features  of  dermoids  ;  and  in  the  ovary  and  elsewhere  may  contain 
hair,  teeth,  nails,  and  overgrown  sebaceous  glands,  which  even  reach  the  complex- 
ity of  a  mammary  gland.  The  cysts  are  embedded  in  a  stroma  of  young  or  of 
mucoid  connective  tissue  in  which  may  be  found  in  varying  frequency  plates  of 
bones,  cartilage,  unstriped  and,  very  rarely,  striped  muscle,  with  nervous  elements 
of  various  kinds,  i.e.,  uni-  and  multi-polar  cells,  medullated  fibres  and  fibres  of 
Remak.  Further,  traces  of  organs  may  exist  as  lungs,  intestine,  eye,  and  lymphoid 
tissue.  In  the  sacro-coccygeal  and  maxillary  regions  a  complete  series  of  transi- 
tions between  dermoid  cysts  and  parasitic  foetuses  has  been  observed.*     Bland 

*I  have  suggested  that  the  complexity  of  these  tumors  depends  on  the  period  of  embryonic  life 
and  the  extent  of  the  blastoderm  involved  in  the  disturbance,  the  tumor  being  more  complex  the 
earlier  the  disturbance. 


I30       GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

Sutton  has  sought  to  connect  the  origin  of  certain  simple  and  complex  dermoids 
with  some  fcetal  canals,  as  the  infundibulum,  the  hyo-lingual  duct,  and  the  neuro- 
enteric  passage. 

Period  of  Origin. — The  nucleus  of  all  dermoids  is  congenital,  with  the  excep- 
tion probably  of  some  cysts  of  the  ovary.  Cutaneous  dermoids  do  not  usually 
appear  till  puberty,  and  this  circumstance  may  be  connected  with  the  accelerated 
activity  of  the  skin,  shown  by  the  development  of  the  hair  in  certain  parts. 

Dermoid  cysts  and  tumors  of  the  ovary  are  commonest  between  fifteen  and 
thirty  years  of  age. 

They  occasionally  become  the  seat  of  epithelioma  and  of  sarcoma. 

A  few  instances  have  been  recorded  in  which  dermoid  cysts  of  the  ovary  have 
been  ruptured,  and  their  contents,  escaping,  have  become  implanted  on  the  omen- 
tum and  peritoneum  and  have  given  rise  to  small  secondary  cysts  of  the  same 
nature. 

5.  Congenital  Hygroma. — These  tumors  of  infancy  are  most  commonly  situ- 
ated on  the  neck  and  gluteal  region,  and  less  frequently  in  the  axilla,  on  the  arm, 
thigh,  and  cheek.  Like  other  cystic  tumors,  the  proportion  of  solid  tissue  and 
cyst  varies  greatly.  The  tumor  may  be  chiefly  composed  of  numerous  intercom- 
municating loculi  embedded  in  gelatinous  connective  tissue,  or  may  be  for  the 
most  part  .solid,  the  cyst  spaces  being  small  and  scattered  ;  exceptionally  it  is  com- 
posed of  one  large  cyst.  The  cavities  are  loculated,  their  walls  are  smooth  and 
rendered  irregular  by  imperfect  septa.  Their  contents  are  serous  fluid,  in  some 
instances  sanious,  rarely  creamy,  and  rich  in  cholesterine.  The  tumors  always  lie 
beneath  the  deep  fascia,  and  tend  to  spread  widely  in  an  irregular  manner  between 
the  mu.scles,  even  infiltrating  their  substance.  In  the  neck  they  occup>y  the  front 
or  lateral  aspects  ;  they  are  often  attached  to  the  sheath  of  the  large  vessels  and 
may  extend  upward  behind  the  pharynx  to  the  base  of  the  skull,  downward 
beneath  the  deep  fascia  into  the  thorax,  or  into  the  axilla.  The  loculi  and  spaces 
are  lined  with  an  endothelium,  the  borders  of  which  are  irregular,  but  not  den- 
tated  in  the  manner  peculiar  to  lymphatic  vessels.  In  some  instances  their  walls 
are  surrounded  by  a  layer  of  unstriped  muscle  fibre.  The  stroma  in  growing 
portions  of  the  neoplasm  has  the  characters  of  embryonic  connective  tis.sue. 
When  the  morbid  growth  infiltrates  muscle  or  a  gland,  striped  muscle  and 
epithelium  may  respectively  be  found  in  it. 

The  pathogeny  of  these  tumors  is  still  somewhat  doubtful.  The  form,  lining, 
and  nature  of  the  contents  of  the  loculi  point  to  their  being  a  variety  of  lymph- 
angeioma.  They  originate  at  a  very  early  period  of  intra-uterine  life,  probably 
the  fourth  or  fifth  month. 

Symptoms. — They  may  merely  giv^e  rise  to  inconvenience  from  their  size, 
but  in  the  neck  often  cause  serious  symptoms  from  pressure  on  the  trachea,  the 
gullet,  and  large  vessels. 

Treatment. — Tapping  may  be  resorted  to  with  good  effect  when  large  cysts 
exist.  Setons  have  been  used  for  the  purpose  of  setting  up  suppuration  and 
inducing  occlusion  of  the  cysts  in  that  manner.  Tincture  of  iodine  may  also  be 
injected  for  the  same  purpose.  But  these  means  are  attended  with  the  danger  of 
setting  up  cellulitis.  The  safest  method  is  excision.  This  operation  should  not 
be  lightly  undertaken,  since  it  is  attended  with  much  difficulty  and  danger,  owing 
to  the  deep  expansions  of  the  growth  and  the  displacement  and  matting  together 
of  important  structures.  Electrolysis  has  also  been  employed,  but  not  with 
satisfactory  results. 

SOLID   TUMORS. 
Fibromata. 

Fibromata  are  tumors  composed  of  adult  or  well-developed  fibrous  tissue. 
They  form  distinctly  circumscribed,  encapsuled,  movable  ma.sses,  which  are  either 
lobulated  or  uniform  in  outline.     They  also  occur  as  pedunculated  subcutaneous 


TUMORS— FIB  R  OMA  TA.  131 

tumors  (molluscum  fibrosum)  and  as  polypoid  growths  from  mucous  membranes. 
In  consistence  they  vary  from  a  density  approaching  that  of  cartilage  to  a  succu- 
lent, yielding,  but  still  not  friable  tissue.  Fibromata  of  the  labia  majora  and 
pedunculated  fd)romata  of  the  skin  are  often  extremely  succulent,  and  large 
(juantities  of  serum  exude  from  them  on  section  ;  this  variety  was  formerly 
described  as  the  fibro-cellular  tumor. 

A  section  of  the  firmer  fibromata  displays  a  number  of  outstanding  fibrous 
bands  on  a  gray,  yellowish,  or  oj^aciue  white  ground,  or  the  section  is  firm,  uniform, 
and  dull  white.  The  fibres  either  interlace,  are  arranged  concentrically,  or  in 
parallel  lamellae.  A  scraping  yields  no  juice.  Microscopically  the  firmer  tumors 
are  comi)osed  of  looser  or  more  compact  bundles  of  fibres,  often  wavy  and  inter- 
lacing, or  disposed  chiefly  parallel  to  each  other  (Fig.  16).  Situated  on  the 
bundles,  in  small  numbers,  are  flattened  nuclei  of  connective-tissue  cells,  the  proto- 
plasm of  which  may  be  demonstrated  to  anastomose  by  processes  around  the 
bundles.  The  softer  forms  are  made  up  of  interlacing  fibrillaj,  more  or  less 
thickly  studded  with  large  round  or  oval  connective-tissue  cells,  whose  protoplasm 
is  continuous  with  the  fibrill^. 

As  varieties,  fasciculated  and  lamellar  fibromata  have  been  described. 

In  some  of  the  laminated  fibromata  layers  of  connective  tissue  are  concen- 
trically disposed  around  blood-vessels  and  nerves.  When  a  nerve  and  its  branches 
are  involved,  as,  for  example,  the  pes  anserinus,  a  very  curious  tumor  composed 
of  tortuous  anastomosing  cylinders  (plexiform  neuro-fibroma)  of  fibrous  tissue  is 
formed.  The  fibrous  nodules  of  cartilaginous  density  found  on  the  pleura  and 
in  the  capsule  of  the  spleen  are  examples  of  laminated  fibromata  in  which  the 
laminge  are  arranged  parallel  to  the  surface. 

The  distribution  of  the  fibromata  is  exceedingly  general,  for  they  occur 
wherever  connective  tissue  exists,  the  following  being  the  chief  sites  :  the  skin 
and  subcutaneous  tissue,  fasciae,  capsules  of  joints  and  synovial  fringes,  the 
nerves,  the  nose,  gums,  the  periosteum  of  the  lower  jaw,  ovary,  round  ligament, 
and  breast. 

Painful  Siibciitaneoiis  Tubercle. — These  tumors  are  situated  in  the  corium  or 
subcutaneous  tissue,  are  rounded,  rarely  exceeding  half  an  inch  in  diameter,  and 
are  usually  single.  They  occur  with  much  greater  frequency  on  the  lower 
extremities,  and  are  more  common  in  women  than  in  men.  Insignificant  in 
themselves,  they  attract  attention  from  the  severe  darting  pain  to  which  they  give 
rise,  sometimes  associated  with  extreme  tenderness.  Probably  in  many  cases  the 
pain  is  much  exaggerated  by  hysteria  or  allied  conditions. 

The  precise  relation  of  these  fibromata  to  nerves  is  still  a  matter  of  (juestion. 
Many  observ^ers  have  failed  to  find  any  connection  with  a  nerve,  while  in  other 
cases  nerve-filaments  have  been  traced  into  the  tumor  or  found  spread  out  over 
its  surface.  xAnd,  in  certain  instances,  the  whole  tumor  has  been  stated  to  be 
composed  of  non-medullated  nerve-fibres  (Virchow). 

A  passing  allusion  may  be  made  to  the  small  fibromata  which  occasionally 
form  around  the  punctures  for  ear-rings.  They  are  notable  from  the  fact  that  not 
rarely  they  recur  after  removal,  but  show  no  other  sign  of  malignancy. 

Fibromata  may  undergo  mucoid  metamorphosis  and  also  calcification,  the 
latter  change  being  often  observed  in  those  connected  with  the  jaw. 

Friction  or  other  forms  of  irritation  may  act  as  exciting  causes  ;  in  two 
instances  I  have  observed  symmetrically-placed  fibromata  over  the  ligamentum 
patellae. 

They  do  not  recur  after  removal,  but  their  relations  with  the  sarcomata  are 
exceedingly  close.  At  times  the  differentiation  between  fibroma  and  fibro-sarcoma 
is  impossible  without  the  microscope.  And,  again,  a  fibroma  may  exist  for  many 
years  and  ultimately  develop  into  a  sarcoma. 

Diagnosis. — Fibromata  are  circumscribed,  fairly  movable,  usually  smooth, 
dense,  but  elastic  and  heavy.  When  pendulous  and  oedematous  they  are  of  soft 
and  yielding  consistence.      Microscopically  they  exhibit  adult  fibrous  tissue  with 


132       GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

scanty  cells,  and  at  growing  points  it  may  be  observed  that  the  young  cells  are 
forming  adult  and  well-developed  fibrous  tissue  ;  while  in  the  fibro-sarcomata  the 
cell-elements  are  abundant  and  their  transformation  into  fibrous  tissue  is  incom- 
plete. 

Li  POM  AT  A. 

Lipomata  or  fatty  tumors  resemble  ordinary  adipose  tissue,  except  that  the 
individual  vesicles  are  often  of  larger  size.  They  are  circumscribed  or  diffused. 
The  common  circumscribed  lipoma  of  the  subcutaneous  tissue  is  easily  recognized 
by  its  lobulated  or  slightly  irregular  outline,  its  mobility,  and  its  elasticity,  which 
often  approaches  semi-fluctuation.  The  overlying  skin,  on  being  raised,  is  found 
to  dimple  slightly,  owing  to  connective-tissue  fasciculi  which  pass  between  it  and 
the  tumor.  This  shells  out  readily  from  a  capsule  of  condensed  connective  tissue, 
and  its  surface  is  smooth,  but  deeply  fissured  and  lobulated. 

The  trunk  and  especially  the  shoulders  are  the  seat  of  election  of  lipomata ; 
perhaps,  it  may  be  said  broadly,  the  regions  of  the  shoulder  and  pelvic  girdle. 
But  they  are  sometimes  observed  on  the  limbs,  and  I  have  seen  two  cases  of 
multiple  lipomata  on  the  arms  of  women. 


Fig    13. — Fatty  Tumor  of  37  years'  growth  on  arm  of  woman,  aet  1 


Fig.  14 — Diffused  Lipoma  of  Neck,- 


They  also  form  between  muscular  planes,  in  the  tongue,  uterus,  walls  of 
stomach  and  intestines,  in  the  scrotum  around  the  tunica  vaginalis,  in  connection 
with  the  periosteum  of  the  skull  and  other  bones,  and  with  the  sheaths  of  blood- 
vessels. Appendices  epiploicce  may  enlarge  and  constitute  tumors.  Masses  of  fat 
connected  by  a  pedicle  with  the  peritoneum  are  also  found  protruding  through 
the  linea  alba,  and  along  the  inguinal  canal  into  the  scrotum,  where  they  simulate 
omental  hernia. 

Age  exercises  a  marked  influence  on  the  formation  of  lipomata ;  middle  life, 
when  adipose  tissue  is  accumulating,  being  that  in  which  the  great  majority  occur. 
But  cases  of  congenital  lipoma  are  not  very  rare.  The  parts  affected  chiefly  are 
the  .sacro-coccygeal  region,  perineum,  neck,  and  back;  and  the  formation  of  fat 
may  be  associated  with  congenital  hypertrophy. 

Mechanical  irritants,  as  carrying  weights  on  the  shoulder  and  back,  are 
exciting  causes  ;  and  it  would  appear  in  such  cases  that  an  irritative  new  formation 
of  connective  tissue  undergoes  fatty  transformation. 

Degenerations. — Lipomata  undergo  softening  or  oily  change  ;  and,  in 
tumors  of  long  standing,  the  connective-tissue  septa  may  become  calcified.  Very 
large  and,  especially,  pendulous  tumors  are  subject  to  ulceration  of  the  dependent 
skin,  perhaps  followed  by  sloughing  and  suppuration. 


TUMO  RS—  A/-VX  OMA  TA . 


133 


An  extensive  formation  of  fat  is  exceptionally  associated  with  myxomatous  or 
sarcomatous  peri-renal  tumors — lij)omatous  myxoma.  True  lipomata  are,  of  course, 
essentially  innocent;  but  they  tend  to  grow  continuously.  The  diagnosis  is 
usually  obvious  from  the  physical  characters  of  the  tumor,  its  seat,  and  the  age  of 
the  patient. 

Diffuse  lipoma  constitutes,  as  its  name  implies,  a  non-circinnscribed,  doughy 
mass,  usually  forming  a  collar  around  the  neck,  and  composed  of  separate  masses  ; 
one  of  these  projects  from  the  nape,  another  from  each  parotid  region,  and  another 
hangs  beneath  the  chin  like  a  devvla]).  Or  such  a  mass  may  be  j^resent  in  any 
one  of  these  regions  without  the  others  being  affected.  I'he  subjects  of  this 
peculiar  growth  are  usually  obese,  and  often  addicted  to  immoderate  use  of 
alcohol.     Brodie  recommended  for  it  large  doses  of  liquor  potassae. 


Myxomata. 

Myxomata  are  new  formations  of  loose,  fibrillar  connective  tissue,  permeated 
with  fluid  which  is  rich  in  mucin.  The  physiological  prototype  of  these  growths 
is  found  in  Wharton's  jelly  of  the  umbilical  cord.     The  commoner  examples  of 


Myxomatoii.'i  Enchondm^  \o  ^X        M_y.ioma 


M:4 


En  c/iofn/rM/itB 


Jiound  cell 
Myjcoma 


Lijjoma 


ST/aline  Mi/xo/na 


imaloiis  ili/xoma 


Fig.  is. 


pure  myxoma  are  pedunculated,  as  the  polypi  of  the  nose,  rectum,  and  some  polypi 
of  the  uterus.  Their  dependent  position  and  narrow  pedicles  favor  oedema.  This 
may  to  some  extent,  but  probably  does  not  entirely,  account  for  their  succulence  ; 
for  in  nasal  polypi  cysts  are  found  evidently  resulting  from  mucoid  transformation 
of  their  substance.  Pure  myxomata  also  occur  in  the  subcutaneons  tissue,  beneath 
the  periosteum,  and  in  the  nerves,  constituting  one  variety  of  neuroma. 

A  section  exhibits  a  glistening,  pale,  jelly-like  tissue,  the  surface  of  which  is 
raised  in  the  centre.  Microscopically,  the  neoplasm  is  composed  of  stellate  and 
round  cells,  of  which  the  protoplasm  is  prolonged  in  delicate  filaments  forming  a 
felting  of  fibrils  (see  Fig.  15).  The  stellate  cells  are  chiefly  characteristic  of 
mucous  connective  tissue ;  in  some  growths  they  exist  exclusively,  while  in  others 
the  round  cells  preponderate.  The  vessels  are  usually  abundant  and  clearly  seen, 
owing  to  the  transparency  of  the  tissue ;  they  often  form  a  wide  meshwork. 

Pure  myxomata  do  not  recur  if  completely  removed,  but  in  the  large  majority 


134       GENERAL   PATHOLOGY  OE  SURGLCAL   DLSEASES. 

of  so-called  myxomata   the  mucous  is  mingled  with  sarcomatous  tissue.     These 
growths  are  described  further  on  as  myxo-sarcomata. 

The  diagnosis,  except  when  the  tumor  is  deeply  seated,  is  patent,  from  the 
appearance,  consistence,  and  seat  of  the  growth. 

Enchondromata. 

Enchondromata  are  tumors  composed  of  cartilage,  chiefly  of  the  hyaline 
variety.  They  present  well-marked  physical  characters.  Their  surface  is  nod- 
ulated and  uneven,  extremely  firm  to  the  touch,  but  not  rarely  there  are  soft 
points  produced  by  mucoid  degeneration.  The  section  is  glistening,  smooth,  and 
translucent,  and  almost  invariably  shows  a  number  of  separate  masses  or  lobes 
divided  by  bands  of  connective  tissue  containing  blood-vessels.  These  bands  are 
often  continuous  with  the  membranous  capsule  constituting  the  perichondrium. 
In  other  cases,  the  section  is  often  greatly  modified  by  secondary  changes. 

Microscopically,  the  commoner  forms  have  practically  the  same  structure  as 
ordinary  hyaline  cartilage.  In  many  the  cartilage  cells  are  more  irregularly 
distributed,  and  more  numerous  in  proportion  to  the  matrix;  the  capsules  are 
larger,  and  in  growing  parts  of  tumors  a  single  capsule  often  contains  two  or  more 
cells.  The  cells  at  the  periphery  beneath  the  perichondrium  are  flattened.  Not 
rarely  stellate  ones  are  observed,  especially  in  the  parotid  tumors,  when  the  car- 
tilage is  produced  by  chondrification  of  connective  tissue.  But  .such  cells  are  also 
observed  in  tumors  of  bone  ;  for  example,  of  the  fingers.  Fibro-enchondromata, 
/.  €.,  growths  with  a  fibrous  matrix,  occasionally  occur  (Fig.  i6). 

The  degenerations  of  chondromata  are  important,  owing  to  the  way  in  which 
they  modify  the  physical  characters.  Mucoid  metamorphosis  produces  liquefaction 
of  the  matrix  and  the  formation  of  cysts,  so  that  the  whole  mass  of  a  large  tumor 
may  be  converted  into  a  large  cavity  surrounded  by  a  thin  wall  of  cartilage ;  or 
the  whole  tumor  may  be  rendered  uniformly  soft  and  diffluent.  The  opposite 
condition  may  result  from  calcification  and  ossification,  which  begin  in  the  centre 
of  the  tumor  ;  or,  if  it  spring  from  a  bone,  from  the  parts  adjoining  the  wall. 
The  process  of  calcification  consists  simply  in  the  deposition  of  lime-salts  in  the 
matrix  and  cells,  while  in  ossification  the  cartilage  is  converted  into  true  bone.  In 
the  latter  the  cells  proliferate,  their  capsules  enlarge  and  open  into  each  other, 
blood-vessels  penetrate  into  the  mass  of  young  cells  thus  formed,  and  tuberculae 
of  bone  are  then  developed  around  the  vessels.  In  some  instances  the  matrix  of 
enchondromata  is  extensively  converted  into  connective  tissue.  Cartilage  cells 
are  also  prone  to  undergo  fatty  degeneration,  a  change  obvious  to  the  naked  eye 
by  the  appearance  of  ochre-yellow  patches. 

The  distribution  of  enchondromata  is  very  wide;  they  occur  most  commonly 
in  the  bones,  in  glands,  as  the  parotid,  the  testicle,  and  breast,  and  in  the  subcu- 
taneous tissue.  Any  bone  may  be  affected,  but  the  digits  of  the  hand  most  fre- 
quently ;  next  in  frequence,  the  lower  end  of  the  femur,  the  head  of  the  tibia, 
the  humerus,  and  the  great  toe.  Among  other  bones  less  liable  to  these  growths 
may  be  named  the  base  of  the  skull,  vertebra,  ribs,  pelvic  bones,  lower  jaw,  and 
scapula.  Enchondromata  of  the  digits  merit  a  special  notice.  They  are  nearly 
always  multiple,  originate  in  infancy  or  early  life,  and  grow  into  large,  nodulated 
masses  around  the  digits  and  metacarjoal  bones,  with  great  deformity  of  the  hand. 
Their  increase  ceases  with  that  of  the  skeleton  generally,  and  in  such  cases  hered- 
ity may  often  be  traced.  They  spring  from  the  medullary  cavity  and  expand 
the  bone  or  burst  through  its  walls  at  one  point  and  then  envelop  it.  Their  source 
is  probably  from  small  masses  of  primordial  cartilage  which  were  not  removed  in 
the  formation  of  the  medullary  cavity,  but  remained  quiescent  for  a  time  and 
ultimately  took  on  active  growth.  Enchondromata  at  the  ends  of  the  long  bones 
— as  the  femur — are  usually  sub-periosteal,  and  in  all  probability  originate  from 
portions  of  the  growing  epiphysial  disc,  which  in  like  manner  remained  unossified. 
Tumors  of  the  shafts  of  the  long  bones  usually  surround  them  more  or  less  com- 


TUMORS—  OS  TK  OMA  TA . 


35 


pletely,  but  are  often  connected  with  a  mass  in  the  medullary  cavity,  which  may 
indicate  that  they  have  sometimes  the  same  mode  of  origin  as  those  of  the  digits. 

The  cartilage  occurring  in  jjarotid  tumors  is  formed  by  the  chondrification  of 
the  connective-tissue  stroma.  These  neoplasms  are  usually  largely  composed  of 
myxomatous  tissue,  which,  in  morbid  growths,  is  often  associated  with  cartilage. 
Pure  enchondromata  occur  in  the  testicle,  but  in  the  majority  of  cases  the  carti- 
lage is  combined  with  sarcoma-tissue  (chondro-sarcoma).  In  fact,  the  sarcomatous 
granulation-tissue  is,  in  part,  directly  transformed  into  cartilage.  Secondary 
tumors,  under  these  conditions,  are  formed  in  the  lym))hatic  glands,  lungs,  etc., 
likewise  largely  comjiosed  of  cartilage.  Hence  it  was  that  some  enchondromata 
were  formerly  believed  to  be  malignant.  It  is  scarcely  necessary  to  add  that  pure 
enchondromata  are  innocent. 

The  diagnosis  is  usually  clear  ;  the  chief  factors  are  the  situation  of  the  tumor, 
its  slow  growth,  its  extreme  hardness,  weight,  and  its  nodulated  surface. 


Filromn    x 


/•'//r/iont/romct 


Osfeoie/-     \ 
C'/io/itiromtf 


Oa/coma 


Fig.  i6. 


OsTEOMATA. 

Of  these  there  are  three  varieties  :  The  ebiirnatcd,  compact,  and  cancellous. 
The  eburnated  have  no  prototype  in  the  normal  skeleton,  except,  perhaps,  in 
osteo-dentine.  They  occur  as  small,  flat  elevations  or  bosses  on  the  surface  of  the 
skull,  and  are  histologically  peculiar  in  having  no  Haversian  canals,  the  small, 
flattened  lacunas  being  arranged  in  lines  parallel  to  the  surface.  Eburnated  osseous 
growths,  usually  described  as  diffuse  osteomata,  also  spring  from  the  bones  of  the 
face  ;  they  form  irregular,  ivory-like  masses,  filling  the  frontal  sinuses,  growing 
from  the  orbit,  especially  near  its  margin,  or  involving  the  whole  superior  maxilla. 
I  know  of  two  instances  of  tumors  of  this  description,  springing  from  the  orbit, 
in  which  the  skin  ulcerated,  the  osseous  mass  protruded,  and  ultimately  wa.s  shed 
like  an  antler. 

Compact  osteomata  are  observed  on  the  shafts  of  the  long  bones,  with  which 
their  structure  is  identical  (Fig.  i6).  They  sometimes  form  slightly-raised  over- 
hanging masses  with  a  wide  base  of  attachment  to  the  bone. 


136       GENERAL   PATHOLOGY  OE  SURGICAL   DISEASES. 

The  name  cancellous  sufficiently  describes  the  structure  of  the  third  variety, 
the  most  common  and  widely  distributed  of  all.  With  rare  exceptions  they  are 
situated  on  the  diaphyses  of  the  long  bones,  near  to,  but  not  necessarily  over,  the 
epiphysial  disc,  and  are  covered  with  a  layer  of  cartilage,  the  deeper  surface  of 
which  grows  continuously  and  is  converted  into  bone.  This  fact,  and  their  situ- 
ation, leave  no  room  for  doubting  that  they  originate  from  aberrant  portions  of 
the  epiphysial  disc  which  have  not  been  converted  into  bone.  Genetically  they 
are  therefore  closely  allied  to  the  enchondromata  of  bones.  I  have  observed  that 
such  exostoses  are  more  common  in  rickety  subjects.  At  times  they  are  multiple, 
affecting  all  the  long  bones  of  the  skeleton  ;  and  in  such  cases,  like  the  multiple 
enchondromata,  they  cease  to  increase  in  size  after  the  completion  of  growth.  A 
marked  hereditary  tendency  often  exists.  The  distal  phalanx  of  the  great  toe 
beneath  the  nail  is  a  common  site  for  exostosis. 

These  osteomata  should  not  be  confounded  with  exostoses  formed  by  ossifica- 
tion of  the  attachments  of  tendons  and  muscles,  such  as  occur  in  connection  with 
the  adductor  magnus,  the  psoas  and  iliacus,  or  the  deltoid. 

Lastly,  osteomata  are  in  rare  instances  found  altogether  unconnected  \vith 
bone — in  the  subcutaneous  tissues,  for  example,  of  the  buttock  or  thigh. 

Masses  of  bone  are  also  formed  in  the  gracilis  and  deltoid  muscles,  but  these 
can  hardly  be  considered  as  true  tumors,  being,  perhaps,  the  result  of  inflammation 
or  over-use.  Those  which  occur  in  the  adductor  longus  are  known  as  "  rider's- 
bone,"  because  they  are  met  with  in  cavalry  soldiers  and  rough-riders. 


Fig.  17. — Non-striped  Myoma  (Uterine  Fibroid).     Stained  with  Picro-carmine.     (X  450.) 
a.  Mass  of  non-striped  muscular  tissue,  in  which  the  rod-shaped  nuclei  and  the  parallel  arrangement  of  the  fibrils  are 
.seen  ;  b    Similar  bundles  of  fibres  cut  transversely.      1  he  sections  of  the  fibrils  have  the  appearance  of  rounded 
cells,  the  section  of  the  roimd  nucleus  is  seen  as  a  dot  in  some  of  the  sections  ;  c.    Spindle-shaped  cells,  of  which 
the  fibrils  {/)  are  composed  ;  d.  Pink  fibrous  tissue  ;  e.  Connective-tissue  corpuscles.     {After  IVoodhead.) 


Myoma. 

[Myoma  is  a  tumor  composed  of  muscular  tissue.  There  are  two  principal 
varieties  :  One,  composed  of  striped  muscular  tissue,  very  rare,  termed  Rhabdo- 
myoma, and  the  other  of  unstriped  muscular  tissue,  and  is  termed  Leio-myoma. 
The  latter  is  the  more  common  form,  and  may  be  found  in  any  organ  in  which 
unstriped  muscle-tissue  is  a  normal  constituent.  The  uterus,  the  wall  of  the 
bladder,  the  prostate,  and  the  kidney  are  the  most  common  seats  of  the  leio- 
myomata.  When  in  the  uterus,  the  myomata  are  designated  according  to  the 
tissue  from  which  they  spring,  as  intra-miiral,  siibnmcous,  and  subserous. '\ 


TUMORS— MYO-FJBR  OMA  TA—ANGEJOMA .  137 

MvO-FinROMATA. 

Myo-fibromata,  as  the  name  implies,  are  composed  of  muscle  and  fibrous 
tissue,  in  varying  proportions.  The  muscle  presents  the  ordinary  characters  of  the 
unstrii)ed  or  involuntary  variety,  and  is  distributed  in  interlacing  fasciculi.  The 
outline  of  individual  fibres  often  is  not  easily  distinguishaljle  in  sections,  but  the 
fibres  may  be  readily  isolated  by  teasing  after  hardening  in  chromic  acid.  In 
some  growths  of  long  duration  the  fibrous  tissue  j^reponderates.  The  naked-eye 
characters  resemble  tho.se  of  a  coarse  fibroma,  the  section  being  marked  by  distinct 
interlacing  fibrous  bundles.  The  growth  is  well-defined,  and  can  usually  be 
enucleated  without  difficulty. 

Degeneration — either  mucoid,  fatty,  or  calcareous — is  not  uncommon,  and 
patches  of  softening  or  collections  of  serum,  forming  cysts,  may  develop  within 
them.  They  occur  in  almost  all  structures  containing  unstri])ed  muscle  ;  with  great 
frequency  in  the  uterus  ;  in  the  ojsophagus,  intestine,  bladder,  testicle,  ovary, 
round  ligament,  and  in  the  prostate,  in  which  they  constitute  the  chief  ])ortion  of 
the  common  enlargement  of  that  organ.  Their  growth  is  slow,  and  clinically  they 
are  benign.  Spindle-celled  sarcoma,  which  also  occurs  occasionally  in  the  uterus, 
can  often  only  be  distinguished  with  great  difficulty  from  myo-fibroma. 

Angeioma. 

Under  this  name  are  included  naevi,  cavernous  tumors,  and  aneurism  by 
anastomosis. 

Ngevi,  or  "  mother's  marks,"  are  tumors  composed  of  convolutions  of  dilated 
capillaries  lying  in  the  corium  and  subcutaneous  tissues.  They  are  always  congen- 
ital, and  at  birth  may  exist  as  a  tiny  red  or  purplish  speck,  which  spreads  more  or 
less  rapidly.  As  a  rule,  the  growth  is  exceedingly  slow,  and  it  may  be  questioned 
if,  in  a  large  number  of  cases,  the  increase  much  exceeds  that  of  the  surface  of  the 
skin.  Their  fate,  if  left  alone,  has  not  been  carefully  studied  :  some  shrink  and 
wither,  others  appear  to  become  warty,  papillated,  and  deeply  pigmented.  In  one 
case  which  I  observed  a  Uccvus  of  the  ear  developed  into  an  aneurism  by  anas- 
tomosis. Superficial  naevi — those,  that  is  to  say,  that  involve  the  corium — appear 
as  bright  red,  or  purple,  and  slightly  raised  patches.  Deeper  ones,  lying  subcu- 
taneously,  form  rounded,  rather  ill-defined,  doughy,  or  spongy  tumors,  which 
diminish  in  size  on  pressure,  and  communicate  a  bluish  tint  to  the  superjacent  skin. 
Many  naevi  involve  both  skin  and  subcutaneous  tissue.  The  superficial  form  is 
usually  described  as  a  capillary,  the  deeper  as  a  venous  or  cavernous  n^evus,  but 
no  distinction  as  regards  their  minute  structure  can  be  drawn  between  them  ;  both 
are  made  up  of  tortuous  anastomosing  capillaries,  usually  only  moderately  dilated. 
A  section  through  a  subcutaneous,  or  so-called  venous  or  cavernous,  neevus  exhib- 
its a  number  of  whitish,  firm,  fat-like  lobules,  united  by  connective  tissue,  show- 
ing to  the  naked  eye  few  indications  of  its  real  structure.  In  rare  instances  the 
capillaries  become  so  much  dilated  as  to  form  cavernous  sinuses,  but  this  is  cer- 
tainly the  exception.*  The  capillaries  of  naevi  are  lined  with  a  layer  of  plump 
endothelium,  and  bounded  with  a  thin  lamina  of  connective  tissue  ;  they  are  usually 
closely  approximated  and  are  supported  by  connective-tissue  trabeculae  rich  in 
nuclei.     Hair  follicles,  sebaceous  and  sudoriparous  glands  are  interspersed. 

The  treatment  of  these  growths  is  detailed  elsewhere. 

Cavernous  angeiomata  are  met  with  in  the  liver,  kidneys,  and  in  the  walls  01 
the  intestines  ;  in  a  leg  which  I  di.ssected  numerous  cavernous  tumors  were  situated 
along  the  course  of  the  large  veins.  They  are  composed  of  large  venous  sinuses 
separated  by  narrow  connective-tissue  trabeculae.  Aneurisms  by  anastomosis  are 
rare  and  are  usually  situated  on  the  scalp.  They  have  an  expansile  pulsation,  and 
their  surface  is  irregular  from  the  projection  of  tortuous  dilated  arteries.     One, 

*  A  good  example  of  this  is  in  llie  Royal  College  of  Surgeons'  Museum,  No.  407. 
10 


138       GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

which  I  injected  and  examined,  involved  the  whole  jnnna  of  a  young  woman,  and 
was  entirely  comi)osed  of  a  very  delicate  net-like  anastomosis  of  minute  arterioles. 
[The  editor  has  seen  a  very  large  congenital  aneurism  by  anastomosis,  in  a 
child  of  two  years,  which  involved  the  penis  and  entire  scrotum.] 

Lymphangeiomata. 

These  are  to  the  lymphatic  vessels  what  naevi  are  to  the  blood-vessels,  and, 
like  the  latter,  are  congenital.  Tumors  composed  solely  of  dilated  tortuous  lym- 
phatic channels  have  been  described,  but  usually  fibrous  hypertrophy  of  the  affected 
part  is  associated  with  many  dilated  and  tortuous  lymphatics,  as,  for  example,  in 
macroglossia.  I  have  observed  considerable  dilation  of  the  lymphatics  in  congen- 
ital hypertrophy  of  the  hand  and  foot. 

Congenital  hygroma  of  the  neck,  as  pointed  out  already,  is  probably  a  form 
of  lymphangeioma. 

Neuroma. 

The  great  majority  of  tumors  classed  under  this  heading  are  simple  fibromata 
springing  from  the  peri-  or  endo-neurium.  They  are  either  merely  embedded  in 
the  nerve-trunk  or  form  nodular  thickenings  of  it,  and  even  individual  fasciculi  of 
the  trunk  may  present  minute  bead-like  enlargements.  It  is  not  rare  to  meet  with 
cases  in  which  nearly  all  the  nerve  trunks  of  the  body  are  studded  with  fibro-neu- 
romata.  Occasionally  these  neoplasms  are  associated  with  molluscum  fibrosum  of 
the  skin.  Rare  instances  of  true  neuroma,  composed  of  convoluted  bundles  of 
medullated  nerve  fibres  have  been  recorded,  and  Virchow  has  described  tumors 
composed  of  delicate  threads,  which  he  regarded  as  amyelitic  fibrils.  Myxo-  and 
spindle-celled  sarcomata  also  occur  in  nerve  trunks,  and  it  may  be  noted  that  it 
would  be  difficult  to  distinguish  histologically  the  latter  from  developing  nerve 
fibres. 

Sarcomata. 

Sarcomata  are  tumors  derived  from  the  connective-tissue  constituents  of  the 
body,  but  their  elements  never  develop  into  fully-formed  or  adult  structures ;  they 
are  always  arrested  at  some  intermediate  stage  in  the  formation  of  the  various  con- 
nective tissues,  as  fibrous  tissue,  bone,  or  cartilage.  Their  elements  are,  therefore, 
often  described  as  embryonic,  and  they  are  spoken  of  as  embryo-tissue  tumors. 
This  name  implies  a  theory  which  is  both  misleading  and  untrue.  It  is  mislead- 
ing because  an  inference  is  apt  to  be  drawn  that  these  tumors  originate  from  em- 
bryonic rudiments  of  connective  tissues,  whereas  by  far  the  majority  originate  in 
adult  life,  and,  as  far  as  we  know,  from  adult  tissues.  It  is  also  untrue,  because 
certain  sarcomata,  as  the  spindle-celled,  have  no  counterpart  in  the  connective 
tissues  of  the  healthy  embryo.  The  true  prototype  of  the  various  forms  of  sar- 
coma may  be  found  in  the  transitions  of  granulation  cells  to  form  fibrous  or  scar- 
tissue  and  callus,  and  clinical  evidence  abounds  indicating  that  many  of  the 
sarcomata  of  later  life  have  an  inflammatory  or  irritative  origin.  On  the  other 
hand,  many  of  those  observed  during  the  first  five  years  of  life  may,  with  much 
probability,  be  referred  to  an  irregularity  in  or  arrest  of  development. 

The  sarcomata  are  divided  into  three  chief  varieties,  the  round-celled, 
spindle-celled,  and  myeloid.  Between  these  many  intermediate  forms  are 
observed  ;  thus,  round  and  spindle-cells  may  be  mingled  in  nearly  equal  propor- 
tions— tnixed sarcotfia  ;  and  myeloid  cells  are  associated  either  with  round  or  with 
spindle-cells.  Again,  the  spindle-celled  sarcomata  shade  off  indefinitely  into  the 
fibromata  (see  Fihro-sarcomata) . 

Round-celled  Sarcoma. — These  again  are  divided  into  two  sub-varieties,  the 
small  and  the  large.  The  former  is  much  the  commoner,  and  its  component  cells 
are  about  the  size  of  leucocytes  or  granulation  cells.  In  the  latter  they  are  as  large 
as  those  of  squamous  epithelium.     A  section  of  a  round-celled  sarcoma  under  the 


TUMORS— SA  R  COMA  TA . 


139 


microscope  shows  a  uniform  surface  formed  of  closely-crowded  cells,  ]>erhaps 
intersected  here  ami  there  by  a  band  of  connective  tissue.  In  this  respect  and 
the  character  of  the  cell  it  differs  essentially  from  cancer.  The  nuclei  are  large 
and  the  protoplasm  around  them  scanty  ;  in  fact,  many  of  the  small  round-celled 
tumors  appear  to  be  composed  almost  entirely  of  nuclei,  in  many  of  which  evi- 
dence of  nucleus  division  (karyokinesis)  may  be  demonstrated  with  appropriate 
reagents.  The  intercellular  substance  varies ;  it  is  usually  scanty  and  homo- 
geneous, sometimes  formed  of  delicate  interlacing  fibrillae  prolonged  from  the 
protoplasm  of  the  cells,  and  sometimes  of  homogeneous  bands.  The  blood-vessels 
are  usuallv  abinidant,  and  in  many  instances  have  no  proper  wall.  They  are 
lined  with  rounded  endothelium,  which  rests  directly  ujjon  the  cells  of  the  tumor. 
Hence,  they  often  become  dilated  or  rupture  and  form  blood-cysts,  which  give 
rise  in  tumors  of  bone  to  pulsatile  expansion. 

Spindle-celled  sarcomata  are  composed  of  either  small  or  large  spindle-cells 
analogous  to  the  fibro-blasts  of  young  granulation  tissue ;  they  possess  an  oval 
nucleus,  and  their  extremities  are  prolonged  into  a  more  or  less  delicate  fibre. 


TrahecnloT Spindle  -cell  Spindle  cell 
partly  cross  cut  //f^(  J 


Giant -cell 
orMyelnid 


Large  Bound-Cell 
Fig.  18. — Sarcoma. 


Small  Round   Cell 
or  Lymplw  Sarcoma 


The  cells  are  closely  approximated,  and  are  arranged  in  parallel  or  intersecting 
fasciculi  or  bundles.  Many  spindle-celled  sarcomata  show  a  partial  transformation 
into  fibrous  tissue.  The  protoplasm  of  the  cells  unites  to  form  a  coarse  stroma, 
only  the  elongated  nuclei  remaining  visible,  as  may  be  observed,  in  many  sub- 
periosteal tumors  of  bones  ;  or  the  protoplasm  is  prolonged  into  filaments  which 
unite  in  fasciculi  (fibro-sarcomata).  Such  tumors  can  only  be  distinguished  from 
fibromata  by  the  large  number  of  nuclei  present,  the  imperfect  development  of 
the  fibrous  tissue,  their  succulence,  and  relatively  rapid  growth. 

Myeloid  sarcomata  occur  almost  exclusively  as  central  tumors  of  bones — 
rarely  sub-periosteal — and  in  the  gum  as  epulis.  They  are  characterized  by  the 
presence  of  irregular  multi-nucleated  masses  of  granular  protoplasm  (giant-cells), 
the  physiological  prototype  of  which  is  the  osteoclast.  They  are  associated  either 
wdth  round  or  spindle  cells,  or  both,  and  transitions  from  the  round  to  giant-cells 
may  be  observed  (Fig.  18).  A  section  has,  in  parts  or  over  the  whole  surface,  a 
peculiar  maroon-red  tint,  by  which  the  nature  of  the  tumor  may  be  recognized. 

Many  sarcomata  of  bone  undergo  partial  transformation  into  cartilaginous  or 


I40        GENERAL   PATHOLOGY  OE  SURGLCAL   DLSEASES. 

osseous  material.  In  the  former  (chondro-sarcoma)  the  intercelhilar  substance  is 
abundant  and  hyaline,  and  becomes  chondrified.  The  latter  (calcifying  or  osteo- 
sarcomata)  are  composed  either  of  round  or  spindle  cells.  The  round  cells  are 
enclosed  each  in  a  mesh  of  a  delicate  fibro.us  reticulum  in  which  lime-salts  are 
deposited.  The  process  is  analogous  to  the  calcification  of  the  imperfectly  formed 
fibrillar  matrix  of  bone  sometimes  observed  in  rickets,  and  in  callus.  In  osteo- 
sarcoma the  secondary  growths  in  lymphatic  glands  and  internal  organs  are  also 
calcified. 

Myxo-Sai-coi7ia. — Some  tumors  of  the  breast,  parotid  gland,  testicle,  and 
rarely  of  the  periosteum,  have  a  white,  translucent,  gelatinous  aspect,  due  to 
mucoid  metamorphosis.  Under  the  microscope  they  show,  in  varying  proportions, 
branched  and  round  cells,  which  stand  out  distinctly  in  an  abundant  homogeneous 
stroma  (Fig.  i8).  Only  a  portion  of  the  growth  may  have  undergone  this  change, 
the  remainder  being  composed  of  ordinary  round  or  spindle-celled  tissue. 

Alveolar  sarcoma  is  another  sub-variety,  clinically  unimportant,  and  is  found 
in  bone,  muscle,  and  subcutaneous  tissue.  The  cells  are  large,  round,  and  not 
unlike  epithelium;  they  form  either  small  masses  in  alveoli,  bounded  by  delicate 
bands  of  fibrous  tissue  ;  or,  more  often,  each  cell  is  enclosed  in  a  mesh  of  a 
fibrous  network. 

Melanotic  Sarcoma. — These  present  characteristics  pathologically  and  clin- 
ically midway  between  the  sarcomata  and  carcinomata.  They,  for  the  most  part, 
originate  in  moles  of  the  skin  and  in  the  choroid  of  the  eye,  and  have  also  been 
observed  on  the  vulva,  hard  palate,  and  growing  from  the  matrix  of  the  nails. 
They  are  extremely  common  in  white  horses.  In  color  they  are  black  or  sepia- 
brown  ;  and  a  section  may  be  pigmented  uniformly  or  only  in  small  parts,  the 
remainder  resembling  medulla.  Histologically  they  usually  have  a  more  or  less 
marked  alveolar  structure,  the  stroma  being  scanty.  The  cells  in  cutaneous  tumors 
are  round  or  irregular  from  pressure,  often  of  large  size,  and  may  have  an  epithe- 
lial aspect ;  they  are  sometimes  mingled  with  spindle  cells.  The  tumors  of  the 
choroid  are  commonly  composed  of  spindle  cells. 

The  pigment  is  deposited  in  granules  within  the  cells ;  and,  to  a  smaller 
extent,  lies  free  in  the  stroma. 

Individual  cases  of  melanotic  sarcoma  vary  greatly  in  malignancy.  In  the 
majority,  the  prognosis  is  exceedingly  bad.  Shortly  after  the  appearance  of  the 
tumor,  small,  pigmented,  secondary  nodules  are  seen  in  neighboring  parts  of  the 
skin,  and  the  nearest  lymphatic  glands  become  affected,  the  growth  sometimes 
extending  directly  in  lines  along  the  lymphatic  channels.  Within  a  brief  space 
dissemination  takes  place  in  internal  organs,  the  liver  being  a  favorite  site  for 
them  ;  and,  in  some  instances,  the  skin  over  the  whole  body  is  dotted  with  the 
growths.  On  the  other  hand,  melanotic  tumors,  having  the  same  general  appear- 
ances, may  grow  slowly,  and  not  recur  even  after  a  tardy  removal. 

From  the  foregoing  account  it  may  be  noted  that  the  melanotic  sarcomata  of 
the  skin  closely  approach  the  cancers,  in  that  they  possess  an  alveolar  structure, 
often  an  epithelioid  type  of  cell,  and  in  the  fact  that  they  originate  in  connection 
with  a  structure — the  skin  (itself  pigmented) — derived  from  epiblast.  And 
further,  as  in  cancers,  the  lymphatic  glands  are  early  affected.  It  may  subse- 
quently be  shown  that  those  attributed  to  the  choroid  really  spring  from  the 
pigmentary  layer  of  the  retina,  which  is  also  of  epiblastic  origin. 

I  have  myself  observed  in  two  instances  melanotic  tumors  continuous  with 
tap-like  ingrowths  of  the  epidermis,  as  in  epithelioma ;  and  for  these  reasons  am 
impelled  to  believe  that  these  tumors  are  really,  in  many  instances,  cancers  origi- 
nating in  patches  of  imperfectly  developed  skin,  such  as  moles. 

Simple,  Circumscribed  Melanotic  Masses. — A  very  remarkable  and  rare  disease 
has  been  described  under  this  name,  in  which  innumerable,  well-defined  masses  of 
black  pigment  are  formed  simultaneously  in  many  organs  and  structures.  The 
primary  focus  of  infection  often  cannot  be  ascertained.  The  nodules  vary  in 
dimension  from  a  microscopic  grain  to  the  size  of  an  egg  or  fist,  and  are  observed 


TUMORS— SARCOMA  TA.  141 

in  the  subcutaneous  tissue,  peritoneum,  breast,  and  in  the  muscular  substance  of 
the  heart.  The  pigment-granules  constituting  the  masses  accumulate  in  the  cells  of 
the  normal  tissues,  namely,  in  the  connective-tissue  cells,  muscular  fibres,  and  epithe- 
lium ;  these  are  destroyed,  and  the  tissues  are  replaced  by  a  nodule,  or  a  tumor 
softened  at  the  centre,  there  being  no  trace  of  a  cellular  new-formation,  such  as 
exists  in  melanotic  sarcoma  and  cancer.  The  disease  in  man  i)roves  fatal  in  a  few 
months  ;  whilst  in  horses,  in  which  it  is  common,  its  progress  is  slow. 

Lymphosarcoma. — This  must  not  be  confounded  with  lymphadenoma.  It  is 
a  variety  of  round-celled  sarcoma,  originating  in  a  lymphatic  gland,  extending  by 
contact  to  a  whole  group  and  to  neighboring  chains,  but  never,  like  lymphadenoma, 
involving  simultaneously  the  whole  lymphatic  system.  The  disease  not  unfre- 
quently  attacks  the  mediastinal  glands,  spreads  along  the  bronchi  into  the  lungs, 
and  involves  the  pericardium.  The  morbid  growth  is  medullary  in  character,  but 
rather  firm,  and  yields  a  milky  juice.  The  microscopic  structure  presents  a  rough 
resemblance  to  the  cortical  portion  of  the  lymphatic  gland,  the  chief  part  consist- 
ing of  1}  mphoid  cells,  arranged  in  rounded  masses  or  in  irregular  cylinders  lying 
in  the  meshes  of  a  coarse,  fibrous  stroma.  A  reticulum,  such  as  is  found  in  lymph- 
adenoma, does  not  exist. 

Glioma,  or  glio-sarcoma,  is  a  variety  of  connective-tissue  tumor  arising  from 
the  neuroglia  of  the  brain,  retina,  and,  in  rare  instances,  the  spinal  cord.  It  is 
commonest  i^n  the  retina  of  children,  and  spririgs  probably  from  the  granular 
layers.  Retinal  gliomata  are  composed  of  small  round  cells,  united  by  a  scanty 
homogeneous  or  fibrillar  intercellular  substance.  In  those  of  the  central  nervous 
system  the  protoplasm  of  the  cells  gives  off  prolongations,  which  are  continuous 
with  a  felting  of  delicate  fibrils. 

In  the  central  nervous  system  these  growths  appear  as  white,  or  pinkish, 
ill-defined  masses,  firmer  than  the  surrounding  brain-tissue,  into  which  they  merge 
insensibly.  Usually  they  are  situated  in  the  convolutions,  and  are  solitary,  but 
occasionally  multiple.  Although  they  possess  the  features  of  local  malignancy, 
they  do  not  give  rise  to  metastasis  in  distant  organs  ;  in  this  respect,  however, 
glioma  of  the  retina  is  distinctly  worse,  being  very  prone  to  recur  locally. 

Myo-  or  Rhabdo-sarcoma. — Mixed  tumors  composed  of  round  cells  and 
striped  muscles  have  been  observed  in  infants  or  young  children.  They  are 
adherent  to  and  sometimes  infiltrate  the  substance  of  the  kidney,  and  in  some 
instances  have  involved  both  organs.  Similar  growths  occur  in  the  testicle ;  and 
both  striped  and  unstriped  muscle  not  rarely  are  present  in  cystic  sarcomata  of 
that  organ.  In  the  rhabdo-sarcomata  the  muscle  takes  the  form  of  transversely 
striated  fibrils,  or  of  elongated  spindle-cells,  also  striated. 

Adcno-sarcoma. — Certain  sarcomata  of  glands,  as  the  breast,  parotid,  and 
testicle,  contain  a  variable  amount  of  the  normal  gland-tissue  distributed  through- 
out their  substance.  The  sarcoma-tissue  originates  in  the  stroma  of  the  organ, 
expands  and  stretches  out  the  gland-tissue,  the  epithelium  of  which  must  therefore 
grow  to  cover  the  increased  surface,  but  otherwise  there  is  probably  no  new 
formation.  Certain  of  the  ducts  or  gland-tubules  are  obliterated,  and  the  inter- 
vening portions  may  be  dilated,  and  form  cysts,  into  which,  in  the  breast  and 
sometimes  the  tescicle,  rounded  masses  of  sarcomatous  stroma  protrude.  Adeno- 
sarcomata  may  be  made  up  of  almost  any  form  of  sarcoma-tissue  ;  but  the  stroma 
is  commonly  composed  of  round  or  stellate  cells  with  a  large  proportion  of 
fibrillar  connective  tissue  (Fig.  19.) 

Cylindroma. — This  name  is  given  to  peculiar  neoplasms  of  rare  occurrence, 
and  mostly  sarcomata.  Their  chief  distinguishing  feature  is  the  presence  of 
intersecting  hyaline  bands  and  cylinders,  which  are  produced  either  by  mucoid 
degeneration  of  strands  of  cells,  or  by  greatly  thickened  blood-vessels,  the  sheaths 
of  which  have  undergone  hyaline  change.  The  latter  condition  is  more  often 
observed  in  cerebral  tumors.  A  somewhat  similar  appearance  is  met  with  in 
growths  of  nerve-plexuses,  as  the  pes  anserinus,  in  which  the  cylinders  result  from 
thickening  of  the  endoneurium. 


142        GENERAL   PATHOLOGY  OF  SURGICAL   DISEASES. 

Endothelioinata  are  growths  arising  from  the  endothelial  linings  of  various 
cavities  of  the  body  and  of  the  blood-vessels.  Endothelium  being  derived  from 
mesoblast  and  belonging  to  the  connective  tissue,  these  growths  must  be  included 
in  the  connective-tissue  series. 

Psammoma,  or  angciolithic  sarcoma,  originates  in  connection  with  the 
membranes  of  the  brain  and  spinal  cord.  It  is  characterized  by  the  presence  of 
spheres,  usually  calcified,  resembling  in  structure  and  mode  of  formation  the 
brain-sand  of  the  choroid  plexus.  The  spheres  are  united  by  fibrous  tissue,  and 
are  sometimes  arranged  in  a  dendritic  fashion.  They  are  composed  of  very  large 
and  thin  endothelial  plates,  disposed  in  concentric  laminae,  and,  according  to 
Cornil  and  Ranvier,  are  formed  by  buds  springing  from  the  walls  of  blood-vessels, 
which  are  numerous.  Presumably  the  cells  are  derived  from  the  endothelium  of 
the  blood-vessels.     In  their  clinical  character  these  tumors  are  innocent. 

General  Characteristics  of  Sarcomata. — Great  variations  exist  in  their 
physical  characters.  The  majority  have  a  well-defined,  rounded,  and  at  times  a 
largely  nodulated  outline,  and  many  are  distinctly  encapsuled.  Some  of  the 
softer,  round-celled  forms  infiltrate  like  cancer.  Their  consistence  includes  every 
grade,  from  that  of  soft  brain-tissue,  or  jelly,  to  that  of  a  fibroma :  in  color  they 
are  creamy  or  pearly  white,  and  often  blotched  with  various  shades  of  red,  yellow, 
and  brown,  produced  by  changes  in  extra vasated  blood.  The  section  is  uniform, 
homogeneous,  faintly  fibrillar,  or  distinctly  fasciculated.  Some  indication  of  the 
structure  may  be  obtained  from  the  naked  eye  character.  Thus  the  round-celled 
growths  are  usually  soft,  medullary,  or  semi-gelatinous  ;  the  spindle-celled  have  a 
smooth,  rather  firm,  homogeneous  section,  and  a  few  faint,  fibrous  bands  only  can 
be  traced  on  their  surface,  or  they  may  be  distinctly  fascicular.  The  appearances 
of  some  of  the  special  varieties  have  already  been  described. 

Modifications  result  from  the  various  forms  of  degeneration  affecting  a  part 
or  the  whole  of  the  mass,  /.  e.,  mucoid,  fatty,  or  caseous  ;  or  from  hemorrhage  and 
cyst-formation.  When  the  skin  gives  way  over  a  sarcoma  it  usually  protrudes  as  a 
red,  soft  mass  of  granulation-tissue.  The  duration,  progress,  and  malignancy  of 
these  tumors  offer  as  much  diversity  as  their  physical  characters.  Soft,  medullary, 
rapidly-growing  neoplasms,  and  the  melanomata,  are  the  most  malignant,  some- 
times killing,  from  generalization  of  the  growth  in  internal  organs,  within  a  few 
months.  At  the  other  extreme  the  spindle-celled  sarcomata  of  the  skin  and  the 
fibro -sarcomata  grow  exceedingly  slowly ;  but  they  are  prone  to  recur  near  the 
cicatrix,  again  and  again  after  removal,  and  five  or  six  operations  may  be  per- 
formed before  the  patient  succumbs  from  exhaustion,  or  dissemination  of  the 
growth.  Such  tumors  were  formerly  described  as  "  recurrent  fibroids."  As 
regards  prognosis,  the  rapidity  of  growth,  consistence,  and  locality  are  of  more 
importance  than  the  microscopic  structure.  Of  this  it  may  broadly  be  said,  that 
the  elementary  round  and  spindle-celled  growths,  especially  the  former,  are  more 
malignant  than  those  in  which  there  is  an  attempt  to  organize  and  form  fibrous 
tissues. 

Locality  is  a  most  important  element,  sarcomata  of  the  testicle  being,  for 
example,  much  more  malignant  than  those  of  the  breast.  Of  tumors  of  bone,  the 
myeloid  are  by  far  the  least  malignant — probably,  in  great  part,  because,  being 
usually  central,  they  are  enclosed  by  an  osseous  capsule. 

The  mode  of  generalization  of  sarcoma  differs  essentially  from  that  of  cancer  ; 
in  the  former  the  blood-vessels  are  numerous,  thin-walled,  often  mere  channels  in 
the  growth,  and  thus  the  conditions  are  most  favorable  for  the  escape  of  its 
elements  into  the  veins,  whence  they  are  carried  into  the  heart,  lungs,  and  other 
viscera  ;  while,  in  the  latter,  secondary  growths  first  appear  in  the  nearest  chain 
of  lymphatic  glands,  and  from  these  the  tumor  elements  pass  into  the  blood  stream. 
But  it  is  erroneous  to  suppose  that  the  glands  are  never  affected  in  sarcoma,  for 
in  growths  of  the  testicle  and  tonsil  it  is  the  rule  (Butlin).  Glands  are  also  often 
involved  by  contiguity,  when  the  growth  originates  near  them,  as  in  tumors  of  the 
ilium.     An  outgrowth  from  a  sarcoma  may  project  into,  and  grow  for  a  great 


TUMORS— PAPILL  OMA  TA. 


M3 


distance  along,  a  vein.  In  a  mixed-cell  sarcoma  of  the  forearm,  I  found  a  pro- 
longation extending  for  some  distance  along,  and  occluding  one  of  the  veins  at 
the  bend  of  the  elbow. 

Epithelial-Tissue  Tumors. 

This  large  and  important  group  comprises  tumors  derived  from  the  epithelium 
of  the  surfaces  and  glands  of  the  body  ;  and  which,  speaking  broadly,  originate 
from  the  epi-  or  hypo-blast.  It  need  scarcely  be  remarked  that  these  tumors  are 
composed  of  both  epithelium  and  connective  tissue  ;  in  fact,  in  some,  the  latter 
preponderates,  as  in  contracting  scirrhus  ;  but  it  is  the  epithelium  which  takes 
the  initiative  in  growth,  and  gives  to  the  tumor  its  si)ecial  character. 

These  neoplasms  are  divided  clinically  into  two  groujjs — the  innocent  and 
the  malignant.  To  the  former  belong  papilloma  and  adenoma,  to  the  latter 
carcinoma. 


A  tfeno  -sa  rcom  a 


Adeno  -Mi/j::oma 
fjTrom  i'reastj 


Adenoma 

yfrcim  Breast, 
[AefoUules      .  \ 
growi/tp  cystic) 


tS^  Adenoma 
I'y'ra/Ti  skin 
o/Jhrv  ari/i) 


deno-jfihro' 
sarcoma, 
fymm   iip) 


Fig.  19. — Adenoma. 


Papillomata. 

The  simplest  are  merely  overgrowths  of  the  normal  papillae  of  the  skin  or 
mucous  membrane,  each  consisting  of  a  central  stem  of  connective  tissue,  con- 
taining capillaries,  and  covered  on  the  surface  by  a  thickened  layer  of  cuticle, 
which  at  the  end  may  be  prolonged  into  a  point.  Such  papillomata  occur  fre- 
quently upon  the  skin  and  tongue. 

Others  are  composed  of  a  series  of  minute  outgrowths,  subdivided  at  their 
tips  (compound  papilloma).  Others  again,  in  the  bladder,  form  branched  or 
dendritic  ma.sses,  covered  with  columnar  epithelium  (villous  growths)  ;  while 
those  that  occur  in  the  ducts  of  the  breast,  and  in  ovarian  and  parovarian  cysts, 
are  more  complex  still,  the  interstices  between  the  papillae  being  prolonged  down- 
ward as  glandular  tubules. 

The  external  form  and  consistence  necessarily  vary  very  greatly,  even  in 
those  springing  from  the  same  structure.  For  example,  warts ;  fleshy,  vascular 
verruca  ;    and    even  long,   spiral   horns — composed  of  closely-packed  cornified 


144       GENERAL   PATHOLOGY  OE  SURGICAL   DISEASES. 

papillae — may  appear  upon  the  skin.  The  cause  is  usually  some  irritant,  and, 
therefore,  papillomata  are  often  multiple,  as  in  the  case  of  warts  on  butchers' 
hands  and  of  the  verrucas,  which  are  associated  with  discharges  from  the  generative 
organs.  In  some  cases  this  is  so  striking  that  a  local  infection  has  been  suggested 
as  the  cause,  and  various  forms  of  bacilli  and  psoro.spermis  have  been  described 
in  connection  with  them. 

Adenomata. 

Adenomata  are  hyperplasias  of  gland-tissue  of  which  the  epithelium  presents 
the  regular  and  orderly  arrangement,  reproduces  the  general  form,  and  does  not 
overstep  the  general  limits  of  the  gland  in  which  they  originate.  Clinically,  they 
are  always  innocent,  but  so  closely  do  the  so-called  adeno-carcinomata  resemble 
them  histologically  that  it  is  rather  by  their  general  characters  and  limits  than  by 
their  microscopic  structure  that  they  may  be  distinguished  in  some  instances  ;  for 
example,  the  true  adenomata  of  the  intestine  never  pass  beyond  the  mucosa,  while 
the  cancers  extend  through  it,  penetrate  the  muscular  coat,  and  even  involve  adja- 
cent organs.  Adenomata  are  described  as  tubular,  acinous,  and  follicular,  accord- 
ing to  the  type  of  gland-tissue.  They  occur  in  the  breast,  intestine,  cutaneous 
glands,  ovary,  thyroid,  parotid,  liver,  and  kidney. 

Physical  Characters. — In  the  breast  and  skin  they  are  nodulated,  encapsuled, 
and  freely  movable ;  in  the  uterus  and  intestine  they  form  polypoid  outgrowths  ; 
in  other  organs,  as  in  the  ovary,  they  may  involve  the  entire  structure.  Cysts 
are  frequently  present,  being  formed  either  from  gland-tubules  or  from  closed 
follicles,  as  in  the  ovary  and  thyroid. 

Microscopically,  the  simplest  form  is  the  common  mucous  polypus  of  the  rec- 
tum, which  is  composed  of  tortuous  branching  tubules  lined  with  a  single  layer  of 
columnar  epithelium,  and  whose  archetype  is  the  Lieberkuhn's  crypt.  The  stroma 
is  soft,  oedematous,  and  made  up  of  a  fibrillar  tissue  with  stellate  and  round  cells. 
The  common  statement  that  adenomata  do  not  secrete  is  erroneous,  for  the  tubules 
of  rectal  polypi  pour  out  quantities  of  mucus,  and  many  ' '  goblet  cells  ' '  may 
always  be  observed  ;  and  in  a  specimen  of  fibro-adenoma  of  the  breast,  removed 
soon  after  lactation,  I  found  a  quantity  of  milk  which  exuded  from  the  section. 
In  fibro-adenoma  of  the  breast  the  gland-tissue  takes  the  form  of  elongated, 
curved,  narrow  cul-de-sacs,  probably  elongated  acini,  or  of  ducts  cut  across  or 
terminating  in  trefoil-shaped  alveoli.  The  new  formation  of  gland-tissue  is  often 
inconsiderable,  and  it  would  appear  as  if  that  of  a  mammary  lobule  were  merely 
stretched  out  and  deformed  by  a  growth  of  connective  tissue. 

Cutaneous  adenomata  are  of  two  kinds — the  sudoriparous  and  sebaceous.  The 
former  are  composed  of  tortuous  columns  of  small,  spherical  epithelium,  the 
latter  of  gland-tissue  of  an  acinous  type,  the  acini  being  filled  with  fatty  matter 
and  epithelial  cells.  Both  form  freely  movable,  firm  tumors,  having  a  lobulated 
structure,  and  they  are  prone  to  undergo  calcerous  degeneration.  The  sebaceous 
adenomata  are  usually  situated  on  the  scalp. 

Carcinoma. 

Carcinomata  are  overgrowths  of  the  epithelial  linings  and  glands  of  the  body, 
which  spread  indefinitely  by  infiltration  through  contiguous  structures,  and  are 
prone  to  affect  early  the  lymphatic  glands  by  transference  of  their  elements  along 
the  lymph  channels.  Those  originating  in  glands  offer  an  irregular,  disordered, 
and  rudimentary  resemblance  to  the  mother  gland  ;  sometimes  it  is  closer,  but  the 
likeness  is  never  so  exact  as  in  the  adenomata,  the  arrangement  of  the  cells  being 
less  regular,  with  no  attempt  at  the  formation  of  a  basement  membrane.  Some  of 
the  clinical  differences  have  already  been  alluded  to. 

Cancers  are  divided  anatomically  into  groups,  in  accordance  with  the  nature 
of  their  epithelium. 

Squamous  epilhc/io/na,  for. example,  springs  from  the  stratified  epithelium  of 


TUMORS—  CA  R  CINOMA . 


M5 


the  skin  ami  mucous  membrane  ;  cylindrical-cclIaU  from  the  coUimnar  epitheHum 
of  the  mucous  tracts  and  glands,  and  sphcroidal-ccllcd,  from  that  which  lines 
secreting  structures  in  the  breast,  kidnev,  testicle,  etc. 

Siiiiamous-ccUcd  Epitheliomata.—  '\\\(t^   form   flattened,  superficial,  or  more 


ffard 
Carcinemci 
^iver  sccondV 
ie  breast  the 
right  side  shows 
Tialftraiis/'ornicc? 
liver  Hs'xiir .  the 
(eff  scirrhuus 
suhstancc.  j/ircei 
almost  {lu'imllccl 

Ca 


Lara  noma  \\ 

(Cerebellum,  seconclaru    \j\ 
^         la   breast.)  '« 


Hard 
Carctnoina 
(Jdciirfi,  seand?[ 
to  trrenst,  tJie 
early  si  age 
at  t/n's  end) 


dfinnl ,)>r  Alveolar 
Carcinoma  /'rrcliuji 
fri/^/it  side  shous 
ifte  ends  o^  tiro 
Lieier/CuhnfoUidrs 
tlie  cancer  aj?/iears 
to  extend  ^roni  these 
into  the  subtitticom, 
coat  A 


Cu/inder  - 
JEhithelial 

Carcirioniu 
(colon,  a 
similar  struc- 
ture foiiTid 
in  h'ver  it/" 
same  case) 


£/tithehoma  , 
or  H/dthelinl 
CarcL/iij/tiii- 


Soft  Carrijioma 
(Kidney  secondary  te 
(h'sopAuffas:  lower 
left  /land  corner  shiM 
a  renal  lobule  witli  a 
cast  J I  Ac  lu'O  caneir 
aliyoli.  Jieil  l/its  a!t 
evidenlli/  transforma- 
tions of'sU4:k  lubes 
]iipAt  edye,  new  gra  - 
nitle  tissue  in  the 
ilroma  Left  edc/e, 
-■  develop  -  of  Ihis  inla 
a  spt/idle  cell  tlroma 


Hard,  Carcixma 
Qileura  sedl 
to  breast 

the  oldest 
part  at 

lAis  end) 


Epitkeli'oma  or 
KpitkeJial  Carxi- 
noma  ^skin  of^ 
cTiieA'  shouinn 
the yland  like 
Structure  ',    several 
birds  nesl  Ijodie-S  are 
seen.  The  stroma  is 
ofcrmeclii'e  lis- 
sue ,  ^iyhly  char- 
f  J/^d   with    younq 
f^  cells.)  ^ 


SpUhehoma 

or 
Epithelial 
Camnoma 


Separata 
Cells 


Fig.  20. — Carcinoma,     (a)  Cell-nests. 


deeply  infiltrating  growths  on  surfaces  lined  by  squamous  or  transitional  epithelmm 
They'often  spring'from  a  crack  or  papilloma,  an  old  ulcer,  a  scar,  or  a  patch  of 
epithelium  thickened  by  long-standing  inflammation. 

The  superficial  outgrowth  or  hypertrophy  of  epithelium  constituting  a  wart  or 
papilloma  is  sometimcb^  followed  by  an  ingrowth  of  the  deeper  layers,  as,  for 


146       GENERAL   PATHOLOGY  OF  SURGLCAL   JDISEASES. 


example,  in  chimney-sweep's  cancer.  However  arising,  the  earh'est  change  is  an 
elongation  of  the  inter-])apillary  processes  of  epithelium,  and  an  infiltration  of  the 
corium  or  mucosa  with  leucocytes.  The  processes  continue  to  grow  downward  as 
tap  or  finger-like  prolongations,  and  soon  are  studded  with  cell-nests ;  finally,  the 
normal  boundary  between  the  epithelium  and  sub-epithelial  connective  tissue  is 
broken  down,  and  the  growing  cells  are  merged  in  the  subjacent  connective  tissue, 
which  is  infiltrated  with  leucocytes.  The  epithelioma  may  then  be  said  to  be 
definitely  formed.  The  growth  now  extends  in  the  direction  of  least  resistance — 
namely,  along  the  connective-tissue  interspaces — and  nuclei  are  carried  with  the 
lymph-stream  into  the  lymphatics.  A  general  infiltration  or  injection  of  the  con- 
nective-tissue interspaces  and  lymphatics  results,  comjiosed  of  tortuous  columns 
and  rounded  masses  of  epithelium.  In  epitheliomata  of  the  tongue,  skin,  and  some 
other  parts,  the  central  cells  of  the  tap-like  prolongations  from  the  surface  and  of 

the  deeper  masses  become  cornified,  so  that  a  trans- 
verse section  shows  a  number  of  concentric  laminae 
bounded  by  a  layer  of  epithelium,  like  the  rete  mu- 
cosum.  These  are  the  epidermic  globes,  cell-nests, 
or  birds' -nests.  But  other  smaller  concentric  whorls 
are  interspersed  irregularly  throughout  the  growth, 
and  perhaps  may  more  strictly  he  termed  cell-nests  ; 
they  are  much  smaller  than  the  epidermic  globes, 
and  are  composed  of  a  few  plump,  central  cells,  un- 
dergoing proliferation,  surrounded  by  two  or  three 
layers  of  small,  flattened  cells  (Fig.  20). 

Ulceration  usually  occurs  through  breaking 
down  of  the  superficial  portions  of  the  neoplasm. 
The  surface  of  the  ulcer,  whether  it  fungates  or  is 
excavated,  is  surrounded  by  a  raised,  hardened, 
often  sinuous  edge,  and  its  base  is  indurated  in  pro- 
portion to  the  depth  of  the  infiltration.  At  times 
the  surface  is  papillary,  or  is  covered  with  thickened  epithelium,  as  in  growths  on 
the  heel ;  and  even  an  extensive  epithelioma  of  the  tongue  may  present  no  ulcera- 
tion. The  lymphatic  glands  are  involved  very  early  in  the  disease,  and  if  left 
alone  its  duration  may  be  only  a  matter  of  months.  Death  supervenes  from 
exhaustion,  consequent  on  the  local  effects  of  the  disease,  and  from  cachexia, 
resulting  from  secondary  growths  in  internal  organs. 

The  chief  seats  of  epithelioma  are  the  junctions  of  skin  and  mucous  membrane 
— as  the  lower  lip,  anus,  and  vaginal  orifice  ;  parts  especially  exposed  to  irritation, 
as  the  tongue  ;  various  parts  of  the  skin,  the  glans  penis,  the  palate,  posterior  wall 
of  larynx,  vocal  cords,  oesophagus,  cervix  uteri,  and  urinary  bladder.  In  the 
latter  organ  it  often  produces  soft  papillary  or  vegetative  outgrowths. 

Rodent  Ulcer,  Rodent  Epithelioma,  Cancroid  of  the  Skin. — These  names  are 
given  to  an  exceedingly  chronic,  slowly-growing  form  of  epithelioma  affecting  the 
upper  part  of  the  face  of  people  advanced  in  years.  Its  favorite  sites  are  the 
external  canthus,  the  side  of  the  nose,  and  temple.  The  disease  first  appears  as  a 
slight  thickening  of  the  skin,  which  spreads  as  a  flattened,  slightly-raised,  super- 
ficial nodule,  of  which  the  centre  becomes  abraded.  An  ulcer  results,  having  a 
smooth,  dry,  pinkish-red  surface,  which  spreads,  with  a  slightly-raised,  rounded, 
firm  border.  Exceptionally,  the  centre  of  the  nodule  remains  smooth,  pale,  and 
cicatricial,  while  the  growth  continues  to  extend  at  its  periphery. 

Histologically,  rodent  epithelioma  is  made  up  of  rounded  or  lobulated  masses 
of  very  small,  round,  or  slightly  flattened  cells,  usually  invading  only  the  corium. 
Cell-nests  with  cornification  are  absent,  except  occasionally  in  the  thickened 
superficial  epithelium  covering  the  edges.  In  sections  of  growths  before  ulceration 
has  taken  place,  the  epidermis  sometimes  forms  an  unbroken  layer,  and  has  no 
connection  with  the  underlying  characteristic  neoplasm.  The  sebaceous  glands  in 
the  neighborhood  are  enlarged,  undergoing  transformation  into  the  small-celled 


Fig.  21. — Epithelioma  of  stump,  of  two 
years'  standing,  from  a  man,  jet.  58. 


TUMORS— CARCINOMA.  147 

growth,  in  which  the  sheaths  of  the  hair  follicles  are  also  involved.  There  can, 
therefore,  be  no  question  that  this  peculiar  neojjlasm  sjjrings  from  the  sebaceous 
glands  and  hair  sheaths,  and  not  from  the  epithelium  of  the  surface.  It  is  placed 
above  the  convolutions  of  the  sudoriparous  glands.  The  disease  may  exist  for 
years,  producing  by  its  extent  great  disfigurement,  and  even  destroying  the  bones 
of  the  skull  and  face,  but  it  never  implicates  the  glands.  There  is  a  great  ten- 
dency to  local  recurrence  after  removal. 

Cylindrical-ceUed  cancer,  or  epithelioma,  is  the  common  form  of  morbid 
growth  met  with  in  the  alimentary  canal,  from  the  cardiac  orifice  of  the  stomach 
to  an  inch  above  the  anus  ;  below  this  point  squamous-celled  epithelioma  occurs. 
It  is  also  observed  in  the  mucous  membrane  of  the  body  of  the  uterus  and  in  the 
bronchial  tubes.  In  minute  structure  these  neoplasms  form  a  more  or  less  close 
reproduction  of  gland-tissue  after  the  tyjje  of  the  tubular  mucous  gland.  They  are 
made  up  of  a  number  of  cylinders  and  alveoli  lined  with  cylindrical  epithelium, 
and  result  from  a  growth  downward  of  the  mucous  glands  into  the  muco.sa.  This 
becomes  in  consequence  greatly  thickened  and  upraised  ;  subsequently  the  growth 
extends  through  the  muscular  coat,  which  on  section  appears  much  increased  in 
breadth.  So  close  a  likeness  in  many  cases  does  the  new  formation  bear  to  gland- 
tissue  that  cylindrical-celled  cancer  is  classed  by  Continental  pathologists  of  high 
repute  among  the  adenomata,  notwithstanding  its  malignancy.  But  in  some 
tumors,  not  otherwise  differing  in  type,  the  cells  retain  the  young  spheroidal  form, 
and  are  distributed  in  solid-  columns  or  rounded  masses,  instead  of  forming  a 
lining  to  the  alveoli.  The  naked-eye  characters  offer  a  great  variety  in  form  and 
consistence.  A  large  number  are  firm  and  cicatricial,  and  the  disease  either  con- 
stitutes a  distinct  tumor,  or  in  the  intestine  has  the  appearance  of  a  limited  cica- 
tricial contraction.  Some  form  soft  medullary  masses  fungating  into  the  intestine, 
whilst  in  others  ulceration  is  the  prominent  feature,  adjoining  viscera — as  the  blad- 
der in  cases  of  cancer  of  the  rectum — being  often  penetrated.  Excepting  rodent 
epithelioma,  this  variety  of  cancer  perhaps  exhibits  the  slowest  progress.  Second- 
ary deposits  are  found  in  the  mesenteric  glands  and  in  the  liver,  to  which  cancer- 
ous emboli  are  carried  by  the  portal  veins.  The  seats  of  predilection  are  the 
cardiac  and  pyloric  orifices,  the  sigmoid  flexure  and  rectum. 

Spheroidal-celled  Cancer. — This  occurs  in  the  breast,  testicle,  ovary,  nose,  and 
palate.  The  common  cancer  of  the  breast  may  be  taken  as  an  example.  This 
takes  the  form  either  of  a  general  infiltration  of  the  gland,  or  of  a  nodule,  the 
physical  characters  of  which  are  detailed  elsewhere.  The  earlier  stages  which  I 
have  studied  in  chronic  mammary  indurations  do  not  differ  essentially  from  those 
of  epithelioma.  The  first  step  is  the  proliferation  of  the  epithelium  lining  the 
ducts  and  acini.  These  become  choked  and  the  surrounding  tissue  thickly 
infiltrated  with  leucocytes.  Next  the  epithelium  breaks  through  the  basement  mem- 
brane and  grows  into  the  connective-tissue  interspaces,  where  the  bulk  of  the  neo- 
plasm is  formed.  As  a  rule,  the  true  gland-tissue  has  already  undergone  atrophy. 
A  reactive  new-formation  of  connective  tissue  follows  the  inroads  of  the  epithelium. 
If  dense  fibrous  tissue  is  formed  in  abundance,  the  tumor  is  hard  and  scirrhous ;  if 
the  connective  tissue  is  soft  and  small  in  quantity,  it  is  medullary.  Between  these 
extremes  every  grade  may  be  observed.  The  amount  and  distribution  of  the 
epithelium  offer  corresponding  variations.  In  scirrhus  it  is  scanty,  the  cells  are 
small  and  arranged  in  elongated  groups  (alveoli),  between  the  broad  fibrous  bun- 
dles. In  softer  tumors  the  cells  are  large,  often  coalescent,  and  arranged  in  long 
chains  and  columns,  or  in  large  rounded  masses.  Rare  examples  are  met  with  in 
which  a  closer  likeness  to  gland-tissue  exists,  owing  to  the  arrangement  of  the  cells 
in  the  form  of  a  lining  to  the  alveoli. 

The  clinical  terms,  hard  or  scirrhous,  soft  or  medullary,  have  lost  their  patho- 
logical significance  ;  the  difference  depends  on  the  relative  amount  of  the  stroma 
and  epithelium  respectively. 

Cancers  undergo  fatty,  mucoid,  and  colloid  metamorphosis.  The  fatty 
change  is  common  in  cancers  of  the  breast,  and  in  squamous-celled  epitheliomata, 


148       GENERAL   PATHOLOGY  OF  SURGLCAL   DISEASES. 

from  a  section  of  which  worm-like  masses  of  fatty  epithelium  may  be  expressed. 
Colloid  metamorphosis  (colloid  carcinoma)  occurs  in  growths  of  the  stomach, 
intestines,  ovary,  thyroid,  and  rarely  in  the  breast.  In  this  change  drops  of 
colloid  material  appear  in  the  protoplasm  of  the  epithelium,  pressing  the  nucleus 
to  one  side  and  distending  the  cell  in  the  form  of  a  vesicle.  The  cell  wall  gives 
way  and  the  cells  merge  together  in  a  gelatinous  mass.  In  the  alimentary  canal 
these  often  constitute  exuberant  outgrowths,  which  on  section  exhibit  to  the  naked 
eye  large  alveoli  bounded  by  thin  bands  of  stroma  and  containing  soft,  white, 
jelly-like  material. 

Cancers  of  the  breast  more  commonly  undergo  mucoid  metamorphosis,  which 
attacks  the  stroma.  The  epithelium  is  unaltered,  and  the  alveoli  are  bounded  by 
broad,  transparent,  hyaline  bands  of  connective  tissue.  A  section  presents  a 
uniform,  moderately  firm,  gelatinous  aspect.  Such  growths  are  described  as 
carcinoma  myxomatodes. 

The  chief  characteristics,  common  to  all  cancers,  are  as  follows  :  they  form 
infiltrations  which  spread  indefinitely  without  any  sign  of  boundary  or  capsule. 
On  section  a  reticulated  or  alveolar  appearance  may  usually  be  distinguished  with 
the  naked  eye.  Their  alveolar  structure  is  marked  under  the  microscope,  a  con- 
dition not  met  with  in  any  other  form  of  malignant  tumor  except  the  alveolar  and 
melanotic  sarcomata.  A  scraping  of  the  surface  yields  a  milky  juice.  This  cannot 
be  obtained  from  soft  sarcomata  until  they  have  been  kept  about  twenty-four 
hours.  Cancerous  ulcers  resulting  from  growths  in  the  skin  are  usually  crateriform, 
with  infiltrated  edges. 

The  elements  of  the  disease  are  carried  directly  along  lymphatic  channels  to 
the  corresponding  group  of  glands,  from  which  general  dissemination  by  the 
blood  takes  place.  Among  organs  commonly  the  seat  of  secondary  formations 
are  the  liver,  lungs,  heart,  adrenals,  kidneys,  spleen,  and  the  bones.  The  disease 
also  spreads  by  contiguity  in  neighboring  parts  and  by  transference  along  the 
lymphatics;  thus,  in  a  case  of  contracting  scirrhus  adherent  to  the  skin — in  which 
there  were  one  or  two  nodules — an  injection  of  Berlin  blue  permeated  the  alveoli 
of  the  primary  growth  and  passed  into  the  minute  lymphatics  of  the  skin, 
demonstrating  the  direct  communication  of  the  former  with  the  lymphatic  system. 
The  blood-vessels  of  cancer  ramify  in  the  stroma,  and  capillaries  never  penetrate 
between  the  cells,  as  in  sarcoma. 

The  largest  number  of  cases  occur  between  the  ages  of  41  and  50  ;  after  that 
they  gradually  diminish.  A  considerable  proportion  are  met  with  earlier  in  life, 
but  only  4  per  cent,  before  the  age  of  20. 

Sarcoma  is  a  disease  of  an  earlier  period,  and  originates  for  the  most  part 
between  the  ages  of  15  and  35. 


PART  II. 

GENERAL  PATHOLOGY  OF  INJURIES. 


CHAPTER  I. 

THE  GENERAL  EFFECTS  OF  INJURY. 

SHOCK. 

Shock  is  the  effect  produced  upon  the  nervous  system  by  violent  stimulation 
of  peripheral  nerves  or  by  mental  emotions. 

Causes. — These  are  exciting  and  predisposing,  but  the  latter  are  in  many 
instances  so  important  that  the  distinction  between  them  can  hardly  be  main- 
tained. 

The  immediate  cause  is  usually  the  excessive  stimulation  of  a  number  of 
sensory  nerves,  as  in  extensive  burns  or  when  a  limb  is  crushed  ;  but  the  seat  of 
injury,  the  mode  of  infliction,  the  surrounding  conditions,  the  age,  sex,  and 
temperament  of  the  patient,  and  particularly  the  amount  of  blood  lost,  are  of  very 
great  importance. 

Injuries  of  the  abdomen,  urethra,  and  testis  are  especially  liable  to  be  followed 
by  shock.  The  effect  of  a  blow  upon  the  epigastrium,  of  the  passage  of  a  catheter, 
and  of  violent  squeezing  of  the  testis,  is  well  known  ;  the  most  typical  examples 
are  produced  in  this  way,  and  sometimes  they  are  so  severe  as  to  prove  fatal. 

Concussion  of  the  brain  may  be  regarded  as  a  form  of  shock,  modified  by 
the  predominance  of  certain  special  and  local  effects.  Division  of  the  cord  in 
castration  ;  section  of  the  bone  in  amputations  ;  blows  upon  the  cardiac  region  ; 
and,  still  more,  injuries  to  the  heart  itself,  are  not  uncommonly  followed  by  very 
severe  shock. 

Loss  of  blood,  if  sudden,  may  of  itself  cause  the  most  intense  shock,  and  in 
all  cases  is  a  very  grave  addition.  Exposure  to  cold  during  operations  renders  a 
patient  especially  liable  to  it,  particularly  when  ether  is  used.  Mental  emotion  is 
of  the  highest  importance ;  of  itself  it  is  sufficient  to  produce  a  fatal  result,  and 
in  all  cases  it  is  a  very  powerful  element.  In  railway  accidents,  for  example,  and 
in  earthquakes,  shock  is  especially  severe ;  it  may  cause  death  without  any 
discoverable  lesion,  and  not  only  immediately  from  intense  emotion,  but  later, 
after  some  days  or  weeks,  from  gradual  failure  of  power.  The  nervous  system  is 
so  profoundly  affected  that  it  is  unable  to  recover  itself:  one  single  stimulus  has 
left  upon  it  an  overpowering  impression. 

Those  who  are  worried  and  anxious  suffer  more  se\"erely  than  others,  and 
nothing  is  more  disastrous  than  the  conviction  that  an  operation  will  be  fatal.  On 
the  other  hand,  in  great  excitement  or  intense  mental  preoccupation,  not  only 
shock,  but  even  pain  is  not  felt,  at  least  for  the  time.  Afterward,  OAving  to 
exhaustion,  reaction  is  usually  more  acute. 

In  children  the  element  of  mental  emotion  is  much  less  prominent,  and 
unless  there  has  been  great  hemorrhage  or  prolonged  exposure  to  cold  (both  of 

149 


ISO  GENERAL   PATHOLOGY  OF  INJURIES. 

which  they  stand  very  badly),  they  suffer  much  less  than  adults.  Probably,  too, 
this  is  one  of  the  reasons  why  the  shock  in  amputation  for  disease  is  so  much  less 
than  it  is  in  a  primary  operation.  Old  people  are  usually  affected  very  slightly, 
but  when  it  does  occur  in  them  it  is  very  grave. 

No  pathological  lesion  has  ever  been  found  ;  even  the  condition  of  the  heart 
is  not  constant,  although  it  is  usually  flaccid  and  relaxed.  The  change  is  essen- 
tially a  molecular  one  \  the  energy  of  the  active  tissues,  especially  the  nerves  and 
muscles,  suffers  the  most  extreme  depression ;  they  are  incapable  of  putting  out 
any  force,  or  of  producing  the  amount  of  heat  requisite  to  maintain  the  tempera- 
ture of  the  body  \  the  power  of  doing  work  of  any  kind  is  lost. 

Those  are  most  liable  to  suffer  from  it  whose  nervous  system  is  already  in 
what  must  be  called,  for  want  of  a  better  term,  a  state  of  depression,  whether  this 
is  due  to  natural  temperament,  or  to  cold,  exposure,  fatigue,  violent  emotion,  loss 
of  blood,  or  other  accidental  conditions. 

Symptoms. — Two  varieties  of  shock  are  described,  the  one  characterized 
by  extreme  depression,  the  other,  which  is  much  the  more  rare,  by  great  excite- 
ment. Upon  what  the  difference  depends,  why  one  form  should  occur  and  not 
the  other,  is  not  known. 

In  the  ordinary  form  the  patient  lies  perfectly  quiet  with  the  eyelids  half- 
closed  and  the  limbs  in  the  position  that  chance  may  have  placed  them ; 
conscious,  but  paying  no  attention  to  anything  around ;  able  to  speak  feebly  and 
slowly,  but  entirely  incapable  of  any  mental  effort.  The  face  has  lost  all  expres- 
sion ;  the  skin  is  cold,  pale,  and  clammy,  that  on  the  forehead  often  being 
covered  with  perspiration  ;  the  pulse  is  frequent,  generally  more  or  less  irregular ; 
the  artery  seems  to  collapse  and  empty  itself  between  each  beat ;  the  respiration 
is  shallow,  and  the  temperature  far  below  normal — sometimes  as  much  as  three  or 
four  degrees.  The  sphincter  ani  is  usually  relaxed  ;  urine,  if  the  bladder  is  full 
at  the  time  of  the  accident,  is  retained ;  but  afterward,  for  many  hours,  the 
secretion  stops  almost  altogether. 

In  the  worst  cases,  such  as  are  almost  certain  to  prove  fatal,  there  is  complete 
absence  of  the  sense  of  pain.  I  have  many  times  seen  patients  dreamily  looking 
on,  without  a  sign  of  intelligence,  while  broken  fragments  of  bone  were  being 
removed  and  search  made  for  bleeding  arteries,  in  limbs  that  had  been  crushed  in 
a  railway  accident. 

Vomiting  is  of  frequent  occurrence ;  in  head  injuries  it  not  uncommonly 
marks  the  onset  of  reaction,  and  in  a  few  moments  the  face  becomes  flushed  and 
the  pulse  regains  its  vigor  and  fullness.  In  other  cases  it  may  either  occur  at  the 
commencement,  when  it  is  of  comparatively  little  significance,  or  later,  after  a 
few  hours,  and  then  it  not  uncommonly  marks  the  beginning  of  the  end. 

Shock  may  be  almost  instantaneously  fatal ;  I  have  known  death  to  occur 
within  five  minutes  from  puncturing  a  small  hydatid  cyst  in  the  liver  ;  or  it  may 
begin  more  gradually  and  slowly  become  worse  and  worse  until  death  ends  the 
scene. 

The  other  variety,  that  which  is  characterized  by  furious  excitement,  is  more 
uncommon.  Its  onset  is  nearly  always  gradual ;  at  the  first  there  is  some  ground 
for  hope,  and  the  general  condition  appears  not  altogether  unsatisfactory,  although 
the  pulse  is  very  rapid  and  devoid  of  power ;  very  soon,  however,  the  patient 
becomes  restless  aud  begins  to  talk  volubly  and  incoherently;  delirium  sets  in  ; 
the  limbs  are  thrown  wildly  about,  utterly  regardless  of  pain  ;  and  in  a  short  time 
this  is  followed  by  a  condition  resembling  furious  mania.  The  result  is  invariably 
fatal,  from  collapse. 

Diagnosis. — Syncope  due  to  failure  of  the  blood-supply  of  the  brain  rarely 
causes  any  difficulty  ;  with  hemorrhage,  especially  when  it  is  internal,  it  is  differ- 
ent. In  many  cases  of  injury  to  the  abdominal  viscera  it  is  practically  impossible 
to  make  a  diagnosis,  the  two  are  so  often  associated.  Given  a  case  of  severe  con- 
tusion followed  by  collapse,  it  may  be  due  to  shock  alone  or  to  shock  complicated 
by  hemorrhage  from  rupture  of  the  viscera  or  tearing  of  a  mesenteric  artery  or 


SHOCK.  151 

vein,  and  there  is  no  certain  method  of  separating  one  condition  from  the  other. 
Faihire  of  sight  due  to  ana;mia  of  the  retina,  constant  yawning  or  deep  sighing 
inspirations,  and  throwing  the  arms  about  over  the  head,  are  very  suggestive  of 
hemorrhage,  but  nothing  more;  and  a  great  deal  of  blood  may  collect  in  the 
abdominal  cavity  without  causing  any  marked  degree  of  dullness. 

Prognosis. — The  condition  of  the  pulse  and  the  temperature  together  give 
the  best  clue  (always  provided  there  is  no  hemorrhage),  but  a  great  deal  depends 
upon  the  kind  of  injury.  Shock  may  prove  fatal  almost  instantaneously,  or  it 
may  be  very  severe  at  first  and  gradually  pass  off;  or,  especially  after  extensive 
injuries,  it  may  steadily  grow  worse  and  worse,  until  at  length  the  pulse  fails  com- 
pletely.    The  maniacal  form  is  nearly  always  fatal. 

Whether  an  operation  should  ever  be  performed  during  the  continuance  of 
shock  is  a  question  that  depends  u])on  the  injury.  So  far  as  primary  amputations 
are  concerned,  I  am  sure  that  the  best  course  to  follow  is  to  stop  the  hemorrhage, 
prevent  decomposition  by  wrapping  up  the  limb  in  a  strong  solution  of  corrosive 
sublimate  (i  part  in  500),  and  leave  it,  not  until  reaction  is  beginning,  but  until 
it  has  thoroughly  set  in — and  this  may  not  be  for  more  than  forty-eight  hours. 
It  is  impossible  at  first  to  say  whether  the  patient  will  live  or  not ;  when  in  this 
condition,  an  operation  will  almost  certainly  prove  fatal.  Even  when  reaction  is 
commencing,  the  same  result  is  highly  probable.  I  have  on  more  than  one  occa- 
sion seen  a  patient's  face  suddenly  change  and  felt  the  skin  grow  cold  again  as  the 
bone  was  being  sawni  through  ;"  while  if  the  hemorrhage  is  stayed  and  decompo- 
sition prevented  (as  it  can  be  in  nearly  every  case),  the  patient  at  least  can  come 
to  no  harm. 

The  exception  to  this  is  where  it  is  necessary  to  perform  an  operation,  such  as 
opening  the  abdomen,  for  the  arrest  of  hemorrhage.  This  must,  of  course,  be 
done  at  once. 

Ether  is  the  anaesthetic  usually  recommended  for  operations  in  these  cases, 
but  chloroform  is  as  safe  if  given  in  very  small  quantities  ;  a  patient  suffering  from 
shock  is  already  almost  insensible  to  pain,  and  requires  very  little  to  produce 
complete  anaesthesia. 

Treatment. — Hemorrhage  must,  of  course,  be  stopped  at  once  ;  crushed 
limbs  rarely  bleed  from  the  large  vessels,  but  often  there  is  a  considerable  amount 
of  general  oozing,  which  is  serious  in  such  a  condition  as  this.  Very  hot  water 
(with  corrosive  sublimate),  and  afterward  firm  bandaging,  is  the  most  satisfactory 
method.  The  elastic  tourniquet  should  not  be  used,  as  it  is  liable  to  cause  slough- 
ing. Where  a  mass  of  muscle  projects  from  the  end  of  a  crushed  stump  and 
persists  in  oozing,  it  may  be  ligatured  and  cut  away. 

Warmth  is  the  first  essential — hot  blankets  round  the  patient,  and  hot  bottles 
outside  these.  Stimulants  are  usually  required,  but  they  must  be  given  in  very 
small  quantities,  at  intervals  of  half  an  hour,  and  careful  watch  must  be  kept  upon 
the  condition  of  the  pulse  ;  as  it  improves  the  intervals  can  be  lengthened.  If 
there  is  much  sickness,  a  larger  amount  may  be  injected  into  the  rectum.  Subcu- 
taneous injections  are  sometimes  resorted  to  when  the  patient  is  insensible  and  an 
immediate  effect  is  desired.  Ether,  perhaps,  acts  more  rapidly  than  brandy,  but 
its  effect  is  more  evanescent.  In  many  cases  ammonia  may  be  given  with  advan- 
tage, either  wath  the  brandy  (liq.  ammoniae  aromat.,  3j)  or  even,  if  the  heart  is 
certainly  failing,  hypodermically,  by  intravenous  injection,  as  in  cases  of  snake- 
bite. 

Strychnia,  digitalis,  and  other  drugs  from  which  much  was  expected,  have  all 
proved  fallacious  ;  a  very  small  quantity  of  morphia  {yi  gr.),  locally,  is  beneficial, 
relieving  the  pain  and  so  diminishing  one  cause  of  the  depression. 

Transfusion  with  blood  or  with  a  saline  solution  is  of  very  little  use,  if  any, 
in  shock  uncomplicated  with  hemorrhage.  Possibly  a  certain  amount  of  benefit 
may  be  derived  from  raising  the  limbs,  surrounding  them  with  cotton-wool,  and 
then  bandaging  them,  so  as  to  diminish  as  far  as  possible  the  area  over  which  the 
blood  in  the  body  has  to  be  distributed. 


152  GENERAL   PATHOLOGY  OF  LNJURIES. 

DELIRIUM  TREMENS. 

Delirium  of  various  kinds  is  met  with  after  injuries.  Sometimes  it  is  due  to 
the  anaesthetic,  or  to  prolonged  exhaustion  and  exposure,  just  as  occasionally  it 
occurs  during  the  convalescence  from  protracted  fevers  ;  in  other  cases  fat-embo- 
lism or  the  absorption  of  some  poison  from  the  surface  of  a  wound  may  be  the 
cause,  but  the  best  defined  and  the  most  characteristic  is  that  which  is  the  result 
wholly,  or  in  great  measure,  of  alcoholism. 

Delirium  tremens  may  occur  without  injury  of  any  kind,  but,  as  met  with  in 
surgical  wards,  it  usually  follows  an  accident,  often  one  of  a  very  trivial  character, 
two  or  three  days  after  it  has  been  inflicted.  Sometimes  it  can  be  traced  to  a  pro- 
longed debauch,  but  it  is  more  frequent  in  those  who,  like  many  brewers'  dray- 
men, if  they  are  never  wholly  sober,  are  never  positively  drunk. 

The  first  night  is  passed  in  comparative  peace,  although  the  patient  may  not 
sleep.  Next  morning  the  tongue  is  white,  flabby,  marked  by  the  teeth,  and 
exceedingly  tremulous ;  the  face  is  flushed  and  anxious,  the  hands  are  strangely 
restless,  the  patient  seems  unable  to  control  them  or  even  direct  their  actions ; 
every  movement  is  attended  with  characteristic  tremor ;  the  appetite  is  lost ;  the 
skin  is  cool  and  often  moist ;  the  bowels  are  confined,  and  generally  there  is  a  ten- 
dency to  nausea.  Toward  evening  the  symptoms  grow  worse  ;  the  pulse  becomes 
very  rapid,  wanting  in  volume,  and  frequently  dicrotic  ;  hallucinations,-  often  of 
the  most  disgusting  character,  make  their  appearance ;  the  patient  yields  easily  to 
control,  but  only  for  the  moment ;  the  same  idea  returns  again  and  again — it  may 
be  the  sight  or  the  sound  of  something  that  fills  him  with  apprehension,  or  it  may 
be  something  utterly  unintelligible,  referring  in  an  indistinct  way  to  his  occupa- 
tion ;  at  the  same  time  there  is  the  most  ceaseless  movement ;  the  hands  are  never 
still,  aimlessly  turning  the  bedclothes  over  and  over,  in  a  curious,  objectless, 
tremulous  manner ;  the  patient  lies  down,  starts  up,  turns  around,  looks  behind, 
beneath,  above  him,  anywhere,  and  does  anything  but  remain  quiet  for  one  single 
instant.  Sleep  is  out  of  the  question.  There  is  rarely  any  violence  ;  almost 
always,  if  spoken  to  gently  and  firmly,  he  will  lie  down  ;  but  it  is  utterly  beyond 
his  power  to  remain  in  the  same  position,  and  all  the  while  there  is  the  most 
extreme  terror,  the  horror  of  something  unknown,  not  to  be  described. 

In  this  way  the  night  is  passed  ;  with  morning  the  symptoms  subside  in  a 
measure,  although  they  do  not  disappear.  The  exhaustion  is  greater,  the  pulse 
feebler,  the  appetite  absolutely  lost,  and  although  the  hallucinations  are  not  so 
prominent,  the  nausea,  tremor,  sleeplessness,  and  restlessness  persist.  The  fore- 
head is  bathed  with  perspiration,  and  the  temperature  is  nearly  alway  subnormal ; 
in  exceptional  cases  (which  are  invariably  fatal)  it  rises  rapidly  in  a  way  that  is 
only  paralleled  in  tetanus  and  injuries  of  the  central  nervous  system. 

If  sleep  returns  the  following  evening,  all  usually  ends  well  and  the  symptoms 
gradually  become  less  and  less  severe ;  but  if  the  patient's  constitution  is  already 
wrecked  by  prolonged  intemperance,  or  if  the  injury  is  a  severe  one,  and  sleep  does 
not  follow,  the  prognosis  becomes  very  grave ;  the  prostration  becomes  more 
marked,  the  pulse  assumes  a  running  character,  the  beats  being  scarcely  distin- 
guishable and  the  volume  exceedingly  small,  the  respiration  becomes  shalloAv  and 
hurried,  the  skin  is  pale  and  dusky,  the  face  cyanosed  and  wet  with  perspiration, 
and  the  strength  fails  rapidly  toward  the  end. 

The  prognosis,  if  the  patient  is  seen  for  the  first  time,  must  be  very  guarded  ; 
the  condition  of  the  pulse  is  the  best  guide,  but  the  age,  the  state  of  the  kidneys, 
and  especially  the  extent  of  the  injury,  require  very  careful  consideration. 

Treatment. — Sleep  and  food  are  the  chief  requisites.  If  a  good  night's 
rest  can  be  secured,  or  if  the  patient  can  be  induced  to  take  a  fair  amount  of  food, 
recovery  may  reasonably  be  looked  forward  to.  Usually  in  these  ca.ses  there  is 
gastritis ;  no  food  has  been  taken  for  .several  days,  and  even  for  longer  periods, 
and  the  appetite  is  completely  lost.  Strong  beef-tea,  with  abundance  of  cayenne 
pepper,  sometimes  answers  when  nothing  else  will ;   milk,  with  eggs  beaten  up,  is 


TRAU.)rAriC  DELIRIUM.  153 

even  l)ettcr,  if  the  patient  can  be  induced  to  swallow  it;  hut  often  he  will  take 
nothing  at  all,  or  only  such  things  as,  from  their  extreme  pungency  or  acidity, 
will  stimulate  a  corrupted  apj^etite. 

l>romide  of  potash  is  sometimes  given  in  very  large  doses,  but  without  much 
avail  :  chloral  is  decidedly  dangerous,  as  it  tends  to  increase  the  vascular  depres- 
sion ;  opium,  or,  better,  morphia  injected  hyi)odermically,  deserves  more  reliance. 
One-third  of  a  grain  given  in  the  alternoon,  before  the  symptoms  attain  their  full 
severity,  and  followed  by  a  second  similar  dose  in  the  evening,  is  often  effectual  ; 
but  care  must  first  be  taken  to  examine  some  of  the  urine.  If  the  opiate  does  not 
succeed,  and  the  sleeplessness  still  persists,  the  head  may  be  shaved,  and  cold 
water  (half-a-dozen  jugfuls)  jjourcd  over  it ;  or  chloroform  may  be  cautiously 
tried,  the  patient  being  kept  under  its  influence  for  twenty  minutes  or  half  an 
hour.  If  these  measures  fail,  if  the  patient  will  not  eat  and  cannot  sleep,  and 
particularly  if  from  the  condition  of  his  kidneys  it  is  not  advisable  to  administer 
opium,  there  is  no  alternative  but  to  give  stimulants.  If  the  pulse  is  a  running 
one,  and  they  are  not  given,  the  patient  will  almost  certainly  die.  In  the  vast 
majority  of  cases  there  is  no  doubt  it  is  better  to  cut  them  off  at  once  (though  it  is 
quite  possible  it  makes  the  patient  worse  for  the  time),  but  I  have  seen  many 
instances  in  which  I  am  sure  the  free  use  of  stimulants  saved  life.  The  best  is 
bottled  stout,  of  the  heaviest  and  sleepiest  description,  and  it  should  be  given 
freely,  without  stint,  until  either  the  pulse  changes  its  character  or  the  patient 
falls  asleep. 

The  bowels  should  be  opened  as  soon  as  possible ;  the  liver  is  almost  always 
congested,  and  it  may  become  necessary  to  administer  nutrient  enemata.  Quinine 
and  bitter  tonics,  or  alkalies,  with  carbonate  of  ammonia,  may  be  advisable  for 
the  gastritis  and  to  improve  the  appetite  ;  tincture  of  capsicum  is  said  to  be  of 
especial  use ;    but  large  doses  of  digitalis  are  too  dangerous. 

[The  use  of  beef  tea  is  usually  followed  after  a  time  by  great  relief,  and  where 
there  is  extreme  weakness  it  may  be  combined  with  brandy  or  sherry.  Of  such  a 
mixture  the  dose  will  vary  from  a  few  drops  every  ten  or  fifteen  minutes  to  a  tea- 
cupful  every  two  hours.] 

In  many  surgical  cases  restraint  of  some  kind  is  absolutely  necessary,  but 
w^herever  it  is  possible,  anything  of  the  nature  of  a  strait-waistcoat  should  be 
avoided.  Of  itself  it  is  sufficient  to  induce  delirium  and  a  severe  degree  of  fever. 
Patients  who  are  suffering  from  delirium  tremens  are  for  the  most  part  very  easily 
controlled,  so  long  as  the  attendant  is  firm  ;  and  it  is  only  in  cases  of  extreme 
violence,  or  when  there  is  a  fracture  which  it  is  absolutely  essential  to  keep  quiet, 
that  any  tight  restraining  appliance  is  advisable. 

TRAUMATIC    DELIRIUM. 

Traumatic  delirium,  in  the  strict  sense  of  that  term — excluding,  that  is  to  say, 
the  delirium  due  to  pyrexia,  that  which  occasionally  follows  an  anaesthetic,  delirium 
tremens,  and  those  forms  which  are  caused  by  the  absorption  of  poisonous  alka- 
loids— is  decidedly  rare.  Sometimes,  however,  a  kind  of  delirium  attributable  to 
nothing  else  is  met  with,  especially  in  old  people  ;  although,  as  it  is  more  usual  after 
fractures,  it  is  possible  that  the  symptoms  are  due,  in  a  measure,  to  fat-embolism. 

The  delirium  is  not  like  that  of  delirium  tremens ;  it  has  not  the  same  rest- 
less, busy  character,  and  the  hallucinations  are  not  of  the  same  di.sgusting  descrip- 
tion. The  patient  is  often  exceedingly  supicious,  imagining  that  every  one  is 
wishing  to  injure  him  ;  but  when  left  to  himself  he  remains  quiet,  watching  every- 
thing perhaps,  and  his  movements  are  not  tremulous.  The  tongue  is  often  furred 
and  white,  but  it  can  be  protruded  without  fibrillar  contractions ;  food  is  taken 
readily  \  and  though  the  patient's  sleep  may  be  disturbed,  there  is  not  the  same 
distressing  insomnia.  Usually  the  symptoms  subside  of  themselves  in  the  course 
of  a  day  or  two,  w-ith  a  moderate  supply  of  stimulants ;  but  it  sometimes  happens 
that,  they  persist,  and  the  mental  disturbance  is  permanent. 


154  GENERAL   PATHOLOGY  OF  INJUR LES. 

TRAUMATIC    FEVER. 

Every  kind  of  fever  that  follows  injuries  has  been  described  under  this  name  ; 
strictly,  it  should  be  limited  to  that  which  results  from  them  directly,  and  should 
be  clearly  separated  from  those  which  are  due  to  septic  decomjiosition  and  other 
secondary  changes.  Two  varieties  may  be  distinguished — the  one  caased  by 
nervous  irritation  ;  the  other  by  the  absorption  of  certain  substances  from  the 
interior  of  the  wound. 

(a)  The  neurotic  form  sets  in  almost  at  once,  reaches  its  maximum  within  the 
first  five  or  six  hours,  and  then  begins  to  subside  again.  Irritation  of  peripheral 
nerves,  pain,  mental  emotion,  and  perhaps  other  causes  appear  to  possess  the 
power  of  increasing  the  production  of  heat,  possibly  by  inhibiting  the  controlling 
influence  of  the  heat-centre.  In  excitable  children,  and  occasionally  in  women, 
the  mere  sight  of  the  preparations  for  dressing  a  wound,  the  knowledge  that  the 
time  for  it  has  come,  or  even  the  apprehension  of  an  operation,  is  sufficient  to 
raise  the  temperature  as  much  as  two  degrees.  The  same  causes,  acting  with  greater 
intensity,  or  under  different  circumstances,  give  rise  to  shock,  a  condition  of 
general  depression  affecting  the  whole  of  the  central  nervous  system. 

(b)  The  other  variety,  that  which  is  caused  by  the  absorption  of  certain  sub- 
stances from  the  interior  of  the  wound,  sets  in  more  slowly,  and  continues  so  long  as 
there  is  anything  to  be  absorbed.  It  is  probably  due  to  some  of  the  products  that 
are  set  free  during  the  coagulation  of  the  blood,  as  it  has  been  shown  that  the 
injection  of  fibrin  ferment  can  excite  pyrexia,  and  that  the  height  to  which  the 
temperature  rises  is  to  a  certain  extent  dependent  upon  the  amount  of  the  extrava- 
sation. At  the  same  time,  other  substances  set  free  from  crushed  and  bruised 
tissues  may  have  some  influence  ;  and  the  tension  which  is  always  present  in  the 
case  of  large  extravasations  may  help,  partly  by  its  effect  upon  the  nerves,  partly 
by  the  way  in  which  it  assists  absorption.  As  a  rule,  the  fever  subsides  in  the 
course  of  forty-eight  hours,  but  it  may  last  a  week  or  more  ;  the  temperature,  which 
is  of  a  remittent  character,  steadily  falling  after  the  first  day. 


SUBCUTANEOUS  INJURIES.  155 


CHAPTICR  II. 

LOCAL  EFLECTS  OF  IXJURV. 

Injuries  are  divided  into  two  classes,  subcutaneous  and  open,  as  the  latter  are 
liable  to  complications  from  which  the  former  are  practically  exempt. 

I.   SUBCUTANEOUS  INJURIES. 

Simple  contusions  only  are  dealt  with  here  ;  injuries  of  special  structures  are 
reserved  for  more  minute  description. 

Contusions  are  caused  by  blows  from  some  hard,  blunt  object,  or  by  violent 
squeezes.  Blood  may  be  extravasated  into  the  skin,  but  the  surface  is  not  broken  ; 
that  constitutes  an  open  wound  at  once.  The  soft  parts  beneath  sustain  the  brunt 
of  the  violence ;  the  connective  tissue  with  its  delicate  vessels  first ;  then  the 
muscles,  which  may  be  crushed  or  torn  ;  veins,  lymphatics,  and,  to  a  less  extent, 
owing  to  their  elasticity,  arteries  come  next ;  while  nerves,  as  a  rule,  resist,  how^- 
ever  much  they  are  stretched.  • 

Contusions  vary  in  degree  from  a  trivial  bruise  to  absolute  crushing.  Clini- 
cally, the  number  and  size  of  the  vessels  torn  are  the  most  important  features. 
In  the  slightest  form — a  wheal,  for  example,  produced  by  the  lash  of  a  whip — 
there  is  no  bruising  perceptible,  merely  redness  and  swelling,  with  local  pain, 
\vhich  soon  subsides.  If  it  is  more  severe,  a  certain  degree  of  ecchymosis  follows  ; 
some  of  the  capillaries  are  ruptured ;  blood  is  effused  into  the  skin  or  the  subcu- 
taneous tissue  ;  and,  according  to  the  structure  of  the  part  and  the  violence  of  the 
injury,  swelling  and  discoloration  make  their  appearance.  In  the  worst  cases,  in 
which  a  large  vessel  has  given  way,  or  in  which  the  tissues  are  soft  and  easily 
torn,  the  amount  of  extravasation  may  be  enormous;  the  skin  may  be  separated 
from  the  deep  fascia  of  the  limb  by  a  layer  of  fluid  blood  extending  over  an 
immense  surface,  and  the  case  may  prove  fatal  almost  at  once  from  hemorrhage 
alone. 

A  circumscribed  swelling  in  the  connective  tissue  is  called  a  hcEmatoma ; 
usually  it  can  be  recognized  at  once  by  its  soft  fluid  centre  and  its  hard  and  firm 
margin.  When  the  blood  collects  in  some  internal  space  it  is  known  as  a 
hematocele.  CephalhcEinatoma  occurs  upon  the  head,  either  in  the  subaponeurotic 
or  the  subperiosteal  layer  of  the  scalp. 

The  blood  pours  out  until  the  tension  of  the  extravasation  is  equal  to  that  at 
the  orifice  of  the  ruptured  vessel,  then  coagulation  sets  in,  and  after  a  variable 
time  the  clot  breaks  down,  forming  a  thick,  turbid  fluid,  darker  than  blood,  but 
still  reddening  when  exposed  to  air. 

The  subsequent  changes  depend  upon  the  amount  of  the  extravasation,  the 
tension,  the  nutrition  of  the  tissues  around,  and  the  way  in  which  the  injured  part 
is  treated.  Absorption  is  the  rule  ;  the  red  corpuscles  and  the  fibrin  break  down, 
the  haemoglobin  is  set  free  and  soaks  into  the  loose  cellular  ti.ssue,  the  fluid  serum 
is  carried  off  by  the  lymphatics,  and,  when  the  amount  is  only  small,  the  white 
blood-corpuscles  wander  away.  If  the  extravasation  is  a  large  one,  the  leuco- 
cytes in  the  centre,  too  far  separated  from  the  living  ti.ssues,  share  the  fate  of  the 
red  ones.  Finally,  the  haemoglobin  is  removed  and  all  traces  of  the  injury  dis- 
appear. 

In  other  ca.ses,  however,  absorption  is  not  so  perfect;  a  certain  degree  of 
organizatiofi  makes  its  appearance  round  the  margin,  lymph  is  poured  out  by  the 
tissues  near,  and  a  layer  of  granulation-tissue,  which  may  become  fibrous  or  even 
bony,  is  developed  around  it.     When  this  takes  place,  the  coloring  matter  dis- 


1 5  6  GENERA  L   PA  THOL  O  G  Y  OE  INJ  URIES. 

appears,  tlie  niiid  in  the  centre  grows  paler  and  paler,  and  at  length  the  blood- 
clot  becomes  converted  into  a  cyst  or,  more  frequently,  a  thickened,  rigid  layer  of 
dense  fibrous  tissue  without  any  central  space.  After  a  time  this  too  disappears, 
probably  undergoing  fatty  degeneration  and  absorption. 

Finally,  if  the  tension  is  high  (as  when  a  large  artery  gives  way),  or  the  part 
is  not  kept  at  rest,  or  the  tissues  round  are  so  badly  nourished  that  they  are  unable 
to  stand  even  the  slight  irritation  of  the  extravasated  blood,  inflammation  sets  in  ; 
and  then,  unless  speedy  steps  are  taken  to  prevent  it,  suppuration  is  very  likely  to 
follow,  the  pyogenic  organisms  finding  their  way  to  the  injured  part,  either  through 
the  blood-vessels,  or  if  blebs  form  upon  the  surface  and  the  epidermis  gives  way, 
directly  through  the  tissues. 

No  material  suits  them  better  than  extravasated  blood,  especially  if  the  tissues 
round  are  injured  by  tension  or  are  not  kept  at  rest.  Hsematoiiiata  in  the  wall  of 
the  thorax  and  between  the  muscles  of  the  abdominal  wall  seem  peculiarly  liable 
to  break  down  ;   the  cephalhaematoma  of  infancy  never  does. 

Signs  of  Contusions. 

The  degree  of  swelling  naturally  varies  with  the  amount  and  situation  of  the 
extravasation  and  the  looseness  of  the  tissues.  Pain,  unless  a  nerve-trunk  is  struck, 
chiefly  depends  upon  the  tension.  In  some  instances — when,  for  example,  the 
testis  is  squeezed  or  the  abdomen  struck — the  shock  is  very  severe.  If  a  large 
vessel  is  torn,  the  loss  of  blood  may  jjrove  fatal  at  once,  and  even  if  it  falls  short 
of  this,  the  hemorrhage  is  often  exceedingly  serious.  The  staining,  if  the  bruise 
is  superficial,  soon  shows  itself;  when  it  is  deep  it  may  not  appear  for  weeks,  and 
then  in  some  far-distant  part ;  rupture  of  one  of  the  deep  veins  of  the  calf,  for 
example,  causes  discoloration  behind  the  internal  malleolus,  and  in  the  palm  of 
the  hand  leads  to  peculiar  purple  crescents  at  the  angles  between  the  fingers.  The 
color  varies  in  the  same  way;  under  the  conjunctiva  it  is  a  bright  red;  in  the 
loose  tissues  of  the  eyelids,  black;  where  the  skin  is  thicker,  it  is  blue  or  green, 
and  when  the  extravasation  is  very  deep  it  is  lemon-yellow.  As  the  stain  dies  out 
it  passes  through  the  same  changes  [giving  in  succession  the  colors  of  the  blood- 
spectrum.] 

Traumatic  fever  is  very  general,  and,  in  the  case  of  large  extravasations,  not 
unfrequently  severe  for  several  days. 

If  the  bruise  is  superficial,  the  skin  over  it  becomes  hot  and  red,  owing  to  the 
increased  vascularity  of  all  the  tissues  round  ;  more  blood  flows  through  the  vessels, 
because  there  is  more  work  to  be  done  and  a  greater  amount  of  repair  is  required. 
Provided  the  part  is  kept  at  rest,  this  soon  subsides ;  but  if  the  tension  is  not 
relieved,  or  if  any  fresh  injury  is  inflicted,  inflammation  .sets  in,  the  swelling 
continues  to  increase,  the  pain  becomes  more  severe,  the  skin  becomes  .shiny, 
perhaps  (edematous,  and  then  there  is  every  prospect  of  suppuration. 

Treatment. — Slight  contusions  are  best  treated  with  cold  or  evaporating 
lotions  ;  lead  lotion  is  especially  useful  if  there  is  any  redness  of  the  skin.  Arnica 
should  not  be  employed  at  all ;  its  merit  is  due  to  the  spirit  the  tincture  contains, 
and  it  often  causes  an  eruption.  Where  the  extravasation  is  considerable,  uniform, 
gentle  compression,  with  many  layers  of  cotton-wool,  checks  the  increase,  limits 
the  hyperemia,  and  promotes  absorption  better  than  anything  else.  Even  when 
the  epidermis  is  lifted  up  and  bullae  are  forming  upon  the  skin,  nothing  answers 
better.  The  fluid  should  be  drawn  off  through  a  minute  puncture  and  absorbed 
with  cotton-wool  or  thick  blotting-paper,  the  epidermis  carefully  replaced,  a  little 
iodoform  dusted  on,  or  collodion  painted  over,  and  then  cotton-wool  carefully 
applied. 

In  very  severe  cases,  w^here  there  is  risk  of  suppuration,  aspiration  often  averts 
the  danger ;  there  is  no  need  to  empty  the  cavity ;  removing  a  small  portion  of 
the  fluid  relieves  the  tension  ;  the  hypersemia  begins  to  diminish  at  once,  the  skin 
loses  its  shiny,  glazed  appearance,  and  absorption  proceeds  unchecked.   Of  course, 


OPEN  WOUNDS.  157 

if  a  large  artery  has  given  way  in  one  of  the  limbs,  so  that  the  collateral  circula- 
tion is  interrupted  and  the  part  below  is  cold  and  oedeniatous,  other  measures  are 
required. 

Occasionally  it  hapi)ens  that  the  contusion  of  the  skin  has  been  so  severe  as  to 
kill  it ;  if  the  extent  is  only  small  and  the  dee])er  structures  are  not  badly  injured, 
the  slough  should  be  allowed  to  separate  of  itself,  and  the  resulting  wound  will 
soon  close;  but  where,  as  in  railway  and  tram-car  accidents,  the  skin  has  been 
stripi)ed  off  from  the  subcutaneous  tissue  for  some  distance  above  the  apparent  seat 
of  injury,  and  it  is  thought  advisable  to  amputate,  the  line  of  incision  must  be 
carried  well  above,  or  the  flaps  are  sure  to  slough. 

2.  orj:\  WOUNDS. 

Injuries  in  which  the  skin  (or  the  mucous  membrane)  has  given  way,  so  that 
the  deeper  structures  are  exposed  to  the  air. 

Wounds  are  described  as  incised,  when  inflicted  with  a  sharp,  clean-cutting 
instrument ;  lacerated  when  the  parts  are  torn  ;  contused  when  they  are  bruised  ; 
axid  punctured  when  caused  by  the  thrust  of  a  pointed  weapon.  Foisofied  wownds, 
in  which  there  is  more  than  the  simple  division  of  the  tissues,  must  be  treated  by 
themselves. 

Incised  JVounds. — In  these  the  injury  is  limited;  on  either  side  there  is  only  a 
thin  layer  of  tissue  the  vitality- of  which  has  been  destroyed.  The  symptoms  are 
pain,  from  division  of  the  nerves  and  exposure  of  the  divided  ends  to  the  air  ; 
bleeding,  from  the  vessels  that  are  cut,  varying  in  ]>roportion  to  their  size  and  im- 
portance ;  and  gaping,  owing  to  the  elasticity  of  the  tissues.  Skin  retracts  more 
than  anything  else,  especially  when  the  wound  is  transverse  (except  in  such  situa- 
tions as  the  palm  of  the  hand,  where  it  is  bound  down  much  too  tightly)  :  arteries, 
if  they  are  simply  wounded,  bleed  most  persistently,  as  the  wound  is  held  widely 
open  ;  if  they  are  completely  divided,  they  shrink  together  and  retract,  so  that 
their  ends  can  hardly  1)6  seen,  and  the  amount  of  bleeding,  except  in  the  case  of 
the  larger  ones,  is  comparatively  inconsiderable  ;  veins  retract  less,  but  unless  they 
are  varicose,  and  hemorrhage  is  favored  by  position,  bleeding  is  seldom  serious 
from  them.  Muscles,  when  cut  across,  shorten  at  once,  and  often  continue  to 
shrink  for  some  time.  Fibrous  tissues  and  nerves,  on  the  other  hand,  retract  but 
little ;  there  is  no  tension  upon  them. 

Contused  and  Lacerated  Wounds. — The  skin  and  the  soft  tissues  are  torn  and 
crushed  and,  especially  in  the  former,  the  injured  area  is  often  very  much  larger 
than  it  appears  to  be.  The  degree  of  gaping  naturally  depends  upon  the  size, 
depth,  and  direction  of  the  hurt;  the  pain  is  usually  of  a  dull,  aching  character, 
not  so  severe  as  in  the  incised  kind  ;  and  the  hemorrhage  is  less  extensive.  Cap- 
illary oozing  may  be  present  to  a  considerable  degree,  but  large  arteries  rarely 
bleed  in  contused  and  lacerated  wounds.  The  inner  and  middle  coats  break  off"  at 
a  different  level  to  the  outer  one,  and  they  curl  up  together  inside  the  sheath,  so 
that  sometimes  not  even  a  drop  escapes.  An  arm  may  be  torn  off"  at  the  shoulder- 
joint  without  any  loss  of  blood  from  the  axillary.  The  fear  is  that,  owing  to  the 
amount  of  dead  and  dying  tissue,  decomposition  may  set  in  and  open  up  the  way 
for  the  whole  series  of  septic  processes. 

Pu7ictured  Wounds. — These  are  caused  by  stabs  with  sharp-pointed  iiistru- 
ments,  such  as  bayonets  and  rapiers.  The  chief  dangers  are  the  very  serious  and 
concealed  injuries  that  may  be  sustained  by  deep-lying  structures,  such  as  important 
vessels  and  viscera,  and  the  fact  that  such  wounds  are  nearly  always  valvular,  so  that 
proper  drainage  is  impossible.  Punctured  wounds,  as  a  rule,  either  heal  at  once, 
or  lead  to  prolonged,  deep-seated,  and  dangerous  suppuration. 


1 58  GENERAL   PATHOLOGY  OF  INJURIES. 

Repair  of  Wounds. 

Wounds  in  all  cases  are  repaired  by  the  formation  of  lymph,  which  first  be- 
comes vascular  and  then  develops  into  a  kind  of  fibrous  tissue.  Subsequently, 
where  special  structures  are  concerned,  such  as  bone  or  muscle,  further  develop- 
ment may  take  place.  If  the  amount  of  exudation  poured  out  is  very  small,  the 
wound  is  described  as  healing  by  xkv^  first  intention  \  if  there  is  a  considerable 
quantity,  as  when  a  cavity  has  to  be  filled  up,  union  is  said  to  take  place  by  the 
second  intention.  Immediate  union,  which  has  been  described  in  the  tongues  of 
animals  after  incised  wounds,  is  merely  a  variety  of  the  former,  characterized  by 
possessing  the  minimum  of  lymph  ;  union  by  the  third  intention  and  healing  under 
a  scab  are  only  modifications  of  the  latter. 

The  changes  that  occur  after  the  infliction  of  a  simple  uncomplicated  wound 
do  not  differ  in  the  least  from  those  that  follow  a  sprain  or  contusion,  or  any  other 
form  of  subcutaneous  injury.  The  hemorrhage  ceases,  partly  from  pressure,  partly 
from  the  coagulation  of  the  blood  and  contraction  of  the  torn  and  bruised  capil- 
laries ;  all  the  blood-vessels  round  the  injured  area  dilate,  more  blood  flows  through 
the  part  (so  that  the  edges  of  the  wound,  if  it  is  on  the  skin,  become  swollen  and 
slightly  reddened),  more  plasma  pours  out  through  their  walls,  and  the  cut  surface 
on  either  side  becomes  infiltrated  with  leucocytes  and  coagulating  fibrin.  At  first, 
shortly  after  its  infliction,  all  the  separate  structures  can  be  distinctly  recognized 
in  the  wound  ;  in  an  hour  or  two  they  become  blurred,  the  interstices  between 
them  and  the  surface  over  them  are  filled  with  the  exudation,  or,  as  it  used  to  be 
described,  the  wound  is  glazed. 

If  the  two  surfaces  are  now  brought  into  apposition,  and  no  irritant  of  any 
kind  is  allowed  to  injure  them,  they  cohere  and  become  glued  so  closely  to  each 
other  that  even  after  twenty-four  hours  it  is  almost  impossible  to  detect  the  line. 
This  is  union  by  the  first  intention.  The  lymph  that  unites  the  surfaces  becomes 
organized,  fresh  vessels  form  from  the  old  ones  on  either  side,  fibroblasts  gradually 
range  themselves  along  them,  the  cells  and  fibres  that  have  been  killed  by  the 
accident,  and  the  small  quantity  of  extravasated  blood  still  left  in  the  wound,  are 
absorbed  and  carried  off  by  the  leucocytes,  and  soon  a  very  thin,  delicate  layer  of 
vascular,  newly-formed  fibrous  tissue  is  all  that  can  be  seen  of  the  lymph  that  filled 
the  wound. 

Meanwhile,  the  surface  becomes  covered  with  epidermis  by  the  budding  of 
the  living  cells  on  either  side,  and  if  the  injury  is  inspected  twenty-four  hours  after 
it  has  been  inflicted,  a  faint  red  and  slightly  swollen  line  is  all  that  is  left.  As 
organization  proceeds,  even  this  becomes  less  distinct ;  many  of  the  new  vessels 
disappear,  and  gradually  the  color  fades  until  it  is  as  pale  as  the  parts  around. 
There  is  no  inflammation  after  a  single,  simple  injurj^  such  as  this ;  the  changes 
are  identical  with  those  that  occur  after  a  bruise,  in  which  the  extravasation  has 
not  been  sufiiciently  great  to  cause  any  tension  ;  there  is  no  loss  of  tissue,  except 
that  which  is  killed  in  the  original  hurt,  and  the  only  changes  that  take  place  are 
the  ordinary  ones  that  are  going  on  every  day;  the  sole  difference  is  in  their 
rapidity  and  energy;  there  is  a  greater  amount  of  wear  and  tear  than  usual,  and 
the  process  of  repair  is  carried  on  with  greater  energy. 

When  the  injury  is  more  severe  than  this — when,  for  example,  a  definite 
portion  of  tissue  is  destroyed  or  lost — the  process  is  exactly  the  same,  always 
provided  that  no  fresh  irritant  appears  upon  the  scene.  Suppose,  for  example,  a 
cavity  is  left  by  the  excision  of  a  tumor,  the  surfaces  of  the  wound  not  admitting  of 
absolutely  accurate  adjustment.  As  before,  the  blood  pours  out,  coagulation  takes 
place,  hemorrhage  ceases,  and  all  the  vessels  round  dilate.  As  before,  lymph 
pours  out  through  their  walls,  and  the  leucocytes  pervade  every  thing — the  softened 
and  swollen  tissues  on  either  side  of  the  wound,  the  little  fragments  of  dead  material 
that  are  left  clinging  to  them,  and  the  extravasation  of  blood  that  fills  the  cavity. 
In  this  case,  the  amount  of  lymph  thrown  out  is  much  greater,  there  is  much  more 
debris  to  be  removed,  and  a  greater  amount  of  repair  required  ;  but  gradually  it  is 


C/CA  TR  rZA  TION.  1 5  9 

all  done,  ami  as  the  vessels  grow  into  tlie  exudation  from  tiie  dilated  capillaries 
round,  the  whole  wound  is  filled  from  all  sides  and  from  below  with  newly-formed 
vascular  lymph,  so  called  granulation-tissue.  This  is  union  by  the  second  intention, 
and  it  onlyiliffers  from  union  by  the  first  intention  in  the  amount  of  lym])h  thrown 
out.  There  is  no  inllammation  or  suppuration,  and  there  is  no  loss  of  tissue  other 
than  that  caused  by  the  original  injury. 

The  mere  presence  of  e.xtravasated  blood  (always  provided  there  is  no  tension 
and  that  it  does  not  undergo  decomposition)  does  not  prevent  union  by  the  first 
intention,  although  it  delays  it ;  there  is  a  greater  amount  of  dead  material  to  be 
absorbed,  and  naturally  the  process  is  slower,  exactly  as  it  takes  longer  to  repair 
the  effect  of  an  extensive  contusion  than  that  of  a  slight  one.  And  the  same  may 
be  said  of  tissue-debris  :  acertain  amount  of  tissue  is  killed  in  every  wound  ;  this 
is  removed  slowly  by  the  leucocytes,  which  literally  eat  their  way  into  it ;  the 
larger  it  is  the  longer  it  takes,  but  so  long  as  it  does  not  cause  tension  or  lead  to 
decomposition,  union  by  the  first  intention  is  the  rule.  The  pedicle  of  an  ovarian 
tumor,  or  a  stump  of  omentum  strangulated  as  tightly  as  possible  and  returned  into 
the  abdominal  cavity,  does  not  interfere  with  immediate  recovery ;  the  lymph 
poured  out  by  the  tissues  round  it  is  able  to  deal  satisfactorily  with  it. 

Healing  under  a  scab  is  the  same  thing.  Supposing  the  cavity,  instead  of 
being  deeply  buried,  involved  the  surface,  the  blood  that  pours  out  from  the 
injured  vessels,  and  the  lymph  that  transudes  through  their  walls,  coagulate  and 
form  upon  the  top,  where  they  are  exposed  to  the  air,  a  coating  which  grows 
harder  and  drier  the  longer  it  lasts.  Under  this  the  lymph  becomes  vascular,  as 
before,  and  if  at  any  time  the  scab  is  removed,  a  smooth,  pale,  glazed  surface  is 
exposed,  consisting  of  myriads  of  leucocytes,  traversed  by  capillaries,  and  gradually 
becoming  organized,  the  deeper  ones  into  fibrous  tissue,  the  superficial  ones,  where 
they  are  in  contact  with  the  already  existing  epidermis  or  epithelium,  into 
flattened  cells  of  the  same  character.  If  the  scab  is  detached  before  the  surface  is 
sound  all  over,  a  peculiar  transformation  occurs  :  instead  of  remaining  flat  the 
topmost  layer  of  the  lymph  is  raised  up  in  the  course  of  an  hour  or  two  into 
myriads  of  little  points,  each  consisting  of  a  capillary  loop,  covered  with  a  layer 
of  leucocytes  ;  in  other  words,  it  assumes  the  typical  character  of  granulation- 
tissue  ;  as  soon  as  the  restraining  influence  of  the  scab  is  removed,  the  newly- 
formed  vessels,  the  walls  of  which  are  exceedingly  delicate,  yield  to  the  influence 
of  the  blood  pressure,  and  stretch  rapidly  upward  in  the  direction  of  least  resist- 
ance, raising  up  with  them  a  little  covering  of  leucocytes,  so  that  the  whole  surface 
appears  granular.  When  this  occurs,  the  superficial  layers  generally  melt  away  as 
pus  ;  but  this  is  not  essential,  and  must  be  regarded  as  a  complication  due  to  the 
incidence  of  pyogenic  organisms. 

If  two  surfaces,  granulating  in  this  manner  and  perfectly  clean,  are  brought 
together  and  held  in  accurate  apposition,  the  granulations  fuse,  vessels  pass  from 
one  to  the  other,  and  union  soon  becomes  firm.  This  is  sometimes  known  as 
union  by  the  third  intention ;  it  is  chiefly  of  service  in  plastic  surgery,  or  after 
extensive  scalp  wounds,  in  which  the  ordinary  treatment  has  failed. 

Cicatrization. 

In  a  simple  incised  wound,  the  edges  of  which  are  brought  together  accurately, 
there  is  no  difficulty  in  understanding  the  reproduction  of  the  epithelial  or  epi- 
dermic stratum  that  covers  in  the  surface  ;  the  cells  of  the  rete  malpighii  proliferate 
and  multiply  rather  more  rapidly  than  before  ;  while  the  old  stratum  corneum  is 
thrown  off"  by  the  increased  exudation  beneath,  and  is  quickly  reproduced  from 
the  growing  cells  below.  The  same  thing  occurs  when  the  extent  of  surface  lost  is 
greater ;  but  the  perfection  of  reproduction  becomes  less  and  less  the  fiirther  the 
cells  lie  from  the  edge  of  the  wound. 

If  there  has  been  any  loss  of  substance  the  cavity  must  first  be  filled  up  by 
the  formation  of  vascular  lymph.     As  soon  as  this  has  taken  place,  or  while  it  is 


i6o  GENERAL   PATHOLOGY  OF  INJURIES. 

taking  place,  organization  begins;  the  deeper  layers  gradually  l^ccome  converted 
into  cicatricial  tissue,  and  draw  the  edges  of  the  wound  together  (in  the  case  of  a 
circular  area,  in  which  the  contraction  takes  place  from  all  sides  toward  the  centre, 
the  importance  of  this  in  connection  with  the  healing  of  wounds  is  easily  calcu- 
lated) :  the  superficial  ones,  on  the  other  hand,  are  transformed  into  epithelium 
under  the  influence  of  the  already  developed  cells  at  the  margin.  Without  the 
presence  of  already  existing  epithelial  or  epidermic  cells  this  is  impossible;  fresh 
epidermis  never  makes  its  appearance  spontaneously  at  a  distance  from  the  edge. 

The  method  is  the  same  whether  the  surface  of  the  lymph  is  protected  from 
all  injurious  influences  or  is  exposed  freely  to  the  air;  but  the  process  is  much 
more  rapid  in  the  former,  and  there  is  no  waste.  In  the  latter,  owing  to  the 
incidence  of  the  omnipresent  pyogenic  organisms,  suppuration  usually  occurs  ; 
many  of  the  superficial  cells  are  killed  and  lost  as  pus;  and  it  is  not  until  the 
ti.ssues  gain  the  upper  hand  and  are  able  to  resist  the  attack  that  organization 
begins  to  make  way  ;  then  it  advances  equally  from  the  margin,  forming  epithe- 
lium, and  from  the  sides  and  base,  forming  fibrous  tissue.  By  degrees,  as  the 
base  contracts  and  the  sides  skin  over,  the  area  over  which  the  pyogenic  germs 
have  power  is  reduced  more  and  more  until  they  are  completely  shut  out.  If  at 
any  time,  before  this  has  happened,  some  other  irritant  comes  to  their  aid,  healing 
stops;  and  if  it  is  of  any  intensity,  the  whole  surface  of  the  wound  may  break 
down  again. 

The  appearance  of  a  wound  as  it  heals,  under  these  conditions,  is  very 
characteristic.  If  the  centre,  where  repair  is  not  yet  complete,  has  been  covered 
by  a  perfectly  dry  scab  or  by  some  clean  non-adhesive  dressing,  and  this  is  re- 
moved, a  pale,  smooth,  glassy-looking  surface  is  exposed  ;  this  is  the  lymph  that 
has  grown  up  to  replace  that  which  has  been  lost.  At  the  margins  it  passes  imper- 
ceptibly into  the  cicatricial  epithelium  ;  the  surface  seems  to  become  dry  ;  it  does 
not  reflect  the  light  so  readily ;  then,  a  little  further  off,  its  color  changes,  be- 
coming rather  more  blue  or  purple ;  and  finally,  it  is  plainly  and  definitely  a 
layer  of  young  epithelium,  continuous  with  that  of  the  skin  around.  As  it 
grows  older  it  becomes  thicker,  and  allows  less  of  the  color  of  the  parts  beneath 
to  show  through. 

If,  on  the  other  hand,  instead  of  being  protected  and  compressed,  the  centre 
of  the  wound  is  exposed  to  the  air,  and  suppuration  has  occurred,  the  appearance  is 
altogether  different.  The  color  is  a  bright,  florid  red  ;  all  the  vessels  are  dilated  ; 
and  the  surface  is  no  longer  smooth,  but  covered  over  with  myriads  of  little  points, 
each  corresponding  to  a  capillary  loop,  which  has  been  stretched  out  in  the  direc- 
tion of  least  resistance,  and  has  raised  up  on  itself  a  covering  of  leucocytes.  On 
this  is  a  little  thin  pus,  formed  from  the  most  superficial  cells  which  have  perished, 
but  only  sufficient  to  make  the  surface  moist.  Round  it,  and  now  seen  very  con- 
spicuously from  the  difference  of  its  level  and  the  smoothness  and  dryness  of  its 
surface,  is  the  thin  bluish  rim  of  young  epithelium,  developing  exactly  as  before. 

In  the  case  of  large  granulating  surfaces,  although  repair  may  advance  rapidly 
at  first,  after  a  time  progress  becomes  more  and  more  slow,  until  often  it  cea.ses 
altogether,  whether  becau.se  further  contraction  is  impossible,  or  because  the 
infective  power  of  the  epithelium  is  too  feeble  at  the  distance.  In  such  cases, 
which  are  exceedingly  common  after  burns,  an  attempt  may  be  made  to  expedite 
matters  by  what  is  known  as  grafting. 

SKIN-GRAFTING. 

There  are  many  ways  in  which  this  may  be  performed.  The  simplest — • 
epidermic  grafting — consists  in  removing  minute  i)ortions  of  the  skin  from  some 
other  part  of  the  body  by  means  either  of  special  grafting  scissors  or  a  sharp  scalpel, 
and  placing  them  on  the  granulating  surface  a  short  distance  from  the  edge.  Each 
of  these  grafts  forms  a  new  centre  from  which  cicatrization  spreads  ;  and  it  may 
not  infrequently  be  noticed,  if  one  is  placed   near  the  margin  when  healing  has 


SKIN-  GRAFTING. 


i6i 


become  slack,  that  the  cells  on  the  other  side,  those  which  are  growing  from  the 
already  existing  epidermis,  suddenly  wake  up  into  activity  too. 

It  is  not  necessary  or  advisable  to  include  the  whole  thickness  of  the  skin  ; 
it  is  quite  sufficient  if  the  cells  which  still  retain  their  power  of  growth  are  used. 
No  real  wound  should  be  left ;  at  the  most,  the  spot  from  which  the  skin  is  taken 
should  be  reddened  or  marked  with  one  or  two  dots  of  blood  coming  from  papillae, 
the  apices  of  which  have  been  taken  off ;  and  the  size  of  the  i)art  that  is  used 
need  be  no  larger  than  that  of  an  ordinary  pin's  head.  If  possil)le,  grafts  should 
always  be  taken  from  the  ])aticnt's  own  body,  and  from  some  part  where  the  epi- 
dermis is  not  too  thick;  but  if  no  objection  is  raised,  the  skin  from  an  amputated 
limb  may  be  made  use  of,  or  that  which  is  removed  in  the  operation  for  phimosis, 
especially  as  the  vitality  of  thee])idermis  is  greater  in  the  case  of  children. 

Grafting  is  of  no  use  unless  the  wound  itself  is  healing  at  the  edges  ;  some- 
times when  this  is  not  the  case — when  the  granulations  are  pale  and  uidematous — 
the  grafts  grow  for  a  few  days,  but  almost  invariably  they  break  down  and  disappear 
again  ;  and  they  should  always  be  placed  with  the  natural  surface  downward,  about 
three-cjuarters  of  an  inch  from  the  margin,  on  that  part  of  the  wound,  in  other 
words,  which  is  in  other  respects  ready  for  cicatrization.     Great  care  should  be 


Figs.  22  and  23. — Drawing  Illustrating  the  Cicatrization  of  Sores  by  Skin-grafting. 


taken  not  to  make  the  surface  bleed.  The  most  satisfactory  dressing  is  a  single 
layer  of  gutta-percha  tissue  or  oiled  silk  perforated  with  a  number  of  minute  open- 
ings, and  covered  with  a  considerable  thickness  of  absorbent  wood-wool.  This 
may  be  left  for  a  week  or  more,  until  the  grafts  are  firmly  set ;  the  excess  of  dis- 
charge, which  might  otherwise  wash  them  away  or  displace  them,  being  absorbed 
through  the  perforations. 

In  the  method  advocated  by  Thiersch,  actual  portions  of  skin  are  used  and  the 
whole  surface  of  the  sore  is  covered  over  at  once.  It  may  be  carried  out  in  recent 
wounds,  but  it  answers  better  in  those  which  have  been  granulating  for  some 
little  time,  and  in  which  the  granulations  are  small  and  florid,  a  condition  which 
usually  follows  the  application  of  caustic  or  compression.  The  surface  must  first 
of  all  be  thoroughly  purified  and  washed  with  normal  salt  solution,  compresses 
soaked  in  the  same  fluid  being  laid  over  the  wound  until  the  strii)s  are  ready.  The 
most  convenient  situation  from  which  to  obtain  the  skin  is  the  arm  or  thigh  ;  the 
epidermis  is  first  thoroughly  scrubbed  with  a  solution  of  corrosive  sublimate  or 
iodide  of  mercury  in  iodide  of  pota-sh ;  then  the  antiseptic  is  washed  away  with 
salt  solution,  and  long  strips  are  cut  off  with  a  sharp  razor  as  wide  as  the  part  will 
allow.     The  limb  must  be  held  firmly  from  beneath  with  one  hand,  so  as  to  put  the 


1 62  GENERAL   PATHOLOGY  OF  LNJURIES. 

skin  upon  the  stretch,  and  a  shaving  as  long  as  it  is  thought  advisable  quickly  taken 
from  the  upper  surface.  The  subcutaneous  fat  should  not  be  included,  but  the 
whole  thickness  of  the  true  skin  is  necessary  (of  course,  it  is  thinner  at  the  sides)  so 
as  to  take  in  the  layer  that  contains  the  horizontal  plexus  of  vessels.  If  the  plasma 
can  enter  into  these  through  the  cut  ends  of  the  vertical  ones  through  which  they 
are  sujjplied,  the  nutrition  of  the  graft  can  practically  be  assured.  .Strip  after  strip 
obtained  in  this  way  is  placed  upon  the  raw  surface  and  pressed  firmly  into  position 
until  the  whole  is  covered.  A  layer  of  protective,  perforated  with  numerous  large 
opening,  is  placed  upon  them,  and  over  this  compresses  wet  with  salt  solution, 
which  are  changed  every  day. 

As  a  rule  the  strips  unite  at  once  ;  occasionally  the  granulations  break  through, 
and  sometimes  the  edges  are  lifted  up  by  the  collection  of  the  discharge  beneath  ; 
even  then  the  whole  area  rarely  perishes. 

[The  method  of  I'hiersch  is  now  generally  adopted  in  America.  The  razor 
is  used  by  a  sawing  motion,  and  thin  strips  of  skin  are  thus  spread  upon  the 
outer  surface  of  the  blade.] 

Frog's  skin  {Anna/s  of  Surgery,  Feb.,  1889)  has  been  used  in  the  same  way. 
The  same  preparation  and  precautions  are  necessary,  the  skin  of  the  back  being 
carefully  detached  from  the  neck  downward.  The  pigment-cells  soon  disappear ; 
but  apparently  the  skin  itself  lives,  and  forms  a  thin  pellucid  covering,  through 
which  the  deep  color  of  the  vascular  lymph  beneath  can  be  seen.  After  a  time 
it  becomes  denser  and  more  opaque,  but  it  does  not  appear  to  possess  the  same 
power  of  resistance  as  human  skin. 

Wolfler  has  employed  flaps  of  mucous  membrane  in  the  same  way,  obtaining 
them  both  from  human  beings  after  operation  and  from  animals.  Stricture  of  the 
urethra,  for  example,  has  been  excised,  and  a  graft  of  mucous  membrane  inserted 
in  its  place,  with  apparently  good  success  ;  and  defects  have  been  remedied  in  the 
eyelids  and  elsewhere. 

Complications  of  Repair. 

If  the  surface  of  the  wound  is  irritated  instead  of  being  kept  at  rest,  it  becomes 
inflamed,  and  the  inflammation  continues  so  long  as  the  irritant  is  at  work.  The 
process  of  destruction  for  the  time  the  cause  is  acting  is  more  vigorous  than  that  of 
repair  ;  healing  is  delayed,  the  loss  of  tissue  is  greater  than  that  due  to  the  original 
hurt,  and  the  wound  increases  in  size,  sometimes  merely  the  surface  melting  away 
(suppuration  and  ulceration)  ;  sometimes,  when  the  irritant  is  more  intense,  the 
base  and  edges  perishing  en  masse  (sloughing  and  gangrene).  Open  wounds  are 
naturally  more  exposed  to  the  action  of  the  irritants  than  closed  ones ;  they  are 
always  liable  to  infection  from  the  air  and  from  contact  with  foreign  bodies,  and 
until  recently  inflammation  was  regarded  as  a  necessary  factor  in  their  repair.  It 
cannot,  however,  be  too  strongly  insisted  upon,  that  it  is  a  complication,  and  an 
absolutely  unnecessary  one,  caused  by  the  action  of  .some  fresh  irritant.  It  does 
occur  occasionally  in  subcutaneous  injuries  as  well  as  in  open  ones,  but  it  should 
not  occur  in  either.  The  sole  difference,  why  it  is  so  rare  in  the  one  and  so  com- 
mon in  the  other,  is  that  the  former  are  protected  from  all  external  injurious  agents 
by  the  skin,  the  latter  are  not.  As  soon  as  the  irritant,  whatever  it  may  be,  is 
removed,  the  inflammation  ceases,  and  if  the  tissues  have  sufficient  vitality  left, 
the  process  of  repair  at  once  begins  to  make  headway  again. 

I.  Simple  inflammation. — This  is  the  product  of  mechanical  or  chemical  irri- 
tants, not  generated  by  organisms  living  in  the  wound. 

Friction,  want  of  rest,  the  tension  of  a  tight  suture,  the  presence  of  an  irri- 
tating dressing  (even  when  it  is  antiseptic),  the  accumulation  of  extra vasated  blood 
or  wound  secretion,  inert  foreign  bodies,  and  many  other  irritants  of  a  similar 
nature  may  cause  it.  Repair  advances  more  slowly  or  is  stopped  altogether,  the 
area  of  redness  spreads,  the  swelling  becomes  more  marked,  the  temperature  of  the 
part  rises,  the  pain  becomes  more  severe,  and  the  patient  feels  feverish.  The 
gravity  of  the  attack  depends  upon  the  nature  of  the  irritant  and  the  condition  of 


COMPLICATIONS    OF  REPAIR.  163 

nutrition.  A  tight  suture  will  cause  a  rise  of  temperature  of  several  degrees,  and 
lead  to  a  train  of  symi>toms  of  altogether  disprojiortionate  severity.  A  bullet  or  a 
piece  of  silver  wire,  ivory  pegs,  or  other  similar  inert  substances,  may  remain 
embedded  in  the  body  for  years,  especially  if  they  are  fixed  in  some  part  that  is 
not  exi)0.sed  to  friction  or  movement.  If  they  are  near  the  skin  or  loose  in  the 
muscles,  the  irritation  usually  leads  to  the  production  of  a  capsule  of  cicatricial 
ti.ssue.  and  not  unfre(iuently,  after  remaining  quiet  for  perhaps  a  number  of  years, 
suppuration  suddenly  sets  in,  the  vitality  of  the  tissues  round  becoming  depressed 
by  age  or  the  addition  of  some  slight  injury. 

If  the  cause  is  removed,  the  inflammation  subsides  and  repair  proceeds  ;  if  it 
continue,  the  vitality  of  the  tissues  is  lowered,  until  at  last  they  become  too  feeble 
to  resist  the  assault  of  the  pyogenic  organisms,  and  suppuration  follows. 

2.  Septic  Inflammation. — Decomposition  of  the  blood  or  lymph  that  fills  the 
wound  is  a  much  more  powerful  cause.  The  micro-organisms  of  i)utrefaction  are 
destroyed  by  living  tissues;  on  the  other  hand,  they  grow  and  thrive  in  the  fluid 
that  exudes  from  them,  especially  when  it  is  kept  at  the  temperature  of  the  body, 
causing  either  septic  fever  or  sapnvmia.  If  the  wound  is  a  recent  one,  and  all  the 
strata  of  loose  cellular  tissue  round  the  bones  and  between  the  muscles  are  open 
and  filled  with  extravasated  blood,  difiiise  inflammation  of  the  most  terrible 
description  is  sure  to  follow,  and  very  likely  prove  fatal  from  the  intensity  of  the 
fever  before  there  is  time  for  suppuration.  If,  on  the  other  hand,  the  tissues  are 
better  nourished,  or  the  poison  is  not  so  active,  and  death  does  not  ensue  in  the 
first  two  or  three  days  from  the  sapraemia,  suppuration  sets  in,  the  germs  finding 
the  soil  that  suits  them  best  in  the  already  half-killed  tissues,  and  one  or  more  of 
the  varieties  of  suppurative  inflammation  follow. 

3.  Suppuration. — The  pus  of  acute  suppuration  always  contains  certain  organ- 
isms ;  it  is  believed,  therefore,  that  it  cannot  occur  without  them,  and  that  they 
are  its  cause.  Ten  or  eleven  different  kinds  are  described  as  possessing  this  prop- 
erty, but  only  two,  a  staphylococcus  and  a  streptococcus,  are  of  common  occur- 
rence. They  kill  the  leucocytes  and  transform  them  into  pus-corpuscles ;  the 
tissues  themselves,  the  walls  of  the  vessels,  and  the  plasma  that  pours  out  through 
them  are  destroyed,  and  converted  by  their  peptonizing  action  into  an  albuminous 
fluid  incapable  of  coagulation  ;  and,  so  long  as  there  is  any  tension  or  any  other 
irritant  to  lower  the  vitality  of  the  tissues  round  them,  they  spread  their  process 
of  destruction  far  and  wdde.  Over  structures  that  are  perfectly  healthy  they  have 
no  power.  In  children,  therefore,  and  young  and  healthy  adults,  suppuration  may 
be  acute  and  severe,  Avhen  there  is  tension  or  septic  decomposition  to  help  the 
germs,  but  it  is  limited ;  the  nutrition  of  the  tissues  is  too  good  for  the  micro- 
organisms to  have  any  effect  outside  the  immediate  sphere  of  the  other  irritants ; 
in  those,  on  the  other  hand,  whose  constitutions  are  wreeked  by  disease  or 
intemperance,  resistance  is  enfeebled,  and  the  suppuration  is  only  too  liable  to 
spread. 

That  in  the  vast  majority  of  instances  these  germs  gain  access  through  the 
wounds  is  absolutely  certain  ;  suppuration  is  of  common  occurrence  in  open 
injuries,  while  it  is  the  exception  in  subcutaneous  ones.  As,  however,  it  does 
happen  occasionally  in  the  latter,  and  as  some  of  the  worst  and  most  fatal  forms 
of  suppurative  disease  occur  without  a  wound  at  all,  it  is  clear  there  must  be  other 
modes  of  entrance,  too.  Sometimes  their  presence  may  be  accounted  for  by  the 
existence  of  cutaneous  lesions  in  other  parts  of  the  body;  but,  in  all  probability, 
as  they  abound  in  the  alimentary  and  respiratory  passages,  they  enter  through  the 
mucous  membrane  and  are  distributed  by  the  blood.  It  is  only,  however,  when 
they  meet  with  tissues  that  have  been  already  injured  in  some  other  way — by  cuts 
or  bruises,  tension,  septic  poisons,  etc. — that  they  are  able  to  cause  coagulation- 
necrosis  and  suppuration. 

A  certain  amount  of  pus,  generally  very  thick  and  viscid  in  character,  is 
occasionally  found  when  the  dressings  are  removed  from  a  wound,  forming  a  thin 
layer  over  some  part  which  the  skin  has  failed  to  cover.      It  causes  no  rise  of  tern- 


i64  GENERAL   PATHOLOGY  OF  LNJURLES. 

perature  or  fever,  and  the  lymph  beneath  heals  over  rapidly  as  soon  as  the  dress- 
ings are  changed.  Possibly,  in  many  cases,  it  is  not  true  pus  (not  the  product  of 
pyogenic  microbes),  but  merely  lymph  which  has  perished,  owing  to  its  distance 
from  its  base  of  nutrition  and  its  contact  with  a  foreign  body.  In  other  cases, 
however,  micrococci  are  present,  having  reached  the  part  through  the  dressings  or 
in  some  other  way,  and  then  the  only  explanation  is  that,  owing  to  the  thorough 
vitality  of  the  lymph  around  and  the  absence  of  all  other  sources  of  irritation, 
they  have  been  unable  to  effect  more  than  the  minimum  of  mischief.  Suppuration 
of  this  description  requires  no  .special  treatment :  its  existence  is  usually  unknown 
until  the  dressings  are  changed. 

Acute  suppuration,  on  the  other  hand,  accompanied  by  tension,  is  marked  by 
very  characteri.stic  signs.  There  is  often  a  chill  at  the  beginning,  or  even  a  rigor; 
the  temperature  rises  rapidly,  the  pulse  becomes  hard  and  frequent,  the  tongue  is 
coated,  the  appetite  lost,  the  skin  hot  and  dry,  the  urine  scanty  and  high-colored  ; 
headache  is  always  present,  and,  particularly  in  children,  there  is  frequentlv  more 
or  less  delirium.  It  is  not  material  whether  the  suppuration  is  on  the  surface  of  a 
wound  or  deeply  buried  in  the  tissues ;  in  either  case  the  symptoms  are  the  same, 
although  in  the  latter  they  are  much  more  severe,  owing  to  the  higher  degree  of 
tension.  Undoubtedly  the  chief  reason  is  the  absorption  of  the  products  of  tissue- 
destruction,  poisonous  substances  produced  by  the  action  of  the  pyogenic  micro- 
organisms. 

Round  the  wound  everything  is  swollen  and  tense,  the  skin  is  hot,  red,  glazed, 
and  exquisitely  tender  ;  often  it  pits  on  pressure,  and  there  is  oedema  spreading  up 
the  inner  side  of  the  limb  along  the  course  of  the  great  vessels,  while  the  pain, 
especially  at  first,  is  violent  and  throbbing.  Later,  when  the  tissues  round  have 
recovered  themselves  and  thrown  out  a  protecting  barrier  of  lymph,  these  local 
signs  become  less  marked,  and  at  the  same  time  the  severity  of  the  con.stitutional 
symptoms  diminishes ;  but  if,  from  any  cause,  the  tension  is  allowed  to  return,  the 
mischief  at  once  becomes  acute  again. 

The  w^orst  complications  are  those  which  follow  the  combination  of  .septic 
decomposition,  tension,  and  suppuration.  If.  in  such  a  ca.se  as  that  mentioned 
already,  in  which  the  loose  cellular  tissue  is  filled  in  all  directions  with  extrava- 
sated  and  decomposing  blood,  a  fatal  result  does  not  ensue  in  the  course  of  the 
first  two  or  three  days  from  saprccmia,  and  if  the  patient  survives  sufficiently  long 
for  suppuration  to  occur  under  high  tension,  there  is  not  one  of  the  forms  of 
suppurative  inflammation  that  may  not  follow :  diffuse  inflammation  of  the 
cellular  tis.sue  is  certain,  but  lymphangitis,  phlebitis,  osteophlebitis,  pyaemia, 
suppurative  arteritis,  secondary  hemorrhage,  sloughing,  and  even  gangrene  may 
occur. 

Treatment  of  Wounds. 

In  every  case  the  first  consideration  is  to  stop  the  bleeding  by  measures  suited 
to  the  circumstances.  What  these  are,  and  how  they  are  to  be  used,  will  be  dealt 
with  later  on,  in  considering  the  injuries  of  vessels. 

The  essential  points  are  to  make  sure  that  the  wounded  surfaces  are  absolutely 
clean,  to  bring  them  into  perfect  apposition  with  each  other,  and  to  protect  them 
from  sources  of  irritation,  whether  friction,  movement,  tension,  or  the  assault  of 
living  organisms. 

I .   Cleanliness. 

Wounds  are  of  two  kinds.  Some  are  inflicted  by  the  surgeon  in  operating, 
others  are  accidental.      In  many  respects  there  is  a  very  material  difference. 

(i)  A  wound  inflicted  in  the  course  of  an  operation  should  not  require  cleans- 
ing, except  from  the  blood  that  covers  and  obscures  the  surface.  Of  course,  where 
old  sinuses  are  present,  as  in  the  removal  of  sequestra,  or  when  the  wound  com- 
municates with  the  inte.stine  or  the  anus,  the  conditions  are  entirely  different. 
Everything  that  comes  into  contact  with  the  wound  or  with  the  skin  near  it 


TRKATMRXT  OF    WOUNDS. 


16:^ 


shoukl  be  already  clean.  The  operator's  hands  and  arms  should  be  well  scrubbed 
with  soap  and  water  and  a  nail-brush.  The  skin  round  the  wound  should  be 
treated  in  the  same  way,  and  then  sponged  with  a  five  jjer  cent,  solution  of  car- 
bolic acid.  The  instruments  should  be  kept  for  at  least  half  an  hour  in  a  solution 
of  similar  strength.  Special  care  should  be  taken  about  the  sponges,  which 
should  be  kept  in  carbolic  lotion  ;  and  nothing  but  a  perfectly  clean  mackintosh 
or  india-rubber  sheet  should  be  allowed  near  the  wound.  If  these  precautions  are 
thoroughly  carried  out,  there  is  no  need  to  wash  the  wound  out  or  to  flush  it  with 
anything,  unless  it  is  desirable  for  the  sake  of  checking  oozing.  Ovariotomy 
wounds,  operations  for  hernia,  excision  of  the  breast,  and  amputation  of  limbs,  for 
example,  if  the  tissues  are  healthy  and  fairly  well  nourished,  should  heal  at  once 
by  the  first  intention. 

Contused  and  lacerated  wounds,  if  they  are  perfectly  clean,  heal  in  the  same 
manner  ;  compound  fractures  by  indirect  violence,  for  example,  very  rarely  suppu- 
rate; the  dead  fragments,  which  are  always  more  abundant  in  such  injuries,  are 
quietly  removed  by  the  leucocytes ;  but  there  is  more  risk.  In  a  simple  incised 
wound  the  amount  of  injured  tissue  is  exceedingly  small,  the  structures  on  either 
side  retain  their  vitality  and  power  of  resistance  unimpaired  ;  in  contused  wounds, 
on  the  other  hand,  the  bruising  is  often  considerable  for  some  distance  round,  and 
there  is  always  the  fear,  even  if  decomposition  does  not  occur,  that  the  pyogenic 
organisms  may  gain  access  to  the  jjart,  as  they  sometimes  do  in  subcutaneous  in- 
juries, and  finding  structures  a-lready  damaged,  cause  suppuration.  The  amount, 
however,  is  never  serious  unless  there  is  some  further  cause — tension,  want  of  rest, 
or  decomposition — continuing  to  depress  the  vital  power  of  the  tissues  around. 

(2)  Suspicious  wounds  and  those  which  are  known  to  be  infected  require  an 
entirely  different  plan.  It  is  certain  that  if  the  bacteria  of  putrefaction  once  gain 
entrance,  and  there  is  dead  tissue  or  extravasted  blood  at  the  temperature  of  the 
body,  they  will  produce  a  poison  which  causes  very 
severe  constitutional  symptoms,  lowers  the  vitality  of 
the  tissues,  and  renders  them  incapable  of  resisting 
the  action  of  other  germs.  Steps  must  be  taken, 
therefore,  either  to  destroy  the  organisms  or  to  re- 
move the  material  in  which  they  grow,  or  preferably 
to  do  both. 

a.  The  first  of  these  indications  is  fulfilled  by 
thoroughly  washing  out  the  wound  and  scrubbing  the 
skin  round  with  an  antiseptic  lotion,  using  an  irriga- 
tor or  a  piece  of  rubber  tubing,  and  passing  it  down 
to  the  bottom  of  all  the  recesses.  If  it  is  in  one  of 
the  extremities  and  otherwise  conveniently  placed,  it 
is  more  satisfactory  to  immerse  the  injured  part 
altogether  in  an  antiseptic  bath  at  the  temperature  of 
the  body  for  two  or  three  hours. 

What  antiseptic  should  be  used  is  to  a  great  ex-  fig.  24. 
tent  a  matter  of  personal  choice  ;  the  ideal  one  has 
not  been  found.  Corrosive  sublimate,  either  alone,  with  chloride  of  ammonium 
(sal  alembroth),  or  Avith  a  minute  quantity  of  hydrochloric  acid,  is  very  effectual. 
One  part  in  a  thousand  is  sufficient  for  general  purification,  one  in  five  or  ten  for 
the  irrigation  ;  but  it  should  never  be  employed  for  large  absorbing  surfaces  such 
as  the  pleura  or  perineum,  or  for  complicated  or  extensive  wounds  in  which  there  is 
any  fear  of  its  retention.  As  a  germicide  there  is  no  doubt  of  its  value,  but  it  has 
many  drawbacks.  Dysenteric  diarrhoea,  vomiting,  collapse,  and  even  death  have 
been  known  to  follow  its  use  ;  in  one  case  under  my  care  (compound  dislocation 
of  the  ankle-joint)  salivation  was  caused  before  the  odor  of  decomposition  dis- 
appeared ;  and  it  ruins  any  steel  instruments  with  which  it  comes  into  contact. 
Further,  it  forms  an  insoluble  compound  with  albumin,  which  is  said  to  be  almost 
inert,  but  this  difficulty  is  to  a  great  extent  overcome  by  the  addition  of  chloride  of 


Irrigating  Can  lor  thondighly 
Washing  out  the  Recesses  of  a  Wound. 


1 66  GENERAL   PATHOLOGY  OF  INJURIES. 

ammonium  or  hydrochloric  acid.  Lister  has  lately  been  experimenting  with  a 
double  cyanide  of  mercury  and  zinc  (of  unknown  composition^  which  may  prove 
more  effectual. 

Carbolic  acid  possesses  the  advantage  of  being  volatile,  but  it  too  is  by  no 
means  perfect.  According  to  Koch,  instruments  to  be  absolutely  pure  should  be 
left  for  at  least  two  days  soaking  in  a  five  per  cent,  solution.  One  part  in  forty  is 
the  ordinary  strength  for  cleansing  wounds  ;  one  in  twenty  for  instruments,  sponges, 
etc.  Olive-green  urine  which  darkens  on  exposure  to  light  is  not  uncommon 
after  its  use  ;  headache,  giddiness  and  sickness  occasionally  occur  ;  and  instances 
of  extreme  depression  with  low  temperature  and  fatal  collapse  have  been  recorded. 
Further,  it  distinctly  tends  to  encourage  oozing  from  the  surface  of  a  wound  by 
its  action  upon  fresh  blood-clots,  and  the  amount  of  discharge  afterward  is  always 
excessive. 

Other  substances  are  recommended  from  time  to  time,  but  with  very  few  ex- 
ceptions they  do  not  appear  to  obtain  general  recognition.  Boracic  acid  is  prac- 
tically non-poisonous,  and  may  be  used  either  as  a  saturated  solution  in  water,  or 
even  dusted  upon  the  wounded  surface,  but  it  is  not  nearly  so  effectual.  Thiersch's 
solution  is  formed  of  two  parts  of  salicylic  acid,  twelve  of  boracic  acid,  and  one 
thousand  of  water.  Hydronaphthol  is  strongly  recommended  as  non-jx)isonous 
and  as  powerful  as  corrosive  sublimate  under  the  conditions  of  actual  practice.  It 
is  very  soluble  in  alcohol,  but  only  slightly  so  in  cold  water.  Salufer  succeeds 
very  well  in  the  hands  of  some,  and  appears  perfectly  safe.  Eucalyptus  prepara- 
tions are  very  agreeable  at  first,  but  patients  are  apt  to  get  tired  of  the  smell. 
Chloride  of  zinc,  which  is  stated  to  be  almost  inert  so  far  as  germs  are  concerned, 
is  undoubtedly  of  very  great  value  under  special  conditions. 

[Solutions  of  Bromine  and  Iodine  have  each  an  exceptional  value  in  certain 
conditions.] 

Whatever  antiseptic  is  used,  unless  it  is  intended  to  treat  the  injury  by  a  con- 
tinuous bath,  or  there  is  some  condition  rendering  it  impracticable,  it  is  most  im- 
portant to  keep  the  surface  dry  and  check  the  amount  of  discharge  as  much  as 
possible.  Germs  cannot  grow  without  fluid.  For  this  reason  Gamgee  preferred 
equal  parts  of  spirit  and  water,  a  saturated  solution  of  borax  wath  about  one-eighth 
of  glycerine  and  equal  parts  of  water,  glycerine,  and  methylated  spirit,  to  the 
watery  solution  of  any  antiseptic. 

This  is  probably  one  of  the  chief  reasons  why  iodoform  has  met  with  such 
favor.  Its  smell  is  exceedingly  peculiar,  very  penetrating,  and  objectionable  from 
its  associations  ;  there  have  been  many  instances  of  serious  poisoning,  and  even  of 
death  from  its  absorption  ;  it  is  by  no  means  certain  that  it  is  a  germicide  ;  yet  as 
a  matter  of  clinical  experience  there  can  be  no  question  that  it  forms  a  most  valu- 
able dressing  for  wounds.  The  hemorrhage  is  stopped  ;  the  surface  becomes  dry  : 
the  amount  of  discharge  is  reduced  to  a  minimum,  and  repair  takes  place  rapidly, 
beneath  the  crust  that  forms,  without  suppuration  or  decomposition.  It  is  chiefly 
used  in  the  form  of  powder,  but  it  may  be  dissolved  in  ether  for  special  purposes, 
or  formed  into  an  emulsion  with  glycerine,  or  sprinkled  over  moist  gauze,  and 
then  well  rubbed  into  the  meshes ;  and  it  may  be  applied  to  quite  recent  wounds 
or  to  those  that  are  already  suppurating.  Elderly  people  are  said  to  be  more  liable 
to  its  effects  than  others,  but,  as  in  some  cases  very  large  amounts  have  been  ased 
without  any  ill  result,  it  is  probable  the  susceptibility  depends  chiefly  upon  indi- 
vidual peculiarities.  An  erythematous  rash,  sometimes  starting  from  the  neighbor- 
hood of  the  wound,  sometimes  general,  is  tolerably  frequent.  Anorexia,  head- 
ache, and  great  depression  occur  in  the  milder  cases  ;  delirium,  sleeplessness,  and 
even  convulsions  in  those  that  are  more  severe  ;  while  in  the  worst  of  all  the  pulse 
is  rapid  and  thready,  the  surface  of  the  body  cold,  and  the  prostration  extreme  from 
the  very  first.  It  appears  to  be  excreted  by  the  kidneys  as  an  iodide,  and  it  has 
been  suggested  that  poisoning  only  occurs  when  the  action  of  these  organs  fails, 
possibly  from  the  formation  of  some  comjx)und  with  an  albumin. 

b.   The  second  indication  is  to  keep  the  wound  clean.     Germs  cannot  live 


TREATMENT  OF   WOUNDS.  167 

without  tluicl,  aiul  have  httlc  or.no  j)0\ver  on  tissues  that  are  perfectly  healthy.  If 
the  interior  of  the  wound  is  kept  dry,  and  the  vitality  of  the  structures  around  it 
is  unimpaired,  they  are  practically  innocuous. 

Unfortunately  cleansing  a  wound  with  an  antisei)tic  causes  other  effects  as  well. 
All  antiseptics  injure  the  tissues  they  touch  to  a  greater  or  less  extent,  and  increase 
the  amount  of  fluid  poured  out  (carbolic  acid  is  probably  the  worst  in  this  respect, 
iodoform  the  best)  ;  and  many  of  them  are  used  with  water,  which,  unless  it  is 
thoroughly  si)onged  out  (again  an  irritant,  of  some  importance  too,  especially  in 
connection  with  the  jjcritoneum),  adds  still  more  to  the  quantity.  In  a  simple  in- 
cised wound,  if  the  surfaces  are  brought  together  and  pressure  is  properly  applied, 
the  amount  of  exudation  is  so  small  that  it  may  be  left  to  the  natural  i)rocess  of 
absorption.  Contused  and  lacerated  wounds,  in  which  the  oozing  has  been  com- 
pletely checked,  may,  if  not  too  much  handled,  be  treated  in  the  same  way ;  or  at 
most  a  little  opening  may  be  left  at  one  angle,  so  that  any  great  exce.ss  of  fluid  can 
drain  off  and  be  absorbed  by  the  dressing  covering  it.  But  a  wound  that  has  been 
thoroughly  cleansed,  and  the  surface  of  which  has  been  sponged  or  washed  with 
strong  antiseptics,  requires  something  more.  If  it  is  left  open,  the  fluid  that  is  poured 
out  naturally  can  escape  at  once  ;  but  if  the  skin  is  united  over  it,  and  no  precau- 
tion is  taken,  the  interior  no  longer  remains  clean  ;  exudation  is  more  rapid  than 
absorption  ;  fluid  collects  ;  tension  is  set  up  ;  inflammation  follows,  and  if  nothing 
is  done  suppuration  is  certain  ;  the  germs  gain  access  to  the  part,  and  destroy  the 
leucocytes  in  just  the  same  wdy  as  they  sometimes  do  when  a  simple  bruise  is  con- 
stantly rubbed  or  hurt. 

To  keep  such  a  wound  clean,  therefore,  and  to  prevent  tension  and  its  con- 
sequences, either  the  edges  of  the  skin  must  not  be  united,  or,  if  they  are,  a  system 
of  drainage  must  be  employed.  The  method  in  which  this  is  carried  out 
depends  upon  the  way  in  which  the  surfaces  of  the  wound  are  adjusted  and  held 
together. 

2.  Apposition  of  the  Wound  Surfaces. 

Want  of  cleanliness  is  altogether  fatal  to  repair  :  the  tissues  cannot  close  the 
wound  until  by  the  production  of  vascular  granulation-tissue  they  have  ejected  all 
injurious  agents,  at  a  certain  sacrifice.  Given  cleanliness,  the  rapidity  with  which 
repair  is  effected  depends  upon  accuracy  of  apposition.  Irregular  injuries  with 
uneven  cavities  are  gradually  filled  from  the  bottom  and  the  sides,  but  the  process, 
in  comparison  with  those  in  which  the  surfaces  are  properly  adjusted,  is  very  slow, 
and  the  amount  of  cicatricial  tissue  much  greater. 

Accuracy  of  apposition  is  effected  by  attention  to  position,  pressure,  sutures, 
and  strapping. 

Position. — In  operations,  incisions  are  planned  to  avoid  tension  and  to 
allow  wounded  surfaces  to  fall  together  of  themselves.  Natural  folds  are  followed 
as  far  as  possible,  and  gravity  is  carefully  considered  with  regard  to  the  attitude  of 
the  patient.  In  chance  wounds,  the  position  of  the  body  and  limbs  must  be 
arranged  to  suit  the  circumstances.  A  great  deal  can  sometimes  be  effected  by 
this,  but  it  must  be  recollected  that  discomfort  may  cause  fever.  In  many  plastic 
operations  the  position  of  the  patient  has  to  be  fixed,  and  this  cannot  be  avoided. 

Pressure. — Properly  ai)i)lied,  this  is  of  the  greatest  assistance.  It  keeps 
the  deeper  parts  of  the  wounds  together  as  well  as  the  superficial  ones  ;  prevents 
the  formation  of  a  cavity  in  which  fluid  can  collect ;  checks  the  tendency  to 
effusion,  and  assists  the  absorption  of  that  which  has  already  been  poured  out. 
Every  structure  in  the  body  exists  under  a  certain  degree  of  tension  ;  as  soon  as 
the  skin  is  divided,  this  disajjpears ;  and  one  object  of  the  dressings  applied 
to  a  wounded  surface  is  to  restore  it  to  its  natural  condition  until  repair  is  com- 
pleted. 

The  ideal  dressing  is  perfectly  soft,  elastic,  absorbent  in  the  highest  degree, 
and  impregnated  with  something  that  will  make  it  safe  against  putrefaction  with- 
out renderinfj  it  in  the  least  irritating.     If  these   conditions  are  fulfilled,  and  if 


1 68  GENERAL  PATHOLOGY  OF  INJURLES. 

abundance  of  the  material  is  used,  an  amputation  wound,  or  such  a  one  as  is  pro- 
duced in  arthrectomy,  may  often  be  left  a  fortnight,  or  even  longer,  untouched, 
and  only  two  or  three  dressings  at  the  most  are  required.  Absorbent  cotton-wool, 
wood-wool  wadding,  treated  with  corrosive  sublimate,  prepared  moss,  and  sponges 
wrung  out  of  carbolic  (the  last  especially  if  elastic  pressure  is  required  to  stop 
haemorrhage)  are  the  most  useful.  A  strip  should  be  laid  on  either  side  of  the 
wound,  some  little  distance  from  the  edge,  so  as  to  press  the  deeper  parts  well 
together,  and,  as  it  were,  force  the  actual  line  somewhat  outward  ;  and  then  all 
the  space  round  and  in  between  should  be  thoroughly  and  carefully  packed, 
especial  attention  being  paid  to  the  hollows  between  the  bones.  Over  this  a  soft 
elastic  bandage  is  placed,  without  reverses;  or  if  a  greater  degree  of  firmness  is 
required,  torn  strips  of  mill-board,  soaked  perhaps  in  plaster  cream,  as  recom- 
mended by  Gamgee,  and  then  the  bandage  over  these.  The  ease  and  comfort  of 
this  arrangement  can  hardly  be  surpassed.  Immobility  is  perfect ;  the  patient 
feels  that  all  is  secure ;  tension  is  prevented  ;  there  is  no  cavity  in  which  fluid  can 
collect ;  the  small  amount  that  is  not  taken  up  by  the  tissues  is  driven  through  the 
edges  of  the  wound  and  harmlessly  absorbed  at  once  ;  vascular  dilatation  cannot 
take  place  to  excess,  and  the  apposition  of  the  injured  surfaces  is  as  exact  as  it  is 
possible  to  make  them. 

Strapping. — This  is  either  employed  in  superficial  wounds  by  itself,  or  in 
deeper  ones  as  an  adjunct  to  sutures,  for  the  purpose  of  distributing  tension  and  of 
immobilizing  structures  on  either  side.  In  operations  on  the  breast,  for  example, 
one  or  more  broad  strips  may  be  advantageously  brought  up  from  the  region  of  the 
back  to  support  the  lower  flap,  draw  it  upward,  taking  the  tension  off  the  sutures, 
and  keep  it  firmly  pressed  against  the  ribs. 

Sutures  are  of  various  kinds  and  various  materials.  Catgut  of  different 
degrees  of  thickness  and  hardened  more  or  less  in  chromic  acid,  according  to  the 
strength  and  endurance  required,  is  the  most  useful.  Silver  or  iron  wire  possesses 
the  advantage  of  being  absolutely  unirritating  and  of  being  easily  fastened,  but 
requires  removal  ;  and  the  same  may  be  said  of  silk.  If  properly  prepared,  and 
so  arranged  that  no  tension  falls  upon  them,  any  of  the.se  materials  may  be  left  for 
weeks  without  causing  the  least  irritation  ;  but  wire  and  silk  almost  always  require 
to  be  removed  at  last ;  catgut  removes  itself. 

Silkworm  gut,  softened  beforehand  in  carbolic  lotion,  so  that  it  will  tie  more 
easily,  is  especially  useful  for  plastic  operations.  Horsehair  is  occasionally  em- 
ployed where  there  is  no  tension  ;  and  in  comparatively  rare  cases  other  materials 
are  used  as  well. 

The  method  is  still  more  variable  ;  the  object  is  to  secure  accurate  adaptation 
of  the  whole  depth  of  the  wound  without  causing  tension  upon  it  anywhere.  In 
deep-seated  or  complex  injuries  this  is  only  possible  by  means  of  buried  sutures, 
which  must  necessarily  be  of  catgut.  Layer  after  layer  of  tissue  is  accurately 
adjusted  and  secured  in  situ,  periosteum  to  periosteum,  muscle  to  muscle,  and 
fascia  to  fascia.  The  deepest  sutures  are  fastened  the  most  firmly  ;  the  superficial 
ones  are  not  so  tight,  so  that  if  anywhere  the  amount  of  effusion  Rowing  to  some 
accidental  source  of  irritation)  is  in  excess  of  absorption,  the  fluid  may  make  its 
way  in  the  direction  of  least  resistance,  toward  the  surface.  It  is  only  by  means 
of  this  kind  that  large  and  complex  wounds,  those  for  example  left  by  amputations, 
can  be  safely  secured  without  drainage;  but,  of  course,  the  surfaces  must  be  per- 
fectly clean  and  healthy,  fit  and  ready  to  cohere  together  at  once.  In  the  presence 
of  suppuration  or  of  decomposition,  sutures  used  in  this  way  could  only  lead  to 
the  most  disastrous  consequences. 

Deep  sutures  {sutures  of  support)  aim  at  effecting  the  same  result,  but  at  the 
expense  of  tension  and  pressure  upon,  the  skin  some  little  distance  off.  Button 
sutures,  for  example  (Fig.  25),  are  cut  from  pieces  of  stout  sheet  lead  of  various 
shapes  and  sizes.  One  of  these  is  placed  on  either  side  of  the  wound,  some 
little  distance  away;  and  while  the  two  are  brought  together  as  closely  as  is 
thought  desirable  by  the  hands  of  an  assistant,  a  stout  silver  wire  is  passed  deeply 


TREATMENT  OF   WOUNDS. 


169 


across  from  one  to  the  other,  and   fastened  in  a  slit  cut  in   the  side  of  the  lead. 

This  relieves  the  edges  of  any  tension  by  transferring  it  to  a  greater  distance  and 

spreading  it  over  a  wider  surface  ;  but,  though  they  are  useful  in 

such   operations  as  excision   of  the  breast,  they  do   not  secure 

nearly  the  same  accuracy  of  apposition   for   the  deeper  parts. 

The  same  may  be  said   of  the  quill  sulure  (Fig.  26),  in  which 

longitudinal   rigid   supports  are   laid   a  little  distance   from  the 

edges  of  an   incised  wound  and  fastened  to  each  other  by  deep 

ties  of  wire  or  some  other  unirritating  material.      Strong  curved 

needles  set  in  a  handle  are  required  for   them  :   the  skin  and 

the  deeper  structures  are  transfixed,  first,  on  one  side,  and  then, 

in  the  opposite  direction,  on  the  other;  if  the  needle  is  threaded 

before  it  is  passed  the  loop  is  caught  and  drawn  out,  so  that  a 

double  suture    is    left ;    if  not,    it  is  threaded  when  the  point 

projects   through   the  skin   on  the  further  side  and  withdrawn, 

carrying  the  suture  with  it.     As  a  rule  such  sutures  cannot  be 

left  more   than  four  or   five  days,  but  everything   depends  upon  the  degree  of 

tension.     Their  chief  object  is  to  prevent  any  strain  upon  the  superficial  ones, 

and  as  soon  as  these  appear  secure  they  should  be  cut,  even  if  they  do  not  require 

it  of  themselves. 

The  td.<istecl  or  figure-of-eight  suture  \s  chiefly  used  after  removal  of  part  of  the 
lip  in  order  to  bring  the  whole  thickness  of- the  cut  surfaces  into  apposition.  It 
is  very  rarely  required  for  simple  harelip,  sutures  of  silkworm  gut  being  nearly 
always  sufficient.  Steel  pins,  silvered  over,  are  introduced  about  half  an  inch  from 
the  margin  of  the  wound  ;  passed  obliquely  down  through  the  whole  thickness  on 


Fig. 


25. — Button 
Suture. 


Fig.  26. — The  Quilled  Suture. 


Fig.  27. — The  Twisted  Suture. 


one  side  as  far  as,  but  not  through,  the  mucous  membrane  ;  then  carried  across  the 
cleft  (Fig.  27),  made  to  enter  at  a  corresponding  point  on  the  other  side, 
and  passed  through  to  the'  cutaneous  surface,  piercing  the  tissues  in  the  oppo- 
site order.  The  surfaces  are  then  brought  together  by  lateral  pressure  and  a 
piece  of  stout  silk  twisted  round  the  projecting  ends  in  a  figure-of-eight.  The 
point  and  the  head  of  the  pin  (if  it  projects  too  far)  are  cut  off  with  pliers ;  the 
skin  beneath  is  guarded  with  a  small  piece  of  lint  or  strapping  ;  and  the  whole 
is  left  expo.sed  to  the  air  so  that  the  blood  may  dry  upon  the  surface  and  form 
an  additional  protection.  The  pins  should  be  removed  in  forty-eight  hours,  or 
suppuration  is  almost  sure  to  occur  round  them,  and  the  marks  caused  in  this  way 
may  be  more  conspicuous  than  the  linear  cicatrix  of  the  operation.  If  po.ssibIe 
they  should  be  withdrawn  by  twisting  them  round,  so  as  to  leave  the  silk  with 
the  coagulated  blood  still  adherent  to  the  surfaces  of  the  skin.  U  it  comes 
away,  strapping  must  be  used  as  a  support. 
12 


lyo 


GENERAL   PATHOLOGY  OF  LNJURLES. 


Superficial  sutures  are  interrupted  or  continuous,  and  may  be  of  any  material 
— catgut,  wire,  silk,  or  horsehair.  Ordinary  straight  needles  with  triangular  points, 
or  Hagedorn's  curved  ones  (which  are  flattened  from  side  to  side,  not  like  the 
ordinary  ones  from  above  downward),  are  the  best,  the  edges  of  the  wound  being 
raised  well  up  with  the  finger  and  the  thumb,  so  that  the  needle  may  be  passed  at 
one  thrust  through  both. 

In  the  interrupted  suture,  the  material  is  cut,  and  knotted  or  twisted  as  the 
case  requires,  each  time  the  incision  is  crossed,  care  being  taken  that  the  knot 
always  lies  to  one  side  and  that  there  is  no  dragging  or  puckering  of  the  skin.  The 
object  of  a  superficial  suture  is  not  to  draw  the  two  edges  together  (this  should  be 


Hon  to  da  it. 
Hon  not  to  do  11 

Fig.  28. — The  Interrupted  Suture. 


Fig.  29. — The  Glovers'  Suture. 


done  by  pressure,  position,  or  other  means),  but  to  hold  them,  gently  but  firmly, 
facing  each  other.      In  all  cases  the  knot  should  be  a  true  one  (Fig  28). 

In  the  cofitinuous  suture  there  is  only  one  knot  at  each  end,  or  if  the  line  is 
very  long,  one  here  and  there.  The  varieties  are  almost  endless.  The  common 
one  is  the  ordinary  glovers'  stitch  (Fig.  29),  simply  over  and  over.  Or  this  is  modi- 
fied by  using  a  double  thread,  except  for  the  first  perforation  and  the  last ;  these 
have  only  a  single  one,  so  that  two  ends  project  from  the  skin,  one  on  either  side 
of  the  wound  at  its  two  extremities,  and  the  suture  can  be  made  secure  at  once  by 
tying  them  together  across  the  line. 

In  the  quilt  suture  (Fig.  30)  the  needle  is  carried  through  the  two  flaj)S,  and 
then  back  again,  so  that  a  loop  is  left  on  one  side,  and  the  two  ends  on  the  other. 
These  two  ends  can  either  be  secured  together  at  once ;  or 
one  may  be  carried  in  the  same  manner  along  the  whole 
length  of  the  wound.  Sometimes  this  is  combined  with 
the  glovers'  suture  ;  an  outside  row  of  quilt  stitching  is 
carried  along  the  whole  distance  to  draw  the  flaps  together, 
and  then  a  line  of  glovers'  is  brought  back  along  the  edges 
to  secure  accurate  apposition.  The  two  ends  of  the  thread 
are  thus  brought  close  together,  and  may  be  tied  at  once. 
This  is  exceedingly  useful  in  cases  in  which  tension  is 
feared,  but  as  a  rule  the  outside  row  requires  division  on 
the  third  day. 

The  great  advantage  of  the  continuous  suture  is  the 
rapidity  with  which  it  is  applied  and  the  accuracy  it 
ensures.  There  is,  on  the  other  hand,  the  serious  objec- 
tion that  if  from  the  presence  of  tension  at  one  single  spot  it  must  be  cut  before 
the  wound  has  healed,  the  whole  is  likely  to  give  way.  Of  course,  it  should  never 
be  employed  by  itself  as  a  circular  suture  round  the  intestine  or  any  other  hollow 
tube,  as  it  would  become  loose  at  once  if  this  collapsed. 

Other  forms  of  suture,  Lembert's,  Jobert's,  etc.,  are  described  in  connection 
with  special  operations. 


Fig.    30. — The   Quilt    Suture 
Applied  to  the  Intestine. 


TREATMENT  OF   WOUNDS.  171 

Drainage. — The  (luestion  of  tlrainage  deijends  upon  the  character  of  the 
wound.  After  any  injury,  no  matter  how  simple,  the  amount  of  exudation  is  in 
excess  of  al)sorption.  If  the  difference  is  only  slight,  the  tissues,  aided  by  judi- 
cious i)ressure  and  rest,  are  able  to  deal  with  it  after  a  little  time,  and  the  balance 
is  restored.  If,  however,  the  difference  is  considerable,  and  no  exit  for  the  surplus 
])rovided,  there  is  a  certain  degree  of  tension  ;  this  inflicts  a  fresh  injury,  and 
inflammation  follows. 

{a)  Simple  Incised  Wounds. — If  the  bleeding  is  stayed  (at  least  that  from 
vessels  of  any  size,  for  too  much  care  may  be  shown  in  this  matter  and  more  harm 
done  than  good),  the  surface  clean,  and  apposition  accurate,  there  is  the  minimum 
of  exudation  ;  absorption  begins  at  once  ;  and  provided  no  fresh  injury  is  inflicted, 
the  balance  is  restored  again  almost  immediately.  The  least  friction  or  movement 
and  it  is  all  undone. 

{b)  Contused  and  Lacerated  Wounds. — Accurate  a])position  is  often  impossible  ; 
a  cavity  is  left  which  must  be  obliterated  by  the  growth  of  vascular  granulation- 
tissue  from  the  sides  and  bottom.  Whether  drainage  is  required  or  not  depends 
upon  the  character  of  the  wound  and  the  amount  of  irritation  to  which  it  is  sub- 
jected. 

Supposing  it  is  perfectly  clean  and  there  is  sufficient  skin  to  cover  it  in,  the 
wound  as  soon  as  it  is  left  fills  with  blood  and  lymph  from  the  dilated  vessels 
around,  until  the  pressure  in  the  interior  is  equal  to  that  exerted  by  the  dressings 
over  it ;  in  other  words,  it  is  almost  in  the  same  condition  as  a  severe  contusion. 
The  sole  difference  is  in  the  amount  of  fluid  ;  in  the  one  case  the  pressure  of  the 
unbroken  skin  limits  the  exudation  from  the  first,  and  there  is  no  source  of  irrita- 
tion other  than  the  tension  ;  in  the  other,  owing  to  exposure  to  the  air,  manipula- 
tion, the  application  of  dressings,  and  other  causes,  even  when  everything  is  abso- 
lutely clean,  the  quantity  is  very  much  more  abundant,  and  the  absorbing  power 
less.  Accordingly,  it  is  usually  advisable  to  provide  some  means  for  escape,  at 
least  for  the  first  twenty-four  hours  ;  either  the  edges  of  the  wound  are  left  slightly 
separated  at  one  spot  and  an  absorbent  dressing  applied ;  or,  if  it  is  thought  that 
is  not  likely  to  be  sufficient,  a  small  drainage-tube,  a  few  threads  of  horsehair,  or 
a  few  strands  of  catgut,  are  placed  in  the  cavity  with  one  end  projecting  from  the 
wound.  At  the  end  of  twenty-four  hours  all  excess  should  cea.se,  and,  if  a  fair 
amount  of  pressure  is  kept  up  over  the  wounded  surface,  absorption  should  bal- 
ance secretion. 

If  the  skin  is  insufficient,  so  that  an  open  wound  is  left,  the  same  plan  may 
still  be  tried,  only  now  an  artificial  protecting  covering  must  be  formed.  In  small 
wounds  which  can  be  kept  at  perfect  rest  this  may  be  done  with  iodoform  ;  the 
powder  is  dusted  over  the  glazing  surface,  a  dry  scab  forms,  the  wound  is  abso- 
lutely protected,  and  the  pressure  is  sufficient  to  check  the  exudation.  In  larger 
ones  an  attempt  may  be  made  in  the  same  direction  by  what  is  known  as  Schede's 
dressing.  Immediately  over  the  wound  is  placed  some  fine  rubber  or  gutta-percha 
tissue,  perfectly  clean,  but  not  moistened  with  carbolic  ;  it  should  be  just  large 
enough  to  overlap  the  edges  of  the  wound.  This  is  covered  with  a  thick  layer  of 
some  absorbent  dressing  (impregnated  with  an  antiseptic  to  act  as  an  additional 
safeguard  against  putrefaction)  and  the  whole  is  then  firmly  and  evenly  bandaged 
over.  The  outer  dressings  absorb  the  surplus  serum  that  exudes  from  the  lymph 
that  fills  the  wound,  and  the  thin  film  of  rubber  tissue  acts  as  a  scab  to  protect 
the  surface. 

(«r)  L-ritated  and  Foul  Wounds. — Where  there  is  perfect  cleanliness,  and  the 
parts  are  kept  absolutely  at  rest,  these  methods  answer  admirably  and  nothing 
more  is  needed.  If  apposition  is  not  quite  accurate,  if  there  has  been  much 
bruising  or  handling,  or  if  the  wound  has  been  foul  and  has  been  subjected  to  a 
thorough  cleansing,  the  amount  of  lymph  that  is  poured  out  is  at  first  too  great 
for  absorption,  and  an  escape  must  be  provided.  The  cause,  however,  is  only  a 
temporary  one,  and  generally,  if  the  dressing  is  absorbent,  a  dependent  opening 
is  all  that  is  required.      Sometimes  a  small  drain  is  advisable,  but  after  the  first 


172  GENERAL   PATHOLOGY  OF  INJUR LES. 

twenty-four  hours  all  excess  should  cease  (there  being  nothing  further  to  cause  it}, 
and  uniform  compression  with  an  absorbent  dressing  should  be  sufficient. 

This  is  not  the  case  when  the  irritation  is  continuous,  whether  it  is  due  to 
the  wound  remaining  foul,  or  to  its  being  subjected  to  constant  friction  or  other 
source  of  irritation.  The  cause  is  then  a  continuous  one,  fresh  injury  is  con- 
stantly being  inflicted  upon  the  tissues,  and  the  amount  of  exudation  continues  to 
increase  to  a  degree  that  is  only  regulated  by  the  extent  and  intensity  of  the 
irritant.  This  fluid,  in  its  turn,  if  the  wound  is  closed,  alTects  the  already  injured 
tissues  by  the  tension  that  it  causes,  or,  in  the  case  of  septic  decomposition,  as 
well  by  the  poisons  it  contains ;  the  wound  becomes  hot  and  swollen,  the  pain 
much  more  severe,  the  temperature  rises,  and,  unless  the  most  ample  provision  is 
made  for  free  and  continuous  escape,  some  form  of  suppurative  disease  is  certain. 
Drainage  acts  in  two  ways.  It  diminishes  the  tension,  relieving  the  pain  and 
checking  the  absorption  of  poisonous  fluids  from  the  interior,  and  it  stops  septic 
decomposition  by  drawing  off  the  fluid  on  which  the  germs  grow  and  gradually 
starving  them  out. 

Chassaignac's  tubes  have  never  been  improved  upon,  except  in  the  (juality  of 
the  rubber.  They  are  of  any  length  and  of  any  diameter,  the  sides  perforated 
with  openings  here  and  there,  and  sufficiently  strong  not  to  collapse.  In  using 
them,  one  end  should  be  passed  down  to  the  bottom  of  the  cavity,  the  other 
brought  out  through  the  wound  at  the  most  convenient  spot  and  cut  flush  with  the 
skin.  It  is  better  that  they  should  point  downward  for  the  sake  of  gravity,  but, 
provided  the  outside  i)ressure  is  properly  arranged,  there  is  no  absolute  necessity 
for  it.  The  end  should  be  secured  with  a  silk  ligature  or  a  "  safety  "  pin,  so  that 
it  may  not  slip  inside  altogether.  One  or  more  may  be  used,  according  not  so 
much  to  the  extent  of  the  wound  as  its  complexity,  and  care  should  be  taken  that 
they  are  sufficiently  large  ;  small  ones  are  filled  with  blood-clot  almost  at  once, 
ancl  are  often  injurious  from  the  false  sense  of  security  they  give.  When  not  in 
use,  drainage-tubes  should  be  kept  in  a  five  per  cent,  solution  of  carbolic  acid. 

As  a  rule,  if  the  wound  surface  was  clean,  a  drainage-tube  may  be  removed 
at  the  end  of  twenty-four  hours.  If  there  was  much  oozing,  it  will  be  filled  with 
clot ;  if  there  was  not,  it  is  not  required  any  further.  Whether  it  should  be  intro- 
duced again  for  a  part  of  the  distance — through  the  skin,  for  example — dej^ends 
upon  the  amount  of  discharge,  the  degree  of  tension,  and  the  presence  of  layers 
of  fascia  which  might  render  the  opening  valvular.  If  the  injury  was  from  the 
first  suspicious,  or  if  there  is  any  fear  of  septic'decomposition  or  of  suppuration, 
and  the  edges  of  the  skin  have  been  brought  together,  it  should  be  replaced  and 
only  shortened  by  degrees  as  the  cavity  fills  up. 

As  it  is  not  unfrequently  necessary  to  dress  a  wound  on  the  day  after  an  oper- 
ation, solely  for  the  purpose  of  removing  a  drainage-tube,  many  attempts  have 
been  made  to  dispense  with  their  use,  or  to  employ  only  such  as  are  spontaneously 
absorbed.  Buried  sutures  cannot  be  recommended  except  when  the  wound  is  a 
clean  incised  one,  and  then  they  are  rarely  wanted.  Neuber's  decalcified  bone 
tubes  cannot  be  relied  upon,  and  the  chicken-bone  drains  of  MacEwen  are  only  to 
be  trusted  in  special  cases  ;  the  rate  of  softening  is  not  uniform,  and  irregular 
pressure  may  cause  kinking.  Catgut  drains  are  rarely  employed  ;  they  do  not 
really  exert  any  capillary  attraction,  and  they  tend  to  block  the  opening  by  soften- 
ing and  swelling  up.  Horsehair  is  a  little  better,  but  if  a  drainage-tube  must  be 
used  in  these  cases  (and  it  is  very  questionable  whether,  when  the  amount  of 
discharge  is  so  small,  it  would  not  be  better  to  trust  at  once  to  the  absorptive 
power  of  the  tissues  under  uniform  compression),  a  thin  slip  of  gutta-percha  tissue 
is  better  than  any.  It  is  not  so  likely  to  become  displaced,  it  prevents  the  edges 
of  the  skin  uniting,  and  by  its  irregularity  forms  a  kind  of  trough  along  which  the 
fluid  can  escape. 

Of  itself  the  mere  presence  of  a  drainage-tube  is  so  mild  an  irritant  that 
whenever  there  is  the  least  suspicion  as  to  the  cleanliness  of  a  wound  the  precau- 
tion should  be  adopted. 


TREATMENT  OF  WOUNDS.  173 

3.  Protection. 

Open  wounds  reiiiiire  protection  from  without  even  more  than  from  within. 
The  surfiice  may  have  been  absohitely  clean  at  the  time  of  the  operation  and  may 
have  l)een  protected  from  all  jjossibility  of  tension  or  of  other  sources  of  internal 
irritation  afterward,  but  this  is  not  sufficient ;  other  irritants  may  gain  access  to  it 
from  the  outside,  and  if  speedy  union  is  desired  the  wound  must  be  made  equally 
secure  against  these.  The  chief  are  friction,  movement,  and  the  presence  of 
certain  micro-organisms,  especially  those  of  jnitrefaction.  The.se  in  i)articular,  if 
they  can  find  a  suitable  soil  in  the  neighborhood  of  a  wound,  are  almost  certain 
to  work  their  way  into  the  interior,  and,  once  there,  make  the  secretion  decom- 
pose. 

The  essentials  of  a  perfect  dressing  are  not  difficult  to  enumerate,  though 
they  are  not  so  easily  found  in  combination.  It  must  be  perfectly  soft,  absolutely 
unirritating  to  the  most  delicate  structure,  sufficiently  elastic  to  keep  up  an  equal 
degree  of  pressure  all  over,  utterly  unable  itself  to  undergo  decomposition,  and 
capable  of  absorbing  an  indefinite  amount  of  albuminous  fluid  without  clogging. 
Wood-wool  wadding  prepared  with  corrosive  sublimate,  salicylic  wool,  absorbent 
cotton-wool,  and  other  similar  substances  answer  these  requirements  fairly  well, 
and  they  possess  the  advantage  of  being  cheap  at  the  same  time,  for,  although  a 
dressing  of  any  one  of  these  materials  may  and  often  does  last  for  a  fortnight  with- 
out being"  changed,  a  considerable  cpiantity  is  required  each  time,  especially  in 
the  case  of  large  wounds. 

In  some  instances  in  which  a  raw  surface  or  a  fresh  blood-clot  is  left  uncovered 
by  skin,  a  thin  piece  of  rubber  tissue,  a  shade  larger  than  the  wound,  should  be 
laid  over  it,  to  prevent  the  dressing  becoming  too  firmly  adherent,  or  by  its 
absorptive  power  desiccating  the  tissues  too  deeply  ;  in  all  other  cases  it  should  be 
placed  immediately  upon  the  skin.  No  water-proof  or  air-proof  covering  should 
be  laid  over  it ;  the  albuminous  secretion  of  the  wound  is  absorbed  and  becomes 
dried  at  once,  forming  a  protective  covering  which,  if  undisturbed,  is  absolutely 
impenetrable  to  any  germ.  The  amount  of  pressure  to  be  used  in  each  case  can 
only  be  judged  of  by  experience  ;  if,  however,  the  dressings  are  of  sufficient 
thickness,  it  can  scarcely  be  too  great.  The  firmer  it  is  (always  provided  it  is 
perfectly  uniform  and  falls  upon  the  right  parts)  the  greater  the  degree  of  immo- 
bility and  the  less  the  risk  of  tension  or  of  the  accumulation  of  discharge.  [Im- 
mobility may  be  secured  in  many  ca.ses  by  applying  a  light  plaster-of- Paris  dressing 
over  the  other  dressings.] 

Subsequent  Treat.mext. 

The  subsequent  treatment  of  a  wound  is  regulated  altogether  by  the  compli- 
cations that  follow.  If  all  the  conditions  essential  to  speedy  repair  are  perfect, 
the  dressing  need  not  be  changed  until  it  is  united.  An  ovariotomy  wound,  for 
example,  is  often  healed  before  the  dressings  are  removed.  Catgut  sutures  are 
absorbed  so  that  the  knots  come  away  of  themselves  ;  silk  or  wire  ones  must  be  cut, 
but  so  long  as  there  is  no  tension  upon  them  they  lie  perfectly  inert  in  a  wound 
that  heals  at  once.  [Silkworm-gut  sutures  uniting  skin  wounds  may  remain 
longer.] 

If,  owing  to  the  amount  of  oozing,  it  is  thought  advisable  to  use  a  drainage- 
tube,  the  dressing  must  be  changed,  as  a  rule,  before  the  third  day,  for  the  sake  of 
removing  it.  I  have  often  left  them  a  week  without  harm,  although  occasionally 
the  newly-formed  lymph  that  surrounds  them  is  bruised  and  made  to  bleed  as  they 
are  withdrawn  ;  but  unless  the  wounds  are  badly  contused  or  have  been  subjected 
to  a  great  deal  of  manipulation,  they  are  of  little  benefit  after  twenty-four  hours, 
although  they  may  not  cau,se  any  actual  mischief.  In  wounds  that  are  foul,  of 
course,  the  conditions  are  different. 

A  certain  degree  of  traumatic  fever  is  to  be  expected  in  the  case  of  any  large 
wound.     The  temperature  may  drop  two  or  even  more  degrees  the  evening  after 


174  GENERAL   PATHOLOGY  OF  LNJURIES. 

an  operation,  or  it  may  begin  to  rise  at  once ;  the  next  morning  in  the  milder 
cases  it  is  normal,  in  those  that  are  more  severe  it  may  be  ioi°  F.  (38.3"  C),  but 
its  highest  point  should  be  reached  within  thirty  hours.  If  it  does  not  begin  to 
subside  then  (it  may,  even  in  subcutaneous  injuries,  take  nearly  a  week  before  it 
drops  to  the  normal)  it  means  either  that  there  is  some  degree  of  tension,  whether 
arising  from  tight  suture  or  from  an  unexpected  amount  of  oozing,  and  that  it  had 
better  be  relieved,  or  else  that  the  precautions  have  failed,  that  decomposition  has 
begun,  and  that  septic  fever  is  commencing. 

Special  Kinds  of  Wounds. 

Punctured  wounds  inflicted  with  a  perfectly  clean,  sharp  instrument  require 
the  same  treatment  as  incised  ones  ;  the  only  fear  is  the  difficulty  of  excluding 
injury  to  deep-seated  structures  ;  the  bladder,  for  example,  may  be  penetrated 
through  the  sacro-sciatic  foramen.  Even  if  the  instrument  was  blunt,  so  that  the 
edges  are  contused,  the  same  plan  may  be  adopted  ;  the  wounds  caused  by  small 
revolver  bullets  nearly  always  heal  readily  if  they  are  not  interfered  with  and  no 
fragments  of  clothing  are  carried  in.  But  if  the  weapon  was  foul,  it  is  better  to 
enlarge  the  opening  at  once,  sponge  it  out  with  an  antiseptic,  and  drain  it 
thoroughly.  If  this  is  not  done  the  surface  is  very  likely  to  heal,  while  deep- 
seated  suppuration  under  high  tension  occurs  beneath. 

Subcutaneous  section  is  often  employed  by  surgeons  when  it  is  wished  to  divide 
important  structures,  such  as  tendons,  fascise,  or  bones,  for  the  purpose  of  correcting 
deformity.  A  minute  puncture  only  is  made  through  the  skin  at  some  specially 
chosen  spot,  frequently  at  a  little  distance  from  the  part  to  be  divided,  if  that  en- 
ables it  to  lie  in  one  of  the  natural  folds  or  avoid  important  structures  with  greater 
certainty.  Then  the  instrument,  a  saw,  chisel,  or  fine  tenotomy-knife,  as  the  case 
requires,  is  pushed  in  and  the  division  effected  with  as  little  disturbance  of  the 
structures  around  as  possible.  The  wound  is  closed  with  some  absorbent  dressing, 
and  the  part  carefully  packed  and  bandaged,  or  placed  upon  a  splint.  If  the  in- 
strument used  is  perfectly  clean  and  no  tension,  friction,  or  undue  movement  is 
allowed,  the  wound  heals  immediately  without  any  more  risk  of  suppuration  than 
in  a  contusion  treated  with  similar  precautions. 

Open  wounds  are  exactly  the  opposite ;  there  is  not  sufficient  skin  to  cover 
them  in,  and  they  have  to  heal  by  granulations  from  the  side  and  base.  If  they 
are  well  protected  from  all  sources  of  irritation  none  of  the  leucocytes  are  wasted 
as  pus,  the  whole  of  the  lymph  becomes  organized — the  deeper  part  into  some 
form  of  connective  tissue,  the  more  superficial  into  epithelium. 

Contused  and  lacerated  wounds  have  been  described  already.  They  are  es- 
pecially serious,  both  from  the  widely-spread  injury  sustained  by  the  tissues,  and 
the  difficulty  of  ensuring  thorough  cleansing.  If  the  structures  round  are  badly 
hurt,  a  certain  degree  of  suppuration  is  not  uncommon,  even  when  the  wound  is 
perfectly  clean  ;  the  injured  tissues  are  unable  to  withstand  the  assault  of  the 
pyogenic  microbes  ;  but  the  result  under  these  conditions  is  never  serious,  unless 
there  is  tension,  or  decomposition,  or  some  other  persistent  irritant.  If  these 
occur  there  is  no  limit  to  the  consequences  that  may  follow. 

Infected  wounds  must  be  thoroughly  cleansed  with  corrosive  sublimate  or 
chloride  of  zinc,  and  then,  according  to  their  character,  either  dried  completely 
and  covered  with  iodoform,  any  accumulation  being  prevented  by  the  use  of  drain- 
age-tubes and  absorbent  dressings,  or  left  widely  open  so  that  there  may  be  no  re- 
tention of  discharge.  If  the  tissues  are  the  stronger,  a  barrier  of  vascular  lymph 
gradually  forms,  and  as  it  organizes,  closes  the  wound  ;  if,  on  the  other  hand,  they 
are  enfeebled  from  intemperance,  Bright's  disease,  or  any  other  cause,  or  if  the 
action  of  the  poison  is  assisted  by  tension,  want  of  rest,  or  any  other  irritant,  the 
process  of  destruction  continues  to  sjjread. 


CICA  TRICES. 


175 


'rhere  are  no  lym- 


C'UATRICES. 

A  cicatrix  or  scar  is  the  splic  c  of  iibrous  tissue  formed  by  the  organization  of 
the  lymph  tiiat  fills  a  woiuul.  At  first  it  is  soft  and  vascular;  then,  as  the  fibres 
of  which  it  is  composed  contract,  it  becomes  dense  and  hard  ;  the  newly-formed 
vessels  disappear,  and  only  a  dead  white  inelastic,  layer  is  left. 
l)hatic  or  elastic  fdjres  in  it ;  the  surface  is 
smooth,  formed  of  a  few  layers  of  epithelial 
cells  ;  no  papillte,  hair-bulbs,  or  glands  are  ever 
developed  if  once  they  have  been  destroyed  ; 
and  except  in  certain  cases  there  is  no  repro- 
duction of  special  tissues.  As  time  advances 
and  the  cicatrix  continues  to  contract,  it  may 
gradually  (at  least  in  the  case  of  union  by  the 
first  intention)  merge  into  the  surrounding  tis- 
sues and  almost  disappear  ;  or,  on  the  other 
hand,  it  may  become  more  and  more  conspicuous 
and  lead  to  the  most  fearful  deformity. 

This  depends  chiefly  upon  its  amount.  In 
wounds  that  heal  by  the  first  intention  there  is 
exceedingly  little  (in  what  used  to  be  called 
immediate  union  it  was  saicl  there  was  none  at 
all)  ;  in  those  in  which  the  amount  is  greater,  as 
when  some  of  the  skin  has  been  destroyed,  a  cer- 
tain degree  of  contraction  usually  follows  ;  and 
where  the  cavity  was  a  deep  one  with  a  fixed  base 
(formed  of  bone  or  fascia)  an  unsightly  depres- 
sion may  be  left ;  but  it  is  only  when  suppuration  occurs,  and  the  destruction 
involves  a  considerable  extent  of  surface,  that  the  full  effect  is  produced.  Burns 
that  destroy  the  whole  thickness  of  the  true  skin  often  leave  the  most  fearful 
deformity.  The  arm  may  be  tied  down  to  the  side,  the  lower  lip  (Fig.  31) 
dragged    down   to    the   sternum,    the   eyelids    pulled   down    or    else    completely 


Fig.  31.- 


-  Effects  of  Burn  on  Neck,  Con- 
traction of  Cicatrix. 


Fig.  32. — Contraction  of  Cicatrix  After  a  Burn, 


closed,  the  mouth  contracted  to  an  orifice  so  narrow  that  the  patient  is  scarcely 
able  to  feed  himself,  and  the  oesophagus  converted  into  a  fibrous  cord  for  the 
greater  part  of  its  length.  The  contraction  begins  in  the  deeper  layers  of  the 
granulation-tissue  long  before  the  wound  has  closed,  and  w-here  the  true  skin  has 
been  destroyed  through  its  whole  thickness  it  progresses  steadily  and  relentlessly, 


176 


GENERAL   PATHOLOGY  OE  LYJURLES. 


taking  advantage  of  every  momentary  neglect,  and  never  giving  ujj  the  ground  it 
has  once  gained  until  in  many  cases  further  shortening  is  physically  impossible. 

This  tendency  can  be  checked  to  some  extent  while  the  wound  is  healing. 
Prolonged  suppuration  undoubtedly  favors  it,  and  much  may  be  done  to  prevent 
this  by  epidermic  grafting,  although  the  result  is  often  very  disheartening.  Splints 
and  other  appliances  can  be  used  to  retain  the  limbs  in  suitable  positions,  but  as  a 
rule  it  is  necessary  to  continue  their  employment  a  long  time  after  the  tissues  have 
healed,  and,  as  a  matter  of  fact,  whatever  is  done,  the  steady  persistence  of  the 
cicatricial  tissue  is  almost  sure  to  gain  the  day  at  last,  especially  if  the  injury 
involves  the  flexor  surface  of  a  joint  (Fig.  32). 

The  best  hope  then  lies  in  plastic  surgery,  the  transplantation   of  a  flaj)  from 

some  other  part  of  the  body  into  a  space 
made  by  the  division  of  the  cicatrix. 
Mere  section  seldom  is  of  much  use.  There 
are  two  ways  in  which  this  may  be  ef- 
fected, but  in  both  the  whole  depth  and 
extent  of  the  cicatrix,  at  least  from  one 
side  to  the  other,  must  be  thoroughly 
excised,  an  operation  requiring  great 
care,  as  not  unfrequently  all  the  important 
nerves  and  vessels  of  a  limb  are  entan- 
gled in  it.  In  one  of  the  fashions  per- 
fectly fresh  flaps  of  skin  are  used,  left  at- 
tached at  one  end,  or  preferably  at  both. 
The  outline  must  first  be  carefully  marked 
out,  and  then  the  skin  and  subcutaneous 
tissue  divided  down  to  the  aponeurosis, 
leaving  a  base  sufficiently  broad  for  nu- 
trition, and  if  possible  including  the  chief 
vessels.  As  a  rule,  the  length  should  not 
exceed  three  times  the  width,  the  meas- 
urements being  taken  before  the  opera- 
tion is  begun.  Then  the  flap  is  carefully 
dissected  up,  laid  in  position,  and  secured 
accurately  by  sutures  all  round  the  free 
margin.  If  it  is  only  left  attached  at  one 
end,  it  must  be  twisted  into  the  required 
situation,  care  being  taken  not  to  stran- 
gulate it  ;  if  at  both,  so  that  it  forms  a 
kind  of  bridge,  the  raw  surface  must  be 
placed  beneath  it  ;  a  strip  for  example, 
may  be  dissected  up  from  the  thigh, 
leaving  it  attached  at  both  ends  and  the  forearm  slipped  under.  Then  the  whole 
must  be  made  absolutely  secure  by  means  of  plaster  bandages,  each  part  being  ban- 
daged first,  and  then  the  two  fixed  together.  The  time  when  the  pedicle  may 
be  divided  depends  upon  the  degree  of  union.  If  the  surface  of  the  flap  has  formed 
definite  cohesions  to  its  bed,  it  may  be  done  as  early  as  the  eighth  day  ;  in  most 
cases,  however,  especially  if  the  margins  only  have  united,  it  is  better  to  wait  four- 
teen ;  and  when  the  pedicle  has  been  much  twisted,  and  the  vitality  appears  low, 
longer  still.  MacCormac  has  used  a  constricting  india-rubber  band  round  the 
pedicle  for  some  days  previous  to  division,  so  as  first  to  establish  to  some  extent  a 
collateral  circulation. 

In  the  other  fashion  the  same  precautions  are  adopted,  but  the  flap  is  dissected 
up  first,  separated  from  its  natural  bed  by  a  strip  of  gutta-percha  tissue,  and  left  to 
granulate  all  over  its  under  surface  ;  then,  at  the  end  of  two  or  three  weeks,  as  the 
case  may  be,  when  it  is  thick  and  vascular,  it  is  transplanted  into  its  freshly  pre- 
pared site.      In  the  meanwhile  it  shrinks  to  comparatively  a  very  small  size,  but  it 


Fig.  33. — The  Same  After  Incisions  and  Extension. 


CICA  TRICKS. 


177 


expands  again  to  some  extent  afterward.  Union  l)et\veen  the  freshened  surface 
and  the  layer  of  granulations  a]j];arently  takes  place  without  any  difficulty  ;  and  as 
there  is  less  fear  of  sloughing,  the  pedicle  can  easily  be  detached  rather  earlier  than 
when  a  fresh  flap  is  used. 

Minor  degrees  of  contraction  may  be  treated  l)y  means  of  extension  (provided 
sound  skin  can  be  found  above  and  below,  on  which  to  fix  the  apj^aratus)  ;  by 
simjjle  division,  and  extension  afterward,  or  by  multiple  incisions,  as,  for  example, 
in  the  case  of  the  fingers,  when  numerous  V-shaped  cuts  may  be  made  along  a  con- 
tracting scar,  and  the  edges  brought  together  from  side  to  side.  Occasionally  a 
long  and  narrow  cicatrix  can  be  dissected  out  with  the  view  of  securing  primary 
union  in  its  jjlace. 


Fig.  34. — Case  of  Epithelioma  Growing  from  a  Cicatrix.     {From  the  Editor's  Work 
on   Tumors.) 


Cicatrices  are  liable  to  various  diseases,  some  of  which  at  least  are  due  to  their 
feeble  vitality. 

Ulceration  is  the  most  common.  On  the  legs,  esjjecially,  the  scars  that  are  left 
by  chronic  varicose  ulcers  rarely  last  any  length  of  time  ;  the  .same  cau.ses  continue 
at  work,  and  even  when  the  original  wound  heals  over,  it  is  quickly  reopened  by 
the  breaking  down  of  the  lowly  organized  cicatrix.  The  scars  of  extensive  burns 
may  remain  unhealed  for  years. 

Neuralgia  occurs  sometimes.  It  may  be  due  to  a  nerve-filament  caught  in  the 
scar-tissue,  and  then  there  is  one  very  painful  spot  which  gives  an  almost  electric 
shock  every  time  it  is  touched  ;  or  in  other  cases  to  a   kind   of  malnutrition,  the 


178  GENERAL   PATHOLOGY  OF  LNJURLES. 

cause  of  which  is  not  known.  There  is  a  constant  burning  pain,  but  the  scar  itself 
is  as  cold  as  ice,  the  skin  all  round  is  glazed,  and  does  not  fall  into  its  natural 
folds  ;  the  color  is  a  dusky  livid  red,  returning  very  slowly  after  compression,  and 
the  whole  part  feels  hard  and  dense.  Usually  this  is  met  with  after  amputations, 
and  it  may  return  again  and  again,  even  when  the  whole  stump  is  taken  away  and 
fresh  flaps  formed  from  the  natural  skin  above. 

Ltching  is  sometimes  complained  of,  and  may  be  described  as  simply  intoler- 
able, without  any  cause  being  found.  Probably  it  is  due  to  irritation  of  some  of 
the  nerve-filaments  in  the  cicatrix,  or  it  may  depend  upon  the  condition  of  the  cir- 
culation. Heat  usually  relieves  it,  but  in  some  cases  cold  and  compression  answer 
better. 

LLypertrophy  is  very  common,  and  passes  by  imperceptible  steps  into  what  is 
known  as  cheloid.  Addison's  or  true  cheloid  must  be  clearly  distinguished,  as  it  is 
of  an  entirely  different  character.  This  variety  forms  a  firm,  hard  mass,  with  a 
more  or  less  rounded  surface,  from  which  spurs  and  branches  run  out  in  all  direc- 
tions. The  general  outline  is  most  irregular  ;  as  a  rule,  it  is  smooth  and  glossy  on 
the  surface,  with  a  few  dilated  capillaries  here  and  there  ;  but  often  the  spurs  are 
perfectly  white.  It  is  rarely  tender  when  touched,  although  it  may  be  the  seat  of 
the  most  persistent  itching.  It  consists  of  nothing  but  a  closely  packed  mass  of 
fibrous  tissue,  with  bundles  running  for  the  most  part  parallel  to  the  surface,  without 
definite  outline. 

Cheloid  may  occur  in  any  cicatrix,  and  at  any  time  after  its  formation.  I 
have  known  it  develop  after  a  blister  ;  but  it  is  more  common  after  burns  than 
anything  else,  especially  if  there  has  been  prolonged  suppuration.  Smallpox  scars  are 
not  unfrequently  attacked  by  it,  and  in  some  instances,  in.Avhich  the  marks  are 
close  together,  the  whole  face  is  transformed  into  a  dense,  rigid  mask,  perfectly 
expressionless,  and  covered  with  seams  and  livid  nodules.  It  is  not  uncommon  to 
find  it  attacking  several  scars  at  the  same  time  ;  and  I  have  known  it  occur  in  four 
members  of  the  same  family.  There  is  no  cure  for  it.  Excision  is  rarely  practica- 
ble, and  even  when  it  is  possible,  it  is  almost  certain  to  be  followed  by  recurrence. 

Epithelioma  not  uncommonly  develops  from  cicatrices  ;  and  sometimes,  espe- 
cially in  the  leg,  it  extends  deeply  into  the  subjacent  structures  before  it  is  noticed 
by  the  patient.  Enlargement  of  the  lymphatic  glands  does  not  occur  so  soon  as 
in  some  of  the  other  varieties,  but  the  treatment  is  the  same. 


BURNS  AND  SCALDS.  179 


CHAPTER  III. 

BURNS  AND  SCALDS. 

Burns  and  scalds  are  due  to  the  local  action  of  intense  heat ;  there  is  no  real 
distinction  between  the  two,  the  effect  in  each  case  depending  upon  the  tempera- 
ture and  the  length  of  time  contact  is  maintained,  whether  it  is  hot-air,  steam, 
flame,  boiling  water,  oleaginous  or  other  liquids,  with  a  high  boiling-point,  or 
molten  metal. 

Burns  are  classified  by  their  depth,  and  the  best  practical  system  is  that  of 
Dupuytren. 

1.  Hyperemia — merely  redne.ss  of  the  skin  with  sufficient  exudation  to  cause 
swelling  and  subsequent  peeling  of  epidermis,  but  not  enough  to  raise  it  in  blisters. 
Scorching  with  a  hot  sun,  if  continued,  will  produce  this,  or  a  very  temporary  ap- 
plication of  hot  air  or  flame.  Unless  very  extensive,  it  is  not  dangerous,  but  if  it 
involves  half  the  body  the  result  is  nearly  always  fatal. 

2.  Vesication.  Bullae  form,  containing  a  more  or  less  clear  fluid  which  coagu- 
lates. The  size  they  reach  depends  chiefly  upon  the  thickness  and  toughness  of  the 
epidermis  ;  one,  for  example,  may  ensheath  the  whole  hand.  These  are  chiefly 
due  to  scalds  or  the  transient  application  of  heated  metal,  and  are  more  painful  and 
much  more  serious  than  the  former  ;  but  though  the  mark  is  often  visible  for  years, 
owing  to  the  way  in  which  it  changes  color  on  exposure,  the  surface  of  the  skin  and 
its  various  appendages  are  entirely  restored. 

3.  Superficial  destruction  of  the  corium.  This  is  difficult  to  tell  from  the  second; 
one  passes  imperceptibly  into  the  other,  and  a  burn  of  the  second  degree  always 
forms  a  ring  of  greater  or  less  width  round  every  patch  of  the  third.  Vesicles  are 
not  so  prominent  a  feature,  and  if  they  are  present  they  usually  contain  a  turbid 
brownish  fluid.  The  surface  is  yellow  or  gray,  or  transformed  into  a  dark  brown 
slough.  The  pain  is  much  more  severe,  especially  after  the  first  two  or  three  days 
when  the  dead  surface  is  beginning  to  separate,  and  a  certain  degree  of  suppurative 
fever  usually  follows.  The  scar  that  is  left  is  permanent ;  the  whole  length  of  the 
papillae  and  the  cells  that  line  the  depressions  between  them  have  been  destroyed, 
so  that  the  natural  surface  is  never  restored  ;  but,  on  the  other  hand,  contraction 
never  takes  place,  diff"ering  in  this  respect  immensely  from  the  next. 

4.  Destruction  of  the  whole  thickness  of  the  skin.  It  is  naturally  impossible 
to  tell  this  from  the  preceding  until  the  sloughs  have  separated  and  cicatrization  is 
beginning;  indeed,  the  third  may  in  places  become  deepened  into  the  fourth  by 
the  suppuration  that  ensues  in  the  course  of  repair.  There  is  no  vesication,  the 
superficial  structures  are  destroyed,  the  central  area  is  covered  with  a  hard,  tough, 
dry  eschar,  surrounded  by  zones  of  the  third  and  second  degrees.  The  pain  at  first 
may  be  slighter,  or  perhaps,  owing  to  the  severity  of  the  shock,  the  patient  at  first 
feels  it  less  ;  but  later,  when  inflammation  sets  in  and  the  sloughs  are  beginning 
to  separate,  it  becomes  very  severe.  The  cicatrix  is  characterized  by  the  most 
inveterate  tendency  to  contract  ;  if  it  is  on  the  flexor  surface  of  a  joint, 
and  is  not  checked  by  treatment,  it  may  continue  until  no  further  distortion 
is  possible. 

5  and  6.  In  these  the  destruction  is  deeper  still ;  in  the  former  the  muscles 
only  are  affected,  in  the  latter  the  whole  thickness  of  the  limb.  As  a  rule,  biurns 
of  this  description  are  local,  involving  only  a  small  part  of  the  body  or  of  one  of 
the  limbs.  Healing  is  always  exceedingly  protracted,  and  it  is  not  uncommon  for 
profuse  hemorrhage  to  take  place  about  the  time  that  the  sloughs  are  beginning  to 
separate. 


i8o  GENERAL   PATHOLOGY  OF  LNJURLES. 

CONSTITUTIONAL  SYMPTOMS. 

These  are  divided  into  three  stages  corresponding  to  different  periods. 

1.  Collapse. — Extensive  burns,  even  if  they  are  superficial,  are  followed  by 
the  most  profound  shock.  In  some  the  prostration  is  complete  from  the  first ; 
pain  is  not  felt,  there  is  only  a  sensation  of  intense  cold  and  thirst.  In  others 
there  is  persistent  restlessness,  with  vomiting  or  low  delirium,  and  in  children  con- 
vulsions. The  collapse  may  continue  for  twenty-four  hours  or  even  more,  the 
pulse  gradually  growing  weaker  and  weaker,  or  reaction  may  set  in.  If  this  is 
long  delayed  the  prognosis  is  very  unfavorable. 

2.  Reaction. — As  the  shock  passes  off  the  temperature  begins  to  rise  and  fever 
commences,  caused  no  doubt  to  some  extent  by  the  pain  and  the  reflex  irritation 
of  the  heat  centre,  but  chiefly  by  the  altered  condition  of  the  blood  and  the  ab- 
sorption of  morbid  products  from  the  wounded  surface.  If  the  burn  is  thoroughly 
covered  up,  away  from  the  air,  so  that  the  ends  of  the  nerves  are  not  irritated,  and 
there  is  no  putrefaction,  the  rise  of  temperature  is  only  slight,  and  subsides  in  the 
course  of  a  few  days.  If,  unhappily,  this  is  impracticable,  as  it  usually  is  in  ex- 
tensive injuries,  septic  fever  follows,  the  temperature  rises  higher  and  higher,  and 
either  saprccmia  with  some  form  of  internal  congestion  proves  fatal,  or  after  a  long 
illness  the  tissues  gradually  gain  the  upper  hand,  throw  out  a  barrier  of  granula- 
tions, and  check  further  absorption. 

It  is  in  this  stage  that  abdominal  and  thoracic  complications,  pleurisy,  pneu- 
monia, enteritis,  duodenal  ulceration,  peritonitis,  etc.,  are  most  common,  although 
they  are  not  confined  to  it.  Sometimes  the  symptoms  are  characteristic,  short, 
hacking  cough,  with  rusty,  blood-stained  sputa,  for  example  ;  more  frequently  there 
is  nothing  definite,  merely  a  continued  high  temperature,  with  quick,  feeble  pulse, 
and  rapidly  failing  strength. 

3.  Suppuration. — This  is  no  more  essential  to  the  healing  of  burns  than  it  is 
in  the  case  of  other  wounds  ;  a  cautery  plunged  into  a  njevus  leaves  a  deep  cavity, 
with  blackened,  charred  edges,  which,  if  protected  from  the  air,  heal  over  without 
a  trace  of  pus.  In  most  cases,  however,  owing  to  the  enormous  extent  of  surface 
and  the  conditions  under  which  burns  occur,  it  is  practically  impossible  to  pre- 
vent the  access  of  living  organisms,  and  the  surface  of  the  granulations  thrown  out 
by  the  tissues  around  always  melts  away.  In  not  a  i^w  this  seriously  increases  the 
depth  of  the  injury,  the  tissues  that  might  have  otherwise  recovered  yielding  before 
the  combined  effects  of  septic  decomposition  and  suppurative  micro-organisms. 

The  stage  of  reaction  passes  into  that  of  suppuration  without  any  definite  line; 
the  transition  is  usually  placed  at  about  the  end  of  the  second  week  \  the  tempera- 
ture begins  to  fall  in  the  morning,  and  if  no  internal  complication  sets  in,  the 
continued  fever  subsides  and  becomes  remittent.  This  continues  until  the  granulat- 
ing surfaces  have  healed.  After  a  time  the  danger  of  visceral  trouble  diminishes, 
but  hectic,  exhaustion,  amyloid  disease,  and  other  complications  that  occur  in 
connection  with  large  suppurating  wounds  are  always  liable  to  follow. 

Pathology. — Fully  half  the  cases  that  die  prove  fatal  from  shock  within  the 
first  forty-eight  hours,  the  post-mortem  appearances  ])resenting  nothing  that  is 
characteristic.  In  the  second  period,  from  the  end  of  this  time  until  suppuration 
has  set  in,  congestion,  or  sometimes  inflammation,  of  internal  organs  is  often 
present.  In  the  earlier  part  the  brain  is  chiefly  affected  ;  later  the  thoracic  and 
abdominal  viscera  suffer  most ;  and  associated  with  this  in  a  certain  proportion  of 
instances  (16  out  of  125  collected  miscellaneously)  is  a  peculiar  lesion,  ulceration 
of  the  duodenum.  This  has  been  found  as  early  as  the  fourth  day  ;  it  is  most  fre- 
quent in  the  second  and  third  weeks,  but  it  may  occur  much  later. 

There  is  no  really  satisfactory  explanation  either  for  the  congestion  or  the 
ulceration.  The  former  has  been  assigned  to  reflex  paralysis  of  the  walls  of  the 
vessels  ;  to  paralysis  of  the  heart  from  over-heated  blood  ;  to  capillary  embolism  ; 
to  changes  in  the  blood  produced  by  evaporation  from  an  extensive  denuded 
surface  ;   and   to   retention  of  poisonous  nitrogenous  compounds  that  are  usually 


BURNS  AND   SCALDS.  i8i 

excreted  l)y  the  skin.  ICxcept  the  first  of  tliese,  however,  none  has  miuh  to  com- 
mend it  ;  the  degree  of  congestion  is  not  in  any  way  proportionate  to  the  extent 
of  the  injured  surface  ;  small  burns  are  sometimes  much  worse  in  this  respect  than 
large  ones  ;  and  burns  on  the  trunk  are  always  more  liable  to  jMilmonary  and 
intestinal  complications  than  others.  The  severity  of  the  shock  is  probably  the 
most  important  factor  ;  its  effects  by  no  means  disappear  when  the  temperature 
rises  ;  the  vitality  of  the  tissues  remains  depres.sed  for  many  days  ;  they  no  longer 
possess  their  normal  power  of  resistance,  and  any  fever-causing  substance  absorbed 
from  the  wound  is  sufficient  to  excite  an  attack  of  diffuse  inflammation. 

I'lceration  of  the  duodenum  is  equally  hard  to  explain.  It  is  not  connected 
with  Brunner's  glands.  The  ulcers  are  perfectly  indolent,  as  if  simply  punched 
out,  and  are  usually  situated  immediately  below  the  pylorus,  rarely  beyond  the 
bile-duct;  there  may  be  only  one,  or  there  may  be  several,  either  separate  from 
each  other  and  circular  in  shape,  or  fusing  together.  The  margins  are  sharply 
cut,  and  the  centre  is  deep,  sometimes  extending  through  all  the  coats  into  the 
pancreas,  or  opening  up  a  large  artery  or  the  peritoneal  cavity  ;  sometimes,  on  the 
other  hand,  cicatrizing  over,  showing  that  the  complication  is  not  always  a  fatal 
one.  There  may  be  very  great  congestion  of  the  duodenum  around,  but  it  is  not 
invariable,  and  they  may  occur  after  burns  of  any  size,  or  in  any  locality,  although 
they  are  more  common  when  the  trunk  is  involved.  The  most  reasonable  sug- 
gestion appears  to  be  that  they  are  due  to  the  action  of  the  gastric  juice  upon 
some  part  of  the  mucous  membrane  in  which  the  circulation  has  been  arrested  by 
congestion  or  by  embolism.  It  is  urged  in  sup])ort  of  this  that  they  are  rarely 
found  beyond  the  orifice  of  the  bile-duct ;  but  it  is  singular,  to  say  the  least  of 
it,  that  the  congestion  or  embolism  should  not  also  sometimes  occur  in  the 
stomach.  It  may  be  present  without  symptoms  of  any  kind,  suppurative 
peritonitis  setting  in  suddenly  and  proving  fatal  almost  at  once ;  or  there  may 
be  diarrhoea  with  melaena,  epigastric  pain,  tenderness,  and  vomiting  of  dark  brown 
fluid. 

Burns  of  the  chest,  abdomen,  and  head  are  much  worse,  both  as  regards 
symptoms  and  complications,  than  those  of  similar  degree  upon  other  parts  of  the 
body.  In  children  and  old  people  the  prognosis,  as  might  be  expected,  is  much 
more  grave  ;  but  the  factor  that  is  of  most  importance  in  estimating  the  risk  to  life 
is  the  extent  of  surface.  A  deep  burn,  if  it  is  limited,  is  often  only  a  local  affec- 
tion ;  a  very  superficial  one,  on  the  other  hand,  caused  by  momentary  exposure 
to  intensely  heated  air  or  steam,  if  it  involves  a  large  area,  will  almost  certainly 
prove  fatal  from  shock,  or,  if  the  patient  survives  this,  from  subsequent  internal  con- 
gestion. When  the  face  is  much  burnt  there  is  always  the  danger  that  the  mucous 
membrane  of  the  larynx  may  have  been  injured  at  the  same  time,  and  that  oedema 
of  the  glottis  and  broncho-pneumonia  will  follow. 

Treatment. — In  a  large  superficial  burn,  the  first  thing  is  to  prevent  the 
patient  sinking  from  collapse  ;  under  the  influence  of  the  shock  the  temperature 
falls,  the  circulation  becomes  feeble,  the  amount  of  heat  and  energy  produced  by 
the  tissues  diminishes,  and  death  may  ensue  simply  from  the  failure  of  power. 
Warmth,  stimulants,  and  opium  are  the  chief  remedies.  The  heat  of  the  body 
must  be  economized  in  every  way,  pain  relieved  as  far  as  possible,  the  heart  pre- 
vented from  failing,  and  the  tissues  supplied  with  diffusible  stimulants  which  will 
help  them  for  the  time  to  do  all  that  they  can.  If  it  can  be  managed,  the  patient 
should  be  placed  at  once,  without  waiting  to  take  off  clothes  that  are  adherent,  in 
a  warm  boracic  bath,  the  temperature  of  w^hich  is  carefully  maintained  ;  and  pro- 
vided the  inhalation  of  the  hot  vapor  is  prevented  by  surrounding  the  neck  with  a 
mackintosh  or  other  waterproof  material,  he  may  be  left  in  this  for  some  hours  until 
reaction  begins.  Meanwhile  the  burnt  fabrics  will  float  off  or  can  be  cut  away, 
without  injury  to  the  parts  beneath  or  exposing  them  to  the  air.  As  soon  as  the 
pulse  begins  to  recover,  all  the  injured  part  should  be  A\rapped  in  many  layers  of 
boracic  lint  or  salicylic  wool,  and  enveloped  with  a  bandage,  a  certain  degree  of  soft 
compression   being  used.      Carbolic  acid  is  much  too  irritating  for  burns,  and 


1 82  GENERAL   PATHOLOGY  OF  INJURIES. 

corrosive  sublimate  applied  to  an  extensive  surface   would   very    probably  prove 
dangerous. 

Thirst  may  be  relieved  with  milk  and  soda  water,  or  very  dilute  acid  drinks. 
How  long  stimulants  are  necessary  must  be  determined  by  the  condition  of  the 
pulse,  but  care  should  be  taken  not  to  push  them  too  far  or  to  continue  them  too 
long  ;  as  soon  as  there  is  a  distinct  improvement  in  the  arterial  tone,  small  quanti- 
ties of  beef-tea  should  be  given  with  them,  and  should  gradually  replace  them  ;  but, 
throughout,  everything  must  be  done  to  maintain  the  strength  of  the  patient.  The 
visceral  congestion  and  inflammation  that  occur  in  the  second  period,  that  of  reac- 
tion, are  distinctly  encouraged  by  everything  that  tends  to  reduce  the  already  weak- 
ened reserve  ;  and  after  this  stage  is  passed,  and  suppuration  has  set  in,  the  ques- 
tion of  recovery  or  not  often  turns  upon  the  balance  that  is  left,  and  the  way  in 
which  it  can  be  economized. 

Diarrhoea  should  be  checked  at  once  with  opium  and  dilute  mineral  acids. 
Pulmonary  complications  must  be  met  with  ether  and  carbonate  of  ammonia.  If 
vomiting  occurs,  it  may  sometimes  be  relieved  by  very  minute  doses  of  vinum  an- 
timoniale,  or  the  stomach  may  be  left  entirely  empty  for  a  time,  and  nutrient 
enemata  given  instead.  Bromide  of  potash  is  often  necessary  in  cases  in  which 
there  is  delirium,  or  evidence  of  commencing  cerebral  congestion,  and  quinine, 
tonics,  and  especially  iron,  in  the  later  stages,  if  the  appetite  is  failing  or  the 
strength  shows  signs  of  giving  way  under  the  prolonged  strain. 

The  local  treatment  depends  upon  the  depth  of  the  burn,  but  the  principle  is 
in  all  cases  alike  ;  protect  the  part  thoroughly  from  the  air,  prevent  decomposition, 
and  change  the  dressings  as  seldom  as  possible. 

In  those  of  the  first  degree,  in  which  the  area  is  limited,  the  ordinary  domes- 
tic appliances,  mashed  potatoes,  lead  lotion,  cold  spirit  and  water,  anything,  in 
short,  that  is  cooling  and  diminishes  the  hypergemia,  answers  exceedingly  well.  Dry 
applications,  such  as  flour,  fuller's  earth,  etc.,  in  many  people  cause  a  degree  of 
irritation  and  of  itching  that  is  almost  as  painful.  Flexible  collodion  or  lead  paint 
is  very  useful,  especially  on  the  body  or  where  the  skin  is  liable  to  friction  from  the 
clothes. 

If  blisters  are  present  already  they  must  be  pricked,  the  fluid  allowed  to  ooze 
quietly  out,  and  the  epidermis  gently  replaced  ;  but  when  the  case  is  .seen  sufficiently 
early,  an  attempt  should  be  made  to  check  their  formation  by  limiting  the  amount 
of  blood  going  to  the  part ;  this  may  often  be  managed  by  investing  the  affected 
area  at  once  with  boracic  lint  (wetted  with  cold  boracic  lotion  if  the  .sense  of 
smarting  is  very  severe),  and  then  with  many  layers  either  of  a  similar  material  or 
of  wood-wool  or  salicylic  wool.  A  flannel  bandage  is  placed  over  the  whole  with 
a  fair  amount  of  pressure,  and  the  part  is  w^ell  raised.  The  dressing  should  be  left 
on  as  long  as  possible,  and  when  it  is  necessary  to  change  it  it  should  be  allow^ed 
to  float  ofi"  in  a  bath.  Carron  oil  (equal  parts  of  lime  water  and  olive  oil)  is  a  very 
favorite  application,  but  the  smell  after  it  has  been  applied  some  little  time  is  very 
nauseating  ;  bicarbonate  of  soda  (a  saturated  solution)  is  stated  to  relieve  the  pain 
more  quickly  than  anything  else,  but  though  I  have  tried  it  in  many  cases, 
I  cannot  say  that  I  have  succeeded  in  persuading  myself  of  its  superiority. 
Zinc  ointment  answers  well  when  the  surface  is  of  small  extent,  and  the  same 
may  be  said  of  vaseline,  carbonate  of  lead  ointment,  resin  ointment,  and  many 
others. 

In  burns  of  limited  size  but  greater  depth,  the  same  principle  must  be  adopted, 
but  for  these  iodoform  and  corrosive  sublimate  can  be  used.  If  there  appears  to 
be  a  chance  of  drying  up  the  sloughs  and  limiting  the  amount  of  exudation,  the 
former  is  the  better,  freely  sprinkling  it  all  over,  and  then  applying  wood-wool 
over  this.  If,  on  the  other  hand,  from  its  position,  or  from  the  length  of  time 
that  has  elapsed  since  the  injury,  and  the  amount  of  exudation  that  is  present,  this 
does  not  appear  to  be  practicable,  the  part  should  be  well  irrigated  with  corrosive 
sublimate,  or  placed  in  a  bath  of  it  for  a  time  and  wrapped  in  boracic  lint.  In 
any  case,  whatever  dressing  is  used  for  a  burn,  it  should  be  left  as  long  as  it   pos- 


BURNS  AND  SCALDS.  183 

sibly  can  be,  and  the  greatest  care  is  re(Hiire(l  when  changing  it  not  to  disturl)  the 
newly-formed  epidermis. 

Finally,  in  some  very  severe  cases  amputation  is  required,  but  this  should  not 
be  thought  of  until  the  shock  is  past,  and  ])referably  not  until  the  line  of  demarca- 
tion is  distinct.  Occasionally  it  is  ])erformed  at  a  later  period,  either  because  of 
prolonged  suppuration  or  because  the  limb,  although  it  has  been  saved,  is  merely 
an  encumbrance. 

After  the  sloughs  have  sei)arated  the  suppurating  surface  left  requires  the  .same 
treatment  as  other  wounds,  the  only  difference  is  that  the  granulations  have  an  ex- 
traordinary tendency  to  become  pale,  flabby,  and  e.xuberant.  This,  which  is  in 
great  measure  due  to  the  distance  from  the  base,  and  the  defective  contraction  of 
the  deei)er  layers,  is  best  kept  in  check  with  nitrate  of  silver.  Either  a  lotion  of 
three  grains  to  the  ounce  may  be  used  for  the  whole  surface,  or,  what  answers  better, 
the  solid  stick  may  be  applied  occasionally  all  round  the  margin.  Grafting  is 
usually  necessary  for  the  healing  of  large  surfaces,  but  often  it  is  very  disappoint- 
ing ;  rapid  progress  is  made  for  a  short  time,  and  then  suddenly  the  whole  of  the 
newly  cicatrized  area  breaks  down  again.  Every  attempt,  however,  should  be 
made  to  procure  early  cicatrization  ;  contraction  cannot  be  prevented  altogether  in 
a  burn  of  the  fourth  degree  (except  by  covering  in  the  whole  granulating  surface 
with  fresh  or  vivified  grafts,  as  already  described  under  cicatrices),  but  the  longer 
the  suppuration  lasts,  the  greater  the  amount  of  dense,  contracting  tissue  that  is 
developed. 

Mechanical  appliances  are  often  required,  partly  to  keep  the  injured  surfaces 
at  rest,  but  chiefly  to  prevent  contraction.  Splints,  extending  apparatuses,  elastic 
bands,  etc.,  must  be  adapted  to  the  special  circumstances  of  each  case,  and  no 
general  rules  can  be  laid  down  for  them,  except  that  their  action  must  be  con- 
tinuous night  and  day.  I  have  known  three  days'  respite  allow  such  a  degree  of 
deformity  to  take  i)lace,  that  the  former  position  was  never  thoroughly  regained. 

[Burns  of  the  fauces  and  upper  air  passages  from  the  inhalation  of  steam  should 
be  treated  by  the  atomization  of  dilute  sulphuric  ether,  and  its  inhalation.  The 
patient  should  be  caused  to  breathe  air  charged  with  atomized  dilute  ether  spray, 
until  danger  of  oedema  of  the  glottis  shall  have  passed.  When  steam  has  been 
inhaled  long  enough  to  scald  the  tracheal  lining  the  case  is  hopeless.  Usually  there 
is  spasmodic  closure  when  the  steam  touches  the  larynx,  and  the  steam  passes  no 
further,  but  the  editor  once  saw  a  case  where  the  unfortunate  patient  had  been 
pinned  fast  by  timbers  so  that  he  was  obliged  to  make  several  inhalations  of  the 
steam  before  he  could  escape.  This  man  died  an  hour  after  reaching  the 
hospital.] 


1 84  GENERAL   PATHOLOGY  OE  LNJURLES. 


CHAPTER  IV. 

MIN  OR     SURGERY. 

THE  SURGEON. 

[There  have  been  many  paraphrases,  changes,  and  interpolations  in  the 
famous  dictum  of  A.  Cornelius  Celsus,  but,  after  all  the  commentaries  that  have 
been  made  upon  it,  the  original  still  stands  unimpaired  by  time.  A  recent  learned 
commentator,  referring  to  Celsus'  remark  about  the  trembling  hand,  says  that 
"  a  shakiness  of  the  hand  may  be  some  bar  to  the  success  of  an  operation,  but  he 
of  a  shaky  mind  is  hopeless."  It  may  be  fairly  presumed  that  Celsus  assumed 
that  any  surgeon  would  be  sound  of  mind  and  have  a  knowledge  of  anatomy. 
He  doubtless  scarcely  considered  it  necessary  to  assert  in  formal  terms  that  the 
surgeon  should  not  be  a  lunatic  or  an  imbecile. 

Celsus  said  :  "A  surgeon  ought  to  be  young,  or  certainly  very  near  to  youth, 
with  a  hand  active,  firm,  nor  ever  trembling,  and  not  less  ready  with  the  left  than 
the  right,  with  eyesight  sharp  and  clear,  intrepid  in  mind,  compassionate,  so  that 
he  wish  him  whom  he  has  received  to  be  cured,  and  not  to  be  moved  by  his  cries 
that  he  may  hasten  more  than  the  thing  requires  or  may  cut  less  than  is  necessary  ; 
but  may  do  all  things  just  as  if  no  impression  was  received  from  the  cries  of  the 
other.  "^ 

Sterilization  of  the  Hands. 

The  skin,  by  careful  washing,  may  be  made  comparatively  free  from  micro- 
organisms, but  it  is  less  frequently  done  than  is  supposed,  and  it  is  with  the 
utmost  difficulty  that  the  subungual  spaces  are  freed  from  them.  Dr.  Kinyoun, 
in  a  report  made  to  the  writer  in  June,  1889,  showed  its  difficulty  by  a  series  of 
experiments  on  the  subject,  made  at  the  Seaman's  Retreat  Hospital  at  New  York. 
The  observations  extended  over  a  period  of  three  months,  and  the  surgical  nurses 
were  instructed  to  use  a  nail-brush  and  scrub  the  hands  with  soap  and  warm  water, 
after  which  they  immersed  them  in  solution  bichloride  of  mercury,  i  to  3000. 
In  some  cases  strong  alcohol  and  ether  was  used.  They  then  assisted  at  opera- 
tions and  dressed  the  wounds  and  ulcers  in  the  wards.  Scrapings  were  taken 
from  beneath  their  finger-nails  at  a  time  when  they  were  making  or  assisting  in 
the  dressing,  or  just  before  an  operation.  "In  all  the  examinations,"  said  Dr. 
Kinyoun,  "in  only  two  instances  were  the  hands  found  to  be  sterile;  in  a// the 
others  Ijacteria  were  found."  Repeated  scrubbing  and  a  most  careful  disinfection 
of  the  hands  are  therefore  necessary  to  prevent  the  surgeon  from  infecting  the 
wound,  and  even  then,  in  most  cases,  the  hands  and  finger-ends  are  rarely  rendered 
aseptic,  but  the  danger  is  probably  reduced  to  a  minimum. 

Clothing. 

The  use  of  a  gown  that  may  be  laundered,  and  thus  kept  clean,  worn  over 
the  clothing  of  the  operator,  is  also  necessary  for  the  prevention  of  the  introduc- 
tion of  microbes  into  the  wound. 


*  The  exact  text  is  as  follows  :  "  Esse  autem  chirurgus  debet  adolescens,  aut  certe  adolescentiae 
proprior;  manu  strenua,  stabili,  nee  unquam  intremiscente,  eaque  non  minus  sinistra,  quam  dextra 
promptus;  acie  oculorum  acri,  claraque ;  animo  inlrepidus,  misericors  sic  ut  sanari  velit  eum,  quem 
accepit,  non  ut  clamore  ejus  motus,  vel  magis  quam  res  desiderat,  properet  vel  minus,  quam  necesse 
est,  secet;  sed  perinde  facial  omnia  ac  si  nullus  ex  vagilibus  alterius  affectus  oriator." 


MINOR  SURGERY.  185 

Instruments. 

It  is  not  economical  to  purchase  cheap  instruments.  Procure  the  bestquaUty, 
for  they  not  only  serve  for  better  work  while  in  use,  but  they  retain  their  useful- 
ness much  longer.  Cutting  instruments  should  have  sharp  edges  when  purchased, 
well-polished  surfaces,  and  be  well  tempered.  All  joints  should  move  easily,  and 
be  so  constructed  that  they  may  be  readily  cleansed.  The  temper  of  a  scalpel  or 
a  chisel  may  be  tested  by  sharpening  it  on  a  fine  oil-stone,  a  lithotrite  by  breaking 
in  its  jaws  a  piece  of  brown  sandstone  the  size  of  a  filbert,  and  forceps  by  close 
e.xamination  ;  the  blades  of  hemostatic  or  pressure  forceps  should  fit  each  other 
accurately  and  work  easily  with  the  thumb  and  finger  of  the  operator.  It  is 
scarcely  possible  to  pay  too  much  attention  to  the  selection  of  instruments. 

The  pattern  of  the  scalpel  blade  may  well  be  left  to  the  judgment  of  the 
individual  operator,  but  a  good  instrument  has  a  handle  that  is  smooth,  easily 
sterilized,  and  neatly  joined  to  the  blade. 

The  surgeon  should  rather  perfect  himself  in  the  use  of  the  instruments  that 
are  in  vogue  than  to  hastily  construct  one  with  only  slight  variation  from  a  pre- 
viously existing  model. 

Instruments  should  be  carefully  sterilized  immediately  before  being  used,  and 
as  carefully  cleansed  and  disinfected  immediately  after  use.  Sterilization  may  be 
effected  by  dry  heat  in  an  ordinary  sterilizer,  or  by  steam,  or  by  boiling  in  water 
for  a  quarter  of  an  hour.  Most  disinfecting  .solutions  spoil  the  polish  and  edge 
of  cutting  instruments  when  they  are  kept  in  them  for  any  considerable  time ;  it 
will,  therefore,  be  found  that  in  most  cases  boiling  in  water  is  the  most  convenient 
means  of  disinfection. 

Probes,  aspiration  needles,  and  hypodermic  needles,  when  needed  in  the 
operating-room,  may  be  plunged  in  alcohol  just  before  using,  or  passed  through 
the  flame  of  a  lamp  or  lighted  gas  jet. 

The  Patient, 

The  patient  must  be  prepared  for  operation  by  a  general  bath  whenever 
practicable,  and  careful  cleansing,  shaving,  and  disinfection  of  the  surface  of  the 
region  to  be  operated  upon.  If  the  operation  is  to  be  upon  the  abdomen,  the 
bowels  should  be  previously  emptied  by  a  brisk  saline  cathartic,  and  a  little 
before  the  operation  the  rectum  well  cleansed  by  injection  of  warm  water,  and 
the  bladder  emptied  of  urine  either  naturally  or  through  the  catheter  ;  female 
patients  should  be  required  to  use  a  vaginal  douche,  and  all  patients  about  to 
undergo  a  serious  operation  should  have  the  urine  examined.] 


THE  AN.^STHETIC. 
I.   LOCAL  ANAESTHESIA. 

Finely-powdered  ice  and  salt  or  ether-spray  causes  numbness  to  the  skin,  but 
the  effect  is  limited  to  the  surface  ;  it  cannot  be  kept  up  without  the  risk  of  slough- 
ing, and  the  pain  of  thawing  is  almost,  if  not  quite,  as  severe. 

Hydrochlorate  of  cocaine  sprayed  or  painted  over  a  mucous  surface  or  a 
recent  wound  will  ensure  local  anaesthesia  for  a  quarter  of  an  hour  or  more ;  but 
it  is  of  no  use  on  unbroken  skin  or  where  the  tissues  are  inflamed.  The  ordinary 
strength  is  gr.  xx  or  ^ss  (1.20  grammes  or  15  grammes)  to  the  ounce,  and  the 
solution  should  always  be  fresh,  as  it  soon  decomposes.  It  may  also  be  employed 
hypodermically,  a  grain  or  a  grain  and  a  half  being  injected  at  a  time ;  but  very 
serious  symptoms — syncope,  delirium,  unconsciousness,  and  even  collapse — have 
been  known  to  follow.  Whether  this  is  due  to  the  products  of  decomposition 
of  the  drug  or  to  personal  susceptibility  is  uncertain.  Capillary  oozing  is  always 
severe  when  cocaine  is  employed. 


1 86  GENERAL   PATHOLOGY  OF  IXJURIES. 

2.   GENERAL  ANAESTHESIA. 

Nitrous  oxide  gas,  chloroform,  ether,  bichloride  of  methylene,  and  a  mixture 
of  equal  parts  of  alcohol,  ether,  and  chloroform  (known  as  the  A.  C.  E.  mixture) 
are  the  chief  agents  used.  The  apparatus  and  the  method  vary  in  each  case,  but 
in  all  alike  the  clothing  should  be  loosened,  false  teeth  removed,  and  the  patient 
placed  in  a  suitable  position  (usually  recumbent,  with  the  head  slightly  raised  and 
turned  to  one  side).  An  anaesthetic  should  not  be  given  for  some  hours  after  a 
meal ;  if  there  is  a  feeling  of  faintness  or  the  pulse  is  weak,  a  small  quantity  of 
brandy  may  be  given  by  the  mouth  or  injected  into  the  rectum. 

Nitrous  oxide  gas  is  especially  useful  for  short  operations  (the  anaesthesia  last- 
ing about  a  minute)  and  as  a  preliminary  to  ether.  It  is  practically  free  from 
danger,  and  is  seldom  attended  with  sickness  or  headache. 

The  gas  passes  from  a  reservoir  through  a  face-piece,  contrived  to  exclude  air 
thoroughly.  After  a  few  inspirations  the  face  becomes  dusky  and  the  breathing 
deeper  ;  then  toward  the  end  of  the  minute  the  eyes  grow  prominent,  the  pupils 
dilate,  the  lips  become  blue,  and  the  respiration  stertorous  ;  at  this  stage  anaesthesia 
is  complete  :  if  the  administration  is  continued  convulsive  movements  begin.  The 
insensibility  may  be  prolonged  without  any  unpleasant  effect  by  giving  a  small 
quantity  of  ether  with  the  gas  after  the  first  few  breaths. 

Ether  is  always  given  through  an  inhaler.  In  Clover's  the  same  air  is  breathed 
over  and  over  again,  and  the  amount  of  vapor  added  is  regulated  by  an  index.  In 
Ormsby's  an  ounce  is  poured  upon  a  sponge  at  the  beginning,  and  the  proportion 
of  fresh  air  varied. 

The  vapor  must  be  admitted  very  gradually  at  first,  as  it  is  so  unpleasant  that 
many  patients  can  hardly  tolerate  it,  and  if  possible  preliminary  anaesthesia  should 
be  induced  with  gas.  As  the  amount  is  increased  the  face  becomes  congested,  a 
period  of  excitement  with  violent  struggling  (especially  in  men  accustomed  to 
drink)  follows,  and  then,  comparatively  suddenly,  the  muscles  relax  and  the 
breathing  becomes  stertorous.  If  Clover's  inhaler  is  used  a  breath  of  fresh  air 
should  be  allowed  every  half-minute  until  anaesthesia  is  complete,  then  the  inter- 
ruptions should  be  more  and  more  frequent  until,  when  the  administration  has 
lasted  some  time,  the  inhaler  is  only  applied  occasionally. 

As  a  general  anaesthetic  ether  is  much  safer  than  chloroform,  and  unless 
contraindicated  should  always  be  used  in  preference.  Unfortunately,  it  is  more 
im pleasant,  leaving  a  severe  headache,  and  the  smell  hangs  about  for  days.  It  is 
not  suited  to  operations  about  the  mouth,  nose,  or  eyes,  to  operations  upon  the 
brain  or  large  vessels,  or  to  cases  of  bronchitis,  empyema,  phthisis,  or  extreme 
abdominal  distention.  Women  and  children  take  it  very  well ;  drunkards  can 
scarcely  be  got  under  its  influence,  unless  they  are  partially  intoxicated  already — 
then  the  transition  from  one  stage  to  the  other  is  very  easy.  Care  must  be  taken 
not  to  bring  it  near  a  naked  light  nor  near  a  Pacquelin  cautery. 

Chiorofonn. — All  that  is  required  is  a  drop-bottle  and  a  fold  of  lint  doubled. 
A  few  drops  are  sprinkled  on  first,  then  a  few  more,  gradually  increasing  the 
quantity,  and  the  lint  is  turned  over  so  that  the  moistened  surface  may  face  the 
mouth ;  it  must  not  touch  it  or  the  skin,  for  fear  of  causing  blisters.  The  pulse 
and  respiration  (not  the  movements  of  the  chest,  but  the  actual  influx  and  efflux 
of  air)  must  be  watched  from  the  first.  Except  in  children,  a  period  of  excitement 
nearly  always' precedes  that  of  unconsciousness,  and  sometimes  in  men  there  is 
severe  struggling ;  but  unless  the  respiratory  muscles  remain  rigidly  contracted, 
there  is  no  need  to  suspend  the  administration.  The  pulse  may  be  increased  in 
frequency  during  the  struggling  stage  and  the  pupil  dilated  ;  as  it  passes  off  the 
respiration  becomes  slow  and  deep,  the  pulse  falls  to  its  normal  rate,  and  the  pupil 
contracts,  still  retaining  its  power  of  reacting  to  light.  Snoring,  and  the  loss  of 
the  conjunctival  reflex,  are  signs  that  the  patient  is  fully  anaesthetized,  and  that 
the  administration  may  be  suspended  for  a  breath  or  two  and  then  carried  on 
more  gradually. 


THE   PRINCIPAL   BANDAGES 


Recurrent  of  Head. 


Oblique  Bandage  of 
Head. 


V-Bandase. 


Occipito-Facial. 


Barton's. 


Gibson's. 


Crossed  Bandage, 
Both  Eyes. 


Chest  Bandage. 


Compressor  of  Mamma.  chest  Bandage  wi  th  Supports. 


Figure-of-Eight  of  Chest. 


Velpeau. 


Velpeau. 


M/XOR   SURGERY.  187 

Chloroform  is  preferable  to  ether  for  all  o|)erations  about  the  mouth  and  nose 
(junker's  apparatus,  in  which  air  is  driven  through  the  litiuid  by  means  of  a  ball 
syringe,  is  especially  suited  to  these),  for  oj^erations  ujjon  the  brain  and  eye,  in 
infants  and  old  people,  in  cases  in  which  the  breathing  is  embarrassed,  and  in 
midwifery.  In  all  other  conditions  ether  is  more  safe  ;  it  is  true  that  deaths  have 
occurred  during  its  administration,  but  the  ])roportion  is  not  nearly  so  large  as  in 
the  case  of  chloroform,  and  the  patients  have  almost  all  been  suffering  from  some 
grave  internal  disorder. 

Chloroform  acts  both  upon  the  heart  and  the  respiratory  centre.  Syncope 
may  occur  with  the  first  few  breaths  before  the  operation,  or  with  the  first  incision 
(it  has  been  suggested  that  in  these  cases  it  is  really  due  to  shock,  the  patient  not 
being  sufficiently  anaesthetized).  Si)asm  of  the  res])iratory  muscles  may  ])rove  fatal 
during  the  struggling  stage.  Later,  even  after  the  administration  is  over,  the 
respiration  or  the  heart  may  stop,  the  latter  usually  giving  the  first  indication, 
though  the  former  is  the  first  to  cease  altogether.  For  this  reason  it  is  absolutely 
essential  to  watch  both  the  pulse  and  the  breathing  throughout. 

An  injection  of  morphia  before  the  chloroform  is  given  enables  anaesthesia 
to  be  produced  much  more  rapidly  and  without  any  struggling,  but  it  very  greatly 
increases  the  danger  of  syncope.  Ether,,  on  the  other  hand,  diminishes  the  risk, 
and  in  many  cases  in  which  it  cannot  be  given  during  the  operation,  it  is  advisable 
to  anaesthetize  the  patient  with  it,  and  when  the  blood  is  well  saturated  substitute 
chloroform. 

The  A.  C.  E.  mixture  may  be  used  instead  of  chloroform  in  many  cases,  but 
care  must  be  taken  that  the  mixture  is  fresh  and  that  very  small  quantities  are  given 
at  a  time.  The  liquids  evaporate  with  different  degrees  of  rapidity,  and  if  a  large 
quantity  is  poured  on  to  an  inhaler  at  once,  nearly  the  whole  of  one  may  come  off 
before  the  others  are  appreciably  affected. 

Bichloride  of  methylene  is  best  given  with  Junker's  apparatus.  Its  com- 
position is  somewhat  doubtful ;  probably  it  is  only  a  mixture,  and  as  it  is  affected 
by  exposure  to  air,  it  should  always  be  freshly  opened.  With  women  it  suc- 
ceeds fairly  well,  and  there  is  very  little  tendency  to  sickness  afterward  ;  but  it 
is  difficult  to  secure  a  sufficient  degree  of  anaesthesia  in  any  patient  accustomed  to 
alcohol. 

Special  Symptoms. — Struggling  dind  excitement  are  particularly  severe  in 
the  case  of  ether.  At  the  beginning  they  are  due  to  the  fearful  sensation  of  chok- 
ing caused  by  the  vapor  being  too  concentrated,  and,  making  allowance  for  this, 
are  under  the  patient's  control.  Later,  they  are  involuntary.  Epileptiform  con- 
vulsions may  occur,  but  the  chief  danger  is  the  sudden  inhalation  of  an  excessive 
amount  of  vapor.  A  considerable  degree  of  excitement  is  sometimes  met  with 
during  the  recovery  from  ether,  especially  if  the  anaesthesia  has  not  been  of  long 
duration. 

Vomiting  is  almost  sure  to  occur  if  the  stomach  is  full,  and  may  prove  serious. 
It  may  happen  at  the  beginning,  but  it  usually  takes  place  later,  or  during  recov- 
ery. Pallor  of  the  face  and  lips,  failure  of  the  pulse,  and  retching  precede  it,  and 
the  administration  should  always  be  stopped  until  the  stomach  is  emptied.  No 
food  should  be  allowed  for  some  hours  after  an  anjesthetic,  merely  a  few  small 
fragments  of  ice,  if  the  thirst  is  great,  and  for  the  first  twenty-four  hours  every- 
thing should  be  cold.  If  vomiting  persists,  bismuth  and  morphia  may  be  given 
and  a  mustard  plaster  applied  to  the  epigastrium  ;  but  usually  it  is  better  to  leave 
the  stomach  altogether  alone  and  feed  the  patient  by  means  of  enemata.  I  have 
known  minim  doses  of  vinum  antimoniale  every  quarter  of  an  hour  succeed  in  a 
case  that  seemed  likely  to  prove  serious. 

Dyspncea  may  arise  from  respiratory  spasyi  during  the  struggling,  but  a  much 
more  common  cause  is  the  falling  back  of  the  tongue  and  the  collapse  of  the  upper 
aperture  of  the  larynx.  When  this  is  slight  it  causes  a  peculiar  stertor,  which  can 
be  relieved  by  pressing  the  point  of  the  chin  forward  and  upward,  or,  if  this  does 
not  succeed,  by  seizing  the  tongue  with  a  broad  pair  of  forceps  and  drawing  it 


1 88  GENERAL   PATHOLOGY  OF  LNJURLES. 

well  out  of  the  mouth.  The  condition  is  easily  relieved  if  the  cause  is  noticed, 
but  as  the  thorax  continues  to  move  naturally  there  is  great  danger  of  overlooking 
the  fact  that  no  air  is  entering. 

Lleart-failure  is  an  accident  peculiar  to  chloroform.  As  already  mentioned, 
it  may  occur  with  the  first  few  breaths,  or  during  and  even  after  the  administra- 
tion ;  and  it  may  be  accompanied  or  not  by  failure  of  respiration.  At  the  first 
suspicion  of  weakening  of  the  pulse  the  anaesthetic  should  be  stopjjed  and  every 
endeavor  made  to  clear  the  lungs  of  the  vapor  that  fills  them  ;  the  tongue  should 
be  drawn  forward  ;  if  the  breathing  is  not  deep  and  thorough  artificial  respiration 
.should  be  commenced,  and  if  there  is  the  least  impediment  to  the  entry  of  air 
tracheotomy  should  be  performed.  A  subcutaneous  injection  of  ether  or  brandy 
may  be  of  some  service,  and  inversion  of  the  patient,  so  that  the  head  receives  a 
full  supply  of  blood,  is  undoubtedly  of  use ;  but  neither  galvanism  nor  nitrite  of 
amyl  has  been  proved  to  be  of  any  practical  benefit. 

\_Suppressioti  of  urine  may  be  one  of  the  disagreeable  after-effects  of  the 
administration  of  ether,  in  persons  with  fatty  kidneys.  One  fatal  case  of  this 
nature  fell  under  the  editor's  observation.  Chloroform  in  such  a  case  is  the  safer 
anaesthetic] 

Bandaging. 

[The  operation  being  finished,  the  parts  well  cleansed  and  dried,  the  applica- 
tion of  suitable  bandages  are  imperatively  required,  for  the  double  purj^ose  of 
assisting  to  maintain  the  wounded  surfaces  in  apposition  and  to  prevent  infection. 
The  wound  should  be  sprinkled  with  iodoform  or  other  desiccating  powder,  a 
thick  pad  of  iodoform  gauze  laid  over  it,  and  next  to  that  a  smooth  layer  of 
absorbent  cotton,  over  which  should  be  laid  rubber  protective,  or  a  bandage  of 
several  thicknes.ses  of  sterilized  gauze.  Sterilized  gauze  has  latterly  superseded 
the  old  cotton  roller  in  the  majority  of  cases. 

After  Treatment. — After  the  patient  shall  have  been  properly  bandaged, 
measures  should  be  taken  to  prevent  shock.  These  consist  in  the  application  of 
external  heat  by  means  of  a  bag,  filled  with  hot  water,  sterilized  flannel  cloths 
well  heated  and  applied  to  the  abdomen  and  extremities.  If  necessary  to  bring 
on  reaction,  brandy  may  be  given  by  the  hypodermatic  syringe,  in  teaspoonful 
doses,  according  to  the  urgency  of  the  case.  Careful  regulation  of  the  diet  is  also 
necessary  when  the  patient  begins  to  take  food.  The  surgeon  should  give  explicit 
directions  about  the  length  of  time  the  patient  should  remain  in  bed.  These 
will  necessarily  vary,  according  to  the  nature  of  the  case,  and  the  position  which 
the  patient  assumes  in  bed  is  not  a  matter  of  indifference,  but,  on  the  contrary, 
should  be  made  the  subject  of  the  surgeon's  directions.  These  points  may  seem 
trivial,  but  their  neglect  may  entail  serious  consequences  to  the  patient.] 


THE    PRINCIPAL   BANDAGES,   II. 


Spiral  of  Elbow. 


Spiral  of  Arm. 


Reverse  Spiral  and  Spiral  of  Arm 
and  Elbow. 


Reverse  Spiral  with  Figure- 
of-Eight  of  Elbow. 


Demi-Gauntlet. 


Gauntlet. 


Double  Spica 
of  Hip. 


Spica  of  Hip. 


Rear. 


Front. 


Figure-of-Eight  of 
Knee. 


Revetse  Spiral  of  Foot  and  Leg. 


Reverse  Spiral,  Foot  and 
Ankle. 


PART  III. 

DISEASES  AND  INIURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  I. 

SURGICAL  DISEASES  OF  THE  SKIN. 

LUPUS.     (Tuberculosis  of  the  Skin.) 

A  very  chronic,  destructive,  and  scar-leaving  form  of  inflammation  of  skin 
and  mucous  membranes,  commencing  in  the  corium  proper.  Leaving  apart  the 
form  known  as  lupus  erythematosus,  we  may  say  that  common  lupus  begins  almost 
invariably  at  an  early  period  of  life,  often  during  childhood,  and  cases  starting 
after  the  age  of  thirty  are  very  exceptional.  Its  subjects  may  be,  at  the  time  of 
the  outbreak,  in  otherwise  good  health  ;  it  is,  however,  asserted  that  they  are  often 
the  offspring  of  phthisical  parents,  and  in  some  cases  they  may  themselves  develop 
later  tubercular  disease.  Koch  has  proved  that  the  bacillus  tuberculosis  is  spar- 
ingly present  in  nodules  of  lupus. 

The  tendency  of  a  patch  of  lupus  is  to  spread  at  its  edges  as  well  as  to  invade 
the  deeper  parts  and  the  adjoining  mucous  membranes ;  spontaneous  cicatrization 
may  occur,  but  generally  the  disease  lasts  .indefinitely  unless  treated.  The  early 
recognition  and  prompt  treatment  of  lupvis  is  most  important  in  preventing  per- 
manent disfigurement. 

The  first  stage  of  lupus  consists  in  the  formation  of  small  yellowish-brown  or 
pink  nodules,  of  softer  consistence  than  the  healthy  skin.  These  are  found  to  con- 
sist of  small-celled  infiltration  of  the  corium,  with  scattered  giant-cells  (in  which 
the  bacillus  of  tuberculosis  may  be  occasionally  detected).  The  nodules  have  a 
semi-translucent  or  "  apple-jelly  "  aspect,  the  next  stage  being  the  breaking  down 
of  the  centre  and  the  formation  of  a  pustule,  succeeded  by  superficial  ulceration  or 
desquamation.  There  is  often  an  extensive  scabbing  or  eczematous  condition  over 
a  lupus  patch,  especially  if  irritated  by  exposure  to  wind,  cold  or  wet  weather,  etc. 
Finally,  the  lupus  nodule  may  cicatrize,  the  scar  formed  being  usually  prominent, 
den.se,  and  often  of  a  pinkish  hue.  But  complete  spontaneous  subsidence  of  a 
lupus  patch  is  rare  ;  whilst  one  part  is  breaking  down  or  cicatrizing,  fresh  nodules 
are  forming  in  the  neighboring  skin,  or  perhaps  at  some  distance  from  the  original 
site,  and  in  a  single  patch  all  the  stages  of  apple-jelly-like  groAvth,  pustules,  ecze- 
matous condition,  ulceration,  and  scarring  may  often  be  observed.  If  situated  near 
a  mucous  membrane  {e.  g.,  of  the  mouth  or  nose),  lupus  tends  to  invade  it,  form- 
ing large,  soft  granulations,  but  not  often  presenting  the  typical  yellowish-pink  or 
brown  nodules  seen  on  the  skin.  The  lips,  gums,  palate,  and  even  the  pharynx 
and  aperture  of  the  larynx  may  be  invaded,  the  Septum  and  cartilages  of  the  nose 
destroyed,  or  great  deformity  (ectropion  and  destruction  of  the  lids)  produced  by 
the  disease  invading  the  conjunctiva. 

The  disseminate  patches  of  lupus  .seen  occasionally  on  various  parts  ot  the 
body  are  no  doubt  due  to  blood-infection  from  a  single  original  patch.      Lupus 

189 


I90     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 

rarely  begins  as  a  primary  growth  in  the  mucous  membranes,  but  occasionally  it 
does  so  ;  for  example,  perforating  the  septum  nasi  by  a  solitary  ulcer.  The  lym- 
phatic glands  are  not  infrequently  secondarily  enlarged,  and  may  break  down  into 
the  ordinary  strumous  glandular  abscess.  So-called  lupus  of  the  genitals  (particu- 
larly of  the  vulva  and  vagina)  is  nearly  always  due  either  to  syphilis  or  epitheli- 
oma. One  character  is  constant  to  lupus,  wherever  situated — a  very  slow  course, 
rebellious  to  treatment,  and  tending  to  relapse  again  and  again  at  intervals  of 
months  or  years.  There  is  also  a  special  liability  to  the  development  of  epitheli- 
oma in  an  old  lupus  patch,  the  cancer  being  then  of  a  most  virulent  and  destructive 
type.  In  connection  with  this  tendency  it  is  worthy  of  note  that  epithelial  down- 
growths  may  frequently  be  seen  in  sections  of  recent  lupus  patches,  and,  in  fact, 
it  is  difficult  to  tell  such  sections  from  those  of  true  epithelioma.  When  lupus 
affects  a  part  of  the  body  covered  with  thick  epithelium  {e.  g.,  the  feet),  warty 
growth  is  a  prominent  feature,  the  soft  nodules  being  entirely  absent.  What  is 
known  as  verruca  necrogenica,  a  condition  seen  on  the  hands  of  those  who  have 
to  handle  dead  bodies,  is  probably  a  form  of  lupus,  microscopical  examination 
showing  the  same  structure,  though  there  is  not  the  same  tendency  to  advance  and 
destroy  the  tissues  as  in  the  ordinary  form  of  the  disease. 

Diagnosis. — Bearing  in  mind  the  origin  at  an  early  age,  the  inveterate  ten- 


dency to  persist  and  to  spread,  the  scarring  left  by  the  disease,  and  the  usual  pres- 
ence of  the  apple-jelly-like  nodules  at  some  part  of  the  patch,  the  student  will  have 
little  difficulty  in  recognizing  most  cases  of  lupus.  The  deposit  of  lupoid  growth 
may  sometimes  be  very  small  as  compared  with  the  scab-formation  and  scaling  of 
epidermis, -and  thus  simulate  an  eczema,  but  the  latter  disease  never  leaves  scars. 
The  greatest  difficulty  arising  in  diagnosticating  certain  cases  of  tertiary  syphilis 
(whether  acquired  or  inherited)  from  lupus,  and  the  term  syphilitic  lupus  is  a 
convenient,  but  not  perhaps  accurate,  one  for  these  cases ;  the  following  points 
will  generally  lead  to  a  correct  diagnosis  :  — 

1.  The  patches  of  "  syphilitic  lupus  "  tend  to  have  a  crescentic  or  horse-shoe 
outline,  and  are  more  commonly  widely  separated  from  each  other  than  those  of 
true  lupus. 

2.  The  tubercles  or  nodules  are  of  a  browner-red  color  and  firmer  consistence 
than  those  of  lupus.      "  Apple-jelly  "  deposit  is  never  seen  in  syphilis. 

3.  Syphilitic  lupus,  when  due  to  the  acquired  disease,  commonly  starts  later 
in  life  (e.  g.,  from  thirty  to  fifty)  than  true  lupus,  though,  of  course,  there  are 
often  exceptions.  When  due  to  inherited  syphilis,  the  disease  tends  to  be  rapidly 
destructive,  and  is  often  accompanied  by  necrosis  of  the  adjoining  bones  (e.  g. , 
palate  and  nasal  bones).  In  fact,  the  latter  form  of  the  disease  is  of  the  nature 
of  phaged^ena,  and  requires  prompt  local  and  constitutional  treatment  to'  arrest 


LUPUS.  191 

its  i)rogress  (cauterization  with  acid  nitrate  of  mercury  and  the  administration  of 
iodide  of  potassium  ami  mercury).  Inlierited  syphilitic  hipus  will  eat  away  in  a 
week  or  two  as  much  tissue  as  urdinar)-  lu])us  will  take  months  or  years  in 
destroying. 

4.  The  i)resence  of  other  symptoms  of  syphilis,  the  [)olymorphism  of  the  skin- 
disease,  the  history  of  acipiired  or  inherited  taint,  will  be  of  value  in  assisting  the 
diagnosis.  For  instance,  Dr.  Hutchinson  treated  a  young  man  who  had  been 
supi)osed  to  be  affected  with  ordinary  lu[)us  of  the  mouth,  destroying  within  a  short 
time  most  of  the  soft  palate.  The  history  of  an  attack  of  interstitial  keratitis 
(from  which  there  still  remained  nebulae)  pointed  to  the  syphilitic  origin  of  the 
disease,  a  diagnosis  confirmed  by  the  rapid  destruction  of  parts  which  had  occurred 
and  the  great  improvement  which  ensued  under  specific  treatment. 

Whenever  the  diagnosis  between  syphilis  and  lupus  cannot  be  made,  a  careful 
trial  of  mercury  and  iodide  of  potassium  should  be  carried  out  for  a  few  weeks,  re- 
meml)ering,  however,  that  both  these  may  occasionally  fail  in  spite  of  the  disease 
being  syphilitic,  local  treatment  by  cauterization  and  the  use  of  iodoform  being 
then  required. 

It  may  be  here  stated  that  there  is  not  the  slightest  evidence  of  true  lupus 
depending  upon  remote  syphilitic  taint,  as  has  been  asserted  by  some  writers. 

Treatment. — Whilst  constitutional  measures — cod-liver  oil,  good  diet,  and 
all  means  likely  to  improve  the  general  health — should  not  be  neglected,  local  treat- 
ment is  always  needed  to  effect  a  cure.  This  consists  in  destroying  the  soft  lupus 
nodules  by  scraping,  cauterization,  or  the  action  of  certain  chemical  destructives. 

1.  Scraping. — This  is  best  performed  (nearly  always  under  an  anaesthetic)  with 
Volckmann's  sharp  spoons,  various  sizes  of  which  are  employed.  The  spoon  is 
used  vigorously  wherever  there  is  any  sign  of  the  lupus  nodules,  and  particularly  at 
the  margin  of  a  patch  ;  it  has  no  effect  upon  normal  skin  or  scar  tissue.  After 
scraping,  the  fine-pointed  actual  cautery  is  often  applied  to  each  excavation  made, 
or  pure  carbolic  acid  may  be  cautiously  used  with  a  small  brush.  The  sores  are 
subsequently  dressed  with  vaseline,  boracic  acid  ointment,  etc.,  and  if  all  the  lupus- 
tissue  has  been  destroyed  they  heal  fairly  rapidly  (of  course,  leaving  scars). 

2.  Destruction  by  CJicmicals. — The  use  of  pure  carbolic  acid  as  an  adjunct  to 
scraping  has  been  alluded  to  ;  it  is  supposed  that  the  pain  of  the  application  is 
diminished  by  subsequent  free  dusting  over  with  powdered  carbonate  of  soda. 
Acid  nitrate  of  mercury  may  be  applied  with  success  to  very  small  lupus  nodules, 
best  on  a  sharpened  piece  of  wood,  which  is  thrust  right  into  them.  Chromic  acid 
fused  on  a  probe  is  recommended  by  Jameson  for  the  same  purpose.  Both 
methods  cause  a  certain  amount  of  pain,  but  this  is  insignificant  compared  with 
that  produced  by  chloride  of  zinc  and  potassa  fusa,  two  caustics  formerly  recom- 
mended but  now  deservedly  abandoned.  Strong  lactic  and  salicylic  acids  have  lately 
come  into  use  ;  both  have  a  marked  preference  for  the  lowly-organized  lupus-tissue 
over  the  healthy  skin.  Salicylic  acid  is  used  in  the  form  of  a  plaster  spread  on 
muslin,  the  plaster  containing  from  20  to  50  per  cent,  of  the  acid  mixed  with 
creasote  (which  deadens  the  pain).  The  application  is  renewed  twice  a  day  until 
the  lupus  nodules  have  broken  down  and  suppurated  freely,  when  some  simple 
ointment  is  applied.  This  salicylic-creasote  plaster  was  devised  by  Unna,  and  is 
known  by  his  name  ;  in  commencing  the  treatment  the  weaker  strength  should 
always  be  used.  Whichever  method  be  adopted,  great  patience  is  requisite  in  the 
treatment,  which  usually  requires  to  be  repeated  several  times  at  intervals  before  a 
cure  can  be  effected,  and  it  must  be  admitted  that  in  some  cases  (especially  if  the 
mucous  membranes  are  much  involved)  none  can  be  hoped  for.  But  the  ten- 
dency of  lupus  to  cause  irretrievable  deformity,  as  well  as  the  danger  of  epi- 
thelioma supervening,  will  encourage  the  surgeon  to  persevere  in  one  or  other  of 
the  methods  of  treatment  recommended. 


192     DISEASES  AND  INJURIES    OF  SPECIAI   STRUCTURES. 

LUPUS    ERYTHEMATOSUS. 

This  disease,  Vjeing  much  rarer  and  less  amenable  to  surgical  treatment, 
requires  only  brief  notice  here.  Like  lupus  vulgaris,  its  pathology  consists  in  small- 
celled  deposits  in  the  corium  (though  it  is  doubtful  if  giant-cells  or  bacilli  are 
ever  found),  and  it  has  a  similar  very  chronic  course.  But  in  lupus  erythematosus 
abnormal  vascularity  of  the  patches  is  much  more  marked,  there  is  hardly  any 
destructive  tendency,  symmetry  is  constant  from  the  first,  the  disease  begins  later 
in  life  than  does  common  lupus,  and  the  local  treatment  of  the  latter  is  here  not 
suitable.  Further,  it  may  be  noticed  that  lupus  erythematosus  has  a  special  predi- 
lection for  certain  parts,  namely,  the  nose,  cheeks,  ears,  and  backs  of  the  hands ; 
and  the  sebaceous  glands  are  especially  involved  in  the  disease  as  well  as  the 
smaller  blood-vessels.  There  is  the  same  tendency  to  leave  scars  as  in  lupus  vul- 
garis, but  they  are  less  conspicuous.  Not  unfrequently  the  patches  of  lupus 
erythematosus  assume  the  bat's-wing  shape — the  body  being  represented  on  the 
nose,  the  wings  on  the  two  cheeks,  while  smaller  patches  exist  inside  each  concha 
of  the  ears.  They  present  a  reddish  or  brown  color,  a  thickened  edge,  and 
dilated  capillaries  or  small  veins,  and  dry  eczematous  spots  are  to  be  noticed  at 
various  parts  of  the  patch. 

The  disease  is  more  common  in  women  than  in  men,  and  especially  in  those 
liable  to  chronic  dyspepsia  and  flushing  of  the  face,  or  with  feeble  circulation,  or 
prone  to  chilblains.  It  seems  to  be  occasionally  started  by  an  attack  of  facial 
erysipelas. 

Treatment. — This  is  very  unsatisfactory,  the  long-continued  use  of  weak 
tar  ointment  and  lotion  or  of  the  oleate  of  mercury  ointment  being,  perhaps,  the 
best.  Pure  carbolic  acid  may  be  applied  to  the  most  prominent  parts,  or  the  fine- 
pointed  actual  cautery  if  the  vascularity  is  very  pronounced. 

BOILS  AND  CARBUNCLES. 

There  is  no  reason  for  separating  these  two  forms  of  cutaneous  and  subcu- 
taneous sloughing  abscess,  since  both  may  be  set  up  by  the  same  general  cause,  the 
only  real  difference  being  that  a  furuncular  abscess  or  boil  discharges  its  contents 
by  a  single  opening,  a  carbuncle  by  several  (which  often  later  coalesce).  And 
several  other  purulent  affections  of  the  skin  are  of  the  nature  of  boils — for 
instance,  the  common  styes  of  the  eyelids,  a  superficial  form  of  whitlow,  and  the 
large  pustules  which,  occurring  usually  in  parts  with  thick  skin,  are  known  as 
ecthyma.  There  is  reason  to  believe  that  all  these  furuncular  abscesses  are  due  to 
the  presence  of  a  micrococcus,  and  their  discharge  is  certainly  contagious  {i.  e., 
it  may  produce  similar  abscesses  in  the  neighborhood  of  the  primary  ones). 

A  variety  of  debilitating  causes  may  lead  to  an  outbreak  of  boils — deficient  or 
improper  food,  the  hydropathic  treatment,  etc. — and  they  are  not  infrequently 
met  with  during  convalescence  from  a  severe  fever  (especially  typhoid).  Training 
for  athletic  purposes,  if  the  change  of  life  is  marked  and  sudden,  often  produces 
them  ;  and  a  too  vegetarian  diet  may  have  the  same  result.  Work  in  the  dissecting 
or  post-mortem  room  occasionally  causes  their  development,  and  the  connection 
between  dial)etes  mellitus  and  carbuncle  was  long  ago  pointed  out  and,  indeed, 
overestimated.  Certain  parts  of  the  body — speaking  generally,  those  in  which 
there  is  a  dense  or  coarse  subcutaneous  layer — are  especially  liable  to  the  develop- 
ment of  boils  and  carbuncles.  The  back  of  the  neck  and  trunk  and  the  buttocks 
are  the  favorite  sites,  though  the  external  meatus  of  the  ear,  the  hands,  and  feet 
are  not  uncommonly  affected.  The  features  of  both  are  too  well  known  to  need 
description,  but  it  may  be  noted  that  throbbing  pain  is  almost  a  constant  symptom 
until  the  pus  and  broken-down  cellular  tissue  are  given  an  exit.  The  extensive 
separation  of  sodden  epithelium  over  and  around  a  carbuncle  is  also  noteworthy. 
Sometimes  boils  abort — that  is,  never  pass  beyond  the  inflammatory  stage — and 
this  is  most  likely  to  occur  if  they  are  protected  from  external  irritation  by  the 


ULCERS.  193 

use  of  thick  plaster  as  soon  as  they  are  recognized.  The  friction  of  a  collar  may 
localize  a  boil  on  the  neck,  that  of  a  hard  seat  in  rowing  may  produce  one  on 
the  buttock,  etc. 

Diagnosis. — It  is  occasionally  a  question  whether  a  superficial  abscess  with 
a  central  slouch  is  of  carbuncular  or  gummatous  nature,  but  the  rapid  course  of  a 
carbuncle  and  the  severe  pain  that  attends  it  will  usually  suffice  to  decide  the 
matter  without  going  into  the  history  as  to  previous  syphilis.  The  ulcer  left  after 
the  slough  has  come  away  is  ragged  and  somewhat  undermined  at  the  edge. 

Treatment. — If  seen  early,  aboil  should  be  protected  by  thick  plaster  (a 
small  central  hole  being  made),  and  any  friction  of  the  clothes  should  be  guarded 
against.  A  saline  aperient  should  be  given,  and  such  dietetic  or  tonic  treatment 
adopted  as  is  indicated  by  the  individual  case.  Painting  tincture  of  iodine  over 
the  inflamed  spot  and  the  injection  into  it  of  a  few  drops  of  strong  carbolic  acid 
solution  are  both  said  to  cause  resolution  in  some  cases,  but  generally  it  is  advis- 
able to  hasten  suppuration  by  warm  fomentations,  the  most  cleanly  being  an 
antiseptic  poultice  (carbolic  acid  lotion — i  in  40 — on  lint,  or  boracic  lint  applied 
moist  under  oiled  silk).  These  antiseptic  fomentations  are  much  better  than  the 
linseed  poultices,  which  have  a  decided  tendency  to  bring  out  a  crop  of  smaller 
furuncles  around  the  primary  one.  If  there  is  very  great  pain,  or  if  the  suppura- 
tive process  appears  to  be  spreading,  an  incision  should  be  made,  the  relief  which 
follows  the  outlet  of  pus  being  very  great.  The  old  free  crucial  incisions  are  pretty 
much  abandoned.  When  all  slough  has  separated,  a  very  good  dressing  is  the 
Ung.  Resinae. 

Sulphide  of  calcium  (gr.  j  daily  in  pills)  and  yeast  are  both  said  to  have  some 
mysterious  effect  in  preventing  or  checking  the  development  of  boils,  styes,  etc., 
but  the  evidence  is  not  very  satisfactory.  Lately  it  has  been  recommended  to  treat 
carbuncles,  if  seen  fairly  early,  by  making  an  incision  and  scraping  and  squeezing 
out  the  purulent  and  necrotic  centre,  subsequently  dressing  the  sore  with  iodoform 
or  carbolic  solution.  This  method,  though  painful,  appears  to  hasten  the  healing 
and  perhaps  to  prevent  the  spread  of  the  carbuncle. 

ULCERS. 

Any  sore  left  by  the  destruction  (gradual  or  sudden)  of  the  superficial  parts 
of  skin  or  mucous  membrane  is  an  ulcer,  the  process  either  starting  from  the  surface 
and  extending  to  the  deeper  parts,  or  vice  versa.  An  ulcer,  for  instance,  may 
begin  as  a  small  pustule,  or  in  the  centre  of  a  patch  of  eczema,  or  it  may  arise  in 
the  sloughing  out  of  a  gumma  or  carbuncle.  In  deciding  the  nature  of  an  ulcer 
we  have  to  consider  its  site,  shape,  depth,  the  character  of  its  edge,  the  surround- 
ing skin,  and  its  base  or  floor.  It  must  not  be  supposed,  however,  that  each  variety 
of  ulcer  has  its  own  peculiar  features,  and  that  we  can  always  tell  the  cause  by 
careful  inspection  of  the  sore  alone  (though  this  will  in  some  cases  suffice).  For 
instance,  some  tertiary  syphilitic  ulcers  may  closely  simulate  rodent  or  epithelio- 
matous  sores,  or  they  may  be  practically  indistinguishable  from  ulceration  due  to 
lupus,  or  even  that  resulting  from  a  carbuncle. 

Certain  terms  are  used  in  describing  ulcers,  independent  of  their  causation, 
of  which  the  following  are  the  chief. 

A  chronic  ulcer  (which  is  seen  so  commonly  in  the  lower  third  of  the  leg)  is 
characterized  by  its  indolent  process,  hard,  congested  edge,  and  unhealthy  base, 
/.  <?.,  unless  healing  under  treatment  no  well-formed  granulations  are  present.  Such 
an  ulcer  may  take  on,  from  neglect  and  the  irritation  of  decomposition,  the  slough- 
ing process.  The  term  phagedcenic  is  applied  if  the  ulcer  steadily  spreads,  but 
without  the  formation  of  large  sloughs,  and  this  feature  is  almost  invariably  due 
to  syphilis. 

An  eczematous  ulcer  is  one  in  which  the  main  features  of  the  disease  are  those 
of  eczema,  the  ulcer  being  comparatively  superficial,  but  usually  intensely  irritable. 
It  is  surrounded  by  pustules  and  "  weeping  "  desquamating  skin. 


194    -DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 

The  terms  congested  and  inflammatory  ulcers  will  be  readily  understood  ;  the 
name  varicose  ulcer  is  inappropriate,  since  it  is  not  the  ulcer  itself,  but  the  tissues 
around,  that  present  the  varicose  veins. 

Since  the  life  or  death  of  the  tissues  depends  chiefly  upon  a  constant  supply 
of  healthy  blood  and  its  free  circulation,  with  the  removal  of  waste  products  by 
the  lymphatics,  it  is  obvious  how  large  a  share  circulatory  defects  are  likely  to  have 
in  the  i)roduction  and  perpetuation  of  ulcers.  Impeded  arterial  supply,  as  after 
ligature  of  a  main  artery  of  a  limb,  or  in  senile  gangrene,  and  venous  obstruction 
of  all  degrees,  afford  examples.  In  old-standing  infantile  paralysis  the  circulation 
of  the  affected  limb  becomes  very  feeble,  and  most  intractable  ulcers  are  liable  to 
form.  Passive  congestion  from  prolonged  standing  is  a  very  frecjuent  exciting 
cause  of  ulcers  of  the  legs,  especially  in  and  after  middle  life. 

Vitiated  conditions  of  the  blood,  as  in  syphilis,  scurvy,  etc.,  are  also  common 
causes,  and  simple  anaemia  may  help  in  producing  ulceration.  The  loss  of  vitality 
of  the  tissues  that  comes  from  old  age  must  be  mentioned.  Paralysis  of  a  sensory 
nerve  may  be  followed  by  ulcers  in  the  affected  area,  partly,  no  doubt,  due  to  the 
action  of  irritants,  such  as  long-continued  pressure,  partly,  perhaps,  to  a  "trophic 
influence." 

The  common  forms  of  ulcer  met  with  in  practice  are  the  following  :  — 

I.    Syphilitic   Ulcers. 

Omitting  the  primary  chancres,  these  are  of  two  chief  varieties — that  due  to 
the  breaking-down  of  a  gumma,  and  the  serpiginous  tubercular  form.  No  part  of 
the  body  is  exempt,  though  certain  regions  are  especially  liable,  such  as  the  upper 
third  of  the  leg,  the  neighborhood  of  the  knee  joint,  over  the  sternum  and  the 
skull. 

In  the  case  of  the  gummatous  ulcer  there  will  be  the  history  of  a  (frequently 
painless)  lump  forming,  the  skin  over  it  becoming  congested  and  breaking  down, 
and  of  the  exit  of  a  slough  which  is  aptly  compared  to  sodden  wash-leather.  The 
sore  left  is  rounded,  with  inflamed  margin  and  sharply  cut  or  punched-out  border, 
and  the  characteristic  ashy-gray  slough  is  often  seen  in  the  cavity  of  the  ulcer. 
Not  infrequently  the  slough  has  been  greater  than  the  amount  of  skin  destroyed, 
/.  e.,  the  edge  will  be  undermined,  but  hardly  ever  to  the  same  extent  as  a  true 
scrofulous  or  tuberculous  sore.  After  healing  has  resulted  a  thin  white  supple  scar 
is  usually  formed,  around  which  may  be  a  brown  pigmented  area,  but  this  last 
feature  is  often  absent,  except  in  the  lower  limb,  and  is  there  not  peculiar  to 
syphilis. 

The  rapidity  with  which  destruction  takes  place  in  tertiary  syphilitic  ulcers  is 
very  marked,  and  serves  to  distinguish  them  from  any  other  forms,  and  equally 
definite  is  their  speedy  healing  under  appropriate  treatment,  but  if  neglected  they 
may  persist  for  long  and  become  indistinguishable  (except,  perhaps,  by  their  site) 
from  the  ordinary  chronic  inflammatory  ulcer. 

The  treatment  consists  in  the  administration  of  iodide  of  potassium  (of  which 
iodide  of  sodium  and  spirits  of  ammonia  are  useful  adjuncts)  or  of  mercury  with 
the  iodide,  and  in  the  local  use  of  iodoform  or  black-wash.  Rest  of  the  part 
affected,  tonics  given  internally,  sea-air,  and  the  avoidance  of  stimulants  may  be  all 
required  in  obstinate  cases.  In  prescribing  iodoform  as  a  dressing  it  must  be 
borne  in  mind  that  the  drug,  though  a  powerful  agent  in  promoting  healing,  is 
liable  to  irritate  the  surrounding  skin,  setting  up  severe  erythema  or  eczema. 
Using  it  as  a  weak  ointment  (5  to  10  grains  to  the  ounce)  or  as  a  powder  diluted 
with  starch,  etc.,  is  often  quite  as  effectual  and  less  likely  to  irritate  than  employ- 
ing the  undiluted  drug. 

The  serpiginous  syphilitic  ulcer  is  usually  preceded  or  accompanied  by  the 
development  of  nodules  or  "  tubercles  "  in  the  skin,  which  are  really  of  the  same 
structure  as  the  larger  gummata.  Their  most  frequent  site  is  perhaps  the  margin 
of  the  hairy  scalp  and  the  alae  of  the  nose,  upper  lip,  etc.     Their  tendency  is  to 


ULCERS.  195 

assume  the  crescentic  or  horse-shoe  outline,  and  steadily  to  advance  in  one  direc- 
tion whilst  healing  in  the  part  first  affected.  I  have  known  such  an  ulcer  to  start 
at  the  ankle  and  (conii)letely  encircling  the  limb)  travel  up  to  the  middle  of  the 
thigh  before  its  further  progress  was  stoi)i>ed  by  treatment.  It  had  never  been 
more  than  an  incli  in  width,  and  left  the  skin  behind  it  quite  supple.  The  ques- 
tion of  diagnosis  of  this  form  from  true  lupus  has  already  been  alluded  to.  In  its 
treatment  the  same  applies  as  to  gummatous  ulcers,  but  it  may  be  mentioned  that 
oleate  of  mercury  ointment  (5,  10,  or  15  per  cent.)  is  often  a  very  useful  local 
application.  In  neglected  or  inveterate  cases  it  is  sometimes  necessary  to  scrape 
the  growth,  or  to  cauterize  it  with  the  acid  nitrate  of  mercury  or  actual  cautery 
before  healing  can  be  obtained.  If  once  thoroughly  healed  it  shows  no  tendency 
to  recur,  unlike  true  lupus. 

2.  Tubercular    Ulcers. 

Apart  from  the  ulceration  due  to  lupus,  we  have  to  consider  the  strumous 
form  resulting  from  tubercular  abscesses  of  the  cutaneous  or  subcutaneous  tissues. 
Although  most  common  in  early  life,  they  may  originate  in  elderly  subjects  (senile 
struma)  and  are  in  the  latter  case  of  very  unfavorable  prognosis. 

Glandular  enlargement  and  abscesses  are  common  complications,  and  pul- 
monary phthisis  is,  of  course,  not  infrequent, 

The  appearance  of  a  tubercular  ulcer  is  very  characteristic  ;  dull,  purplish  con- 
gestion of  the  edge,  extensive  undermining  of  the  .skin,  thin,  oily  discharge,  and 
pale,  flabby  granulations  at  the  base  usually  leave  no  doubt  as  to  the  diagnosis. 
When  they  heal  a  thick  scar  is  generally  formed,  often  with  small  cutaneous 
"  tags  "  along  it. 

The  treatment  consists  in  destroying  the  Avail  of  the  ulcer  and  sinus  by  scrap- 
ing or  cauterization,  and  subsequently  dressing  the  cavity  with  iodoform.  Boracic 
fomentations,  etc.,  cod-liver  oil,  residence  at  the  seaside  or  in  the  country,  good 
food,  etc.,  are  most  important  aids  to  recovery. 

3.  Chronic  Inflammatory  Ulcer  of  the  Leg. 

The  chronic  inflammatory  ulcer  of  the  leg  is  seen  especially  amongst  the 
poorer  classes.  The  lower  third  of  the  leg  toward  the  inner  side  is  its  usual  site, 
and  it  often  starts  in  some  injury.  The  vitality  of  the  tissues  is  previously  lowered 
as  a  rule,  however,  by  prolonged  congestion  from  standing  ;  both  varicose  veins 
and  eczema  are  its  frequent  forerunners.  The  patient  often  states  that  the  ulcer 
commenced  as  a  small  pustule,  or  that  intense  irritation  at  one  spot  led  him  to 
produce  an  abrasion  by  scratching.  A  weak  heart  or  chronic  bronchitis  may  favor 
the  obstruction  to  the  return  of  blood,  the  presence  of  the  ulcer  increases  the 
congestion,  and  thus  a  vicious  circle  is  set  up. 

The  ulcer  usually  causes  much  pain  and  discomfort,  though  cases  differ  much 
in  this  respect ;  not  only  the  edge  becomes  callous,  but  the  floor  also,  and  if  it 
has  existed  long  the  immediately  subjacent  bone  undergoes  condensing  ostitis, 
to  which  may  be  partially  due  the  aching  pain  felt.  Steadily  increasing,  the  ulcer 
may  encircle  the  limb  and  spread  upward  over  a  large  area,  and  at  any  time, 
from  neglect  of  cleanliness,  etc.,  it  may  take  on  sloughing  action.  The  older 
the  patient,  as  a  rule,  the  less  does  the  chance  of  healing  become,  though  some 
very  intractable  ulcers  are  met  with  in  young  women  in  whom  no  constitutional 
cause  can  be  assigned. 

Treatment  in  very  inveterate  cases  must  be  merely  palliative,  and  a  variety 
of  applications  (such  as  the  Ung.  Zinci,  the  Ung.  Acidi  Boracici,  weak  carbolic 
lotions)  may  be  tried  in  turn  until  one  is  found  to  suit  the  individual  case.  Am- 
putation of  the  limb  is  occasionally  necessary,  but  should  rarely  be  urged,  since 
the  low  vitality  of  the  tissues  above  often  greatly  impairs  the  result,  and  the  risk 
to  life  in  all  elderly  subjects  is  not  inconsiderable. 


196     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 

A  large  number  of  these  ulcers  can,  however,  be  cured,  though,  unfortunately, 
there  is  great  likelihood  of  the  scars  breaking  down  again.  The  following  meas- 
ures will  be  found  useful : — 

a.  Rest  and  elevation  of  the  limb  are  most  important  and  should  l)e  carried 
out  as  far  as  possible. 

b.  Bandaging  the  leg  from  the  foot  to  the  knee,  either  with  the  ordinary 
linen  bandage  or  with  an  elastic  (Martin's)  bandage.  The  latter  cannot  be 
used  unless  the  ulcer  is  almost  healed,  and  by  its  keeping  in  moisture  some- 
times causes  too  great  discomfort  to  be  borne.  An  elastic  stocking  will  often  be 
of  use  in  such  cases.  Carefully  applied  strapping  above  and  below  the  ulcer  is 
also  beneficial. 

c.  To  clean  a  foul  ulcer  and  to  promote  granulation  there  are  few  dressings 
more  valuable  than  boracic  fomentations,  made  by  wetting  boracic  lint  and 
applying  one  or  two  thicknesses  of  it  under  gutta-percha  tissue.  The  dressing 
must  be  changed  once  or  twice  daily,  according  to  the  amount  of  discharge. 

d.  The  Ung.  Resinae,  Ung.  Iodoform,  Ung.  Plumbi  Subacetatis,  and  the  two 
previously  mentioned  are  of  use  according  to  the  special  indication,  that  is, 
whether  stimulating  or  soothing  applications  are  required. 

e.  Skin-grafting  and  sponge-grafting  are  valuable  if  the  granulations  have 
been  got  into  a  healthy  condition  and  the  patient  can  be  kept  in  bed  for  a  i^^^ 
weeks.  In  using  the  skin-grafts  they  should  be  cut  into  minute  pieces  and  only 
the  epithelial  layer  employed. 

/.  In  a  large  number  of  cases  tonics  do  good,  the  bowels  should  be  kept 
regularly  open,  alcoholic  excess  forbidden,  and  if  varicose  veins  are  present,  it  is 
often  helpful  to  limit  the  amount  of  fluids  taken,  so  far  as  is  judicious. 

There  is  one  drug  which  has  a  very  beneficial  action  upon  inveterate  ulcera- 
tion, especially  in  old  people,  namely,  opium,  the  administration  of  which  is  said 
also  to  check  the  progress  of  phagedsenic  or  sloughing  action. 

g.  Blistering  the  edge  of  a  callous  ulcer  was  strongly  recommended  by  Syme, 
and  is  occasionally  useful.  Some  surgeons  have  advocated  incising  both  base  and 
floor  of  such  ulcers,  with  a  view  to  start  a  fresh  granulating  process. 

4.  Traumatic  Ulcers. 

As  already  noted,  a  considerable  proportion  of  the  previous  class  of  ulcers 
originate  in  some  injury,  often  a  very  slight  one,  but  we  have  to  note  some  due 
to  severe  contusion  of  the  skin  of  healthy  individuals — really  direct  traumatic 
gangrene.  This  is  especially  likely  to  occur  in  regions  where  the  skin  lies  imme- 
diately over  a  bone — for  instance,  the  tibia  or  patella.  An  antiseptic  poultice 
followed  by  some  simple  ointment  is  the  best  treatment,  skin-grafting  being  advis- 
able if  the  ulcer  is  large.  The  limb  should  be  carefully  kept  at  rest  during  treat- 
ment if  the  ulcer  is  situated  over  a  joint. 

In  this  class  come  the  ulcers  of  artificial  production,  which  may  at  first  give 
rise  to  difficulty  in  diagnosis.  A  hysterical  or  idle  girl,  for  the  sake  of  exciting 
sympathy  or  notice,  applies  some  strong  chemical  irritant  to  the  skin,  using  great 
cleverness  sometimes  in  concealing  the  cause  of  the  ulcer  which  results,  and  in 
preventing  it  from  healing.  In  one  case  I  knew  of  a  young  lady  who  had  applied 
sulphuric  acid  to  the  front  of  the  left  elbow,  causing  a  deep  ulcer,  in  which,  for 
some  time,  the  brachial  artery  lay  exposed.  The  unusual  situation  of  these  facti- 
tious ulcers,  their  rapid  formation,  and  the  character  of  the  patient  will  usually 
excite  suspicion  as  to  their  true  origin. 

5.  Malignant  Ulcers. 

Rodeii-t  Ulcer,  Epithelioma,  Fu7igating  Sarcomata,  Scirrhous  Ulcers. — These 
need  not  be  described  here,  as  they  come  under  the  head  of  tumors.  It  may  be 
mentioned,  however,  that    epithelioma   may  supervene  in  the  course  of  any  in- 


Ny£VI. 


197 


tractable  ulcer  which  has  lasted  for  some  years,  antl  that  a  ])articiilarly  malignant 
form  is  liable  to  develop  in  old  lupus  patches,  the  patients  being  usually  past 
middle  life. 

NON-MALIGNANT  GROWTHS  OF  THE  SKIN. 

N/EVl. 

The  essential  feature  of  all  angeiomata  or  naevi  depends  upon  the  presence 
of  convoluted  vessels  closely  packed  together,  commonly  small  veins  and  capil- 
laries, but  occasionally  arteries.  One  form  consists  in  a  widespread  area  of  small 
vessels,  such  as  is  seen  on  the  face — the  "port-wine  stain;"  another  (the  true 
venous  neevus)  is  situated  more  deeply  and  composed  of  much  larger  veins. 

The  terms  cutaneous  and  subcutaneous  are  used  with  reference  to  naevi, 
though  no  sharp  line  of  distinction  can  be  drawn.  They  may  be  met  with  on 
any  part  of  the  body,  the  head  and  neck  being  their  most  frequent  site,  and  it  is 
common  to  find  more  than  one  on  the  same  subject.  If  sections  be  made  of  an 
ordinary  cutaneous  ngevus,  it  is  curious  to  notice  how  slightly  the  lumen  of  the 
vessels  shows  in  comparison  with  the  thickness  of  the  cellular  wall.  There  is  no 
doubt  that  after  birth  a  neevus  frequently  increases  in  size  ;  on  the  other  hand, 
with  advancing  years  they  may  shrivel  in  part  or  entirely  disappear.  Sometimes 
they  ulcerate — a  curious  fact  considering  their  high  vascularity.  "Port-wine" 
naivi  usually  remain  unchanged  throughout  life  if  untreated,  and  are  by  far  the 
most  resistant  to  treatment. 

A  7/iole  is  a  congenital  local  hypertrophy  of  the  skin,  pigmented,  and  with 
usually  abundant  growth  of  hair  on  it.  Moles  are  of  little  importance  if  seated 
on  a  part  of  the  body  naturally  concealed  by  the  dress,  and  even  on  the  face  are,  if 
small,  sometimes  considered  ornamental.  But  there  is  an  undoubted  tendency  for 
them  in  advanced  life  to  become  the  seat  of  melanotic  sarcoma,  and  for  this  reason 
their  excision  should  be  advised.  However,  sometimes  they  are  so  large  that  re- 
moval by  operation  would  leave  an  awkward  wound,  and  here  a  plastic  operation 
may  be  called  for.  They  can  also  be  destroyed  by  repeated  cauterization,  but  the 
process  is  not  so  satisfactory  as  excision. 

One  most  curious  growth  allied  to  a  mole  is  occasionally  seen  on  the  scalp — 
lobulated  and  softish  projections  of  the  skin  with  deep  furrows  between  them,  so 
arranged  as  strongly  to  suggest  the  brain  convolutions. 

The  treatment  of  ncevi  consists  principally  in  one  or  other  of  the  following 
measures  : — 

1.  The  application  at  several  parts  of  the  naevus  of  the  actual  cautery  (fine- 
point).  This  is  most  effective  and  leaves  but  little  scar.  It  is  well  to  proceed 
cautiously,  and  to  do  little  at  the  fir^t  operation  rather  than  too  much. 

2.  If  subcutaneous  and  venous,  the  cautery  point  may  be  thrust  in  several 
directions  through  the  nsevus,  introducing  it  through  only  one  opening  in  the 
skin. 

3.  Excision  is  suitable  for  small  naevi,  and  is  by  some  considered  better  than 
cauterization. 

4.  Electrolysis  has  of  late  been  extensively  tried,  two  needles  being  used  as 
the  poles,  and  both  pushed  into  the  growth  at  a  short  distance  from  each  other. 
They  should  be  introduced  at  several  points.  The  method  may  be  successful  in 
leaving  imperceptible  scars,  but  it  is  an  uncertain  one  and  needs  to  be  repeated 
several  times,  as  a  rule,  before  much  improvement  occurs.  It  is  especially  adapted 
for  naevi  of  the  face. 

Such  measures  as  vaccination  over  the  na^vus,  the  applitation  of  ethylate  of 
sodium,  and  subcutaneous  ligature  are  occasionally  useful,  especially  the  latter — 
but  this  has  the  drawback  of  possible  sloughing  of  the  skin. 


198     DISEASES  AND   INJURIES    OF  SPECIAI    STRUCTURES. 

Warts. — \PapiUoiiia.'\ 

[There  are  four  varieties  of  the  papillomata,  viz.  :  wart,  mucous  tubercle, 
condyloma,  urethral  caruncle]. 

Warts  are  chiefly  met  with  about  the  hands  of  young  adults  or  children,  and 
are  composed  of  hypertrophied  papillae  covered  with  epithelium.  Each  papilla 
contains  a  central  vascular  loop,  and,  especially  if  scratched  and  irritated,  is  liable 
to  bleed.  They  may  occur  in  great  numbers  on  the  hands  (especially  the  dorsum) 
and  forearms,  and  may  undergo  simultaneous  and  rapid  atrophy.  In  their  treat- 
ment it  is  important  for  the  patient  to  abstain  from  "picking"  and  irritating 
them  ;  perhaps  the  best  local  application  is  the  glacial  acetic  acid,  which,  applied 
repeatedly  with  a  small  brush  or  point  of  wood,  will  soon  cause  them  to  shrivel 
and  drop  off.  Nitric  acid  is  more  painful  in  its  action  and  less  certain  ;  nitrate 
of  silver  is  useless  as  a  rule. 

In  elderly  subjects  single  warty  growths  are  met  with, the  tongue,  lips,  and  scalp 
being  often  affected.  They  are  much  more  serious  than  those  of  early  life,  from 
their  liability  to  go  on  to  epithelioma.  This  is  especially  the  case  with  warts  of 
the  tongue  and  lips,  and  on  this  account  it  is  usually  advisable  to  excise  them. 

The  venereal  form  of  wart  {condyloma)  is  seen  about  the  vulva,  the  prepuce, 
glans  penis,  and  scrotum,  in  cases  of  gonorrhoea  or  vaginitis.  They  are  especially 
prone  to  develop  if  there  is  phimosis  and  retention  of  the  discharge,  to  the  irrita- 
tion of  which  they  are  due.  They  may  attain  a  very  large  size  and  have  very  vas- 
cular bases.  Sometimes  a  neglected  condyloma  becomes  wart-like,  but  true 
acuminate  or  pointed  warts  have  no  real  relation  with  syphilis.  In  treating  them  the 
gonorrhoea  should  be  cured,  circumcision  performed  if  there  is  phimosis,  a  drying 
powder  applied,  and  strict  cleanliness  used.  If  they  show  no  tendency  to  shrivel 
under  this  treatment  they  should  be  excised  with  scissors,  and  the  bleeding  checked 
if  necessary  with  the  actual  cautery  at  a  dull  red  heat. 

Salicylic  acid  is  a  powerful  agent  in  softening  warty  and  hard  epithelial 
growths  of  the  skin,  and  is  of  much  use  in  treating  corns  on  the  feet.  It  may  be 
applied  in  the  form  of  plaster  which  is  renewed  daily,  or  as  a  cream  made  with 
glycerine.  As  soon  as  the  softening  process  is  complete  the  part  should  be  soaked 
in  warm  water,  and  the  overgrown  epithelium  pared  off  with  a  knife.  Of  course, 
injurious  pressure  should  be  removed  so  far  as  is  practicable. 

[Clavus.  —  Corn. 

A  corn  is  a  callosity  of  the  epidermis  caused  by  pressure  with  friction  where- 
by the  skin  becomes  thickened  and  painful.  The  external  surface  of  the  corn  is 
broad,  its  substance  narrowing  as  it  projects  .inward,  becomes  conical,  and  much 
pain  is  produced.  This  conical  point  of  the  hardened  epithelial  cells  is  termed 
the  "  core  "  or  "  eye  "  of  the  corn,  and  it  acts  as  a  foreign  body  by  being  driven 
upon  the  true  skin.  ''Soft"  corns  are  sometimes  produced  between  the  toes. 
They  do  not  differ  anatomically  from  the  other  variety,  but  by  reason  of  being 
constantly  bathed  in  the  natural  moisture  of  the  part  derived  from  the  sweat  glands 
are  softened. 

The  treatment  consists  in  removing  the  pressure  and  paring  off  the  thickened 
epidermis.  Great  relief  will  usually  be  experienced  by  painting  the  corn  with  the 
following  application  :  — 

R  .    Ext.  cannabis,  indicse  fl.,     ...  grammes     I 

Acidi  salicylici, "         8 

CoUodii, q.  s.  ad.  .  "       50  M. 

The  collodion  film  thus  produced  may  be  removed  together  with  a  consider- 
able layer  of  epidermis,  without  pain,  at  the  expiration  of  thirty -six  to  forty-eight 
hours.  Another  thick  coat  should  then  be  applied  and,  after  about  the  same  time, 
again  shaved  off  as  before.] 


JDISEASES    OF   THE   NAILS. 


199 


[Horns. — Cornu  Cutancmn,  Dcnnato-keras. 

Horns  are  outgrowths  of  the  epithelial  surface  which  may  occur  on  almost 
any  portion  of  the  cutaneous  surface,  but  are  most  frequent  on  the  scalp  and  face. 
These  growths  resemble  a  clubbed  toe-nail  or  finger-nail,  and  are  sometimes 
grooved.* 

Horns  are  in  general  easily  removed,  but  are  occasionally  found  firmly 
attached  to  the  periosteum.     They  should  be  extirpated  as  soon  as  recognized.] 


DISEASES  OF  THE  NAILS. 

Like  the  hairs,  the  nails  are  liable  to  be  invaded  by  the  fungus  of  tinea  ton- 
surans and  of  favus,  both  mycelium  and  spores  being  occasionally  found  in  their 
substance.  In  association  with  eczema  of  the  hands  or  feet  the  nails  may  become 
affected,  the  inflammation  then  chiefly  involving  their  roots  and  causing  secondary 
changes  in  the  nutrition  of  the  nails  themselves.  With  severe  general  psoriasis, 
too,  there  is  sometimes  great  thickening  of  the  nail- 
substance,  which  becomes  brittle  and  opaque,  but  in  the 
slighter  cases  the  nails  usually  escape.  A  form  of  dry, 
chronic  onychitis  is  also  met  with,  in  w^hich  no  general  skin 
disease  exists.  A  very  troublesome  disease  to  treat ;  arsenic 
given  internally  being  the  most  likely  measure  to  do  good, 
combined  with  frequent  soaking  the  affected  finger-ends  in 
a  tar  lotion. 

Syphilitic  onychitis  usually  occurs  during  the  secondary 
stage  ;  the  nail-ends  become  brittle  and  irregular,  this  form 
occurring  both  in  the  acquired  and  inherited  disease. 
Sometimes  the  nail-root  is  especially  involved,  becoming 
narrowed  as  though  it  were  pinched  laterally  (see  "  Illustra- 
tions of  Clin.  Surgery,"  vol.  2,  plate  81).  Shedding  of  the 
affected  nails  may  then  occur,  new,  healthy  nails  ultimately 
taking  their  place. 

A  peculiar  and  troublesome  form  of  ulceration,  creep- 
ing round  the  nail,  and  occasionally  resulting  in  its  com- 
plete detachment,  is  met  with,  especially  in  those  who  have 
to  do  ^vi^Yi  post-ino7-tem  work,  surgical  dressings,  etc.  It  is,  as  a  rule,  decidedly 
painful,  although  it  is  not  necessary  in  most  cases  to  remove  the  nail  for  its  cure, 
yet  the  finger  should,  if  possible,  be  kept  protected  by  an  antiseptic  dressing  under 
oiled  silk.  Powdered  boracic  acid,  or  a  pow^der  containing  equal  parts  of  iodo- 
form, tannic  acid,  and  oxide  of  zinc,  will  be  found  of  service  as  a  local  applica- 
tion. 

The  exfoliation  of  a  nail  as  the  result  of  a  crush  is  too  well  known  to  need 
description,  but  it  may  be  noted  that  frequently  the  process  is  very  gradual  and 
painless,  and  in  such  cases  there   is  no  need  to  hasten  it  by  premature  avulsion. 


Fig.  36. — Chronic 
Onychia. 


[*  I  removed  a  horn  from  the  third  finger  of  a  female  child  at  the  Rush  Medical  College  Clinic, 
in  1892.  D.  J.  Hamilton  mentions  a  case  of  a  boy  where  the  whole  skin  was  covered  with  them 
from  the  crown  of  the  head  to  the  sole  of  the  foot.  Dr.  Porcher,  of  Charleston,  S.  C,  reported  a 
case  of  a  horn  seven  inches  in  length  and  two  and  three-quarter  inches  in  diameter  growing  from  the 
forehead  of  a  negress  aged  about  fifty-two.  Dr.  A.  L.  Sands,  of  Cold  Spring,  N.  Y.,  removed  a  horn 
from  the  back  of  the  head  of  a  white  woman  aged  fifty.  This  horn  was  six  and  a  quarter  inches  long 
and  three  inches  in  circumference.  It  was  of  sixteen  years'  growth.  Dr.  Pausa,  of  Naples,  in  1836, 
removed  one  six  inches  in  length  from  the  parietal  scalp.  Mr.  Dalby,  in  1847  {Lancet),  removed 
a  horn  six  inches  in  length  from  the  head  of  a  female  patient.  Dr.  Souberbiele,  in  185 1  {Am.  Jour. 
Med.  Set.),  reported  the  extirpation  of  a  horn  eight  to  nine  inches  long,  from  the  forehead  of  a 
woman  aged  eighty  two.  The  most  curious  of  reported  cases,  however,  is  that  of  Paul  Rodnques  ot 
Mexico,  {Lancet,  1825),  who  was  the  subject  of  an  enormous  horn  measuring  fourteen  inches  at  the 
base.  This  horn  had  three  branches  of  which  the  central  was  largest.  It  was  curved  and  descended 
several  inches  below  the  ear,  thence  turned  forward  on  the  cheek.] 


2  00     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 


Fig.    37  — Onychia  Maligna. 


A  new  nail   is   probably  more   likely  to   grow  if  the  exfoliation   is   left  wholly 
to  nature. 

A  slight  injury  is  sometimes  the  primary  cause  of  what  is  known  as  onychia 
maligna,  an  affection  practically  confined  to  children.     The  nail  beconv-s  loosened, 

altered  in  shape  and  much  discolor- 
ed, the  finger-end  swells  up  and  dis- 
charges a  fetid  pus  from  below  and 
around  the  nail.  So  severe  may  the 
inflammation  be  in  onychia  maligna, 
if  neglected,  that  the  terminal  pha- 
lanx is  liable  to  necrose,  and  there 
is  little  or  no  tendency  to  spontane- 
ous cure.  This  may  be  due  to  the 
fact  that  its  subjects  are  generally 
delicate  or  "strumous"  children. 
With  proper  treatment  recovery  is  usually  very  rapid.  The  diseased  nail  should 
be  removed  with  forceps,  and  a  dressing  of  iodoform,  or  of  the  liquor  arsenicalis 
(one  drachm  to  the  ounce)  applied.  If  these  measures  fail,  a  single  application 
of  the  acid  nitrate  of  mercury,  or  nitric  acid,  will  usually  sufficeto  stop  the  ulcera- 
tion. Tonics,  especially  iron,  are  generally  useful  adjuncts  to  the  local  treatment. 
Ingrotving  toe-nail  is  nearly  always  met  with  at  the  outer  side  of  the  great  toe, 
and  may  be  produced  by  the  pressure  of  tight  boots,  or  by  cutting  the  nail  too 
deeply  away  at  its  angles.  Unhealthy  granulations  form  around  and  bury  the  edge 
of  the  nail,  and  much  discomfort  is  thereby  produced.  The  treatment  in  the  early 
stage  consists  in  the  removal  of  pressure  from  the  toe  and  applying  a  few  shreds  of 
cotton-wool,  charged  with  the  astringent  powder  already  mentioned,  under  the 
edge  of  the  nail  with  a  probe.  Cleanliness  and  the  daily  repetition  of  this  process 
will  sometimes  suffice.  If  it  does  not  succeed  the  central  portion  should  be  scraped 
thin  with  a  piece  of  glass  and  some  thin  lead-foil  inserted  under  the  angle.  The 
nail  itself  should  never  be  removed  if  it  can  possibly  be  avoided  ;  when  it  grows 
again  it  is  even  more  distorted  than  it  was  before.  The  granulations,  if  very 
exuberant,  may  be  cut  away,  and  iodoform  dressing  applied  ;  but  removal  of  the 
whole  of  the  side  of  the  fleshy  part  of  the  toe,  though  strongly  recommended  by 
some,  is  unnecessarily  severe. 

[The  removal  of  the  entire  nail  with  its  matrix  is  occasionally  necessary,  and, 
although  clubbed  nail  may  result,  yet  the  great  relief  furnished  by  the  operation 
is  a  sufficient  justification  for  its  performance.  Touching  the  site  of  the  matrix 
with  the  red  hot  iron,  after  extirpation,  may  prevent  the  nail  from  being  repro- 
duced.] 


INJURIES   OF  BLOOD-VESSELS.  201 


CHAPTER  II. 

INJURIES  AND  DISEASES  OF  BLOOD-VESSELS. 

SECTION  I.— INJURIES. 

Blood-vessels  may  be  contused  or  bruised  ;  ruptured,  either  partially  or  com- 
pletely;  wounded,  or  divided.  When  the  external  coat  remains  intact,  as  in  lig- 
ature of  arteries,  and  in  some  cases  of  contusion,  and  when,  owing  to  the  way  in 
which  a  vessel  is  torn  across,  the  coats  are  twisted  together,  no  blood  is  lost.  In 
every  other  case  the  immediate  and  most  prominent  symi^tom  is  hemorrhage,  either 
externally  or  into  the  substance  of  the  tissues. 

Hemorrhage  may  be  capillary  (coming  not  so  much  from  the  capillaries  them- 
selves as  from  vessels  too  small  to  secure  individually),  venous  or  arterial. 

.    Local  Symptoms. 

Capillary  hemorrhage  is  never  serious  except  in  patients  with  the  hemor- 
rhagic diathesis.  It  is  sometimes  tolerably  abundant  from  the  walls  of  an  abscess, 
the  sudden  relief  of  pressure  causing  the  delicate  capillaries  in  the  granulation- 
tissue  to  give  way;  and  after  the  application  of  Esmarch's  bandage,  when  a  limb 
has  been  kept  anaemic  throughout  the  course  of  a  prolonged  operation,  it  may  be 
so  considerable  as  to  make  the  operator  doubt  whether  there  has  been  any  real 
advantage  to  the  j)atient ;  but  as  a  rule  it  stops  at  once  on  exposure  to  the  air, 
especially  if  the  part  is  raised  at  the  same  time,  or  with  gentle  compression.  Ice- 
cold  water  may  be  poured  over  the  exposed  surface  if  this  fails ;  or  better  still, 
water  at  the  temperature  of  130°  F.,  about  as  hot  as  can  be  borne  with  the  hand. 
Carbolic  lotion  should  not  be  used,  as  this  tends  to  make  the  clot  disintegrate  again. 
In  many  cases,  especially  after  amputations  in  which  the  bloodless  method  has  been 
adopted,  it  is  better  to  close  the  wound  and  trust  to  firm  bandaging  and  elevation 
than  to  keep  the  patient  waiting  on  the  operating  table ;  but  due  provision  must 
be  made  for  drainage,  or  there  may  be  a  considerable  degree  of  traumatic  fever. 

Venous  hemorrhage  is  recognized  by  the  dark  color  of  the  blood  and  the 
steady  character  of  its  flow.  Unless  there  is  considerable  pressure  upon  the  cardiac 
side  (as  when  a  ligature  is  tied  round  the  limb,  and  occasionally  in  hemorrhoids) 
the  stream  is  always  continuous,  never  in  jets.  Usually  it  comes  from  the  lower  or 
distal  end,  but  when  a  large  trunk  is  wounded,  or  a  varicose  vein,  in  which  the 
valves  are  incompetent,  gives  way,  the  rush  from  the  cardiac  side  may  be  so  great 
as  to  prove  fatal  within  a  very  few  minutes.  The  slightest  pressure,  applied  to  the 
right  spot,  or  merely  raising  the  part  so  that  it  is  not  dependent,  is  sufficient  to 
stop  the  flow  at  once  ;  but  many  instances  are  recorded  in  which,  for  want  of  this 
simple  precaution,  this  accident  has  proved  fatal. 

Arterial  hemorrhage  may  be  primary,  at  the  time  of  the  injury  ;  recurrent, 
within  twenty-four  hours ;  or  secondary,  from  any  time  after  this  until  the  wound 
in  the  vessel  is  healed.  The  distinction  between  the  two  last  is  of  considerable 
importance.  Recurrent  hemorrhage  is  due  to  failure  in  the  temporary  closure  of 
an  artery  ;  the  ligature  by  which  it  is  secured  has  slipped,  or  pressure  has  failed,  or 
as  the  heart  recovers  from  the  shock  and  beats  more  vigorously  the  clot  has  been 
washed  out,  and  the  contracted  condition  of  the  vessel's  wall  unfolded  again  by 
the  internal  pressure.  Secondary  hemorrhage,  on  the  other  hand,  points  to  a  failure 
in  the  measures  by  which  permanent  closure  is  effected.  The  wall  of  the  artery  is 
too  badly  nourished,  from  atheroma  or  from  suppuration  round  it,  for  the  exuda- 
14 


20  2     DISEASES  AND  INJURIES    OE  SPECIAL   STRUCTURES. 

tion  to  become  organized  ;  or  the  ligature  has  been  tied  so  tightly  that  it  cuts 
through  before  the  protecting  barrier  of  lymph  is  sufficiently  strong  to  resist ;  or 
the  presence  of  a  sequestrum  or  of  some  other  foreign  substance  has  caused  ulcera- 
tion without  repair.  The  symptoms,  too,  are  different;  the  former  is  sarely  sudden 
and  is  seldom  serious  unless  the  wound  is  loosely  covered  over  with  a  thick  layer' 
of  absorbent  material ;  then  sometimes  it  escapes  notice  until  a  very  large  amount 
has  been  lost  and  the  patient's  face  is  blanched.  The  latter,  though  it  rarely 
occurs  without  giving  a  warning  (some  slight  stain  on  the  dressings  the  day  before), 
may  be  of  the  most  serious  description,  especially  as  it  nearly  always  comes  from  the 
largest  vessels,  in  which  the  pressure  is  very  high. 

In  primary  hemorrhage  from  a  wounded  artery  the  blood  is  bright  red,  and 
comes  in  distinct  jets,  which,  even  in  vessels  smaller  than  the  radial  at  the  wrist, 
may  shoot  three  or  four  feet.  Occasionally,  however,  when  the  patient  is  anaes- 
thetized with  nitrous  oxide,  or  is  partially  asphyxiated  from  excess  of  carbonic  acid, 
the  color  is  darker,  approaching  that  of  venous  blood  ;  and  when  the  wounded 
vessel  is  concealed  at  the  bottom  of  some  deep  cavity,  the  flow  may  apparently  be 
continuous.  Recurrent  hemorrhage,  when  the  opening  is  expo.sed,  does  not  differ 
in  any  material  way ;  but  sometimes  in  secondary  bleeding  after  ligature  of  an 
artery  in  its  continuity  the  blood  wells  up  slowly  in  a  continuous  stream,  coming 
from  the  distal  end  only,  and  having  lost  its  force  in  the  collateral  vessels. 

When  the  blood,  instead  of  escaping  externally  on  the  surface  of  a  wound, 
pours  into  the  tissues  or  one  of  the  natural  cavities  of  the  body,  the  local  symptoms 
are  regulated  by  the  size  of  the  vessel,  the  pressure  of  the  stream,  and  the  readiness 
with  which  surrounding  structures  yield.  Hemorrhage  from  small  vessels  is  rarely 
important  unless  the  number  that  give  way  is  very  great,  as  in  some  of  the  dorsal 
or  lumbar  haematomata.  There  is  local  swelling,  which  usually  disappears  again 
after  a  time,  although  it  occasionally  ends  in  organization  or  suppuration.  If, 
however,  the  vessel  is  an  artery  of  any  size,  and  the  tension  is  not  checked,  the 
tissues  may  become  inflamed,  or  suppuration  may  set  in,  or  the  part  may  even 
become  gangrenous  from  the  collateral  circulation  being  cut  off. 

Hemorrhage  into  the  pleural  or  peritoneal  spaces,  internal  hemorrhage  in  the 
strict  sense  of  the  term,  often  causes  no  local  symptoms.  In  other  cases  a  certain 
degree  of  dullness  can  be  made  out  in  the  dependent  parts,  and  an  alteration  in 
the  level  of  the  fluid  in  different  positions  of  the  body,  especially  as  blood  when 
extravasated  into  serous  sacs  coagulates  slowly  ;  but  although  this,  when  it  does 
occur,  is  distinctive,  its  absence  proves  nothing. 

COXSTITUTIOXAL    SYMPTOMS. 

The  rapidity  with  which  the  blood  is  lost  is  almost  as  important  as  the  quan- 
tity. When  it  pours  out  under  high  pressure  from  some  great  artery,  the  face 
becomes  pale  and  livid  at  once;  the  lips  are  white,  the  extremities  cold,  the  pulse 
low  and  quivering,  and  the  respiration  hurried  and  shallow,  interrupted  every  now 
and  then  by  yawns  or  deep  sighs.  The  voice  is  lost,  there  are  noises  in  the  ears, 
the  eyesight  fails,  nausea  comes  on,  and  the  arms  are  tossed  vaguely  and  wildly 
about  over  the  head.  If,  on  the  other  hand,  the  loss  is  more  gradual,  the  face 
and  lips  become  peculiarly  transparent,  like  wax,  the  pulse  is  small  and  fluttering, 
the  breathing  quick  and  very  irregular  in  depth,  giddiness  and  faintness  come  on 
with  the  least  exertion,  and  if  the  loss  continues,  dropsy  makes  its  appearance, 
owing  to  the  impoverished  condition  of  the  blood.  In  such  a  state  the  slightest 
further  drain  may  prove  rapidly  fatal.  Sudden  hemorrhage  produces  a  much 
more  marked  effect  than  oozing  to  the  same  amount  continued  over  several  hours ; 
and  the  consequences  at  the  extremes  of  life  are  much  more  serious  than  in  adult 
age.  Even  when  the  immediate  effect  is  not  fatal,  recovery  is  often  incomplete, 
the  patient  never  really  regaining  strength,  but  dying,  perhaps  some  months  later, 
from  some  intercurrent  trouble. 


INJURIES   OF  BLOOD-VESSELS.  203 

Natural  Arrest  of  Hemorrhage. 

The  natural  means  by  which  hemorrhage  is  stayed  are  partly  constitutional, 
partly  local. 

1.  Constitutional. — The  force  of  the  heart-beat  diminishes  in  proportion 
to  the  amount  of  blood  that  is  lost ;  in  syncope  it  can  scarcely  be  felt.  Mean- 
while, before  the  strength  returns,  the  blood  has  time  to  coagulate,  and  with  good 
fortune  this  may  prevent  further  loss.  In  the  case  of  large  arteries,  however,  it  is 
seldom  effectual;  as  the  fainting  passes  off,  the  heart  regains  its  power,  and  the 
bleeding  begins  again.  Sometimes  temporary  cessation  and  recurrence  alternate 
more  than  once  before  death  ensues.  It  is  said  that  the  blood  which  is  lost 
toward  the  end  coagulates  more  readily  than  that  which  comes  at  the  beginning, 
and  this  may  help  a  little. 

2.  Local. — Owing  to  the  structure  of  the  internal  and  middle  coats  of  an 
artery,  the  inner  tube  contracts  as  soon  as  it  is  divided  and  shrinks  to  such  an 
extent  that  only  a  small  orifice  is  left.  This  is  due,  in  part  at  least,  to  its  muscu- 
lar fibres.  At  the  same  time,  owing  to  its  great  elasticity,  the  two  ends  retract 
and  become  separated  from  each  other  by  a  considerable  distance,  the  inner  part 
again  shrinking  very  much  more  than  the  outer.  If  the  vessel  is  put  on  the 
stretch  first,  so  as  to  bring  this  elasticity  into  full  play,  as  when,  for  instance,  a 
limb  is  torn  off,  the  orifice  may  contract  and  retract  to  such  an  extent  that  no 
blood  at  all  is  lost.  As  a  rule,  however,  a  certain  amount  pours  out,  and  this 
flowing  over  the  torn  and  irregular  surface  formed  by  the  broken  ends  of  the 
internal  and  middle  coats  and  the  interior  of  the  sheath,  coagulates  and  fills  all 
the  space  round  and  inside  the  ruptured  end  with  what  is  known  as  the  external 
clot. 

Generally,  but  by  no  means  invariably,  an  internal  clot  forms  as  well.  The 
blood  as  it  whirls  round  in  the  closed  ends  forms  a  conical-shaped  coagulum,  the 
base  of  which  rests  upon  the  ruptured  coats,  to  which  it  is  firmly  adherent,  while 
the  apex,  lying  loose  in  the  interior,  reaches  as  high  as  the  next  largest  branch. 
This,  when  it  is  present,  must  act  to  some  extent  as  a  buffer,  saving  the  outer  clot 
from  the  shock,  but  it  is  not  essential  to  permanent  repair. 

If,  when  the  heart  recovers,  this  combined  barrier  is  sufficiently  strong  to 
resist  the  impact  of  the  blood,  the  permanent  changes  begin.  The  vasa  vasorum, 
the  minute  vessels  in  the  sheath,  and  those  which  lie  in  the  tissues,  round,  dilate  ; 
more  plasma  pours  through  their  walls  ;  the  leucocytes  pour  out  more  rapidly  and 
in  larger  numbers  ;  the  torn  ends  of  the  fibres  swell  up  and  disappear  ;  and  gradu- 
ally the  external  clot  and  the  base  of  the  internal  one  are  invaded  from  all  sides 
by  the  cellular  exudation,  and  the  fibrin  and  red  blood-corpuscles  are  gradually 
replaced.  The  endothelium  of  the  vessel  itself  near  the  torn  end  disappears  as 
such  and  fuses  with  the  growing  lymph ;  probably,  except  in  the  largest  trunks, 
under  the  stimulus  of  injury  it  regains  some  of  its  lost  power  and  begins  active 
growth  again.  Possibly  some  of  the  leucocytes  in  the  still  circulating  blood, 
where  it  whirls  round  and  round  the  conical  clot,  help  as  well,  gradually  filling  up 
the  narrow  cleft  that  lies  between  it  and  the  wall.  In  any  case,  by  the  third  day 
a  button  of  firm,  newly-formed  lymph  seals  the  end  of  the  vessel,  lying  between 
the  edges  of  the  curved-in  coats,  to  which  it  is  firmly  adherent.  After  a  time  this 
lymph  becomes  vascular  ;  new  vessels  form,  some  coming  from  the  vasa  vasorum 
in  the  thickened  and  softened  coats,  others  springing  from  the  cavity  of  the  vessel 
above,  many  from  the  sheath  as  well ;  and  organization  rapidly  follows.  The 
final  change  is  the  shrinking  of  the  newly-formed  tissue,  the  gradual  obliteration 
of  many  of  its  vessels,  and  the  contraction  of  the  artery  above  the  seat  of  division 
up  to  the  origin  of  its  next  large  branch. 

When  an  artery  is  divided  in  its  continuity  the  changes  are  the  same ;  but 
repair  is  much  less  perfect  at  the  distal  than  the  proximal  end,  and  secondary 
hemorrhage  is  much  more  common  from  the  former  than  from  the  latter.  In 
some  cases,  the  two  ends  separate  completely  and  retain  no  connection  with  each 


204     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

other  ;  more  frequently  a  fibrous  band  is  left  between  them  ;  and  occasionally  a 
vessel  is  developed,  and  enlarged  by  slow  degrees  until  it  re-establishes  a  direct 
communication. 

\\'hether  hemorrhage  ceases  spontaneously  or  not  depends  partly  upon  the 
size  of  the  vessel,  partly  upon  the  character  and  direction  of  the  wound.  If  the 
artery  is  torn  in  two,  even  the  axillary  at  the  shoulder  may  close  completely  with- 
out the  loss  of  a  drop  of  blood.  In  a  case  of  clean  division,  as  with  a  knife,  the 
result  is  more  doubtful  ;  an  artery  the  size  of  the  temporal  (provided  it  is  perfectly 
healthy)  usually  causes  no  trouble  ;  the  brachial  or  the  posterior  tibial  in  the 
upper  part  of  its  course  retracts  sufficiently  for  a  time ;  but  hemorrhage  is  almost 
certain  to  commence  again  as  soon  as  the  heart  regains  its  power.  In  the  femoral 
this  almost  always  happens.  A  transverse  wound  which  does  not  completely  sever 
the  vessel  never  stops  bleeding  of  itself  unless  it  is  of  the  most  minute  dimensions  ; 
the  elasticit}'  of  the  coats  holds  the  wound  open,  and  many  of  the  worst  cases  of 
hemorrhage  are  traceable  to  the  incomplete  division  of  some  comparatively  small 
branch. 

Arteries  that  are  either  rigid  from  atheroma,  or  are  contained  in  rigid  canals, 
whether  made  of  bone,  fibrous  tissue,  or  the  dense  cicatricial  tissue  met  with  after 
old  suppurating  wounds  (such  as  septic  compound  fractures),  naturally,  if  they  are 
divided,  cannot  retract,  and  consequently  bleed  furiously. 


Treatment  of  Hemorrhage. 

The  first  thing  always  is  to  secure  the  bleeding  point  wherever  it  may  be,  and 
whether  it  is  an  artery  or  a  vein.  The  subsequent  treatment  turns  entirely  upon 
whether  this  can  be  done  or  not. 

1.  If  the  Bleeding  Point  has  been  Secured. 

When  the  loss  of  blood  is  sudden,  every  care  must  be  taken  to  keep  the  heart 
and  brain  as  well  supplied  as  possible.  Any  quick  movement,  particularly  raising 
the  head,  might  at  any  moment  bring  on  fatal  syncope.  The  patient  should  be 
laid  perfectly  flat,  without  a  pillow,  and  with  all  the  clothing  loosened  round  the 
chest ;  it  may  not  be  possible  to  remove  it.  The  limbs  should  be  raised,  and  they 
may  be  even  iightly  bandaged.  Hot  bottles  and  warmed  blankets  should  be 
packed  all  around,  and  every  attempt  made  to  maintain  the  temperature.  If  the 
heart  is  failing,  hypodermic  injections  of  brandy  or  ether  may  be  tried  ;  in  other 
cases,  very  small  quantities  of  hot  brandy  and  water,  not  more  than  half  a  tea- 
spoonful  at  a  time,  may  be  given  at  frequent  intervals  by  the  mouth.  Rectal 
injections  of  warm  water  are  sometimes  of  great  service,  absorption  taking  place 
with  very  great  rapidity,  owing  to  the  diminution  of  fluid  in  the  vessels.  Finally, 
if  none  of  these  measures  suffice  to  maintain  the  action  of  the  heart,  intravenous 
transfusion  with  human  blood  or  with  saline  solution  may  be  tried.  The  blood  of 
other  animals,  in  spite  of  the  fact  that  it  is  said  to  have  succeeded,  must  never  be 
used  ;  the  plasma  of  the  one  destro3's  the  blood-corpuscles  of  the  other,  and,  even 
if  it  does  not  cause  general  clotting,  makes  the  destruction  worse  ;  and  milk  does 
not  appear  to  possess  any  advantage.  Intra-peritoneal  transfusion  has  succeeded  in 
animals,  but  I  am  not  aware  of  its  having  been  tried  in  men. 

Where  the  loss  of  blood  is  gradual  the  same  method  may  be  adopted  ;  but 
instead  of  relying  upon  the  temporary  effect  of  stimulants  careful  dieting  is  required 
with  easily  digested  food,  and  after  a  time  very  mild  preparations  of  iron  in  small 
doses.  If  the  loss  has  been  severe,  cases  of  this  kind  require  watching  for  many 
weeks. 

2 .  If  the  Bleeding  Point  Cannot  be  Secured. 

In  the  internal  hemorrhage  this  is,  of  course,  often  impossible  ;  and  even 
when  it  is  external  it  is  a  rule,  in  primary  bleeding,  not  to  interfere  further,  if  the 


INJURIES    OF  ARTERIES. 


205 


loss  has  ceased  when  tlie  wound  is  exi)osed.  The  injured  part  may  be  covered 
with  iodoform  under  gentle  pressure,  and  must  be  watched  night  and  day  ;  ])ut  it 
should  not  be  explored. 

In  cases  of  this  kind  great  care  is  recpiired  to  prevent  collapse  on  the  one 
hand  and  avoid  reaction  on  the  other.  The  wound  in  the  vessel  is  closed  chiefly 
by  coagulum,  and  the  main  hojje  lies  in  this  not  being  washed  away  when  the 
heart  regains  its  power.  Accordingly,  stimulants  should  never  be  given  unless 
the  case  is  desperate.  Absolute  rest,  warmth,  and  small  fragments  of  ice  from 
time  to  time,  to  relieve  thirst,  are  all  that  is  possible  at  first.  Later,  if  other 
conditions  admit  of  it,  small  doses  of  opium  (combined  with  gallic  and  sul- 
phuric acids)  are  very  beneficial  ;  but  the  diet  must  be  kept  low ;  the  patient 
must  not  be  allowed  to  rai.se  a  finger  ;  and  even  talking  must  be  prohibited  until 
there  is  a  reasonable  chance  of  the  wound  in  the  vessel  having  become  sealed. 
The  actual  onset  of  secondary  hemorrhage  can  nearly  always  be  traced  to  cough- 
ing, laughing,  straining  at  stool,  or  some  other  trivial  exertion. 


INJURIES  OF  ARTERIES. 
Rupture. 

Rupture  of  an  artery  may  be  complete  or  incomplete,  and  may  occur  with  or 
without  an  external  wound.  It  is  said  to  be  com])lete  when  all  the  coats  are  divided 
at  any  one  spot,  not  necessarily  in  their  whole  circumference. 


I .   Incoviplete  Rupture. 

The  coats  of  an  artery  may  be  torn  by  a  contusion,  if  the  vessel  is  superficial, 
or  is  caught  against  the  bone  (the  common  femoral,  for  instance)  ;  or  they  may 
give  way  from  ovet-extension,  especially  at  the  knee  joint,  and  in  the  reduction  of 
old  dislocations.  In  the  operation  of  ligature,  jjartial  rupture  is  often  produced 
deliberately,  with  the  view  of  effecting  more  certain  closure. 

Owing  to  their  anatomical  structure,  the  internal  and  middle  coats  usually  give 
way  without  the  external  (Fig.  28).  If  tied  tightly  wdth  a  narrow  ligature  they  are 
cut  as  cleanly  as  if  divided  with  a  knife,  and  then  they  retract  some  little  distance, 
but  do  not  curl  in  far.  On  the  other  hand,  in  contusions,  and  when  an  artery  is 
torn  from  over-extension,  they  not  un frequently  twist  up 
together,  and  completely  close  the  lumen.  In  disease, 
when  an  artery  is  rigid  and  calcareous,  or  is  softened  and 
thinned,  partial  rupture  is  not  uncommon  ;  but  the  beha- 
vior of  the  coats  of  the  vessel  is  entirely  different,  and 
usually  the  rupture  sooner  or  later  becomes  complete. 

Partial  rupture  of  an  artery  may  end  in  its  occlusion  ; 
in  imperfect  repair  with  the  formation  of  a  traumatic  an- 
eurysm ;  or  in  complete  rupture. 

In  the  first  of  these  three  the  clot,  as  already  descrilied, 
forms  on  and  beyond  the  torn  ends  of  the  internal  and 
middle  coats,  and  gradually  becomes  replaced  by  vascular 
organizing  lymph ;  the  artery  is  obliterated,  although 
occasionally  a  small  vessel  forms  subsequently  in  the  band 
that  joins  the  ends  ;  and  the  consequences  depend  upon 
the  collateral  circulation.  If  this  is  good,  no  ill  result 
ensues  ;  if  the  walls  of  the  vessels  generally  are  rigid,  and 
the  heart's  action  w^eak,  or  if,  owing  to  extravasation, 
dilatation  of  the  neighboring  branches  is  impossible,  gan- 
grene follows. 

In  the  second,  organization  and  repair  begin,  but  the  ^'^^-,38;— Laceration  of  thej^ter- 
process  is  not  completed  ;  and  under  the  influence  of  the    jury,  with  a  Coaguium  (^5). 


2o6     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

blood-pressure  the  still  unbroken  external  coat,  the  blood-clot  that  lines  it,  and 
the  tissues  outside  it  stretch  more  and  more  until  they  form  the  wall  of  a  sac,  in 
other  words,  a  traumatic  aneurysm.  This  is  distinguished  from  the  ordinary  form 
(which  likewise  can  usually  be  traced  back  to  some  violent  strain)  by  the  fact  that 
the  wall  of  the  artery  for  the  rest  of  its  course  is  perfectly  healthy. 

In  the  third  case  the  remaining  part  of  the  wall  gives  way,  either  at  once  or 
later,  after  partial  repair  and  the  formation  of  an  aneurysmal  sac  ;  the  rupture 
becomes  complete. 

2 .    Complete  Rupture. 

When  there  is  an  external  wound  the  hemorrhage  is  usually  profuse,  and  if 
the  vessel  is  large,  continues  until  either  syncope  sets  in  or  the  result  proves  fatal. 
Sometimes,  however,  when  the  artery  has  been  violently  pulled  out,  as  when  a 
limb  is  torn  off,  the  internal  and  middle  coats  curl  up  so  tightly  that  the  blood 
does  not  escape. 

When  there  is  no  external  wound  the  blood  spreads  far  and  wide  in  the  limb, 
wherever  the  resistance  is  least,  forming  what  is  known  as  an  arterial  hcetnatovia. 
It  is  most  common  in  connection  with  fractures,  and  the  reduction  of  old  disloca- 
tions of  the  humerus.  If  the  rent  is  a  large  one,  and  the  tissues  round  the  vessel 
are  loose  and  yielding,  as  in  the  case  of  the  axillary  and  popliteal,  the  loss  of 
blood  may  be  so  profuse  as  to  cause  syncope ;  an  immense,  ill-defined  swelling 
forms  within  a  few  moments  ;  the  pain  is  extreme  :  the  limb  beyond  becomes 
swollen,  oedematous,  and  cold  :  and  the  pulse  in  the  distal  vessels  ceases  com- 
pletely. Pulsation  can  rarely  be  detected,  except  perhaps  over  a* limited  area ; 
and,  as  a  rule,  there  is'  no  bruit,  or  if  there  is.  it  is  not  conducted  along  the  vessel, 
as  in  the  case  of  an  aneurysm.  When,  on  the  other  hand,  the  opening  is  a  small 
one,  or  the  tissues  immediately  around  it  resist  and  restrain  the  outflow,  the  symp- 
toms are  much  more  vague,  and  resemble  at  first  those  of  traumatic  aneurysm  ; 
then,  perhaps  quite  suddenly  and  after  several  days,  the  barrier  gives  way,  and  the 
full  effect  is  produced  at  once. 

The  diagnosis  of  an  arterial  hcematoma  from  an  acute  and  deep  abscess  is 
sometimes  very  difficult,  as  there  may  be  a  considerable  degree  of  inflammation 
round  it.  If  a  thrill,  or  bruit,  or  pulsation  can  be  detected,  it  is  clear  at  once ; 
but  in  any  case  of  doubt,  a  puncture  with  a  grooved  needle  is  perfectly  safe. 
Occasionally  it  is  mistaken  for  a  rapidly-growing  malignant  tumor. 

Treatment. — Simple  occlusion  of  a  large  vessel  as  a  direct  result  of  injury  is 
very  rare  ;  the  small  ones  maybe  more  commonly  affected,  but  then  the  symptoms 
are  too  vague  to  be  recognized.  If  it  is  noticed  that  the  limb  is  cold  and  has  lost 
sensibility  and  power,  and  that  the  pulse  cannot  be  felt  in  the  parts  below  without 
there  being  any  swelling  or  extravasation  to  account  for  it,  the  diagnosis  is  very 
probable.  The  limb  should  be  raised,  wrapped  thoroughly  in  cotton-wool  without 
being  bandaged,  and  carefully  watched.  If  gangrene  sets  in,  it  will  probably  be 
of  the  dry  variety,  and  if  the  access  of  moisture  can  be  prevented  a  line  of  demar- 
cation will  gradually  form  without  any  constitutional  disturbance.  One  or  two 
toes  only  may  be  lost,  even  when  the  popliteal  is  blocked. 

Traumatic  aneurysm  usually  makes  its  appearance  some  time  after  the  acci- 
dent, as  a  soft,  pulsating  swelling  in  the  course  of  one  of  the  arteries.  It  can 
readily  be  emptied  by  pressure  upon  the  trunk  above,  and  fills  itself  again  in  the 
characteristic  manner.  As  the  vessel  from  which  it  springs  is  perfectly  healthy,  it 
may  be  dealt  with  in  almost  any  manner  that  is  suited  to  the  locality  and  size  of 
the  artery.  When,  for  example,  it  occurs  in  the  anterior  tibial  in  connection  with 
fracture  of  the  leg  (the  most  common  form)  it  usually  gets  well  of  itself  while  the 
fracture  is  becoming  firm. 

Afi  arterial  hcematoma  is  much  more  serious,  whether  it  occurs  at  once  or  is 
secondary  to  the  formation  of  an  aneurysm.  If  the  extravasation  has  ceased  to 
extend  and  the  circulation  in  the  limb  below  is  good,  gentle  pressure  may  be  tried, 
partly  to  support  the  vessel,  partly  to  assist  absorption.     If,  on  the  other  hand,  the 


INJURIES   OF  ARTERIES.  207 

swelling  continues  to  increase  there  is  no  alternative,  an  attempt  must  be  made  to 
find  the  seat  of  injury  and  tie  the  artery  above  and  below.  The  vessel  must  be 
compressed  on  the  cartiiac  side,  a  free  incision  made  into  the  extravasation,  all  the 
clots  turned  out,  and  the  seat  of  injury  exposed.  Then  a  ligature  must  be  placed 
round  it  above  and  below,  at  a  sufficient  distance  to  ensure  the  wall  being  healthy, 
and  if  it  is  thought  advisable  the  trunk  may  be  completely  divided  in  between. 
A  director  or  a  stout  probe  passed  through  the  opening  into  the  vessel  renders  its 
isolation  from  the  blood-stained  and  thickened  tissues  round  much  more  easy.  In 
this  way  I  secured  the  external  iliac  and  the  common  femoral  for  a  rupture  of  the 
intermediate  portion  of  the  artery,  which  only  became  complete  four  weeks  after 
the  receii)t  of  the  injury  that  caused  it.  The  presence  of  gangrene  leaves  no 
choice;  amputation,  if  practicable,  must  be  performed  without  delay. 

Wounds  of  Arteries. 

The  effects  of  complete  transverse  division  of  an  artery  in  a  wound  have  been 
already  described.  The  internal  and  middle  coats  contract  and  retract  ;  if  the 
vessel  is  a  very  large  one  death  ensues,  in  spite  of  this,  at  once.  If  not  so  large, 
syncope  occurs  ;  the  heart  beats  more  feebly,  and  an  external,  and  then  an  internal, 
coagulum  forms.  Sometimes  this  is  not  enough  ;  when  the  heart  regains  its  power, 
bleeding  recommences  and  soon  i)roves  fatal ;  in  most  instances,  fortunately,  and 
probably  in  all  when  the  artery  is  as  small  as  the  temporal  and  the  walls  are  healthy, 
the  combined  resistance  is  sufficient ;  lymph  is  poured  out,  and  organization  and 
permanent  repair  set  in. 

Incomplete  division,  on  the  other  hand,  unless  the  wound  is  a  minute  puncture, 
does  not  admit  of  repair  unaided.  A  transverse  cut  is  held  widely  open  by  the 
elasticity  of  the  wall,  and  a  longitudinal  one  gapes  with  every  pulse-beat.  Prob- 
ably most  of  the  cases  of  persistently  recurring  hemorrhage  from  small  and 
medium -sized  vessels  are  really  due  to  the  fact  that  the  wall  is  only  partially  cut 
through  ;  complete  division,  allowing  the  coats  to  retract  all  round,  is,  in  many 
cases,  an  effectual  cure 

Arterial  hemorrhage  can  only  be  mistaken  when  the  blood  wells  up  from  the 
bottom  of  some  deep  cavity ;  or  when,  some  days  after  the  complete  division  of 
an  artery,  repair  fails  at  the  distal  end.  When  this  occurs  the  flow  is  continuous 
rather  than  intermittent,  but  its  steady  persistence  and  rapidity  rarely  leave  the 
question  in  doubt  for  long. 

Treatment. — The  treatment  of  a  wounded  artery  depends  upon  the  size 
and  position  of  the  vessel,  and  upon  whether  the  bleeding  has  already  ceased  or 
is  still  going  on.  In  the  former  case  steps  must  be  taken  to  prevent  recurrence ; 
in  the  latter,  as  the  natural  method  of  arrest  is  insufficient,  provision  must  be 
made  to  assist  and  supplement  it. 

Temporary  Measures. — Hemorrhage  must  be  stopped  at  once  by  pressure 
upon  the  bleeding  point  or  upon  the  artery  above.  If  the  spot  is  the  right  one 
the  amount  of  force  that  is  required  is  exceedingly  small.  The  subclavian  can 
be  controlled  with  the  thumb  pressing  it  down  upon  the  first  rib,  the  operator 
standing  behind  and  somewhat  over  the  patient ;  the  brachial  is  even  easier, 
especially  in  the  middle  of  the  arm  where  it  lies  in  the  angle  on  the  inner  side  of 
the  biceps.  In  the  lower  limb  very  little  is  required  for  the  femoral  as  it  passes 
from  beneath  Poupart's  ligament,  and  digital  compression  can  easily  be  maintained 
for  half  an  hour  and  more,  if  the  operator  stands  well  above  the  patient  so 
that  his  arms  are  almost  straight.  In  Hunter's  canal  a  firm  grasp  can  control 
it  against  the  femur  from  the  inner  side,  but  it  cannot  be  kept  up  for  long.  The 
tibials  are  only  superficial  for  a  short  distance  above  the  ankle ;  in  the  upper 
part  of  the  leg  they  are  out  of  reach. 

Firm  flexion  at  the  knee  or  elbow  diminishes  the  force  of  the  stream  below 
very  considerably,  and  may,  if  carried  far  enough,  stop  it  altogether ;  but  it  is 
very  painful. 


2o8     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 


In  thin  people  and  in  children  the  abdominal  aorta  can  be  felt  beating  just 
above  and  a  little  to  the  left  of  the  umbilicus,  and  here  it  can  be  compressed 
with  ease.     If,  however,  there  is  much  fat,  or  the  abdomen  is  prominent,  it  is 

much  more  difificult,  and  sometimes  it 
can  hardly  be  managed  even  with  Lis- 
ter's tourniquet. 

Tourniquets  are  required  when  com- 
pression has  to  be  maintained  for  any 
length  of  time ;  the  simplest  is  Es- 
tnarc/i  s,  apiece  of  ^-inch  rubber  tubing 
twelve  or  eighteen  inches  long,  with 
a  hook  at  each  end.  No  anatomical 
knowledge  is  required.  It  is  simply 
stretched  out  and  wound  around  the 
limb  above  the  bleeding  point,  or  in 
the  case  of  the  hip  and  shoulder 
arranged  in  a  figure-of-eight  with  one 
loop  in  the  axilla  or  groin,  as  the 
case  may  be,  and  the  other  held  to 
prevent  slipping.  A  small  wooden 
block  to  fit  over  the  artery  is  very 
useful  for  the  femoral  at  Poupart's 
ligament ;  it  must  be  grooved  on  the 
upper  surface  to  receive  the  band, 
and  padded  on  the  lower,  so  that  the 
Fig.  39.-Petit's  Tourniquet.  whole  prcssure  may  fall  upon  the  right 

spot. 
There  are,  however,  several  disadvantages  in  connection  with  this.     Nerves 
have  been  paralyzed  by  it,  the  prolonged  compression  and  ansemia  leading  to 


Fig.  40.— Petit's  Tourniquet  Applied  to  the  Brachial.  Fig.  41. — The  Same  Applied  to  the  Femoral. 


physiological  interruption.       It   encourages  sloughing,   especially  if  applied   to 
check    primary   hemorrhage    before   amputation.      The  amount  of   oozing  that 


INJURIES   OF  ARTERIES. 


209 


Fig.  42. — Signoroni's  Tourniquet. 


follows  when  it  is  removed  is  so  great  that,  although  it  absolutely  prevents  loss  of 
blood  from  large  vessels  (and  so  is  of  undoubted  service  when  nothing  better  is  at 
hand),  it  is  sometimes  question- 
able whether  in  the  case  of  a 
large  wound  the  real  saving  has 
been  very  considerable  ;  and  it 
is  intensely  i^ainful.  Accidents 
of  this  kind  are  much  more 
likely  to  happen  when  the  limb 
has  been  previously  rendered 
bloodless  by  the  use  of  Esmarch's 
bandage,  but  they  have  been 
known  to  follow  the  application 
of  a  single  rubber  band.-'^ 

Other  kinds  of  tourni(|uets 
are  only  of  use  for  special  arteries. 
Petit' s  (Fig.  39)  can  be  employed 
for  most  below  the  axilla  and  the 
groin.     The  pad,   or  preferably 

a  roller  about  an  inch  and  a  half  thick,  is  placed  over  the  main  vessel,  the  band 
is  buckled  close  to  the  limb  and  the  screw  turned  quickly,  so  as  to  compress  the 
artery  as  soon  as  the  veins  and  avoid  passive  congestion.  A  bandage  around  the 
limb  is  advantageous,  as  it  prevents  the  skin  being  dragged.  SignoronV s  (Fig.  42) 
is  horse-shoe  shaped  with  a  pad  at  each  end  (one  for  pressure  upon  the  artery,  the 
other  to  give  sufficient  resistance)  and  a  screw  and  ratchet  in  the  middle,  so  that 
the  arc  can  be  opened  or  closed  at  will.  It  is  chiefly  of  use  for  the  femoral  in  the 
groin,  the  larger  pad  being  placed  well  beneath  the  tuberosity  of  the  ischium. 
Lister' s  is  made  in  the  same  way,  but  is  of  larger  size  and  intended  for  the  ab- 
dominal aorta.  It  should  be  placed  upon  the  patient's  right  side,  so  that  the  vessel 
does  not  slip  off  the  fourth  lumbar  vertebra,  and  should  only  be  screwed  up  at 
the  last  moment,  and  with  just  enough  force  to  interrupt  the  circulation. 

Davy  s  rectal  lever  is  a  smooth,  round  bar  of  wood  which  is  introduced  through 
the  anus  into  the  end  of  the  sigmoid  flexure,  so  as  to  cross  the  common  iliac  in  the 
angle  between  the  lumbar  spine  and  the  psoas.  By  raising  the  handle  the  vessel 
is  readily  compressed.  It  may  be  used  for  the  right  side  as  well  as  for  the  left, 
and  to  control  the  branches  of  the  internal  as  well  as  those  of  the  external  iliac ; 
but  great  care  has  to  be  taken  in  introducing  it,  owing  to  the  folds  that  are  always 
present  in  the  rectum.      Perforation  has  been  produced  by  it. 

In  cases  of  emergency  a  tourniquet  can  be  improvised  at  once  out  of  a  hand- 
kerchief tied  round  the  limb  and  twisted  tightly.  A  stone  should  be  placed  inside 
it  to  make  a  firm  pad  over  the  vessel. 

In  wounds  of  the  neck  and  in  some  parts  of  the  trunk  pressure  with  the  finger 
on  the  bleeding  point  is  the  only  temporary  expedient  of  any  good. 

Wherever  it  is  possible  and  the  bleeding  is  not  too  serious,  the  patient  should 
be  removed  at  once  to  a  convenient  couch  or  bed.  This  must  be  done  with  the 
greatest  care,  the  patient  not  being  allowed  to  raise  himself  or  make  the  least  effort. 
Then,  as  soon  as  a  good  light  has  been  obtained,  the  clothing  must  be  gently 
separated  or  cut  over  the  seat  of  injury,  all  blood-stained  bandages  and  wraps 
removed,  and  the  wound  thoroughly  inspected. 

If  the  bleeding  has  ceased  and  does  not  return  when  the  tourniquet  is  removed, 
the  parts  around  may  be  quietly  sponged  and  the  wound  itself  dusted  with  iodo- 
form, but  the  clot  must  on  no  account  be  detached.  Careful  watch  must  be  kept 
for  recurrent  hemorrhage  ;  a  tourniquet  may  be  placed  on  the  limb  ready  to  be 
screwed  up  at  any  instant.  It  is  quite  possible  that  when  the  heart  regains  its 
power,  slight  serous  oozing  will  begin,  and    that  very  soon  the  coagulum  will  be 

[*  Many  of  these  objections  may  be  removed  by  placing  four  or  five  layers  of  gauze  between 
the  tubing  and  the  skin,  before  tightening.] 


2IO     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 

washed  away  and  the  bleeding  recommence ;  but  until  this  happens  any  interfer- 
ence is  unjustifiable.  The  best  hope  lies  in  absolute  rest ;  if  the  clot  is  not  dis- 
turbed organization  may  set  in  and  gradually  render  the  wound  secure. 

Penna7ie?it  Measures. — If  the  bleeding  ]jersists,  it  must  be  stopped  either  by 
making  use  of  some  general  remedy,  such  as  heat,  cold,  or  pressure  ;  or  by  isolating 
and  securing  the  vessel.  Which  of  these  plans  is  to  be  adopted  depends  upon  the 
size  and  position  of  the  bleeding  point. 

Cold. — Simple  exposure  to  the  air  is  sufficient  to  stop  oozing  from  small  vessels  ; 
if  a  greater  effect  is  desired,  ice-cold  water  or  ice  itself  may  be  used.  It  acts  upon 
the  muscular  coat  and  consequently  is  of  especial  use  when  many  small  arteries 
have  been  divided. 

Heat. — Hot  water  (temp.  125°  F.  to  140°  F. ,  practically  as  hot  as  can  be 
borne  with  the  hand)  acts  better  than  cold  on  tissues  that  have  been  exposed  to 
the  air  for  some  time  (as  in  prolonged  operations)  or  rendered  bloodless  by 
Esmarch's  bandage.  The  actual  cautery  is  used  where  the  structures  are  soft  and 
spongy  and  the  oozing  persists  without  its  being  possible  to  define  any  one  spot. 
It  should  be  black  or  at  the  most  dull  red  ;  if  it  is  brighter  the  tissues  are  burnt 
away  and  stick  to  the  iron,  so  that  when  it  is  removed  the  bleeding  begins  again. 
When  applied  to  an  artery  an  eschar  is  formed,  generally  of  all  the  coats,  which 
curl  up  together,  and  an  internal  coagulum  is  deposited  almost  at  once  upon  the 
injured  tissues.  The  proce.ss  is  not  instantaneous  ;  if  the  vessel  is  of  any  size  the 
point  of  the  cautery  must  be  held  in  steady  contact  with  it  for  some  moments,  or 
the  closure  is  incomplete.  Secondary  hemorrhage  is  more  common  after  this  than 
after  torsion  or  ligature. 

Pressure  is  of  much  wider  application.  General  oozing  that  does  not  yield 
at  once  to  cold  or  heat  may  be  effectually  checked  by  bringing  the  surfaces  firmly 
together.  It  is  by  far  the  most  convenient  method  for  arteries  of  the  scalp ;  the 
occipital  or  temporal  may  be  secured  at  once  with  a  bandage ;  indeed,  care  is 
required  in  applying  a  capelline  one  not  to  interrupt  the  circulation  unnecessarily. 
In  punctured  wounds  involving  the  deep  palmar  arch  there  is  practically  no  alter- 
native, and  nearly  always,  even  when  arteries  are  secured  in  other  ways,  pressure 
is  employed  to  assist,  partly  for  the  sake  of  the  support  it  gives,  partly  because  of 
the  control  it  exercises  over  the  circulation. 

If  the  bleeding  point  is  on  one  of  the  limbs  and  the  hemorrhage  is  definitely 
arterial,  the  pressure  must  be  applied  systematically,  and  with  a  clear  idea  as  to 
what  is  required.  A  well-padded,  accurately-fitting  splint  is  essential  to  offer  a 
certain  degree  of  resistance  and  to  keep  the  part  at  rest.  The  whole  of  the  limb 
beyond,  and  for  some  distance  upon  the  cardiac  side,  must  be  carefully  packed 
with  cotton-wool  and  bandaged.  A  graduated  compress  made  of  many  layers  of 
lint,  placed  one  upon  the  other  and  cut  so  as  to  form  a  cone,  must  be  adjusted 
upon  the  exact  spot ;  the  apex  piece  may  advantageously  be  made  of  cork ;  and 
then  one  or  two  small  strips  of  strapping  must  be  carried  over  the  base  to  fix  it 
securely  in  its  proper  j)lace.  Further,  a  small  longitudinal  roll  of  lint  may  be 
adjusted  over  the  course  of  the  main  artery  above  the  wound  and  secured  in  the 
same  way.  Then,  finally,  separate  bandages  are  to  be  placed  over  each  of  the 
compres.ses,  so  that  the  pressure  upon  one  can  be  varied  or  removed  without  affect- 
ing the  other.  The  limb  should  be  raised  after  the  bandages  are  in  position,  and 
the  joint  above  flexed,  so  as  still  further  to  check  the  flow  ;  but  very  careful  watch- 
ing is  required  for  fear  of  gangrene.  If  no  trouble  of  this  kind  threatens,  and  if 
the  hemorrhage  does  not  return,  the  dressing  of  the  wound  should  be  left  undis- 
turbed as  long  as  possible  ;  and  when  it  is  detached  the  lowest  piece  of  the  com- 
press should  be  left  untouched.  When  the  tissues  have  healed  beneath,  and  the 
wound  in  the  vessel  is  sound,  it  will  come  away  of  itself;  and  if  the  part  is  well 
dusted  with  iodoform  and  kept  dry,  there  is  no  fear  of  any  extensive  suppuration 
occurring. 

The  plan  may  be  adopted  for  punctured  wounds  of  the  deep  palmar  or 
plantar  arch.     The  amount  of  pressure  is   not   so   important  as  the  exactness 


INJURIES   01  ARTERIES.  211 

of  its  application  ;  very  little  really  is  required  if  it  is  on  the  right  spot;  if  it  is 
on  the  wrong  one,  either  the  bleeding  continues  or  it  causes  sloughing. 

Pressure  is  also  needed  sometimes  for  other  arteries  which  have  been  injured 
in  parts  that  are  peculiarly  inaccessible.  The  internal  pudic,  for  example,  or  some 
abnormal  branch,  may  be  wounded  in  lateral  lithotomy  in  such  a  way  that  it  can- 
not be  secured  ;  or  one  of  the  intercostals  may  be  punctured  by  a  stab.  A  dilatable 
india-rubber  bag  may  be  used  for  these.  It  must  be  introduced  into  the  wounded 
part,  inflated  by  means  of  a  tube,  and  then  secured  with  a  clip  or  stopcock.  If  this 
fails,  digital  compression  for  twenty-four  hours  may  be  tried,  or  some  form  of  acu- 
pressure ;  but  it  must  always  be  recollected  that  often  in  these  cases  the  vessel  is 
only  punctured,  and  that  complete  division  may  bring  the  bleeding  to  an  end  at 
once. 

If  the  artery  lies  in  a  bony  canal  (the  descending  palatine,  for  exami)le,  which 
has  been  wounded  in  the  operation  for  cleft  palate)  hemorrhage  can  only  be 
stopped  by  plugging,  using  either  a  rounded  splinter  of  wood,  or,  if  the  vessel  is 
on  the  face  of  a  stump,  some  wax  or  soap. 

Elevation  causes  marked  contraction  of  the  arteries  of  a  limb,  and  is  very 
useful  as  an  adjunct,  but  of  itself  it  has  little  or  no  power,  except  over  the  bleed- 
ing from  veins  and  capillaries. 

It  is  still  an  open  question,  when  there  is  distinct  arterial  bleeding  from  some 
deep-punctured  wound,  how  far  it  is  justifiable  to  trust  to  pressure.     The  alterna- 


Fig.  43. — Different  Modes  of  Applying  Acupressure. 

tive,  enlarging  the  opening  and  trying  to  find  the  bleeding  point,  which  may  quite 
possibly  lie  on  the  other  side  of  the  limb  (the  posterior  tibial,  for  example,  has 
been  wounded  from  the  front),  is  often  an  operation  of  very  great  difficulty,  and 
sometimes,  from  the  circumstances  of  the  case,  simply  impossible.  Even  when 
there  is  every  assistance  at  hand,  the  attempt  has  often  failed,  and  certainly,  unless 
all  the  conditions  for  a  prolonged  search  are  favorable,  pressure  is  advisable,  at 
least  as  a  temporary  measure.  The  progress  of  the  case  will  generally  determine 
whether  further  steps  should  be  taken  or  not. 

Acupressure  is  of  great  use  in  certain  special  cases.  Occasionally,  for 
example,  an  artery  is  imbedded  in  such  dense  cicatricial  tissues  that  it  can  neither 
retract  and  close  nor  be  isolated  for  ligature.  I  have  on  two  occasions  secured 
the  posterior  tibial  in  this  way  when  everything  else  had  failed.  Or  it  may  lie  in 
an  aponeurosis,  so  that  it  is  practically  under  the  same  conditions ;  or  it  may  be 
so  deep  at  the  bottom  of  a  wound,  and  close  against  the  periosteum,  that  an 
extensive  incision  and  prolonged  dissection  would  be  required  to  get  near  it.  In 
such  cases  as  these  a  curved  needle  may  be  passed  beneath  the  bleeding  point  and 
a  figure-of-eight  ligature  placed  over  the  two  ends,  as  in  the  twisted  suture,  or  a 
straight  needle  may  be  passed  beneath  or  over  the  vessel  and  then  thrust  into  the 
tissues  in  a  different  direction,  so  as  to  close  it  by  its  pressure.  The  length  of 
time  it  should  be  left  depends  upon  the  size  of  the  vessel  and  the  condition  of  the 
wound  (Fig.  43). 

Eorcipressure  is  admirably  adapted  for  securing  with  rapidity  a  number  of 


212     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 


small  bleeding  vessels.  Catch  forceps  are  used  with  strong,  bluntly-serrated  ends  ; 
the  bleeding  point  (with  as  little  of  the  tissue  round  it  as  can  be  managed)  is 
seized,  the  blades  clamped  together  over  it,  and  left  for  a  few  moments  while  the 
operation  is  continued  or  others  are  being  caught.  On  removal  the  crushed  end 
forms  a  flat  band  which  does  not  open  out  again  ;  the  internal  and  middle  coats, 
which  are  broken  across  by  the  pressure,  curl  up  inside  and  a  coagulum  forms  at 
once.  It  is  as  efticient  as  torsion  for  all  small  vessels  and  much  more  rapid,  and 
in  many  operations  (such,  for  example,  as  excision  of  the  breast)  enables  the  use 
of  ligatures  to  be  dispensed  with  altogether. 

Tof'sion. — When  a  limb  is  torn  off  the  large  vessels  rarely  bleed  ;  the  inner 
coats  of  the  artery  shrink  up  inside  to  such  an  extent  that  the  end  is  completely 
closed  and  a  coagulum  forms  at  once.  Torsion  acts  on  the  same  principle.  It 
may  be  carried  out  in  different  ways,  unlimited  or  limited.     In  the  former  the 

end  of  the  artery  is  seized  with  a  pair  of  broad- 
ended  serrated  forceps,  clamped,  and  then 
twisted  around  as  far  as  its  natural  connections 
allow,  or  sometimes  twisted  off  altogether;  in 
the  latter  the  artery  is  drawn  out  in  the  same 
manner,  but  fixed  with  a  pair  of  forceps  placed 
upon  it  transversely  about  a  third  of  an  inch 
from  the  end,  and  this  projecting  part  is  twisted 
until  it  no  longer  uncoils  itself  (Fig.  44). 

There  is  no  question  as  to  the  very  great 
advantages  that  torsion  possesses.  It  is  better 
than  forcipressure,  for  while  the  end  is  crushed 
in  the  same  way  into  a  flat  riband,  the  internal 
and  middle  coats,  instead  of  being  merely 
broken  off,  are  coiled  up  and  rolled  around 
together  inside.  There  is  no  ligature  to  be 
absorbed  (although  now  that  catgut  is  chiefly 
used  this  is  not  so  material),  and  temporary 
closure  does  not  depend  upon  the  security  of  a  knot ;  in  other  words,  there  is  no 
fear  of  recurrent  hemorrhage  from  this  giving  way.  The  end  of  the  vessel,  if 
suppuration  occurs,  sloughs  off,  it  is  true,  but  so  it  does  with  a  ligature.  If,  on 
the  other  hand,  the  wound  heals  at  once,  it  rapidly  becomes  organized  into  a 
cicatrix.  For  plastic  surgery  there  is  no  doubt  as  to  its  superiority,  for  even 
catgut,  however  prepared,  is  a  foreign  body  and  diminishes  the  chance  of  primary 
union.  The  largest  vessels  can  be  secured  with  perfect  safety,  and  even  when 
they  are  diseased,  if  the  surrounding  tissues  are  caught  and  twisted  up  with  the 
end,  a  conical  cap  is  formed  which  is  sufficient  to  resist  internal  pressure  until 
(unless  nutrition  is  exceedingly  feeble)  organization  takes  place. 

Ligature. — This  is  the  only  method  of  universal  application  (although  in 
many  cases  torsion  or  forcipressure  is  preferable),  and  the  only  one  by  which  an 
artery  can  be  safely  secured  in  its  continuity. 

I.  W/ieii  the  Artery  is  Already  Divided. — If  the  vessel  is  of  any  size  the  end 
is  seized  with  a  pair  of  artery-forceps  and  drawn  out  from  its  sheath ;  if  it  is  small 
it  must  be  separated  carefully  from  the  adjacent  tissues,  and  the  ligature  tied  firmly 
around  it  in  a  reef  knot.  An  attempt  should  always  be  made  to  divide  the  internal 
and  middle  coats,  but  care  should  be  taken  not  to  cut  the  artery  through  ;  the 
amount  of  force  required  is  very  slight.  An  internal  clot  begins  to  form  almost 
immediately,  and  usually  it  reaches  up  the  vessel  as  high  as  the  next  largest 
branch.  Lymph  pours  out  from  the  vasa  vasorum  and  the  capillaries  in  the  tissues 
near ;  organization  begins,  and,  if  the  wound  heals  at  once  without  suppuration, 
the  end  of  the  vessel,  the  sheath,  and  the  tissues  around  it  are  welded  together 
into  an  inextricable  mass  of  cicatrical  tissue. 

The  fate  of  the  ligature  and  of  the  portion  of  the  vessel  it  surrounds  depends 
upon  the  material  and  the  way  in  which  the  wound  heals. 


Fig.  44. — Effects  of  Torsion  upon  an  Artery, 
showing  the  Incurvation  and  Laceration  of 
the  Inner  Coats.  From  paper  by  Bryant, 
"Med.-Chir.  Trans.,"  i86S. 


INJURIES    OF  ARTERIES.  213 

Except  in  special  cases,  ligatures  are  made  of  finely  twisted  silk,  soaked 
previously  in  a  five  i)er  cent,  solution  of  carbolic  acid,  or  of  catgut  prepared  with 
carbolic  acid  and  kept  in  carbolic  oil.  It  answers  better  if  the  catgut  is  hardened 
first,  after  Lister's  plan,  in  chromic  acid,  as  otherwise  it  is  absorbed  too  soon. 
Silk,  if  the  w^ound  heals  at  once,  is  encapsuled  in  the  cicatrix,  the  included  por- 
tion of  the  vessel  gradually  becoming  absorbed,  owing  to  the  pressure  around  it. 
Exceptionally,  after  lasting  perhai)s  many  weeks,  the  ligature  gives  rise  to  a  certain 
degree  of  irritation,  cuts  its  way  through,  and  comes  out.  Catgut,  on  the  other 
hand,  unless  it  is  very  old,  disapi)ears  completely,  the  length  of  time  it  lasts 
depending  upon  its  age,  thickness,  and  method  of  preparation.  If  it  has  been 
tied  tightly,  the  included  jjortion  disappears  too  ;  if  loo.sely,  it  may  remain 
unabsorbed,  and  then,  at  least  in  the  case  of  an  artery  ligatured  in  its  continuity, 
it  becomes  a  source  of  weakness  rather  than  otherwise.  If  suppuration  sets  in 
the  ligatures,  whether  of  silk  or  catgut,  come  away,  cutting  through  the  vessel,  and 
the  distal  end  sloughs. 

2.  Ligature  of  a  Vessel  in  its  Continuity. — When  an  artery  has  to  be  tied  in 
situ  the  conditions  are  very  different  from  when  it  presents  on  the  face  of  a  stump. 
In  the  latter  case  the  end  is  seen  and  drawn  down  from  the  sheath  into  which  it 
has  shrunk,  the  internal  and  middle  coats  are  divided,  and  the  artery  begins  to 
contract,  as  well  as  retract,  at  once.  It  has,  comparatively  speaking,  lost  a  great 
deal  of  its  importance  ;  the  femoral  artery,  for  example,  in  a  stump  contracts 
almost  immediately  to  less  than  half  its  previous  diameter  :  the  amount  of  tissue 
it  has  to  keep  supplied  with  blood  is  reduced,  and  though  what  is  left  has  more 
work  than  usual,  owing  to  the  amount  of  repair,  the  blood-pressure  falls  propor- 
tionately. An  artery  tied  in  its  continuity  is  under  totally  different  conditions  ; 
two  ends  have  to  be  closed  instead  of  one,  retraction  cannot  take  place  in  the 
same  way,  and  the  pressure  is  not  in  the  least  diminished  :  there  is  as  much  tissue 
to  be  supplied  after  the  operation  as  there  was  before. 

The  operation  consists  in  exposing  the  artery  at  the  selected  spot  (anatomical 
details  chiefly  determining  where  this  may  be),  opening  the  sheath  of  the  vessel, 
passing  the  needle  around  it  with  as  little  disturbance  as  possible,  withdrawing  it 
threaded,  and  then  tying  the  ligature  without  lifting  the  artery  out  of  its  bed. 

Repair  is  very  much  slower  at  the  distal  end  than  at  the  proximal ;  the  inter- 
nal clot  is  always  smaller,  and  is  often  absent ;  retraction  is  much  less  complete, 
and  secondary  hemorrhage,  when  it  occurs,  nearly  always  comes  from  this,  ^^'hy 
it  should  is  not  so  clear ;  the  vasa  vasorum  are  interrupted,  but  this  alone  will 
hardly  account  for  it,  and  the  arterial  pressure  on  that  side  must  be  much  lower 
than  on  the  other. 

Many  attempts  have  been  made  to  diminish  this  liability.  Compression  with 
a  ligature  has  been  tried,  the  internal  and  middle  coats  being  carefully  preserved 
from  injury  ;  and  there  is  no  doubt  it  succeeds  in  animals.  A  ligature  that  will 
last  for  some  time  without  causing  irritation  is  tied  around  the  vessel,  just  tightly 
enough  to  close  the  cavity  without  dividing  the  coats  ;  a  coagulum  forms  inside, 
organization  follows,  and,  before  the  ligature  has  lost  its  holding  power,  the  lumen 
is  completely  sealed.  Silk  may  be  used  for  this  purpose,  but,  as  it  is  always  liable 
to  cause  a  certain  degree  of  irritation,  a  thick,  round  cord  of  specially  prepared 
catgut  is  preferred.  Barwell  has  made  use  of  a  flat  band,  cut  from  the  aorta  of  an 
ox,  with  the  same  idea.  Probably  kangaroo-tail  tendon  is  better  still,  as  it  pos- 
sesses great  power  of  endurance,  and  can  be  secured  more  easily.  In  some  cases 
a  knot  has  been  dispensed  with,  and  the  ligature  fastened  somewhat  after  the  man- 
ner of  a  clove  hitch  ;  for  there  can  be  no  doubt  that  when  ulceration  of  the  vessel- 
wall  does  occur,  it  usually  gives  way  opposite  the  projection  it  forms.  But  these 
results,  however  good  they  have  been,  have  not  yet  convinced  surgeons  that 
(except  perhaps  in  the  case  of  the  innominate  and  common  iliac)  compression  is 
safer  than  division.  Too  great  force,  it  is  admitted,  should  not  be  used  ;  but  a 
tight  ligature  is  certainly  safer. 

There  is  more  to  be  said  in  favor  of  a  double  ligature  with  division  of  the 


214     DISEASES  AND   INJURIES    OE  SPECIAL   STRUCTURES. 

trunk  between.  If  this  is  done,  the  ends  retract  at  once  (in  the  case  of  the 
femoral  upward  of  half  an  inch)  owing  to  the  elasticity  of  the  vessel ;  and  the 
condition  is  assimilated  much  more  closely  to  that  of  ligature  upon  the  face  of  a 
stump.  Prepared  silk,  catgut,  or  kangaroo  tendon  may  be  used,  and  the  ligature 
should  always  be  tight.  If  there  is  no  suppuration,  the  ends  of  the  vessel  and  the 
portion  of  tissue  included  in  the  ligature  are  invaded  by  lymph  and  replaced  by 
cicatricial  tissue.  The  permanent  clo.sure  takes  place  by  the  organization  of 
the  little  button  of  exudation  that  is  formed  in  the  base  of  the  internal  clot, 
between  the  retracted  edges  of  the  inner  and  middle  coats,  and  in  the  short 
contracted  space  between  this  and  the  ligature.  If  suppuration  does  occur, 
and  the  ligature  cuts  through,  the  more  perfect  retraction  undoubtedly  diminishes 
the  danger. 

Styptics  are  substances  which  either  cause  intense  contraction  of  the  vessels 
or  hasten  the  coagulation  of  the  blood.  Perchloride  of  iron,  turpentine,  alum, 
subsulphate  of  iron,  and  matico  leaf  are  chiefly  recommended  ;  but,  wherever  it  is 
possible,  other  remedies  should  be  tried  again  and  again  instead.  They  altogether 
prevent  union  by  the  first  intention,  and  cause  a  very  great  deal  of  inflammation. 
However,  in  some  cases  in  which  there  is  persistent  rapid  oozing,  which  nothing 
seems  to  check,  they  do  succeed.  The  surface  of  the  Avound  must  be  rendered 
absolutely  dry  before  any  one  of  them  is  applied. 

Choice  of  Method,  i.  IVlieii  the  Artery  is  Exposed  on  a  Stump. — Small 
vessels  contract  under  the  influence  of  heat,  cold,  or  exposure,  and  if  pressure  is 
applied  afterward  give  no  further  trouble.  Forcipressure  is  useful  for  larger  ones  ; 
torsion  or  ligature  for  the  largest.  Styptics,  acupressure,  plugging,  and  other 
remedies  are  only  employed  under  special  conditions.  Pressure  and  elevation 
should  never  be  neglected.  If  the  end  of  the  vessel  can  be  seen,  it  is  safer  to 
secure  it  with  a  ligature,  even  if  it  does  not  bleed  at  the  time. 

Whether  torsion  or  ligature  is  the  better  when  the  walls  of  the  vessel  are  dis- 
eased is  an  open  question.  If  torsion  is  used,  sufficient  of  the  tissues  round  must 
be  included  to  form  a  cap  over  the  end.  If  ligature,  a  broad  and  rather  stout 
strand  of  catgut  should  be  chosen,  and  some  of  the  tissues  round  should  be  included 
so  as  only  to  compress  the  vessel ;  a  tight  ligature  would  cut  it  in  two  at  once.  The 
great  hope  in  these  cases  lies  in  early  union  ;  the  ligature  or  the  twisted  end  of  the 
vessel  can  be  relied  upon  for  a  week  or  ten  days.  If  union  round  the  artery  is  fairly 
sound  at  the  end  of  that  time,  it  is  probably  sound  inside  as  well,  and  the  organ- 
ized coagulum  will  hold  ;  if  suppuration  takes  place,  or  if  nutrition  is  so  feeble 
that  organization  fails,  the  end  of  the  artery  perishes,  and  secondary  hemorrhage 
is  only  too  probable. 

2.  When  an  Artery  is  Injured  in  its  Continuity. — If  it  is  exposed  at  the  bottom 
of  a  wound,  bruised  but  not  divided,  two  ligatures  should  be  placed  upon  it,  one 
above,  the  other  below,  and  the  trunk  severed  between.  When  it  is  wounded,  this 
rule  is  imperative,  for  if  one  end  only  is  tied,  the  other  bleeds  profusely  as  soon  as 
the  collateral  circulation  is  established,  and  though  the  stream  may  not  be  so  forci- 
ble it  is  equally  persistent. 

If  it  is  not  exposed  and  the  hemorrhage  is  severe,  a  tourniquet  must  be  placed 
upon  the  trunk  higher  up,  and  the  wound  enlarged  by  careful  dissection  until  the 
bleeding  point  is  found.  If  this  is  not  done,  it  is  impossible  to  be  certain  whence 
the  hemorrhage  comes.  Tying  the  trunk  of  the  vessel  higher  up,  even  supposing 
it  were  certain  to  be  the  right  one,  does  not  succeed  ;  either  the  collateral  circula- 
tion is  good,  and  then  secondary  hemorrhage  occurs  from  the  distal  end  ;  or  it  is 
bad,  and  gangrene  results. 

[The  "  Golden  Rule  "  of  Guthrie  :  "  Tie  both  etids  of  the  bleeding  vessel  in 
the  wound,  enlarging  the  Tvound  if  tiecessary."'] 

To  these  rules,  however,  there  are  a  few  exceptions  : 

I.  Punctured  wounds  of  the  tonsil,  or  behind  the  angle  of  the  jaw  with  severe 
arterial  hemorrhage.  Exposure  of  the  bleeding  point  by  dissection  is  out  of  the 
question  ;  the  common  carotid  must  be  tied  in  the  hope  of  checking  the  hemor- 


INJURIES    OF  ARTERIES.  215 

rhage.      It   has    been    reconiniended   to  tie  the  external  too,  just  above  the  bifur- 
cation, with  the  view  of  cutting  off  a  large  amount  of  the  collateral  supply. 

2.  Punctured  wounds  of  the  deep  })alniar  and  the  plantar  arches  must  be 
treated  by  pressure,  as  already  described. 

3.  If  the  vertebral  is  injured,  it  is  generally  better  to  trust  to  packing  from  the 
bottom  with  iodoform  gauze  than  to  attempt  ligature.  The  diagnosis,  however, 
at  the  root  of  the  neck  is  impossible  without  some  exploration  ;  and  it  may  occa- 
sionally happen  that  the  artery  can  be  secured  there. 

4.  Very  deep  punctured  wounds,  in  which  it  cannot  be  determined  what  has 
been  injured  or  where  it  has  been  injured,  are  probably  better  treated  l)y  jjressure, 
at  any  rate  for  a  time,  especially  if  the  light  is  not  perfect  and  thorough  assistance 
is  not  at  hand.  There  is  no  telling,  in  such  cases,  if  the  operation  is  once  begun, 
where  it  is  likely  to  stop. 

5.  In  cases  in  which  one  of  the  limbs  has  been  disorganized  from  cellulitis, 
or  a  sequestrum  has  ulcerated  into  a  vessel,  amputation  may  have  to  be  performed. 
These,  however,  are  to  be  judged  upon  their  own  merits  ;  it  is  not  merely  the  loss 
of  blood  or  the  risk  of  secondary  hemorrhage,  but  the  fact  that  the  limb,  if  it 
were  saved,  would  be  useless  afterward,  that  determines  the  operation. 

When  an  artery  has  been  ligatured  in  its  continuity,  the  greatest  care  must  be 
taken  to  avoid  gangrene.  The  limb  should  be  wrapped  in  cotton-wool  from  one 
end  to  the  other  ;  surrounded  with  hot  water  bottles  (not  too  close)  ;  and  slightly 
raised  so  as  to  assist  the  circulation  as  far  as  possible.  Bed  sores  form  in  these 
cases  with  unusual  rapidity,  and  healing  is  very  protracted.  Afterward,  the  wast- 
ing of  the  tissues,  and  particularly  of  the  muscles,  is  often  very  considerable,  and 
if  the  artery  was  an  important  one,  and  the  patient  past  middle  life,  the  size  and 
strength  of  the  part  never  thoroughly  return,  and  it  remains  cold  and  liable  to 
chilblains  and  chronic  ulceration  for  the  rest  of  life. 

If  the  collateral  circulation  fails  from  atheroma  of  the  arteries,  weakness  of 
the  heart,  external  pressure,  or  a  great  transverse  wound  dividing  many  branches, 
gangrene  ensues.  If  it  is  of  the  moist  variety,  amputation  must  be  performed  ; 
fortunately,  however,  it  is  usually  dry,  and  then  the  patient  may  escape  with  the 
loss  of  one  or  two  fingers  or  toes,  as  the  case  may  be. 


Defective  Repair. 

Repair  may  prove  defective  at  different  periods  and  under  different  conditions  ; 
in  every  case  it  leads  to  hemorrhage,  which  may  be  external  (recurrent  and 
secondary)  ;  or  internal  (arterial  hematoma,  traumatic  aneurysm,  arterio-venous 
aneurysm,  and  aneurysmal  varix). 

I.   Recurrent  Hemorrhage. 

This  usually  occurs  within  the  first  few  hours,  rarely  or  never  after  four  and 
twenty,  and  it  is  always  traceable  to  failure  in  some  of  the  measures  upon  which 
temporary  arrest  depends.  A  ligature  may  have  slipped  ;  some  artery  may  have 
been  overlooked  from  its  not  bleeding  at  the  time  ;  a  clot  may  have  been  displaced 
by  some  accidental  movement ;  or  an  artery  may  have  been  injured  without  being 
opened.  In  any  case,  when  the  heart  regains  its  power  the  hemorrhage  returns, 
at  first  quietly  and  then  seriously,  especially  if  the  wound  is  covered  up  with  a 
thick  layer  of  loose  absorbent  dressings. 

The  treatment  depends  upon  the  amount.  If  there  is  merely  slight  oozing, 
an  attempt  may  be  made  to  check  it  by  pressure,  cold,  and  elevation.  If  this 
fails,  or  if  the  amount  is  serious,  distending,  for  example,  the  flaps  of  an  amputa- 
tion, the  patient  must  be  placed  under  an  anaesthetic,  the  wound  laid  open,  and 
the  bleeding  point  secured  as  in  primary  hemorrhage,  following  the  same  rules. 


2i6     DISEASES  AND  INJURIES    OE  SPECIAL   STRUCTURES. 

2.   Secondary  Heviorrhage. 

This  is  due  to  failure  in  the  measures  by  which  permanent  arrest  is  effected. 
Either  the  amount  of  lymph  poured  out  is  insufficient,  or  it  does  not  become 
vascularized  and  organized  in  time ;  or,  owing  to  the  presence  of  some  additional 
irritant,  inflammation  sets  in,  impairing  the  nutrition,  not  only  of  the  newly 
formed  lymph,  but  of  the  vessel-wall  as  well.  Whatever  it  is,  whether  the  artery 
is  on  the  face  of  a  stump  or  has  been  tried  in  its  continuity,  a  slight  amount  of 
blood-stained  discharge  is  noticed  one  day,  usually  about  the  time  the  ligature 
takes  to  cut  through  the  vessel ;  the  next  there  is  a  little  more  ;  and  then  suddenly, 
from  some  accidental  exertion,  coughing  or  straining  at  stool,  there  is  a  furious 
outburst.      Fortunately  there  is  nearly  always  a  warning. 

Causes. — Secondary  hemorrhage  is  due  to  the  same  causes  that  delay  heal- 
ing of  wounds  in  other  structures. 

{a)  Constitutional. — Pyaemia,  septicaemia,  renal  disease,  and  other  conditions 
that  interfere  with  all  reparative  processes,  strongly  predispose  to  it. 

{b)  Local — Malnutrition  of  the  wall  of  the  vessel,  whether  arising  from  athe- 
roma or  because  it  has  been  separated  from  its  sheath.  Clearly,  if  the  wall  of  an 
artery  is  already  badly  nourished,  it  is  not  likely  to  repair  the  results  of  an  injury 
readily. 

The  addition  of  some  other  ii'ritant  is  the  most  common  cause  of  all.  The 
ligature  itself  is  one,  although  it  may  be  very  slight ;  but  with  this  already  present 
only  a  little  more  is  required,  and  that  little  is  easily  supplied.  Want  of  rest  is  a 
common  cause,  straining,  rough  transport,  or  rough  handling,  for  example  ;  the 
neighborhood  of  a  large  collateral  branch  with  its  constant  pulsation  is  another  ; 
but  by  far  the  most  important  is  the  presence  of  suppuration.  If  this  occurs  in  a 
wound  it  always  attacks  the  weakest  tissues,  those  already  injured  by  a  ligature ; 
the  wall  of  the  artery  becomes  soft  and  yields,  and  organization  in  the  inner 
clot  fails.  For  this  reason,  secondary  hemorrhage  is  much  more  common  in 
wounds  that  are  complicated  by  suppuration  than  in  those  that  are  repaired 
without. 

Premature  yielding  of  the  ligature  is  very  serious.  In  animals  no  ligature  is 
required  ;  it  is  sufficient  if  the  inner  and  middle  coats  are  divided  so  that  they 
can  curl  up ,  or  if  a  ligature  is  used,  it  simply  need  be  placed  round  the  vessel  so 
as  to  compress  it ;  but  in  man  this  cannot  be  relied  upon.  If  the  ligature  yields 
too  soon,  whether  it  is  prematurely  absorbed  or  the  knot  gives  way,  the  outer 
wall  loses  its  support  before  the  internal  organization  is  complete,  and  then  there 
is  always  danger  of  the  protecting  barrier  failing  and  secondary  hemorrhage 
taking  place. 

Treatment. — This  depends  upon  whether  the  artery  is  on  the  face  of  a 
stump  or  has  been  ligatured  in  its  continuity. 

{a)  On  a  Stump. — Pressure  and  elevation  should  be  tried  first,  but  if  it  con- 
tinues the  bleeding  point  must  be  sought  and  found,  even  if  it  is  necessary  to  open 
up  the  flaps  again  and  break  down  all,  or  nearly  all,  the  union.  The  only  excep- 
tion is  when  the  stump  is  almost  healed,  and  it  is  tolerably  clear,  from  the  effects 
of  pressure,  that  it  is  either  the  main  vessel  itself  or  an  immediate  branch.  In 
these  circumstances  the  brachial  may  be  ligatured  for  an  amputation  immediately 
below  the  elbow,  the  subclavian  when  the  limb  has  been  removed  at  the  shoulder- 
joint,  and  the  common  femoral  if  at  the  hip. 

If  the  stump  is  sloughing  (as  it  often  is  in  these  cases)  the  artery  must  be  dis- 
sected up  some  little  distance  and  tied  well  above  the  infected  part.  The  actual 
cautery  answers  for  the  time,  but  if  the  vessel  is  of  any  size  it  cannot  be  relied 
upon. 

ib)  When  an  Artery  has  been  Ligatured  in  its  Continuity. — Rest,  cold,  and 
pressure  should  also  be  tried  here  first,  but  if  the  warning  is  repeated,  or  if  the 
loss  is  at  all  considerable,  it  is  better  not  to  delay  further.  It  is  true  that  some 
cases  have  lived  through  repeated  hemorrhages  and  have  recovered,  but  many  more 


INJURIES   OF  ARTERIES. 


:i7 


have  dieil  ;  and  there  can  he  no  (juestion,  so  far  as  the  lower  hnib  at  least  is  con- 
cerned, that  the  wound  should  be  opened  up  (a  tourniquet  being  i)laced  on  the 
vessel  above),  the  two  ends  deliberately  dissected  clear  and  ligatured.  In  the 
upper  limb,  the  artery  (especially  the  brachial)  has  been  tied  nearer  the  trunk 
with  occasional  success,  but  the  anatomical  conditions  here  are  very  different.  If 
this  treatment  fails,  amputation  must  be  performed. 


3.   Arterial  Hicmatoina. 

This  condition  is  exactly  ecjuivalent  to  that  of  any  artery  ruptured  subcuta- 
neously,  and  must  be  treated  in  the  same  way.  There  is  no  sac,  simply  a  wide- 
spread extravasation  with,  if  the  vessel  is  a  large  one,  interruption  of  the  circula- 
tion and  threatening  gangrene  beyond.  If  it  is  the  axillary,  an  attempt  may  be 
made  to  turn  the  clot  out  through  a  free  incision  and  tie  both  ends.  If  the 
femoral  or  the  popliteal,  and  the  patient  is  young  and  the  rest  of  the  arteries 
healthy,  the  same  may  be  done ;  but  if  the  conditions  are  not  perfectly  favorable 
in  other  respects,  aminitation  is  the  only  hope. 


4.    Traumatic  Aneurysm. 

Sometimes,  when  repair  is  incomplete,  a  traumatic  aneurysm  forms  in 
way  as  after  partial  rupture.  Either  the  cicatrix  or  the  injured  coats  are 
ciently  strong  to  resist  internal  pressure, 
or  they  are  not  supported  well  enough 
from  outside,  and  they  gradually  yield 
and  stretch.  It  is  only  so  long  as  the 
aneurysm  is  very  small  that  the  relation 
they  bear  to  it  can  be  traced  ;  as  soon  as 
it  forms  a  perceptible  enlargement  the 
tissues  that  surround  it,  consolidated  by 
the  pressure  and  thickened  by  slight 
inflammation,  constitute  the  outer  part 
of  the  wall,  while  the  inner  surface,  as  in 
aneurysms  that  result  from  disease  alone, 
is  lined  with  laminated  fibrin.  The 
course,  terminations,  and  signs  of  a  trau- 
matic aneurysm  are  identical  with  those 
of  the  ordinary  variety  ;  the  difference 
consists  in  the  condition  of  the  rest  of 
the  wall  of  the  vessel.  As  it  is  perfectly 
healthy  quite  up  to  the  sac  itself,  ligature 
may  be  practiced  in  any  part,  near  it  or 
far  from  it,  above  or  belo\v,  that  offers 
the  best  prospect  of  cure.  Many  of 
these,  however,  recover  without  opera- 
tion, under  pressure  or  flexion. 


the  same 
not  suffi- 


FiGS.  45  and  46 — Aneurysmal  Varix, 


5.   Arterio-venous  Aneurysm. 

This  and  the  remaining  form,  aneurysmal  varix,  are  met  with  under  the  same 
condition,  when  an  artery  and  a  vein  have  been  wounded  at  the  same  time  and 
place  and  repair  has  not  been  perfected. 

In  aneurysmal  varix  there  is  no  sac,  merely  the  direct  communication  of  an 

artery  with    a  vein ;    the   artery  is    somewhat    dilated    above,  much    contracted 

below,  while   the  vein    is  enlarged,  thickened,    tortuous    in   all   directions,   and 

pulsates  strongly.     The  limb  below  is  usually  wasted,   but  it   may  be  enlarged 

IS 


2iS    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


and  in  a  state  of  solid  oedema.     There  is  a  peculiar   jnirring  or  buzzing  sound  to 
be  heard  over  it,  propagated  along  the  veins  toward  the  trunk  (Figs.  45  and  46). 

Arterio-venous  aneurysm,  on 
the  other  hand,  has  a  sac,  de- 
veloped chiefly  from  the  tissues 
that  form  the  channel  of  com- 
munication between  the  two  ves- 
sels ;  and  the  aneurysmal  symp- 
toms are  more  marked,  the  venous 
ones  less  distinct  (Figs.  47  and 
48). 

The  most  common  situation 
is  at  the  bend  of  the  elbow,  owing 
to  accidents  during  bleeding,  but 
they  may  occur  elsewhere,  espe- 
cially from  sword-thrusts.  Aneu- 
rysmal varix  should  not  be  inter- 
fered with ;  an  elastic  support 
may  be  worn  to  keep  it  in  check, 
but  nothing  further.  Arterio-ve- 
nous aneurysm,  on  the  other 
hand,  should  be  treated  as  an 
aneurysm,  first  by  pressure  upon 
the  artery  above  and  upon  the  vein,  and  then,  if  this  fails,  by  ligature. 


Fig.  47. — Mr.  Cock's  Case  of 
Arterio-venous  Aneurysm. 


Fig.  48. — Aneurysm  Laid  Open. . 
The  Laminated  Clot  in  the  Sac. 


INJURIES    OF   VEINS. 

\'eins,  like  arteries,  may  be  bruised,  torn,  or  wounded  ;  but  except  under 
special  conditions,  serious  bleeding  rarely  follows. 

Contusions. — Thrombosis  of  a  vein  occasionally  follows  bruises,  strains  [and 
fractures],  without  any  extravasation  having  been  noticed.  Probably  the  internal 
coat  has  been  injured  ;  coagulation  has  taken  place  ;  and  the  clot  has  continued 
to  grow  until  it  has  filled  the  interior.  Owing  to  the  freedom  of  anastomosis, 
serious  obstruction  is  unusual. 

Laceration. — Subcutaneous  laceration  of  small  veins  is  of  common  occurrence, 
but  the  pressure  is  so  low  that  the  vessels  close  and  the  hemorrhage  ceases  before 
a  dangerous  amount  of  blood  is  lost.  If,  however,  the  trunk  is  a  large  one,  or  a 
branch  is  pulled  off  from  the  side,  and  the  tissues  round  are  soft  and  yielding,  as 
in  the  axilla,  the  amount  of  extrava.sation  may  be  sufficient  to  cause  gangrene  or 
even  to  threaten  life. 

Wounds. — Punctured  wounds  and  small  incised  ones  that  run  in  the  direction 
of  the  vessel  should  be  sewn  up  with  a  continuous  catgut  suture  ;  the  interior 
usually  remains  patent,  but  occasionally  a  coagulum  forms  and  thrombosis  occurs. 
If  the  wound  is  transverse,  unless  it  is  very  small,  the  vessel  should  be  tied  above 
and  below,  and  the  division  rendered  complete. 

Small  veins  if  cut  in  two  collapse  immediately.  Large  ones  may  cause  a 
serious  loss  of  blood  from  the  proximal  end  ;  and  if  there  is  any  compres.sion  on  the 
cardiac  side  of  the  wound,  or  if  the  vein  is  varicose  or  dilated  so  that  the  valves 
cannot  act,  the  hemorrhage  may  prove  fatal  within  a  comparatively  short  space  of 
time.  Ligature  is  only  required  in  the  case  of  the  largest  trunks,  and  then  as  a 
precaution  \  but  it  can  do  no  harm,  and  it  does  not  cause  phlebitis.  Elevation, 
or  the  slightest  degree  of  local  pressure,  is  almost  always  sufficient. 

Gangrene  of  a  limb  rarely  follows  ligature  even  of  the  chief  vein,  owing  to  the 
freedom  of  anastomosis.  Sometimes  there  is  a  certain  degree  of  venous  obstruction 
followed  by  tension  and  solid  oedema,  but  it  is  by  no  means  invariable.  The 
axillary,  for  example,  is  not  unfrequently  ligatured  in  excisions  of  the  breast  without 
any  ill  consequence,  so  long  as  the  lymphatics  are  not  obstructed  :  and  the  same 


INJURIES    OF   VEINS.  219 

may  be  said  of  the  femoral.  \\'hen  the  chief  artery  of  a  linib  is  wounded  at  the 
same  time,  the  risk  is  greater,  Ijut  the  external  iliac  artery  and  vein  have  been  tied 
simultaneously  without  any  bad  result;  and  this  has  happened  on  many  occasions 
in  the  case  of  the  femoral.  rrol)ably  it  is  safer,  when  such  an  operation  is  recpnred, 
to  delay  it  as  long  as  jio.ssiblc  with  the  view  of  encouraging  the  collateral  circula- 
tion, but  this  is  by  no  means  essential,  and,  of  course,  is  impracticable  in  the  case 
of  a  wound. 

I'".NTR.\Nci£  ov  Air  into  the  Veins. 

This  exceedingly  dangerous  accident  rarely  occurs  except  in  connection  with 
the  great  veins  of  the  neck.  In  these  the  pressure  during  ins])iration  is  negative, 
and  "the  blood  is  sucked  into  the  thorax.  Under  the  ordinary  conditions  they  are 
partly  filled  from  l)ehind,  partly  closed  by  the  collapse  of  their  walls.  If  inspira- 
tion is  very  deep,  or  their  coats  are  thickened,  or  if,  as  often  happens  while  deep- 
seated  tumors  are  being  removed,  they  are  held  open  by  the  traction  upon  the 
cervical  fascia  which  invests  them,  and  at  the  same  time  an  accidental  opening  is 
made  in  their  wall,  air  is  sucked  in  with  a  peculiar  hissing,  gurgling  sound,  and 
the  right  auricle  is  filled  at  once  with  a  bright,  frothy  mixture. 

The  consequences  depend  upon  the  amount.  If  it  is  at  all  considerable  death 
is  instantaneous  ;  the  frothy  mixture  cannot  raise  and  close  the  valves,  and  the  cir- 
culation comes  to  an  end.  Where  it  is  not  sufficient  for  this,  the  patient  suddenly 
becomes  pale  and  livid,  the  pupils  dilate,  the  pulse  is  small  and  flickering,  the 
respiration  hurried  and  gasping,  and  the  heart's  action  violent  and  irregular.  As 
the  air  is  dissolved  this  passes  off,  and  gradually  the  heart  begins  to  beat  with  reg- 
ularity again,  but  the  danger  is  not  all  over,  for  sometimes,  even  after  some  hours, 
alarming  symptoms  suddenly  return.  Possiby  this  is  due  to  the  air  having  entered 
the  pulmonary  capillaries,  but  more  probably  to  the  shock. 

This  accident  usually  occurs  in  operations  about  the  root  of  the  neck  ;  but  it 
has  been  known  to  hapjjen  in  wounds  of  the  axillary  and  even  more  distant  veins. 
The  greatest  care  must  be  taken  in  all  operations  about  this  region,  especially  as  it 
is  often  necessary  to  exert  a  good  deal  of  traction  upon  the  structures,  lifting  them 
well  up  to  see  what  is  beneath.  Any  vein  that  is  exposed  and  requires  division 
should  be  ligatured  first ;  and,  as  Treves  suggests,  a  basin  of  water  and  a  sponge 
should  be  placed  by  the  side  of  the  patient's  head,  that  at  the  least  sign  the  wound 
may  be  filled  at  once. 

If  the  peculiar  hissing  sound  that  characterizes  this  accident  is  heard,  either 
the  finger  or  the  sponge  full  of  water  should  at  once  be  placed  upon  the  vein,  regard- 
less of  everything  else,  and  the  patient's  thorax  comj^ressed.  Possibly  by  this 
some  of  the  air  may  be  forced  l)ack  again.  Artificial  respiration  should  not  be 
employed,  but  every  attempt  should  be  made  to  keep  ujj  the  action  of  the  heart 
and  to  maintain  a  sufficient  supply  of  blood  to  the  brain,  by  the  hypodermic 
injection  of  stimulants  and  by  lowering  the  head  and  raising  the  limbs. 


2  20    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


SECTION    11.— DISEASES  OF   BLOOD-VESSELS. 


Angeioma. 

Angeiomata  are  tumors  composed  entirely,  or  almost  entirely,  of  blood-vessels. 
For  the  most  part  they  are  congenital ;  many,  however,  are  not  noticed  for  a 
month  or  so  after  birth,  and  arterial  ones  may  not  make  their  appearance  until 
much  later.  They  may  be  composed  of  arteries,  veins,  or  capillaries,  or  of  all 
three  together.  Sometimes  they  consist  merely  of  already  existing  vessels  enor- 
mously dilated  and  varicose  ;  more  often  of  newly-formed  ones  as  well,  and  certain 
varieties  are  not  unfrequently  associated  with  other  forms  of  congenital  growth. 

Capillary  angeiomata  (cutaneous  nsevi)  have  been  noticed  already  among 
diseases  of  the  skin. 

Venous  angeiomata  (subcutaneous  or  venous  nsevi)  may  occur  in  conjunction 
with  capillary  ones,  or  independently,  either  in  the  subcutaneous  tissue  or  in  other 
parts.  Some  of  them  appear  to  be  formed  merely  of  dilated  veins,  others  resem- 
ble rather  the  cavernous  structure  of  the  penis,  being  composed  of  irregular,  thin- 
walled  spaces  in  direct  communication  with  arteries,  and  these  may  be  associated 
with  congenital  lipomata,  blood,  and  serous  cysts,  and  occasionally  with  rapidly- 
growing  sarcomata.  As  a  rule,  venous  naevi  form  soft,  irregular,  but  distinct 
masses,  easily  compressible,  and  filling  up  again  as  soon  as  the  pressure  is  removed. 
Some  few  of  the  cavernous  ones  merit  the  name  of  erectile  tumors,  but  there  is 
very  rarely  any  pulsation  to  be  detected.  Their  color  varies  with  their  position. 
If  beneath  the  skin  they  are  blue,  like  veins  ;  if  under  a  mucous  membrane,  bright 
red  ;  and  their  consistence  varies,  of  course,  with  the  amount  of  solid  growth  that 
is  present.  In  many  cases  they  remain  stationary  for  years  ;  not  unfrequently  they 
degenerate  or  become  cystic  ;  sometimes,  after  lying  unaltered  for  a  great  length 
of  time,  they  suddenly  enlarge,  ulcerate,  and  give  rise  to  severe  hemorrhage. 
Venous  naevi  must  be  carefully  distinguished  from  meningocele  or  encephalocele 
when  they  occur  at  the  root  of  the  nose  or  at  the  angles  of  the  orbit ;  and  if  there 
is  the  suspicion  of  a  doubt,  the  tumor  should  certainly  not  be  touched. 

Various  methods  of  treatment  may  be  adopted,  according  to  the  size,  posi- 
tion, and  rapidity  of  the  growth  of  the  tumor.  Probably,  if  in  a  part  of  the  body 
in  which  they  are  not  seen,  and  if  there  is  no  evidence  of  increase  in  size,  the 
best  plan  is  to  leave  them  alone,  certainly  for  a  time.  Excision  is  the  most 
certain,  and  leaves  an  exceedingly  small  scar;  the  amount  of  hemorrhage  is  very 
slight.  Electrolysis  (using  only  the  positive  pole)  is  tedious  but  safe,  and  leaves 
no  mark  at  all.  The  constant  current  should  be  used,  four  or  six  cells  of  Stohrer's 
battery.  The  negative  pole  is  attached  to  a  metal  plate  covered  with  wash-leather  ; 
the  positive  to  one  or  more  steel-tipped  needles,  insulated  for  about  half  their 
length.  These  are  introduced  into  the  ngevus,  jmrallel  to  each  other.  As  soon  as 
the  current  is  turned  on  the  blood  begins  to  coagulate  round  them,  and  when  they 
are  withdrawn,  a  hard,  dense  track  is  left.  If  bubbles  of  gas  make  their  appear- 
ance, it  is  a  sign  that  the  current  is  too  strong.  Where  a  rapid  effect  is  desired 
the  actual  cautery  is  the  most  successful  application.  One  perforation  is  made  in 
the  skin,  and  then  the  fine  platinum  point  is  thrust  through  the  substance  of  the 
growth  in  various  directions.  If  it  is  of  the  right  temperature  the  pain  is  very 
slight  and  no  blood  is  lost.  [Electrolysis  frecpiently  fails,  where  the  angeioma 
extends  deeply  into  the  tissue.  The  more  superficial  the  angeioma  the  greater  the 
probability  of  cure  by  electrolysis.]  In  other  cases  setons  may  be  employed  ;  or 
threads  dipped  in  perchloride  of  iron  ;  or  portions  may  be  ligatured  subcutaneously  ; 
.or  the  growth  may  be  divided  in  various  directions  with  a  tenotomy  knife,  and 
pressure  applied  afterward.     In  cases  in  which  extensive  nsevi  are  associated  with 


DISEASES    OF  BLOOD-VESSELS. 


ra]ii(lly-in(reasing  solid  growths  in  cliildreii,  the  outward  application  of  strong  lead 
lotion  is  of  decided  beneht,  at  any  rate  for  a  time.  Injections  should  never  be 
used,  for  fear  of  causing  embolism. 

Artt-rial  iX)i^cioma  (arterial  varix,  cirsoid  aneurysm,  and  aneurysm  by  anasto- 
mosis, are  other  terms  descriptive  of  essentially  the  same  condition)  is,  in  com- 
parison with  these,  of  very  rare  occurrence,  and  althougli  it  may  be  congenital  in 
some  instances,  is  seldom  met  with  before  puberty. 

It  is  known  as  arterial  varix  when  only  a  single  artery  is  involved,  as  cirsoid 
aneurysm  if  there  is  a  mass  together,  and  as  aneurysm  l)y  anastomosis  when  the 
capillaries  and  venules  are  dilated  as  well. 

The  most  common  situation  for  it  is  the  scalp  (especially  round  and  above  the 
ear),  but  it  may  occur  in  any  part  of  the  body.     Sometimes  it  is  stated  to  have 
developed  from  a  nrevus  ;   in  other  instances  it  appears  to  have  followed  injury,  and 
possibly    may   have  originated   as   some 
form   of  arteritis ;    in    the    majority    no 
reasonable  cause  or  explanation  is  forth- 
coming (Fig.  49). 

In  its  typical  form  it  is  composed 
of  a  mass  of  enormously  dilated,  tortuous 
arteries,  twisted  inextricably  together, 
and  covered  with  thin-walled  pouches. 
It  projects  somewhat  above'  the  skin 
(which  is  often  dangerously  thin  over  the 
most  prominent  ])arts)  ;  it  is  soft,  lobu- 
lated,  easily  emptied  by  direct  pressure, 
and  to  a  less  extent  by  pressure  upon  the 
trunk  supplying  it ;  but  it  fills  again  at 
once,  and  its  outline  is  very  ill-defined, 
the  branches  that  supply  it  only  assuming 
their  normal  character  some  distance 
from  the  main  body.  A  thrill  and  a 
distinct  bruit  can  be  detected  over  the 
main  part,  and  followed  along  the  vessels 
in  the  course  of  the  blood-stream.  By 
its  pressure  it  gradually  causes  absorption 
of  the  structures  round,  cutting  deep 
grooves  in  the  bones,  and  rendering  the 
skin  so  thin  that  it  is  in  imminent  danger  of  giving  way. 
some  nerve  is  accidentally  involved. 

Spontaneous  cure  is  unknown  ;  it  may  remain  passive  for  years  and  then  again 
begin  to  enlarge,  or  it  may  grow  steadily  the  whole  time.  If  the  skin  gives  way 
the  hemorrhage  is  of  the  most  alarming  character,  and  may  prove  almost  imme- 
diately fatal. 

Excision  is  the  only  treatment  that  deserves  any  reliance.  Ligature  of  the 
trunk  supplying  the  tumor  has  failed  far  more  frequently  than  it  has  succeeded,  and 
renders  subsequent  operations  more  dangerous  on  account  of  the  development  of 
the  collateral  circulation.  Pressure  checks  advance  in  some  of  the  more  chronic 
cases,  but  can  do  no  more.  Ligature  en  masse  has  answered  in  a  few  instances, 
although  in  one  at  least  recurrence  took  place. 

If  it  is  on  the  scalp,  temporary  ligatures  may  be  placed  on  the  carotids,  or  the 
trunks  supplying  the  tumor  may  be  compressed  with  hare-lip  pins,  and  then,  with 
the  aid  of  one  or  two  assistants  to  keep  up  digital  compression  while  the  ligatures 
are  being  placed  and  tied,  the  skin  may  be  reflected  from  part  of  it,  and  the  rest 
of  the  growth  excised  with  the  minimum  of  loss.  If  it  is  on  the  extremities  the 
same  plan  may  be  tried,  but  in  several  cases  amputation  has  been  found  necessary, 
sooner  or  later. 


Fig.  49. — Cirsoid  Aneurysm  of  the  Scalp. 


There  is  no  pain  unless 


222     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

H.'EMOPHILIA. 

Haemophilia,  or  the  hemorrhagic  diathesis,  is  a  peculiarity  of  constitution 
that  is  distinctly  hereditary  ;  but  though  it  may  be  transmitted  by  mothers  to  their 
sons,  it  is  very  rarely  manifested  except  in  males.  Female  children  themselves 
are  very  seldom  affected. 

Nothing  is  known  as  to  its  cause ;  no  definite  change  is  found  constantly  in 
the  walls  of  the  vessels,  and  there  is  no  apparent  alteration  in  the  blood.  At  first 
it  coagulates  as  readily  as  usual,  and  though  after  a  time  it  becomes  thin  and 
watery,  the  same  thing  occurs  after  profuse  hemorrhage  from  people  who  are  not 
bleeders.  The  aspect  or  appearance  is  not  in  any  way  characteristic,  and  before- 
hand there  is  nothing  to  tell  whether  a  patient  is  a  bleeder  or  not.  The  tendency 
to  it  is  most  marked  in  infancy  and  childhood  ;  if  it  does  not  develop  then  the 
patient,  as  a  rule,  remains  free.  In  a  few  instances  it  seems  to  have  spontaneously 
died  out,  and  in  all  probability  the  tendency  to  it  varies  in  intensity  at  different  times. 

In  some,  the  bleeding  is  spontaneous,  coming  from  mucous  or  synovial  sur- 
faces, in  others  it  is  traumatic  only.  The  slightest  injury  may  cause  it ;  bruises 
are  followed  by  enormous  extravasations  in  which  the  blood  remains  fluid  for  a 
great  length  of  time,  and  the  extraction  of  teeth  is  especially  serious.  It  is  said 
that  trivial  injuries  are  more  often  followed  by  bleeding  than  grave  ones,  but  this 
is  open  to  question.  It  is  not  arterial  or  venous,  the  blood  simply  appears  to 
pour  out  from  the  tissues  themselves  in  a  ceaseless  stream. 

Spontaneous  hemorrhages  are  stated  to  be  often  preceded  by  symptoms  of 
congestion,  but  they  more  usually  occur  without  warning.  When  the  joints  are 
involved  it  is  not  infrequently  taken  for  rheumatism,  especially  as  there  is  a 
decided  tendency  for  it  to  occur  in  cold  and  damp  weather.  The  swelling  is 
sudden,  involving  the  peri-synovial  tissues  as  well  as  the  cavity  of  the  joint  and 
accompanied  by  ecchymoses.  Permanent  enlargement,  and  even  ankylosis,  may 
follow  if  the  attacks  are  repeated.  The  mucous  membrane  of  the  nose  and  that 
of  the  gastro-intestinal  tract  are  the  most  frequent  seats,  but  in  some  the  bleeding 
comes  from  almost  every  part. 

No  si)ecial  treatment  is  of  any  avail.  Internal  styptics  have  been  used  freely, 
and  every  kind  of  external  one,  without  success.  Not  unfrequently  the  patient 
continues  to  lose  blood  until  not  a  drop  seems  to  be  left,  and  then  rapidly  begins 
to  recover ;  but  they  rarely  reach  old  age  or  even  adult  life.  In  the  case  of  teeth, 
carefully  applied  pressure  is  the  most  successful  ;  a  cork  should  be  fitted  into  the 
holloAv,  the  cavity  thoroughly  packed,  and  then  the  teeth  of  the  other  jaw  pressed 
tightly  against  it  by  means  of  a  webbing  strap  around  the  head.  In  this  way  I 
have  succeeded  in  checking  it  in  several  members  of  a  well-known  family.  The 
actual  cautery  seems  to  be  of  no  special  use,  and  of  course  no  measure  that 
involves  a  wound  should  ever  be  attempted.  [The  editor  has  known  one  case  of 
persistent  hemorrhage  that  w^as  due  to  long-continued  use  of  sulphate  of  quinine.} 


DISEASES  OF  ARTERIES. 

Inflammation. 
Arteries,  if  subjected  to  long-continued  irritation,  become  inflamed  like  other 
structures,  the  character  of  the  inflammation  depending  upon  the  cause.  It  may 
commence  in  the  intima  (endarteritis),  the  media,  or  the  sheath  (peri -arteritis), 
and  it  may  be  acute  or  chronic,  the  exudation  becoming  absorbed,  undergoing 
organization,  degenerating,  or  being  transformed  into  pus,  according  to  the 
persistence  and  intensity  of  the  irritant. 

I.   Simple  Traumatic  Arteritis. 
The  best  example  is  that  caused  by  a  ligature  ;  the  minute  vessels  in  all  the 
parts  around  dilate,  lymph  pours  out,  the  amount  depending  very  largely  upon 


DISEASES   OF  ARTERIES.  223 

the  nature  of  the  irritant ;  some  is  absorbed,  the  rest  becomes  vascular  and  is 
organized  into  a  cicatrix.  If  the  ligature  disappears  without  causing  a  sufficient 
degree  of  irritation,  or  if  the  tissues  are  so  badly  nourished  that  they  are  unable 
to  carry  out  active  repair,  the  cicatrix  is  very  likely  to  be  too  weak  and  to  yield 
to  the  strain  that  falls  on  it. 

Similar  changes  occur  after  wounds,  bruises,  ;uul  the  impaction  of  non- 
infective  emboli. 

2.   Suppurative  Arfcrifis. 

This  may  begin  in  the  interior,  from  the  presence  of  an  infective  embolus,  or 
on  the  exterior,  as  peri-arteritis.  In  the  latter  case  the  organisms  generally  enter 
through  a  wound,  but  when,  for  example,  there  is  a  suppurating  aneurysm,  they 
must  reach  the  part  either  through  the  blood-stream  or  the  lymphatics ;  the 
constant  pressure  and  tension  irritate  the  tissues  and  break  down  their  power  of 
resistance,  and  the  pyogenic  germs,  which  otherwise  are  innocuous,  at  once  begin 
their  work  of  destruction. 

In  pysemic  embolism,  whether  infarction  occurs  or  not,  the  destruction  is  so 
rapid  and  so  general  that  the  changes  in  the  wall  of  the  artery  cannot  be  distin- 
guished, the  tissues  melt  at  once  into  intensely  infective  pus.  When,  however, 
the  suppuration  begins  in  the  outer  coat,  after  ligature,  for  example,  the  course  of 
events  can  be  traced  fairly  well.  The  vasa  vasorum  dilate  and  become  sheathed 
with  leucocytes,  the  fibrous  tissue  melts  away,  the  muscular  bands  split  up,  the 
endothelial  cells  perish  and  become  detached,  and  at  length,  although  the  wall  of 
an  artery  resists  better  than  most  structures,  it  is  gradually  eaten  through  or  so 
weakened  that  it  gives  way.  As  a  rule,  before  this  occurs  the-  white  corpuscles 
collect  upon  the  inflamed  wall  and  form  a  protecting  thrombus. 

The  subsequent  course  depends  upon  the  intensity  of  the  irritant  on  the  one 
hand  and  the  activity  of  nutrition  upon  the  other. 

(rt;)  If  there  is  no  additional  cause  at  work,  no  tension,  mechanical  irritation, 
or  absorption  of  septic  products,  the  suppuration  may  cease,  the  tissues  gaining 
the  upper  hand,  and  the  wall  of  the  artery  remain  intact,  as,  for  example,  usually 
occurs  when  a  vessel  is  exposed  upon  the  floor  of  a  simple  ulcer ;  or  the  result 
may  not  be  quite  so  good  ;  one  part  of  the  wall,  for  example,  may  be  so  weakened 
that  it  yields  and  forms  an  aneurysm,  or  the  interior  may  be  completely  closed  by 
a  thrombus,  or  part  of  the  artery  may  perish  and  slough,  loss  of  blood  being 
prevented  by  the  sealing  of  the  ends. 

{b)  If,  on  the  other  hand,  the  vitality  of  the  tissues  is  too  much  impaired  for 
organization  to  be  effectual  (as  in  phagedtena),  or  if  some  other  irritant  appears 
upon  the  scene  (especially  septic  decomposition),  the  germs  prove  themselves  the 
stronger  and  the  tissues  give  way.  The  wall  of  the  vessel  is  softened,  the  clot 
disintegrates  before  it  is  organized,  and  secondary  hemorrhage  occurs. 

This  accident  may  happen  when  a  wound  heals  by  the  first  intention,  and 
even  after  it  has  healed,  if  the  cicatrix  is  thin  and  weak  and  the  structures  around 
soft  and  yielding  ;  but  it  is  much  more  common  after  suppuration,  especially  if  the 
nutrition  of  the  tissues  is  impaired,  whether  from  pre-existing  atheroma  or  from 
septic  decomposition. 

A  special  form  of  embolic  arteritis  is  met  with  in  connection  with  ulcerative 
endocarditis.  The  vegetations  detached  from  the  valves  sometimes  cause  suppu- 
ration, as  in  pyaemia ;  but  not  unfrequently  they  merely  give  rise  to  a  certain 
degree  of  softening  and  inflammation,  by  which  the  walls  of  the  vessels  are 
unduly  weakened.  In  all  probability  a  very  large  number  of  the  aneurysms  that 
occur  in  young  children  may  be  accounted  for  by  this,  the  dilatation  beginning 
opposite  the  embolus,  not  above  it. 

3.   Syphilitic  Arteritis. 

Arterial  disease  is  of  common  occurrence,  both  in  acquired  and  hereditary 
syphilis,  especially  in  the  brain.      Probably  the  apparent  frequency  with  which 


o 


224    DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 

this  organ  is  involved  may  be  explained  by  the  gravity  of  the  symptoms  that 
follow,  by  the  fact  that  its  vessels  are  easily  examined,  and  by  the  anatomical 
peculiarities  of  their  lymphatic  sheath.  Usually  single  vessels  only  are  affected 
and  often  only  small  portions  of  them  (Fig.  50). 

The    exudation    is    similar    to    that 
.,  which  occurs  elsewhere,  with,  however,  a 

,:--'i':--:  ^^:^r:^^^'<.'-H^A-'-  special  tendency  to    fibroid    transforma- 

tion ;  it  is  doubtful  if  it  ever  calcifies. 
Sometimes  it  commences  as  a  peri-arte- 
ritis,  distinct  gummata  forming  on  the 
vessel  and  occluding  it  more  or  less  by 
their  pressure ;  more  frequently,  how- 
ever, it  involves  the  deeper  layers  of  the 
intima,  causing  such  an  enormous  degree 
of  thickening  that  the  interior  of  the 
vessel  is  almost  closed.  If  the  endothelial 
lining  is  involved  as  well,  a  thrombus 
forms  over  the  affected  part,  and  renders 
this  complete.  In  the  brain  this  may 
lead  to  white  softening,  from  the  blood- 
supply  being  cut  off,  or  to  aneurysm.  In 
the  most  fortunate  examples  the  exuda- 
tion is  absorbed  again  more  or  less  com- 
pletely, leaving,  however,  the  vessel  tortu- 
ous, inelastic,  and  weakened,  so  that  it  is  always  liable  to  give  way. 

Similar  changes  are  found  in  the  vessels  of  gummata,  and  it  has  been  sug- 
gested that  the  consequent  diminution  in  the  amount  of  blood  they  receive  is  the 
immediate  cause  of  the  degenerative  changes  they  undergo  as  soon  as  they  reach 
a  certain  size. 


»>. 


1^ 


FlG.  50. — Syphilitic  Disease  of  One  of  the  Cerebral 
Arteries.  The  inner  coat  is  thickened  by  fibrous 
tissue,  and  the  lumen  is  much  narrowed. 

(Bowlhy.) 


4.   Arteritis  Obliterans. 

This  name  has  been  given  to  a  peculiar  form  of  inflammation,  which  some- 
times occurs  in  arteries  during  middle  life.  Nothing  is  known  as  to  its  pathology. 
It  is  exceedingly  chronic  in  its  course,  beginning  in  the  smaller  vessels  and  steadily 
involving  the  larger  ones,  causing  them  first  to  become  hard  and  thick,  and  then 
gradually  closing  them.  It  is  often  accompanied  by  very  severe  pain  and  usually 
ends  in  dry  gangrene.  When  it  occurs  in  younger  subjects,  especially  in  the  arm, 
it  is  very  liable  to  be  confused  with  occlusion  of  the  artery  caused  by  deep-seated 
growths,  especially  cervical  exostoses. 

5.    Gouty  Arteritis. 

A  few  cases  are  recorded  in  which  a  moderately  acute  attack  of  periarteritis 
has  occurred  in  gouty  subjects  past  middle  life,  possibly,  therefore — as  syphilis, 
injury,  and  all  ordinary  causes  could  be  eliminated — due  to  gout.  It  has  been 
noted  in  the  temporals  with  a  certain  degree  of  redness  of  skin  and  tenderness 
over  their  course,  and  in  the  brachial.  Usually  it  ends  in  thrombosis  and  oblitera- 
tion, the  ultimate  consequences,  of  course,  varying  with  the  collateral  circulation. 

Tubercular  infiltration  of  the  perivascular  sheath  of  the  cerebral  arteries  is 
of  common  occurrence,  and  certain  facts  render  it  probable  that  occasionally  tuber- 
cular masses  rupture  into  arteries  and  cause  embolism  (especially  in  connection 
with  the  bones),  but  no  definite  tubercular  arteritis  has  yet  been  described. 


6.    Chrouic  Arteritis  or  Atheroina. 

Chronic  inflammation,  with  its  consequence,  atheroma,  is  very  common  in 
late  adult  life,  although  probably  its  beginning  is  laid  at  a  much  earlier  period. 


DISEASES   OF  ARTERIES.  225 

The  larger  vessels  are  chiefly  affected,  and  those  ])arts  upon  which  the  strain  is 
greatest,  the  arch  of  the  aorta  for  example,  the  origin  of  branches,  the  spot  where 
the  external  iliac  becomes  the  femoral,  and  generally  the  convexities  of  all  the 
curves  ;  but  the  arteries  of  the  brain,  especially  those  at  the  base,  those  of  the 
lower  limbs,  and,  in  the  abdomen,  the  splenic,  suffer  almost  as  often. 

It  can  be  traced  to  the  effect  of  strains,  sudden  or  long  continued.  It  is 
more  frecpient  in  men  than  women,  it  affects  those  esi)ecially  who  have  to  under- 
take sudclenly  great  ])hysical  exertion,  and  it  involves  those  parts  of  the  vascular 
system  which  are  the  first  to  feel  such  effects.  The  pulmonary  artery,  for  example, 
is  always  exemjjt  unless  there  is  some  obstruction  to  the  flow  of  blood  through  the 
lungs,  causing  hypertrophy  of  the  right  ventricle  ;  then  it  suffers  equally.  Alcohol 
helps  to  ])roduce  it,  and  so  do  ])lethora  and  gout,  for  much  the  same  reason,  but 
it  is  doubtful  if  syphilis  has  more  than  an  accidental  connection.  Bright's  disease 
and  arterio-capillary  fibrosis  are  especially  likely  to  be  followed  by  it. 

Its  first  appearance  is  as  a  gray  semi-translucent  sjjot,  slightly  raised  above 
the  surface  ;  this  grows  larger  and  larger,  coalesces  with  others  like  it,  becomes 
more  yellow  in  color,  and  at  length  forms  a  distinct  elevation,  elongated  or  circu- 
lar in  shape,  according  to  the  part  of  the  artery  in  which  it  is  situated.  It  is 
caused  by  an  inflammatory  exudation  into  the  subendothelial  cellular  layer,  imme- 
diately under  the  lining  of  the  vessel.  Probably  it  begins  here,  partly  because 
the  texture  is  somewhat  looser  than  elsewhere,  partly  because  it  is  the  first  to  feel 
the  strain.  The  middle  coat  -is  but  little  affected  until  the  musadar  fibres  begin 
to  waste,  then  it  yields,  loses  its  elasticity,  and  becomes  rigid.  The  outer,  on  the 
other  hand,  is  usually  involved  nearly  as  much  as  the  inner. 

In  some  instances  the  exudation  may  disappear  again,  leaving  the  wall  intact, 
but  of  this  naturally  there  is  no  evidence.  As  a  rule  it  either  becomes  fibrous, 
forming  firm,  slightly  raised,  yellow  patches,  still  covered  with  endothelium  ;  or 
undergoes  degeneration,  either  fatty  or  calcareous,  or  both  together.  Not  unfre- 
quently  the  outer  portion  becomes  organized,  while  the  inner  decays. 

The  reason  of  the  difference  is  probably  to  be  found  in  the  condition  of  the 
blood-supply.  The  vasa  vasorum  ramify  in  the  outer  and  middle  coats,  but  do 
not  supply  the  sub-endothelial  layer  ;  this  is  nourished  chiefly  or  entirely  by  diffu: 
sion  through  the  endothelium.  When  inflammation  sets  in,  and  the  lymph- 
corpuscles  increase  in  number,  so  simple  a  process  as  this  is  insufficient,  and 
degeneration  begins  before  new  vessels  can  develop.  On  the  other  hand,  in  the 
outer  layers,  where  the  blood-supply  is  much  more  abundant,  organization  is  the 
rule. 

Fatty  degeneration  is  marked  by  a  change  in  color  and  consistence.  The 
patch  becomes  more  yellow,  it  grows  softer  and  softer,  so  that  in  extreme  cases  it 
is  almost  fluid,  and  then  suddenly  the  endothelium  gives  way,  and  the  contents — 
fatty  molecules,  cholesterin,  and  crystals  of  stearin — are  discharged  into  the  vessel. 
Fortunately  they  do  no  harm,  beyond  blocking  up  perhaps  some  minute  branch  ; 
but  an  atlieromatous  ulcer  is  left,  an  excavated,  ragged  spot,  often  of  considerable 
size,  with  the  endothelium  gone,  the  tunica  media  softened  and  weakened,  and 
the  integrity  of  the  vessel  only  maintained  by  the  thickened,  inelastic  outer  coat, 
which  is  fused  with  the  structures  round. 

Calcareous  degeneration  is  usually  secondary  to  this,  the  fluid  part  disappear- 
ing, and  the  caseous  debris  left  becoming  infiltrated  with  lime-salts  until  it  forms 
an  irregular  plate,  lying  in  the  wall  of  the  vessel,  exposed  more  or  less  to  the 
blood-stream,  and  not  unfrequently  projecting  into  it  at  some  point. 

The  appearances  produced  by  these  changes  are  naturally  very  variable.  The 
artery  may  be  dilated  along  its  whole  course,  or  here  and  there  ;  not  unfrequently 
it  is  elongated  and  tortuous,  while  the  walls  are  rigid  and  inelastic,  thickened  in 
places  and  tied  down  by  adhesions  to  the  sheath,  dangerously  thinned  perhaps  in 
others.  The  inner  surface  is  still  worse  ;  in  some  parts  there  are  firm,  raised 
nodules  of  a  grayish  color,  still  smooth  ;  in  others  the  endothelium  has  given  way, 
leaving  a  ragged    excavation    with  fringed    and  overhanging  edges,   lined  with 


2  26    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

caseous  debris  or  calcareous  plates,  and  in  others  again  the  irregularities  are  con- 
cealed beneath  adherent  thrombi.  Rupture  sometimes  occurs  in  the  arteries  of 
the  brain  in  which  the  adventitia  is  poorly  developed  ;  elsewhere  it  is  unusual,  as 
the  outer  coat  becomes  thick  enough  to  resist. 

The  loss  of  elasticity  and  the  destruction  of  the  surface  are  soon  followed  by 
worse  results.  The  walls  stretch  and  yield,  the  vessels  are  thrown  into  curves  and 
loops,  so  that  what  is  known  as  a  locomotive  pulse  is  produced  ;  the  parts  beyond 
are  ill-nourished  and  ill-supplied  with  blood,  and  as  enlargement,  of  the  collateral 
circulation  is  impossible,  the  least  difficulty  is  liable  to  be  followed  by  gangrene. 
It  is  by  far  the  most  common  cause  of  aneurysm,  sacculated  as  well  as  dissecting. 
If,  as  usually  happens,  one  part  of  the  wall  becomes  weak  and  soft  from  inflamma- 
tion, without  an  extensive  degree  of  atheroma,  the  sacculated  form  is  produced. 
If,  on  the  other  hand,  degeneration  occurs  at  an  early  period,  so  that  the  lining 
membrane  ruptures  before  the  coats  are  welded  together,  the  dissecting  one  fol- 
lows, and  the  blood  works  its  way  down,  between  the  layers  of  the  wall,  until  it 
either  bursts  into  the  vessel  again,  or  breaks  the  outer  coat  and  pours  into  the  tis- 
sues round.  Thrombosis  is  even  more  common,  the  blood  coagulating  upon  the 
irregular  projections,  and  perhaps  completely  occluding  the  vessel.  Embolism 
may  occur,  or  the  orifices  of  the  small  branches  (the  coronary  arteries,  for  instance) 
may  be  closed  by  the  contraction  of  the  fibrous  tissue  round  them  ;  or  ruyjture 
may  take  place,  or,  in  short,  almost  any  of  the  troubles  that  can  happen  in  con- 
nection with  the  blood-vessels  or  the  blood  supply. 

The  importance  of  atheroma  in  the  production  of  secondary  hemorrhage 
cannot  be  over-estimated.  Clearly,  if  the  walls  of  the  vessels  are  badly  nourished 
and  inflamed  already,  immediate  repair  after  injury  is  hardly  probable.  Fortu- 
nately, the  change  is  often  local,  and  if,  for  example,  the  popliteal  is  diseased, 
the  femoral  in  Hunter's  canal  may  be  sound. 


De(;eneration  of  Arteries. 

The  coats  of  arteries  are  liable  to  degenerate  and  decay  as  age  advances 
without  any  preceding  inflammation,  although  naturally  the  tAvo  are  often  asso- 
ciated, and  the  same  thing  is  met  with  in  younger  people  as  a  result  of  marasmus, 
anaemia,  and  exhausting  illness. 

Fatty  Degeneration. 

Fatty  degeneration  of  the  intima  is  not  unusual  in  the  aorta  ;  apparently  it 
begins  in  the  stellate  sub-endothelial  cells  of  the  intima,  and  forms  opaque  yellow, 
sharply  outlined  patches,  which  may  be  distinguished  from  atheroma  by  the  fact 
that  they  are  superficial  and  scarcely  raised.  The  deeper  parts  are  quite  healthy. 
It  has  no  clinical,  importance. 

When,  on  the  other  hand,  it  involves  the  media,  especially  in  the  case  of  the 
brain,  the  wall  is  so  weakened  that  there  is  imminent  danger  of  rupture. 

Calcareous  Degeneration. 

This  is  especially  liable  to  occur  in  the  cerebral  arteries  and  in  the  tibials  of 
old  people.  It  involves  the  middle  coat  chiefly,  and  appears  to  be  a  primary 
calcareous  degeneration  of  the  unstriped  muscle-cells.  They  gradually  disappear 
and  are  replaced  by  calcified  rings,  which  fit  so  closely  together  and  are  so  nu- 
merous that  the  arcery  becomes  converted  into  a  calcified  tube.  Ultimately  the 
intima  is  affected  too,  but  this  does  not  occur  so  early  or  so  extensively  as  in 
atheroma ;  the  adventitia  sometimes  becomes  hypertrophied  so  as  to  form  a 
protecting  sheath  ;  sometimes,  on  the  other  hand,  it  wastes  away  and  nothing  but 
these  calcified  rings  is  left.  The  effect  upon  the  circulation  is,  of  course,  exceed- 
ingly grave  ;   the  loss  of  elasticity  impedes  the  flow  of  l)lood  and   prevents  any 


DISEASES   OF   VEINS.  227 

variation  in  the  supply,  the  roughness  of  the  surface  increases  the  friction,  the 
diameter  is  diminished  by  the  increased  thickness,  there  is  always  imminent  dan- 
ger of  thrombosis  and  embolism,  and  the  establishment  of  a  collateral  circulation 
is  usually  impossible.  As  might  be  exjjected,  it  is  the  most  important  factor  in 
the  causation  of  senile  gangrene,  especially  the  dry  form. 

In  addition  to  these  changes,  the  arteries  of  old  ])eople  are  often  immensely 
elongated  and  tortuous  without  there  being  any  evidence  of  atheroma,  fatty  degen- 
eration, or,  as  it  is  often  met  with  in  those  who  are  ninety  years  of  age  and  over, 
of  renal  di-sease.  In  all  probal)ility  this  condition  is  due  to  the  gradually  failing 
power  of  the  muscular  walls  of  the  vessel,  and  to  the  loss  of  support  from  the  struc- 
tures round  ;  for  it  is  most  marked  in  those  whose  limbs  are  greatly  wasted.  Usu- 
ally it  is  associated  with  a  certain  degree  of  fibrous  thickening,  so  that  the  vessel 
is  unusually  distinct  to  the  touch,  but  probably  this  is  to  be  regarded  as  a  com- 
pensative hypertrophy  ;   it  is  not  the  result  of  inflammation  or  of  iniduly  high  vas- 


cular tension. 


DISEASES  OF  VEINS. 


Varicose  Veins. 


Veins  are  described  as  varicose  when  they  are  hal)itually  distended  and  dilated 
beyond  their  normal  size.  This  is  most  common  in  the  lower  limb  and  in  con- 
nection with  the  spermatic  and  hemorrhoidal  plexuses  (varicocele  and  hemor- 
rhoids), but  it  may  occur  in  any  part  of  the  body. 

Causes. — Varicose  veins  are  caused  either  by  an  increase  in  the  blood-pres- 
sure or  by  a  diminished  power  of  resistance  in  the  walls,  or  by  both  together. 

Increased  blood-pressure  by  itself  may  give  rise  to  the  most  extreme  degree  of 
varicosity,  as  seen  in  cases  in  which  the  inferior  vena  cava  has  been  obstructed, 
and  the  front  and  sides  of  the  abdomen  are  covered  with  tortuous  masses  of  dilated 
veins,  studded  with  pouches  in  all  directions.  More  frequently,  however,  although 
it  helps,  as  in  pregnancy,  heart  disease,  etc., 
it  is  only  one  of  the  exciting  causes,  and 
perhaps  not  the  most  important. 

Diminished  power  of  resistance  is  pro- 
duced in  various  ways.  Occasionally  a  vein 
becomes  (and  remains)  varicose  after  some 
strain.  In  other  instances  the  wall  is  weak- 
ened by  inflammation,  or  suddenly  loses  10.  ^i.— 
some  support  to  which  it  has  been  accustomed.  Sometimes,  as  varicose  veins  are 
distinctly  hereditary,  there  may  be  a  congenital  defect  of  structure,  but  probably 
in  the  great  majority  of  instances  the  deficiency  is  really  due  to  the  feeble  develop- 
ment of  the  muscular  coat  and  to  its  being  easily  tired  out.  Varicose  veins  are 
especially  common  in  those  in  whom  the  circulation  is  weak  and  the  vascular  tone 
defective.  Long-standing  obstruction,  or  any  other  cause  that  entails  upon  the 
muscular  coat  an  unusual  degree  of  strain  for  an  unusual  length  of  time,  leads 
either  to  hypertrophy  (as  in  a  simple  case  of  obstruction  of  the  vena  cava)  ;  or,  if 
the  nutrition  is  feeble,  to  dilatation  with  thinning  in  some  parts,  and  fibrous 
thickening  (so  that  the  walls  become  firm  and  inelastic)  in  others. 

Varicose  veins  are  rarely  met  with  in  children  ;  after  puberty  they  become 
more  common  up  to  middle  life,  and  then  again  the  tendency  diminishes.  In 
spite  of  the  effects  of  pregnancy,  men  are  said  to  be  more  liable  to  them  than 
women,  and  those  especially  whose  occupations  entail  long  standing  or  very  great 
and  sudden  muscular  exertion. 

The  internal  saphena  vein  suffers  with  exceptional  frequency,  from  its  length, 
the  effects  of  gravity,  the  small  amount  of  support  it  receives,  as  it  lies  outside  the 
deep  fascia,  and  the  amount  of  blood  discharged  into  it  from  the  deep  muscular 
and  intermuscular  veins.     The  narrowing  of  the  saphenous  opening  is  probably 


2  28    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

of  no  importance.  Sometimes  the  whole  length  is  involved,  more  often  only  parts 
of  it  here  and  there,  the  intermediate  portions  being  altogether  normal ;  or  the 
main  trunk  may  be  intact  and  the  branches  varicose,  or  only  the  minute  tribu- 
taries, the  venules  in  the  skin,  dilated.  The  deep  veins  of  the  leg  (but  not  those 
of  the  thigh)  are  often  affected  to  a  greater  extent  than  the  superficial  ones,  and 
the  disease  may  commence  in  them  ;  very  often  it  shows  itself  first  where  the  two 
sets  of  branches  communicate  with  each  other.  The  external  saphena  suffers 
almost  as  often,  and  not  unfrequently  the  whole  of  the  foot  or  ankle  is  covered 
with  a  network  of  tortuous  dilated  vessels,  running  apparently  indiscriminately. 
In  other  parts  of  the  body  (except  in  connection  with  the  testes,  labia,  and 
rectum)  varicose  veins  are  rarely  seen  unless  there  is  obstruction  of  one  of  the 
great  trunks. 

Varicose  veins  are  not  only  dilated,  but  lengthened  and  thrown  into  loops  and 
curves.  In  some  places  the  walls  are  immensely  thickened  by  the  fresh  develop- 
ment of  fibrous  tissue,  so  that  when  the  vessels  are  cut  across  they  remain  gaping 
widely  open  with  little  or  no  tendency  to  contract.  In  other  parts  they  are  thinned 
and  stretched,  and  so  twisted  up  together  that  they  form  an  ill-defined  spongy 
swelling  resembling  cavernous  tissue.  The  valves  have  often  disappeared  altogether 
or  are  reduced  to  shreds,  which  have  no  power  of  preventing  regurgitation  or  sup- 
porting the  column  of  blood.  The  skin  is  sometimes  thickened,  but  more  fre- 
quently it  grows  thinner  and  thinner,  until  the  vein  almost  protrudes  through  it, 
and  even  the  bones  beneath  may  be  grooved  and  cut  into  deep  channels  by  the 
persistent  pressure. 

Symptoms. — Varico.se  veins,  so  long  as  the  circulation  and  nutrition  are 
good,  give  rise  to  very  little  inconvenience,  merely  a  sense  of  aching  or  of  weight 
after  exercise.  Occasionally,  possibly  because  a  nerve  is  pressed  upon,  there  is 
more  acute  pain,  and  it  is  believed  that  deep-seated  muscular  varices  are  some- 
times the  cause  of  painful  cramps.  The  diagnosis  rarely  presents  any  difficulty, 
the  color,  shape,  distribution,  and  the  difference  in  tension  according  to  position 
are  sufficiently  characteristic.  There  may  be  a  distinct  impulse  in  coughing, 
especially  when  the  upper  part  of  the  internal  saphena  is  dilated,  and  it  is  said  that 
this  condition  may  simulate  femoral  hernia. 

If,  however,  from  any  cause — age,  ill-health,  over-exertion,  fatigue,  etc. — the 
circulation  begins  to  flag,  the  dilatation,  the  enormous  weight  of  the  column  of 
blood,  greatly  increased  in  diameter  and  unbroken  by  valves,  and  the  loss  of  vas- 
cular tone,  soon  produce,  or  help  to  produce,  much  more  serious  effects.  Chronic 
congestion,  with  cjedema  and  more  or  less  thickening  and  hypertroi)hy  of  the  con- 
nective tissue  of  the  part,  is  the  first  thing  to  happen.  The  red  blood-corpuscles 
escape  through  the  walls  and  cause  deep  pigmentation.  The  general  nutrition  of 
the  tissues  fails,  chronic  ulcers  form,  trivial  injuries  are  not  repaired,  but  leave 
behind  them  persisting  sores ;  the  skin  becomes  irritated  and  eczematous,  and  at 
last — not  so  much  because  of  the  varicose  veins  themselves  as  because  of  the 
general  failure  of  the  circulation  of  which  they  are  but  one  of  the  signs — the  whole 
limb  becomes  more  or  less  affected. 

Thrombosis  is  an  exceedingly  common  complication,  the  blood  coagulating 
in  one  of  the  outlying  parts  ;  sometimes  the  clot  is  absorbed,  more  frequently  it 
becomes  organized  or  undergoes  degeneration.  Phleboliths  produced  in  this  way 
can  nearly  always  be  found  in  the  prostatic  plexus.  Occasionally  the  skin  over  the 
vein  gives  way,  and  very  serious  hemorrhage  results. 

Treatment. — i.  Palliative. — All  obstructions  must  be  removed  as  far  as 
possible.  Tight  garters  are  exceedingly  injurious.  In  pregnancy  the  patient  must 
rest  as  much  as  possible,  or  as  is  consi-stent  with  health,  and  wear  a  bandage  or  a 
stocking  both  during  and  for  some  time  afterward.  The  bowels  must  be  kept 
well  open,  and  long  standing  and  excessive  walking  avoided,  although  a  reason- 
able amount  of  exercise,  stopping  short  of  fatigue,  is  decidedly  beneficial. 

If  the  varix  has  made  its  appearance  suddenly  after  exertion,  the  walls  of  the 
vein  must  be  carefully  protected  from  strain  for  some  considerable  time.    The  limb 


DISEASES   OF   VEINS.  229 

should  be  kept  at  rest,  in  the  horizontal  position,  for  two  or  three  weeks,  according 
to  the  size  of  the  vein,  and  then  carefully  supported. 

In  the  majority  of  cases  all  that  can  be  done  is  to  caution  the  patient  against 
the  evil  effects  of  standing,  etc.  ;  maintain  the  general  health  l)y  means  of  tonics, 
combined  with  good  food,  Iresh  air,  and  a  fair  amount  of  e.xercise,  and  sujjply 
some  kind  of  sup])ort.  Silk  anklets,  elastic  stockings,  and  the  appliances  generally 
in  use  serve  the  i)uri)ose  for  which  they  are  intencled  very  ill ;  they  produce  the 
maximum  of  constriction  when  first  applied,  and  then  each  week  relax  more  and 
more  until  replaced  ;  they  are  usually  much  too  tight,  and  generally  cause  con.sider- 
able  wasting  of  the  muscles.  If  worn  once  the  limb  becomes  so  used  to  their 
pressure  that  the  patient  can  hardly  be  induced  to  leave  them  off.  Bandages  of 
thin  flannel,  domet,  or  perforated  rubber  are  much  better,  as  they  can  be  put  on 
with  just  sufficient  pressure  and  no  more,  instead  of  an  iron  rule  being  followed  in 
all  cases  alike. 

Upward  friction  and  massage  should  be  practiced  every  night  when  the  ap- 
pliance is  removed.  If  bleeding  threatens,  the  part  should  be  well  bandaged  and 
kept  at  rest ;  if  it  breaks  out  (the  usual  situation  is  the  lower  third  of  the  leg)  the 
limb  must  be  raised  at  once.  The  hemorrhage  is  exceedingly  profuse,  but  it  comes 
from  the  proximal  or  cardiac  end,  and  raising  the  limb  stops  it  instantaneously.  If 
inflammation  sets  in  and  the  veins  become  hard  and  painful,  showing  that  they  are 
filled  with  clots,  the  patient  should  be  confined  to  bed,  the  limb  placed  in  a  slant- 
ing position  on  a  leg  rest,  and' covered  with  lead  lotion. 

2.  Radical. — In  a  certain  number  of  cases  the  radical  cure  may  be  tried. 
As  a  rule,  it  is  only  advisable  where  the  superficial  veins  are  concerned,  and  where 
the  part  involved  is  limited  in  extent.  Sometimes,  however,  it  is  beneficial  in 
cases  of  varicose  ulcer,  in  which  the  persistence  of  the  sore  appears  to  be  depen- 
dent upon  the  vein.  I  have  known  an  ulcer  heal  while  the  patient  was  in  bed 
recovering  from  the  operation,  and  remain  sound  for  fifteen  years  afterward, 
although  previously  it  was  always  relapsing. 

The  choice  lies  between  acupressure  (with  or  without  subcutaneous  division), 
ligature,  and  excision. 

(a)  Acupressure. — This  is  performed  by  passing  a  flat  needle  beneath  the  vein, 
while  it  is  pinched  up  with  the  finger  and  thumb,  and  then  twasting  a  figure-of- 
eight  suture  over  the  ends,  protecting  the  skin  beneath  by  means  of  a  piece  of 
bougie  or  quill.  The  needles  should  be  about  three-quarters  of  an  inch  apart,  and 
the  vein  may  be  divided  subcutaneously  with  a  tenotomy-knife  between  them. 
They  should  not  be  left  in  for  more  than  a  week,  and  if  any  inflammation  occurs 
this  time  should  be  shortened.  Failure  is  not  infrequent  and  there  is  always  the 
risk  of  transfixing  the  vein. 

(/i)  Ligature. — A  small  incision  is  made  over  the  vessel,  an  aneurysm-needle 
passed  round  it  and  threaded  with  catgut.  The  ligature  left  when  the  needle  is 
withdrawn  is  tied  and  the  ends  cut  short.  This  method  may  be  combined  with 
the  former,  ligatures  being  placed  in  the  intervals  between  the  pins. 

((t)  Excision. — This  is  by  far  the  most  effective  method,  but  it  is  only  suited 
to  a  very  limited  number  of  cases.  The  skin  is  reflected  from  off  the  vein,  the 
incision  being  as  far  as  possible  longitudinal  ;  the  vessel  is  carefully  isolated  from 
the  surrounding  tissue,  a  double  ligature  (catgut)  is  placed  round  it  at  each  end 
and  round  each  branch,  and  the  whole  intervening  portion  excised.  Where  any 
great  length  of  vein  is  involved  this  is,  of  course,  impossible,  but  the  comparatively 
isolated  bunches  of  veins  that  are  frequently  met  with  on  the  inner  side  of  the 
lower  third  of  the  thigh  and  leg  can  often  be  treated  very  satisfactorily. 

Thrombosis. 

A  thrombus  is  a  clot  that  develops  inside  the  heart  or  one  of  the  vessels  dur- 
ing life.  It  is  distinguished  from  a  post-mortem  coagulum  by  the  fact  that  it  is 
drier,  harder,  less  elastic,  and  distinctly  adherent  to  the  interior. 


2  30    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Red  thrombi  are  formed  in  stagnant  blood,  white  ones  in  that  which  is  still 
circulating.  The  former  are  uniform  all  through,  the  latter  are  built  up  in  strata, 
some  of  which  are  more  colored  than  others.  \'ery  often  the  two  occur  side  by 
side,  a  white  one  forming  first  and  gradually  blocking  up  the  pas.sage  until  suddenly 
coagulation  becomes  complete. 

Causes. — Thrombosis  is  due  either  to  some  alteration  in  the  wall  of  the 
vessel,  to  .some  change  in  the  blood,  or  to  both  causes  together.  It  occurs  chiefly 
in  those  parts  in  which  the  circulation  is  most  feeble,  beginning,  for  example,  in 
the  dilatations  of  varicose  veins,  or  behind  valves  ;  where,  on  the  other  hand,  the 
stream  is  rapid  and  forcible,  as  in  the  central  part  of  an  aneurysm,  it  may  be 
delayed  for  a  great  length  of  time. 

{a)  The  least  change  in  the  condition  of  the  lining  membrane  is  sufficient, 
whether  due  to  injury,  inflammation,  or  degeneration.  The  blood-plates  are  de- 
posited at  once  upon  any  surface  that  is  not  perfectly  healthy,  and  then  the  fibrin 
begins  to  collect.  Foreign  bodies  introduced  into  the  blood-stream  naturally  cause 
this  at  once.  Stagnation  very  probably  acts  in  the  same  way.  In  typhoid,  ad- 
vanced phthisis,  and  other  exhausting  diseases  it  is  not  uncommon  for  clots  to 
form  quietly,  without  any  injury  or  inflammation,  in  the  veins  of  the  lower  ex- 
tremities. These  apparently  commence  behind  the  valves,  in  the  layer  of  blood 
that  under  such  conditions  remains  stagnant  there,  the  endothelium  of  the  lining 
membrane  losing  its  vitality  for  want  of  a  fresh  supply,  and  causing  the  blood  in 
contact  with  it  to  coagulate.  Very  possibly,  hoAvever,  in  these  conditions  the 
composition  of  the  blood  is  altered  too. 

{b")  It  is  an  undoubted  fact  that  certain  conditions  of  the  blood  greatly  favor 
coagulation,  and  also  that  certain  substances  introduced  into  the  blood  (includ- 
ing the  fluids  squeezed  from  some  of  the  organs  of  the  body)  cause  general  intra- 
vascular clotting,  but  the  extent  to  which  this  takes  place  in  disease  is  quite 
unknown.  In  various  forms  of  septic  poisoning  distant  thrombosis  is  not  uncom- 
mon, possibly  owing  to  the  destruction  of  blood-plates  or  colorless  corpuscles, 
especially  as  there  is  usually  at  the  same  time  failure  in  the  force  and  vigor  of  the 
circulation  ;  but  the  subject  requires  further  investigation. 

Thrombosis  in  arteries  is  rare  except  as  a  result  of  injury,  inflammation,  or 
atheroma  ;  in  veins,  on  the  other  hand,  it  is  exceedingly  common,  occurring  both 
as  a  primary  affection  and  secondary  to  injury  or  phlebitis  ;  in  capillaries  it  can 
only  occur  when  the  wall  of  the  vessel  is  gravely  injured  or  actually  killed. 

The  changes  that  thrombi  undergo  vary  according  to  their  locality  and  cause. 

Venous  thrombi  occasionally  continue  to  spread  toward  the  heart,  until  at 
length  they  meet  with  a  vessel  in  which  the  current  is  too  rapid.  In  this  way 
continuous  clots  of  immense  length  may  be  formed,  spreading  through  veins  of 
larger  and  larger  size,  until  at  last  the  rounded  end  projects  through  a  side  open- 
ing into  the  cavity  of  one  of  the  largest.  Here  it  may  stop  and  do  no  further 
harm,  or  it  may  be  broken  off  and  form  an  embolus,  or,  if  the  current  fails  in 
strength  from  any  cause,  it  may  reach  the  heart  itself.  This  is  especially  likely  to 
occur  when  they  originate  from  poisoned  wounds. 

1.  Resolution  is  not  uncommon.  Large  masses  of  coagulated  blood  may 
melt  away  and  disappear  within  twenty-four  hours,  as  is  seen  not  unfrequently  in 
the  rapid  cure  of  aneurysm  by  means  of  E.smarch's  bandage.  If  they  last  over  this 
they  are  usually  permanent.  What  becomes  of  the  clot,  how  it  vanishes,  is  not 
known  ;  of  course,  the  channel  is  completely  restored. 

2.  Organization. — This  takes  place  in  the  same  way  as  in  an  artery:  lymph 
pours  out  from  all  the  minute  vessels  around,  and  gradually  replaces  the  clot. 
Whether  the  endothelial  cells  or  the  white  corpuscles  in  the  circulating  blood  help 
or  not  is  uncertain.  Then  fresh  vessels  form  ;  fibroblasts  develop  along  their 
course,  and  gradually  the  clot  and  the  walls  of  the  vein  are  welded  together  into 
a  mass  of  fibrous  tissue.  In  many  cases  the  cavity  is  obliterated  ;  sometimes, 
however,  capillaries  communicating  with  the  lumen  of  the  vessel  above  and  below 
enlarge  and  form  a  direct  connection  again  ;  or  the  clot  shrinks  to  one  side  and 


DISEASES   OF   VEINS.  231 

leaves  part  of  the  channel  free.  At  any  rate,  it  is  not  unusual  to  find,  after  some 
long  period,  that  a  blocked  vein  becomes  pervious  again,  a  few  strands  of  fil)rous 
tissue  being  left  across  the  interior  or  clinging  to  one  side  of  it,  showing  the  fate 
of  the  obstruction.  In  the  case  of  aneurysms,  in  which  there  is  often  an  enormous 
thickness  of  laminated  clot,  organization  is  a  very  slow  proceeding,  accompanied 
by  shrinking  and  fatty  degeneration. 

3.  Degeneration. — Large  thrombi  in  the  interior  of  a  vein  gradually  become 
softer  and  softer  in  the  centre,  turning  from  red  to  yellow,  and  yellow  to  white, 
until  they  are  filled  with  a  fluid  at  first  sight  not  unlike  pus,  but  in  reality  con- 
sisting merely  of  ca.seating  debris.  The  outer  walls  in  contact  with  the  still  circu- 
lating blood  usually  form  a  firm  casing  ;  occasionally  they  break  down,  and  then 
the  liquid  contents  are  poured  into  the  blood-stream,  causing  minute  embolisms, 
and  the  thrombus  is  said  to  be  canalized. 

Sometimes,  especially  in  the  case  of  the  small  thrombi  forming  behind  the 
valves  in  veins  and  in  the  prostatic  plexus,  calcareous  degeneration  occurs 
instead,  and  what  are  known  as  phleboliths  are  formed — small  rounded  and 
often  i^edunculated  masses,  enclosed  in  a  fibrous  sheath,  and  consisting  mainly 
of  phosphate  of  lime,  with  small  quantities  of  sulphate  of  lime  and  of  potash. 

4.  Infective  softening. — If  the  micrococci  of  suppuration  gain  access  to  the 
clot,  either  through  a  local  wound,  through  the  wall  of  the  ves.sel,  or  through  the 
circulating  blood,  it  becomes  .soft  and  breaks  down  into  a  fluid  apparently  of  the 
same  character,  but  in  reality  altogether  different.  Each  fragment  of  the  blood 
that  enters  into  the  current  carries  with  it  the  germs  of  suppuration  ;  wherever  it 
becomes  impacted,  it  cuts  off  the  blood-supply,  lowers  the  vitality  of  the  tissues 
and  renders  them  incapable  of  resisting  the  assault  of  the  organisms  it  has  brought 
with  it  :  in  other  words,  each  embolus  becomes  the  starting-point  of  a  pysemic 
abscess. 

Consequences.— I .  Inflammation. — Every  thrombus  causes  a  certain  degree 
of  inflammation  of  the  wall,  so  that  if  the  vessel  is  superficial,  the  skin  over  it 
becomes  red  and  tender  and  the  soft  cellular  tissue  around  infiltrated  with  lymph. 
If  the  cause  is  not  an  infective  one,  this  ends  in  organization  and  repair,  clearing 
up  as  the  thrombus  does  ;  if,  on  the  other  hand,  it  is  infective,  suppurative  arteritis 
or  phlebitis  follo^vs,  as  the  case  may  be. 

2.  Obstructiofi. — This  differs  very  much  according  to  the  size  and  importance 
of  the  vessel.  In  the  case  of  an  artery  the  pulse  ceases  at  once  and  the  limb  below 
becomes  pale,  numbed,  and  powerless  ;  even  gangrene  may  set  in  (the  dry  form) 
if  the  collateral  circulation  is  not  good.  When  a  comparatively  small  vein  is 
involved,  there  is  little  or  no  difficulty  to  the  return  of  blood,  owing  to  the  free 
anastomosis  in  most  parts  of  the  body  ;  but  when  it  is  an  important  one,  such  as 
the  ilio-femoral,  and  any  length  of  it  is  obstructed,  the  consequences  may  be  very 
serious.  This  is  of  common  occurrence  after  parturition  (phlegmasia  alba  dolens) 
[and  sometimes  after  fractures  of  the  leg]  ;  the  limb  becomes  tense,  white,  and 
painful,  the  vein  can  be  felt  as  a  hard,  knotted  cord,  and  the  weight  is  so  great  that 
the  patient  can  hardly  move  the  part.  Sometimes  this  clears  up  within  a  very  short 
time,  the  clot  apparently  melting  away.  More  frequently  recovery  is  only  partial ; 
the  thrombus  becomes  organized,  and  either  shrinks  to  the  wall  of  the  vessel,  or 
is  perforated  by  small  anastomotic  veinlets,  so  that  the  channel  is  opened  up  again 
more  or  less  completely.  Occasionally  it  persists  without  yielding  at  all,  and  then, 
especially  if  the  lymphatics  are  involved  as  well,  a  condition  of  what  is  known  as 
solid  oedema  sets  in,  often  ending  in  what  is  practically  elephantiasis.  The  skin 
and  the  cellular  tissue  become  enormously  and  irregularly  thickened  by  the  growth 
of  fibrous  tissue,  the  natural  texture  of  the  part  is  lost,  and  the  weight  ma}-  be 
so  great  that  the  patient  is  almost  unable  to  lift  it. 

In  cases  in  which  the  anastomotic  circulation  is  more  free,  as  when  the 
interior  vena  cava  is  obstructed  by  a  thrombus,  the  collateral  veins  become 
hypertrophied,  so  that  the  skin  over  the  front  and  sides  of  the  abdomen  is 
covered  with  great,  tortuous   masses.      At   first,  perhaps,  this  compensates,  but 


232    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

when  the  obstructed  vein  is  as  important  as  the  one  mentioned,  it  rarely  suffices 
for  long,  dilatation  soon  begins,  the  limbs  become  cedematous  and  swollen,  the 
nutrition  fails,  and  chronic  ulcers  appear. 

Finally,  if  spreading  thrombosis  occurs  over  a  large  area  and  involves  the 
orifices  of  collateral  branches,  moist  gangrene  is  very  likely  to  ensue. 

3.  Embolism  has  been  already  mentioned  as  one  of  the  remote  consequences 
of  thrombosis.  It  nearly  always  originates  from  venous  thrombi  and  affects  first 
the  pulmonary  circulation,  but  it  may  originate  in  the  portal  system.  The  conse- 
quences depend  upon  the  size  and  the  nature  of  the  embolus. 

Embolism. 

Embolism  is  the  impaction  in  some  part  of  the  blood-stream  of  a  substance 
which  from  its  size  or  nature  cannot  be  driven  further ;  the  substance  itself  is  an 
embolus. 

Emboli  are  derived  from  many  different  sources.  A  fragment  of  a  thrombus 
is  one  of  the  most  common.  An  end  may  be  bodily  torn  off,  especially  if  it 
projects  through  a  side  opening  into  the  cavity  of  a  larger  vein  ;  or  the  whole 
clot  may  undergo  decay  and  disintegration,  so  that  a  mass  of  soft  debris  is  dis- 
charged into  the  circulation  at  once.  Vegetations  are  occasionally  swept  off  from 
the  cardiac  valves,  or  calcareous  or  caseous  fragments  from  an  atheromatous  ulcer. 
Malignant  growths  (especially  carcinomata)  sometimes  perforate  the  walls  of  veins 
and  sprout  into  the  interior.  Abscesses,  whether  due  to  pyogenic  or  tubercular 
organisms,  may  do  the  same,  the  coats  of  the  vessel  gradually  softening  until 
the  endothelium  ruptures  without  any  protecting  thrombus  having  been  formed. 
Liquid  fat  is  often  forced  in  the  blood-stream  in  cases  of  fracture,  and  in 
exceptional  instances  many  other  substances,  even  parasites,  find  their  way  in. 

Embolism  may  occur  either  in  the  systemic  or  the  pulmonary  arteries,  or  in 
the  portal  vein,  the  embolus  originating,  as  a  rule,  in  the  venous  system  or  the 
heart,  and,  of  course,  following  the  direction  of  the  circulation.  Wherever  it 
originates,  it  is  swept. along  until  it  meets  with  some  vessel  too  small  for  it  to  pass 
through.  Usually  this  corresponds  to  the  point  of  bifurcation.  Then,  if  it  is 
liquid,  it  splits  up  into  finer  ones  ;  if  soft  and  yielding,  like  a  recent  clot,  it 
moulds  itself  to  the  interior  ;  and  if  hard  and  rigid  it  becomes  fixed  and  completes 
the  obstruction  by  causing  coagulation  around. 

The  immediate  result  is  to  stop  the  current  through  that  branch.  How  this 
affects  the  area  it  supplies  depends  upon  the  size  and  nature  of  the  embolus  and 
the  perfection  of  the  collateral  circulation. 

Instant  death  may,  of  course,  ensue  if  one  of  the  large  branches  of  the 
pulmonary  artery  is  blocked,  or  the  middle  cerebral.  In  other  cases,  however, 
every  attempt  is  made  to  keep  up  the  full  supply  of  blood  through  the  collateral 
branches. 

a.  If  these  are  fairly  abundant  and  healthy,  so  that  dilatation  is  possible,  no 
ill  result  ensues  ;  there  is  a  temporary  blanching  of  the  part,  the  pulse  fails  below 
and  it  feels  cold  and  numb,  but  this  soon  passes  off  and  is  followed  by  transient 
hypereemia,  in  which  all  the  vessels  share.  Later  this  general  enlargement  of  the 
collateral  supply  gradually  narrows  itself  down  to  one  or  two  of  the  shortest  and 
straightest  routes,  and  everything  is  restored  to  its  natural  condition. 

/;.  If,  on  the  other  hand,  either  dilatation  is  impossible,  or — as,  for  example,  in 
the  case  of  the  retina — there  is  no  collateral  circulation,  the  part  gradually  becomes 
starved  out  and  dies.  If  it  is  in  the  interior  of  the  body  it  undergoes  fatty 
degeneration  ;  if  it  is  on  one  of  the  extremities,  dry  gangrene. 

r.  In  certain  organs  (the  lungs  and  kidneys  in  particular)  what  is  known  as 
infarction  occurs.  The  collateral  circulation  is  not  sufficiently  good  to  maintain 
the  full  blood-jjressure,  but  yet  is  developed  to  a  certain  extent  ;  the  blood  pours 
into  the  anaemic  area(t'.  ^. ,  from  the  capsular  vessels  in  the  kidney)  with  sufficient 
strength  to  fill  the  capillaries,  but   not  sufficient   to   maintain   its  course.     As  a 


DISEASES   OF   VEINS.  233 

result  all  the  minute  vessels  become  engorged,  stasis  sets  in,  the  walls  of  the  capil- 
laries perish,  the  red  blood-cori)uscles  i)ass  through  and  fill  all  the  interstices,  and 
practically,  at  length,  the  whole  area  is  absolutely  solid  with  blood,  forming  what 
is  known  as  a  hemorrhagic  infarct.  In  the  lungs  this  is  seen  in  its  most  charac- 
teristic form,  a  conical  mass  of  tissue,  black  and  hard  ;  the  base  of  the  cone 
abutting  in  the  pleura,  the  apex  corresponding  to  the  embolus,  and  the  size 
depending  upon  that  of  the  blocked  vessel.  In  the  case  of  an  ordinary  non- 
infective  embolus  this  slowly  undergoes  fatty  degeneration,  a  zone  of  hyperaemia 
forming  round  it,  and  the  lymph-corpuscles  invading  it  from  the  exterior,  and 
quietly  absorbing  it  until  nothing  but  a  depressed  cicatrix  is  left. 

The  effect  of  an  embolus,  however,  depends  not  only  upon  its  size  and  the 
arrangement  of  the  blood-vessels,  but  upon  its  nature.  So  long  as  it  is  absolutely 
imirritating  (the  fragment,  for  example,  of  a  simple  thrombus),  the  inflammation 
it  excites  is  merely  sufficient  to  cause  organization  of  the  clot  that  forms  round  it 
and  seal  it  to  the  side.  In  ulcerative  endocarditis,  however,  the  vegetations  that 
are  detached  from  the  valves  are  often  so  irritating  that  the  walls  of  the  arteries  in 
which  they  are  impacted  become  soft  and  yield  before  the  blood-pressure,  so  that  an 
aneurysm  is  formed.  And  in  suppurative  phlebitis,  when  pyogenic  micro-organisms 
have  gained  access  to  the  interior  of  the  clot,  and  have  caused  it  to  break  down 
into  a  puriform  infective  fluid,  the  consequences  are  more  serious  still.  Wherever 
the  debris  is  carried,  it  brings  with  it  infective  germs,  which  find  in  the  engorged 
and  lifeless  mass  of  tissue  the  soil  that  suits  them  best ;  as  a  result,  the  whole  affected 
area  melts  away  at  once  into  the  most  intensely  infective  pus,  and  a  true  pya^mic 
abscess  is  developed. 

Inflammation  of  Veins. 

Inflammation  of  veins  may  begin  either  in  the  tissues  round  (periphlebitis) 
or  in  the  interior  from  the  endothelial  surface.  It  is  nearly  always  acute ;  the 
chronic  form,  corresponding  to  the  atheromatous  degeneration  of  arteries,  is 
seldom  met  with  except  in  the  thick-walled  dilatations  of  varicose  veins,  and, 
owing  to  the  difference  in  the  blood-pressure,  does  not  possess  the  same  degree 
of  significance. 

I.   Simple  Acute  Phlebitis. 

This  is  due  either  to  injury  (ligature,  contusion,  etc.),  the  presence  of  a  throm- 
bus, or  to  some  morbid  condition  of  the  blood,  of  which  gout,  rheumatism,  and 
syphilis  are  the  best  known.  If  a  thrombus  is  not  already  present,  one  is  formed 
as  soon  as  the  inflammation  begins  to  affect  the  endothelial  lining. 

The  changes  that  take  place  are  those  already  described  in  thrombosis  ;  the 
wall  of  the  vein  becomes  thickened,  softened,  and  more  vascular,  a  greater  amount 
of  lymph  is  poured  out,  the  endothelium  changes  in  appearance,  though  whether 
it  takes  an  active  share  in  the  production  of  the  exudation  is  not  known,  and  the 
thrombus  itself,  the  coats  of  the  vein,  and  the  tissues  around  it  are  infiltrated  with 
masses  of  lymph-corpuscles.  The  effect  is  the  same  whether  the  thrombus  is 
primary  and  the  cause  of  the  inflammation,  or  whether  it  is  secondary,  the  attack 
beginning  from  the  outside  as  periphlebitis. 

As  soon  as  the  irritation  subsides  the  lymph  is  in  part  absorbed  and  in  part 
converted  into  fibrous  tissue.  The  thrombus,  as  already  described,  may  either  be 
absorbed,  undergo  organization,  or  decay  in  the  centre  and  ultimately  be  canalized. 
Sometimes  the  cavity  of  the  vein  is  restored  completely,  more  frequently  it  is 
obliterated  for  a  time,  and  then  subsequently,  as  the  clot  is  organized  or  canalized, 
regains  its  normal  shape  and  size  to  a  greater  or  less  extent. 

Symptoms. — When  the  vein  is  superficial  it  can  be  felt  as  a  hard,  knotted 
cord,  standing  out  under  the  skin  and  surrounded  by  inflamed  cellular  tissue.  It 
is  exceedingly  tender  to  the  touch,  but,  unless  the  periphlebitis  is  very  acute,  and 
the  vein  quite  under  the  surface  (as  in  the  case  of  a  varicose  internal  saphena)  the 
skin  is  seldom  much  reddened.  There  is  often  a  very  considerable  degree  of  pain 
and  stiffness,  especially  on  movement,  or  when  the  limb  is  allowed  to  hang  down  ; 
16 


234    niSEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

and  sometimes  there  is  very  considerable  constitutional  disturbance.  In  the  case 
of  the  deeper  veins  the  diagnosis  chiefly  rests  upon  the  deep-seated  hardness  and 
tenderness,  the  peculiarly  clumsy  appearance  of  the  part,  the  sense  of  weight  and 
pain  when  the  limb  is  allowed  to  hang  down,  the  relief  as  soon  as  it  is  raised,  and 
the  evident  distention  of  the  more  superficial  vessels.  (Generally  a  certain  amount 
of  superficial  cedema  can  be  detected  on  the  distal  side  of  the  obstruction,  round 
the  malleoli,  for  example,  in  cases  of  phlebitis  of  the  deep  veins  of  the  leg. 

Gouty,  rheumatic,  and  syphilitic  phlebitis  can  only  be  distinguished  by  the 
other  symptoms  that  accompany  these  disorders ;  they  have  no  certain  distinctive 
character  of  their  own,  although  the  gouty  variety  is  occasionally  metastatic.  They 
all  have  a  decided  tendency  to  symmetry,  they  affect  the  superficial  veins  rather 
than  the  deep  ones,  and  the  lower  limbs  much  more  frequently  than  the  upper. 
Recurrence  is  exceedingly  common  in  the  gouty  variety,  and  may  continue  in  the 
syphilitic  form  all  through  the  secondary  period,  but  it  is  seldom  that  permanent 
obliteration  is  caused  by  either. 

Treatment. — Rest  is  absolutely  essential  until  at  least  all  trace  of  inflamma- 
tion and  tenderness  has  disappeared.  Serious  extension  of  the  thrombus  and 
detachment  of  outlying  fragments,  causing  embolism,  are  rare  accidents,  consid- 
ering the  very  large  number  of  cases  of  phlebitis  of  varicose  veins  of  the  leg,  but 
they  do  happen  occasionally,  and  every  precaution  must  be  taken  to  avoid  them. 

Elevation  is  no  less  essential  for  the  sake  of  the  return  circulation  and  to 
relieve  tension.  Cold  lead  lotion,  as  a  rule,  causes  the  inflammation  to  subside 
within  a  few  days ;  but  in  cases  of  gout,  and  where  the  arteries  are  atheromatous, 
belladonna  (equal  parts  of  the  extract  and  glycerine)  and  warmth  should  be  used 
instead.  The  bowels  should  be  kept  well  open  ;  the  diet  should  be  light,  without 
stimulants,  and  if  there  is  any  evidence  of  gout,  rheumatism,  or  syphilis,  appro- 
priate remedies  should  be  employed. 

Afterward,  when  all  the  inflammation  has  subsided,  the  patient  may  be  allowed 
to  get  about  with  a  support,  and  if  the  leg  is  much  wasted,  or  has  a  tendency  to 
remain  cold  and  oedematous,  massage  may  be  used  to  improve  the  circulation. 

2.   Suppurative  Phlebitis. 

This,  too,  may  originate  either  as  a  periphlebitis  or  in  the  interior.  Examples 
of  the  former  are  often  seen  in  diffuse  inflammation  of  the  cellular  tissue ;  the 
pyogenic  organisms  rapidly  destroy  the  coats  of  the  veins,  spreading  along  the 
loose  cellular  tissue  round  them,  and  causing  them  to  slough  or  melt  away  into  the 
purulent  fluid  that  fills  up  every  interstice.  As  the  endothelium  is  approached 
coagulation  takes  place,  and  although  the  thrombus  shares  the  fate  of  all  the  rest 
of  the  structures,  fortunately,  in  the  vast  majority  of  cases,  it  extends  sufficiently 
far  and  sufficiently  rapid  to  act  as  a  barrier  and  prevent  the  poison  spreading  far 
and  wide  in  the  circulation.  If  it  fails,  or  if  it  is  broken  down,  general  pyeemia 
is  almost  certain.  This  is  of  common  occurrence  in  acute  suppurative  osteomye- 
litis, and  in  otitis  media,  infective  inflammation  with  thrombosis,  spreading  along 
the  coats  of  the  veins  into  larger  and  larger  trunks,  until  at  length  the  puriform 
clot  that  fills  the  vessel  gives  way  and  is  scattered  all  over  the  body,  causing 
metastatic  abscesses  wherever  it  comes. 

Acute  spreading  phlebitis  of  the  same  character,  and  ending  in  embolic 
pyaemia  in  the  same  way,  may  begin  in  the  interior  of  a  vein  as  well  as  round  it. 
This,  of  course,  unless  pyaemia  has  already  developed,  can  only  take  place  after 
the  cavity  of  the  vein  has  been  opened.  Usually,  under  these  circumstances,  the 
vessel  either  collapses  at  once  or  a  coagulum  forms  and  extends  up  to  the  next  set 
of  valves  or  the  next  large  branch.  If,  however,  septic  decomposition  sets  in 
before  organization  has  taken  place,  and  lends  its  aid  to  the  micrococci  of  suppu- 
ration, the  clot  melts  away  at  once  into  an  infective  puriform  fluid,  and  there  is 
every  chance  of  a  widespread  distribution  of  infective  emboli  all  over  the  body, 
even  before  the  rest  of  the  tissues  succumb  or  the  diffuse  cellulitis  assumes  alarm- 
ing proportions. 


ANEURYSM. 


235 


SECTION  111— ANEURYSM. 

An  aneurysm  is  a  circumscribed  tumor  developed  in  connection  with  the 
interior  of  an  artery,  and  containing  either  fluid  or  coagulated  blood. 

Aneurysms  have  been  classified  in  various  ways  :  by  their  cause  (traumatic  and 
idiopathic,  or  spontaneous)  ;  by  their  shape  (fusiform,  sacculated,  and  dissecting), 
and  by  the  share  the  wall  of  the  vessel  takes  in  their  construction  (true  and  false). 
Some  of  these  distinctions  are  very  important. 

All  aneurysms  are  in  a  certain  sense  of  the  term  traumatic,  due  either  to  one 
single  sudden  strain  or  to  the  continued  effect  of  slighter  ones ;  but  the  term 
traumatic  aneurysm  is  reserved  for  those  cases  in  which  a  perfectly  healthy  artery 
has  been  injured  in  some  accident,  and  either  the  wall,  or  the  cicatrix,  or  the 
coagulum  that  closed  the  wound,  has  expanded  into  a  sac.  There  is  a  very  great 
difference  in  the  matter  of  prognosis  and  treatment  between  this  variety  and  the 
so-called  idiopathic  or  spontaneous  on^,  in  great  measure,  if  not  entirely,  the  result 
of  disease. 

The  terms  j-ar^z/Az/^^/ and ///x//(?r;«  almost  explain  themselves;  the  former  is 
applied  to  those  cases  in  which  a  pouch  is  developed  from  one  side  of  an  artery  ; 
the  latter  to  those  in  which  the  whole  circumference  of  the  artery  is  stretched  more 
or  less.  As,  for  example,  in  aneurysms  of  the  arch  of  the  aorta,  no  distinct  line  can 
be  drawn  between  the  two,  or  between  the  latter  and  what  is  known  as  aneurysmal 
dilatation.  Dissecting  aneurysm,  on  the  other  hand,  is  a  very  distinct  variety  ;  it 
can  only  occur  in  the  larger  arteries,  and  results  from  an  early  rupture  of  an  athero- 
matous abscess  in  the  wall.  If  this  occurs  before  the  coats  are  welded  together 
by  inflammatory  exudation,  the  blood  may  make  its  way  down  between  the  lavers 
of  the  wall  for  long  distances,  and  ultimately  break  either  into  the  interior  again 
or  outside.  In  the  former  case  it  may  give  rise,  for  a  short  distance,  to  the  appear- 
ance of  a  double  aorta. 

Aneurysms  used  to  be  described  as  true,  when  all  the  coats  of  the  artery  were 
to  be  traced  in  the  wall,  or,  according  to  others,  when  one  of  them  could  be.  This, 
of  course,  is  only  possible  when  the  aneurysm  is  fusiform  in  shape  or  exceedingly 
small  in  size,  and  the  distinction  is  not  worth  maintaining. 

An  aneurysm  sometimes  ruptures,  suddenly  or  gradually,  producing  the 
same  effect  as  if  the  artery  had  given  way — an  arterial  haematoma.  A  diffuse 
aneurysm  is  a  contradiction. 

Idiopathic  or  Spontaneous  Aneurysm. 

Idiopathic  aneurysm  is  due  to  the  yielding  of  a  weakened  part  of  a  vessel 
under  the  influence  of  the  blood-pressure. 

Causes. — (a)  All  forms  of  inflammation  predispose  to  aneurysm  by  the  way 
in  which  they  weaken  the  wall  of  the  vessel.  Atheroma  is  the  most  common, 
especially  in  its  earlier  stages,  when  the  muscular  coat  is  infiltrated  with  lymph  and 
weakened,  without  as  yet  any  considerable  degree  of  degeneration.  If  at  a  later 
period  the  floor  of  one  of  the  ulcers  yields  and  gives  way,  the  adventitia  is  usually 
sufficiently  thickened  by  that  time  to  render  it  secure.  Dissecting  aneurysm  must, 
of  course,  be  due  to  atheroma.  Embolism  is  not  infrequent,  especially  in  young 
subjects,  not  because  of  the  obstniction  it  causes  (for  then  aneurysm  would 
frequently  follow  ligature),  but  owing  to  the  softening  and  inflammation  of  the 
vessel  at  the  injured  spot.  In  other  cases  it  is  a  form  oi  peri-arteritis.  either 
syphilitic,  as  in  the  vessels  at  the  base  of  the  brain,  or  suppurative,  when,  for 
example,  small  aneurysms  form  on  branches  of  the  pulmonary  artery  in  the  wall  of 
phthisical  cavities. 


236    DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 

{p)  Injury  acts  both  as  a  predisposing  and  an  exciting  cause.  Its  effects  are 
best  seen  in  the  case  of  the  popliteal,  the  inner  and  middle  coats  of  which,  even 
when  it  is  healthy,  maybe  ruptured  by  over-extension  of  the  knee.  Probably  one 
reason  why  aneurysms  are  so  common  in  this  artery  is  that  even  when  this  does  not 
take  place,  the  walls  are  ea.sily  injured  in  the  constant  and  violent  flexion  and 
extension  to  which  they  are  subjected.  In  a  few  instances  an  aneurvsm  has 
developed  in  an  artery  that  has  been  subjected  to  long-continued  compression. 

{/)  The  immediate  cause  is  the  blood-pressure.  If  the  coats  of  an  artery  are 
weakened  by  injury  or  inflammation,  they  gradually  yield  before  it,  especially  if  it 
is  raised  by  hypertrophy  of  the  left  ventricle.  Bright' s  disease,  chronic  alcoholism; 
plethora,  or  other  causes.  In  many  instances  the  first  commencement  of  an 
aneurysm  is  traced  to  some  sudden  exertion,  which  either,  as  in  the  popliteal, 
directly  ruptures  one  or  more  of  the  coats  of  the  vessel  by  over-extension,  or  pro- 
duces practically  the  same  result  by  the  immense  increase  in  the  blood  pressure 
that  attends  sudden  and  violent  muscular  efforts. 

This  serves  to  explain  why  aneurysms  are  so  much  more  common  in  men  than 
in  women  (with  the  exception  of  those  of  the  carotid,  which  are  equally  frequent 
in  both),  and  particularly  among  those  who  are  exposed  to  sudden  strains.  Further, 
it  gives  a  satisfactory  reason  for  the  extreme  frequency  with  which  the  popliteal 
artery  and  the  arch  of  the  aorta  suffer  in  comparison  with  others. 

Aneurysms  are  most  common  between  thirty  and  fifty  years  of  age,  when  the 
arteries  are  diseased,  and  the  heart  and  the  muscular  system  have  not  lost  their 
vigor.  Soldiers  and  sailors  are  especially  liable  to  them,  partly  from  their  occupa- 
tion, partly,  perhaps,  because  of  syphilis,  although  the  share  that  this  takes  in  the 
development  of  aneurysm  is  probably  not  a  large  one. 

[The  influence  of  climate  is  a  constant  but  as  yet  imperfectly  understood 
factor  in  the  production  of  aneurysm.] 

Mode  of  Formation. — Fusiform  and  dissecting  aneurysms  are  only  met 
with  in  connection  with  the  largest  arteries.  The  former  are  caused  by  a  uniform 
expansion  of  all  the  coats,  so  that  the  cavity  of  the  vessel  is  increased  in  diameter 
and  somewhat  lengthened.  The  outer  coat  usually  becomes  thickened  and 
strengthened  by  the  addition  of  fibrous  tissue  formed  from  the  lymph  that  is 
poured  out  in  its  interstices ;  the  inner  may  be  unaltered,  although  it  is  usually  in 
a  more  or  less  advanced  stage  of  atheroma ;  while  the  middle  always  degenerates, 
the  muscular  fibres  becoming  further  and  further  separated  from  each  other  and 
ultimately  disappearing  altogether.  Dissecting  aneurysm,  which,  singularly  enough, 
is  more  common  in  women  than  in  men,  is  rare  at  all  times,  and  is  only  met  with 
in  the  aorta. 

Sacculated  aneurysm  may  arise  by  itself  from  the  side  of  a  vessel,  or  as  a 
further  development  from  a  weakened  spot  in  the  wall  of  a  fusiform  one.  So  long 
as  it  is  small,  the  adventitia,  thickened  and  more  densely  fibrous  than  elsewhere, 
can  be  traced  over  it,  and  it  may  appear  to  be  still  lined  with  intima  ;  but  even  in 
small  ones  the  middle  coat  is  wanting,  and  in  those  of  moderate  size,  and  still 
more  in  large  ones,  no  distinction  of  coats  can  be  made  out  in  any  part.  The 
sac-wall  is  formed  of  fibrous  tissue,  partly  the  product  of  inflammation  excited  by 
the  constant  pressure,  partly  the  residue  of  the  structures  which  it  has  displaced, 
turned  on  one  side,  and  caused  to  atrophy.  Even  bone  and  cartilage  waste  away 
before  an  aneurysm,  but  as  they  resist  longer  than  most  other  structures,  portions 
of  them  are  occasionally  found  in  the  wall,  projecting  into  the  sac.  The  lining 
membrane  may  be  smooth  and  shining,  or  covered  with  calcareous  plates  and 
irregular  from  atheroma,  but  it  cannot  be  separated  from  the  fibrous  wall. 

Fusiform  aneurysms  rarely  contain  any  clot,  or,  at  the  most,  a  small  thrombus 
formed  upon  a  projecting  calcareous  plate.  Sacculated  ones,  on  the  other  hand, 
are  seldom  quite  empty  and  may  be  completely  filled.  It  varies  in  character  and 
appearance,  according  to  its  age,  and  whether  it  has  been  formed  from  stagnant  or 
circulating  blood.  The  oldest  part,  that  which  lines  the  sac  wall,  is  hard,  dense, 
and  yellowish-white  ;   inside  this  are  generally  many  layers,  more  or  less  coherent, 


ANEURYSM,  237 

some  colored  and  others  not.  but  less  firm  ;  and  inside  these  again  very  often  a 
loose,  soft,  and  recent  coagulum.  No  sharp  distinction  can  be  drawn  between 
them,  although  the  extremes  are  exceedingly  different.  The  one  is  known  as 
laminated  ox  active  clot,  containing  very  few  red  corpuscles.  As  the  blood  whirls 
round  in  the  interior  the  platelets  are  whipped  out  from  it  and  deposited  upon  the 
irregularities  of  the  surface  until  they  are  welded  together  into  a  coherent  mass  by 
the  fibrin  that  they  form.  This  is  repeated  again  and  again,  and  layer  after  layer 
is  thrown  down,  some  quite  colorless,  others,  when  the  circulation  is  slower,  con- 
taining a  few  red  corpuscles,  until  in  successful  cases  the  whole  interior  is  filled. 
Even  when  this  does  not  happen  the  wall  is  rendered  immensely  stronger  wherever 
the  layers  are  formed,  and  as  the  size  of  the  cavity  diminishes  the  expansive  power 
of  the  blood  pressure  diminishes  too. 

The  loose  red  coagulum  formed  from  stagnant  blood  is  called  in  distinction 
passive.  Its  behavior  is  always  very  uncertain  ;  sometimes  it  melts  away  and  dis- 
appears, so  that  an  aneurysm  that  felt  quite  solid  one  day  may  the  next  pulsate  as 
strongly  as  ever  ;  sometimes,  on  the  other  hand,  it  shrinks  and  becomes  organized, 
or  under  the  impact  of  the  blood  stream  is  flattened  out  into  a  colored  lamina.  It 
is  not,  therefore,  so  useless  as  its  name  implies.  The  future  destiny  of  the  lami- 
nated clot  cannot  be  regarded  as  certain.  The  white  corpuscles  it  contains  undergo 
fatty  degeneration  and  the  longer  it  lasts  the  thinner  and  harder  it  becomes,  until 
at  length  in  old  cases  it  disappears  altogether,  probably  undergoing  fatty  transforma- 
tion and  absorption.  There  is  no  proof  that  it  becomes  organized,  its  density  is 
too  great. 

Sacculated  aneurysms  may  attain  an  enormous  size ;  not  unfrequently  more 
than  one  is  present,  and  in  any  case  the  heart  and  every  artery  in  the  body  that  is 
accessible  should  be  carefully  examined  before  the  treatment  is  determined. 

Symptoms. — The  first  appearance  of  an  aneurysm  is  a  soft,  elastic,  circum- 
scribed, and  pulsating  swelling  in  the  course  of  one  of  the  large  arteries.  Its  fea- 
tures vary  according  to  the  amount  of  clot  it  contains.  At  first  it  is  filled  with 
fluid  blood,  but  by  degrees,  as  fibrin  is  deposited,  it  becomes  firmer  and  harder, 
until  at  length  in  some  cases  it  is  absolutely  solid,  and  presents  all  the  characters 
of  a  solid  growth.  The  pulsation  varies  in  the  same  way.  So  long  as  the  contents 
are  fluid  and  the  cavity  communicates  directly  with  an  artery,  this  is  characteris- 
tic ;  the  sac  becomes  tense  with  each  beat  of  the  heart  and  expands  in  all  direc- 
tions ;  it  is  not  merely  the  lifting  up  and  falling  down  of  the  ma.ss,  as  when  a  solid 
growth  rests  upon  the  wall  of  a  vessel,  it  is  an  expansile  pulsation,  and  this  pecu- 
liarity can  usually  be  recognized  at  once  by  placing  the  fingers  one  on  either  side 
of  it,  or  one  above  and  the  other  below.  As,  however,  it  becomes  solid  this  is 
lost.  At  first  there  may  be  some  pulsation  communicated  to  the  tumor  from  its 
resting  upon  the  artery  ;  but  even  this,  when  the  vessel  is  thrombosed,  disappears, 
and  it  remains  perfectly  motionless. 

The  difference  in  the  tension,  which  is  no  less  marked  a  feature,  depends  upon 
the  same  cause.  If  the  limb  is  raised,  the  artery  contracts,  and  so  long  as  the  con- 
tents are  fluid  the  pulsation  and  the  tension  in  the  sac  diminish  ;  if  it  is  allowed  to 
hang  down,  the  effect  is  just  the  reverse.  If  the  artery  is  compressed  upon  the 
cardiac  side  the  pulsation  ceases,  the  tumor  shrinks  in  size,  and  may  even  become 
perfectly  empty  and  collapse.  When  the  finger  is  raised,  it  fills  again  in  two  or 
three  beats,  expanding  forcibly  in  all  directions. 

In  nearly  all  cases,  so  long  as  the  blood  circulates  through  the  cavity,  a  bruit 
is  heard  all  over  the  tumor,  synchronous  with  the  beat  of  the  heart,  and  very  often 
a  thrill  is  felt.  These,  of  course,  vary  very  greatly,  not  only  in  different  cases,  but 
at  different  times  in  the  same,  as  they  depend  upon  the  position  of  the  orifice  and 
the  amount  and  situation  of  the  laminated  clot  deposited  inside.  Care  must  be 
taken  in  investigating  this  not  to  compress  the  artery  against  a  subjacent  bone,  as 
a  distinct  bruit  can  be  caused  in  this  way  even  when  the  vessel  is  perfectly 
healthy. 

In  internal  aneurysm,  on  the  other  hand,  or  where  the  tumor  is  inaccessible, 


238    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

these  signs  may  Ijc  wanting  altogether,  and  then  the  diagnosis  must  be  made  i)artly 
from  the  effect  upon  tlie  pulse,  partly  from  the  pressure  sym])toms. 

The  pulse  in  the  parts  below  is  always  modified,  the  force  of  the  heart  is  lost 
in  stretching  the  sac,  and  little  or  none  of  this  is  returned,  owing  to  the  absence 
of  elastic  recoil.  If  the  aneurysm  is  a  large  one,  especially  if  it  is  near  the  centre 
of  the  circulation,  compensative  hypertrophy  of  the  left  ventricle  sets  in  ;  if  it  is 
further  away  the  collateral  circulation  enlarges,  but  in  any  case  the  pulse  below  is 
wanting  in  strength,  the  sphygmographic  tracing  shows  the  wave  is  lower  and  less 
marked,  and  the  tissues  beyond  are  ill  supplied  with  blood.  In  some  instances  the 
wasting  and  loss  of  strength  produced  in  this  way  are  ver)^  characteristic. 

An  aneurysm,  by  its  immense  and  constantly  varying  pressure,  always  causes  a 
certain  degree  of  inflammation  in  the  tissues  around.  In  most  cases  this  is  merely 
sufficient  to  develop  the  fibrous  capsule,  but  sometimes,  especially  in  the  axilla  and 
the  groin,  where  the  enlargement  is  very  rapid,  suppuration  sets  in,  and  the  whole 
sac  sloughs  out.  In  addition,  it  often  gives  rise  to  very  important  signs  by  the  way 
in  which  it  interferes  with  the  structures  near  it.  Bones  are  absorbed,  being  hol- 
lowed out  or  perforated,  as  in  the  case  of  the  sternum,  without  of  necessity  a  trace 
of  inflammation  ;  cartilages  are  treated  in  the  same  way,  although  the)-  resist  longer  ; 
muscles  become  reduced  to  flattened,  fibrous  bands  ;  veins  are  obliterated  ;  nerves 
stretched  and  expanded  into  ribands,  and  in  certain  situations  other  organs,  such 
as  the  oesophagus,  trachea,  or  thoracic  duct,  compressed  and  prevented  from  work- 
ing. The  symptoms  caused  in  this  way  are  naturally  of  the  most  varied  character. 
Intense  neuralgic  pain,  referred  to  the  distribution  of  the  nerves  and  worse  at 
night,  is  one  of  the  most  common  ;  spasmodic  contraction,  paralysis,  wasting, 
hyperaesthesia,  and  alteration  in  the  electric  reaction  may  occur.  The  sympathetic 
in  the  neck  may  be  pressed  upon,  causing  vaso-motor  and  pupillary  changes.  The 
recurrent  laryngeal  maybe  paralyzed,  giving  rise  to  a  peculiar  and  most  significant 
tone  of  cough.  There  may  be  the  most  intense  pain  from  pressure  upon  the  cords 
of  the  brachial  plexus.  In  short,  there  is  scarcely  a  symptom  due  to  nerve  irrita- 
tion or  compression  that  does  not  occur  sometimes  in  connection  with  aneurysm. 
Immense  congestion,  with  dilatation  of  the  veins,  redema,  and  even  moist  gan- 
grene may  be  caused  by  pressure  upon  one  of  the  great  venous  trunks.  Dyspnoea 
and  dysphagia  may  occur  from  partial  occlusion  of  the  trachea  or  oesophagus.  And 
even  in  some  very  rare  cases  the  artery  itself  may  be  so  compressed  by  the  aneurysm 
springing  from  it  as  to  cut  off  the  circulation  through  it,  and  so  effect  a  permanent 
cure. 

Progress  and  Termination. — Aneurysms,  especially  fusiform  ones,  that 
partake  rather  of  the  character  of  aneurysmal  dilatation,  and  those  which  occur  in 
old  people  who  lead  (luiet  lives,  occasionally  last  for  many  years  unchanged. 
This,  however,  is  exceptional ;  as  a  rule,  if  left  to  themselves  they  either  undergo 
spontaneous  cure  or  prove  fatal  from  rupture  of  the  sac,  suppuration,  pressure  upon 
some  important  organ,  or,  especially  in  the  case  of  large  thoracic  ones,  syncope. 

I.  Spontaneous  cure  may  be  produced  in  various  ways. 

{a)  The  sac  may  gradually  be  filled  with  laminated  clot,  until  at  length  the 
artery  itself  is  occluded,  or  there  is  merely  a  narrow  channel  left,  running  down 
through  the  centre  of  the  tumor.  A  certain  amount  of  active  clot  is  present  in  all 
cases  of  sacculated  aneurysm,  forming,  as  it  were,  in  the  eddies  of  the  blood-stream  ; 
if  this  is  diverted  from  time  to  time  into  different  directions,  so  as  to  fill  up  one 
part  after  another,  or  if  the  circulation  through  it  is  rendered  very  slow  and 
uniform  by  some  accident,  such  as  the  development  of  the  collateral  circulation, 
the  pressure  of  the  aneurysm  upon  the  artery  above,  or  the  formation  of  a  fresh 
aneurysm  upon  the  same  trunk  higher  up,  it  sometimes  happens  that  the  whole  sac 
is  obliterated  and  cure  effected  (Fig.  52). 

When  this  occurs  the  tumor  becomes  smaller  and  harder,  the  characteristic 
expansile  pulsation  ceases,  although,  so  long  as  the  artery  is  unobliterated  it  may 
be  lifted  up  and  down  with  each  beat,  and  the  bruit  and  thrill  disappear.  At  the 
same  time  the  collateral  vessels  can  sometimes  be  detected  ;  and  not  unfrequently 


ANEURYSM. 


239 


their  enlargement  is  attended  witli  a  certain  amount  of  aching  pain.  Finally,  the 
whole  sac  shrinks  to  a  small,  hard  nodule,  sessile  upon  the  artery. 

(/')  The  distal  orifice  of  the  sac  may  he  suddenly  ])lugged  by  a  detached  frag- 
ment of  clot.  In  this  case  the  aneurysm  rapidly  becomes  filled  with  stagnant 
blood,  which  coagulates,  forming  a  loose,  soft  clot,  and  then  gradually  shrinks 
under  the  pressure  e.xerted  upon  it  by  the  displaced  tissues  around.  If  the  coagulum 
extends  into  the  orifice  of  the  artery,  the  cure  is  likely  to  be  permanent,  organiza- 
tion taking  place  in  that  part  of  the  recent  clot  which  is  in  contact  with  the  intima 
of  the  vessel,  the  rest  being  ultimately  absorbed. 

Rapid  cure  of  this  kind  is  usually  attended  with  a  severe  degree  of  pain  for  a 
short  time,  the  limb  feeling  exceedingly  tense  and  full,  and  the  part  beyond  cold 
and  numbed.  Ultimately  the  collateral  circulation  enlarges  and  the  sac  shrinks 
up  as  before. 

((•)  Suppuration  may  occur.  The  loose  cellular  tissue  round  the  sac  becomes 
more  and  more  inflamed  ;  the  outline  of  the  tumor  disappears  ;  the  skin  over  it 
becomes  hot,  red,  and  cedematous  ;   the  size  of  the  part  increases  rapidly;  there  is 


a.  The  cut  edge  of  the 
arterial  coats  where 
healthy. 

aa.  The  coats  in  the 
diseased  and  occluded 
part  of  the  artery.  Their 
substance  is  dispersed 
and  blended  with  the 
new  fibrous  tissue,  b, 
which  fills  the  vessel,  yet 
not  so  much  diffused  but 
that  they  can  still  be 
traced  to  the  mouth  of 
the  aneurysm  (opposite 
the  upperc). 

c.  The  aneurysm  sac, 
composed  of  laminated 
clot  and  compressed  tis- 
sue welded  together  in- 
definitely. 

d.  Scarcely  laminated 
clot,  filling  the  hollow  of 
the  sac. 

The  vein,  with  two 
valves  in  its  lower  part, 
is  seen  close  behind  the 
artery . 


Fig.  52. — Section  through  an  Aneurysm  of  the  Popliteal  Artery,  Cured  nearly  two  years  before  by 
Digital  Pressure.  The  aneurysm  is  not  dissected  out,  but  left  embedded  in  the  popliteal  fat,  e,  e. 
The  arterj'  is  occluded  with  the  aneurj-sm. 


intense,  throbbing  pain,  with  high  fever,  and  then  suddenly  the  skin  gives  way  over 
it,  and  pus  mixed  with  sloughing  shreds  of  fibrin,  chocolate-colored  masses  of  the 
broken-down  blood-clot,  and  perhaps  fresh  arterial  blood,  pours  out.  Suppuration 
has  taken  place  round  the  aneurysm  and  it  has  sloughed.  If  the  walls  of  the  artery 
above  and  lielow  have  been  able  to  resist  the  action  of  the  pyogenic  micrococci, 
and  form  and  organize  a  thrombus  in  their  interior,  hemorrhage  may  never  occur 
and  the  cure  may  be  permanent ;  if,  on  the  other  hand,  as  too  frequently  hajipens 
under  the.se  circumstances,  the  nutrition  of  the  tissue  fails,  organization  lags  behind, 
the  clot  softens  and  melts  away  under  the  influence  of  the  blood-pressure,  and  the 
gush  of  arterial  blood  may  prove  instantaneously  fatal. 

2.  Enlargement. — The  pressure  in  the  interior  of  an  aneurysm  increases  in 
proportion  to  its  cubic  contents.  Partly  for  this  reason,  partly,  perhaps,  because 
after  a  certain  time  the  tissues  round  it  resist  less  well,  it  is  not  uncommon  to  find, 
after  it  has  reached  a  certain  size,  that  the  rate  of  growth  becomes  much  more 
rapid  and  the  wall  exceedingly  thin.  In  these  circumstances,  if  it  does  not  prove 
fatal  from  syncope,  suppuration,  or  pressure  upon  some  organ  essential  to  life, 
rujiture  occurs  sooner  or  later. 


240    DISEASES  AND  INJURES  OF  SPECIAL  STRUCTURES. 

The  way  in  which  this  takes  place  and  the  symptoms  to  which  it  gives  rise 
vary  with  the  situation.  Hemorrhage  into  a  serous  sac  is  usually  rapidly  fatal,  a 
great  stellate  opening  forming  and  admitting  a  full  rush  of  blood.  When  it  occurs 
on  a  mucous  surface,  on  the  other  hand,  days  may  pass  before  the  final  outburst, 
the  orifice  being  very  minute  and  becoming  plugged  with  a  coagulum  which  only 
allows  a  certain  amount  of  leakage  from  time  to  time.  Rupture  on  the  cutaneous 
surface  is  still  more  rare,  unless  preceded  by  inflammation  and  suppuration.  The 
tumor  may  render  the  skin  red,  tense,  and  shining,  or  may  even  raise  the  epidermis 
up  in  the  form  of  a  blister,  so  that  bloody  serum  soaks  through  and  forms  a  scab 
on  the  surface  ;  but  unless  suppuration  occurs,  or  a  slough  is  formed,  external 
hemorrhage  is,  comparatively  speaking,  a  rare  form  of  death.  In  the  majority  of 
cases  of  rupture  the  sac  gives  way  subcutaneously,  and  the  blood  is  extravasated  into 
the  cellular  tissue.  A  small  amount  usually  escapes  at  first,  causing  some  increase 
in  the  size  of  the  tumor,  then  it  coagulates  and  forms  a  wall  around  itself.  After 
this  it  may  remain  quiet  for  several  days,  or  may  cause  suppuration,  or  may,  in 
very  exceptional  instances,  lead  to  the  development  of  a  new  and  stronger  sac. 
More  frequently  it  is  only  the  prelude  to  a  more  extensive  hemorrhage  which  pours 
in  all  directions  into  the  cellular  tissue  around,  causing  the  most  intense  pain,  and 
leading  to  complete  cessation  of  the  circulation  in  all  the  parts  below.  The  patient 
may  faint  at  once  and  become  collapsed,  partly  from  the  loss  of  blood,  partly  from 
the  shock  and  pain  ;  the  limb  beyond  becomes  cold,  oedematous,  and  pulseless ; 
the  region  of  the  aneurysm  is  immensely  distended  ;  all  bruit  and  pulsation  disap- 
pear, and  if  speedy  steps  are  not  taken  moist  gangrene  is  inevitable.  An  aneurysm 
that  is  enlarging  very  rapidly,  especially  in  one  direction,  is  sometimes  described 
as  leaking  ;  either  the  sac  has  already  given  way,  or  it  is  in  imminent  danger  of 
doing  so,  and  there  is  the  greatest  risk  that  actual  rupture,  which  in  an  aneurysm 
of  any  size  is  hopeless  so  far  as  the  limb  is  concerned,  and  always  places  life  in 
very  serious  jeopardy,  may  occur  at  any  moment. 

In  the  case  of  ruptured  popliteal  aneurysm,  the  appearance  of  the  limb  is  not 
unlike  that  produced  by  deep-seated  suppuration  ;  the  skin  all  round  the  back  of 
the  joint  is  red,  tense,  and  oedematous  on  pressure,  and  the  pain  is  most  acute  and 
throbbing,  and  the  history  may  be  that  of  a  rapidly  forming  abscess ;  but  the 
cessation  of  the  circulation  in  the  limb  below,  the  coldness  and  oedema  of  the  part, 
and  the  loss  of  sensibility  in  the  toes,  point  unmistakably  to  some  grave  interrup- 
tion in  the  blood-supply.     Moist  gangrene  in  such  cases  is  inevitable. 

Diagnosis. — i.   In  its  earlier  stages,  while  it  still  pulsates. 

{a)  Aneurysm  may  occasionally  be  confounded  with  a  form  of  aneurysmal 
dilatation  chiefly  met  with  in  the  innominate  and  the  abdominal  aorta  in  young 
women.  The  dilatation  and  the  pulsation  are  often  exceedingly  well-marked,  but 
the  age  and  sex,  the  effects  of  tonics,  especially  iron,  and  the  evidence  of  other 
nerve  troubles  are  usually  sufficient  to  make  the  diagnosis  certain  at  once.  As  the 
dilatation  disappears  again  completely  there  can  be  no  serious  morbid  lesion  in  the 
wall  of  the  vessel. 

{F)  Fluid  tumors,  bursee,  hydatid  and  other  cysts,  and  chronic  abscesses  in  the 
neighborhood  of  large  arteries  or  on  their  walls  occasionally  present  great  dilifi- 
culty.  If,  however,  they  pulsate  they  do  not  expand  in  the  way  that  an  aneurysm 
does,  and  though  they  contain  fluid  they  cannot  be  even  partially  emptied  by 
pressure  upon  them.  A  bruit  or  thrill  is  exceptional,  though  it  may  be  produced 
if  the  artery  is  compressed  or  bent  irregularly. 

{/)  Pulsating  sarcomata  are  usually  found  in  early  life  or  in  localities  in  which 
aneurysm  is  either  very  rare  or  practically  unknown,  and  even  when  they  do  grow 
from  such  places  as  the  back  of  the  knee  joint  the  diagnosis  is  seldom  difficult. 
The  pulsation  is  not  expansile  ;  the  bruit,  when  there  is  one,  can  only  be  heard 
over  a  limited  area  ;  the  tumor  cannot  be  emptied  either  by  direct  pressure  or  by 
compression  of  the  artery  above,  and  even  if  it  can  be  reduced  in  size,  it  refills 
slowly,  not  with  the  rapid  bound  of  an  empty  aneurysmal  sac.  In  some  instances, 
however,    when    the    tumor    is    intra-pelvic,    a    positive    statement    is    often    im- 


ANEURYSM.  241 

possible  without  examining   the  case  more  than  once  and  watching  the  manner 
of  its  growth. 

2.  Aneurysms  that  do  not  pulsate,  whether  this  arises  from  their  being  already 
filled  with  laminated  clot  or  from  some  peculiar  anatomical  relation  to  the  artery 
from  which  they  spring,  are  exceedingly  difficult.  All  the  ordinary  signs  fail  com- 
pletely, there  is  no  pulsation  or  bruit,  the  tumor  cannot  be  emptied,  it  lies  in  the 
region  of  an  artery,  but  it  cannot  be  separated  from  it  or  lifted  off  it.  In  short, 
in  all  such  a  most  guarded  opinion  must  be  given  until  the  case  has  been  watched 
some  little  time.  If  it  is  a  cured  aneurysm  it  will  slowly  tend  to  become 
smaller  and  smaller ;  if  it  is  not  cured,  but  merely  prevented  pulsating  by  some 
accidental  condition,  it  will  either  cure  itself  or  some  day  pulsation  will  suddenly 
make  its  appearance. 

3.  Ruptured  and  suppurating  aneurysms  can  usually  be  recognized  by  the 
complete  and  sudden  obstruction  to  the  circulation  in  the  part  below.  Even  if  no 
history  can  be  obtained,  the  coldness  of  the  distal  portions,  the  oedema,  numbness, 
and  cessation  of  the  pulse,  should  at  once  arouse  suspicion.  In  any  case  of  doubt 
the  introduction  of  a  grooved  needle  can  do  no  harm,  but  both  the  patient  and  the 
oj^erator  must  be  prepared  for  any  measure  that  is  necessary.  Suppuration  may  be 
distinguished  from  simple  rupture  by  the  intensity  of  the  local  signs  of  inflamma- 
tion. 

Treatment. — Aneurysms  may  be  treated  in  many  different  ways,  according 
to  the  conditions  under  which  they  are  placed,  but  the  idea  is  the  same  in  all,  to 
bring  about  one  or  other  of  those  changes  by  which  spontaneous  cure  is  effected, 
viz.,  the  deposit  of  laminated  clot,  the  rapid  coagulation  of  the  contents  of  the  sac, 
or  the  exclusion  of  the  aneurysm  from  the  circulation,  as  in  suppuration. 

I.  The  Deposit  of  Laminated  Clot. 

This  may  be  accomplished  either  by  increasing  the  amount  of  fibrin  in  the 
blood,  or  by  rendering  the  circulation  through  the  sac  as  slow  and  as  uniform  as 
possible.  Of  these  two  the  first  is  at  present  entirely  beyond  our  power ;  nothing 
is  known  that  can  increase  or  diminish  the  amount  of  fibrin  without  at  the  same 
time  causing  even  more  serious  changes,  and  it  must  be  remembered  that  an  increase 
in  the  quantity  of  fibrin  is  not  the  same  thing  as  increasing  the  readiness  to  coag- 
ulate. 

The  circulation  through  the  sac  may  be  controlled  by  constitutional  or  local 
measures,  or  by  both  together. 

{a)  Constitutional  Treatment. — Rest,  in  the  recumbent  position,  is  of  the 
utmost  importance  ;  it  lessens  the  force  of  the  heart-beat,  reduces  its  frequency, 
and  keeps  it  uniform.  The  sudden  enlargement  of  an  aneurysmal  sac  can  often  be 
traced  directly  to  some  comparatively  trivial  exertion. 

The  diet  must  be  restricted.  In  many  instances  it  is  of  advantage  to  adopt 
Tufnell's  system.  The  patient  is  placed  on  a  well-made  hair  mattress,  with  a  water 
cushion,  and  forbidden  to  raise  hand  or  foot  for  any  reason.  The  diet  is  reduced 
to  eight  ounces  of  solids  and  six  of  fluids  per  diem  (six  ounces  of  bread  with  a  little 
butter,  two  of  meat,  and  six  of  milk),  and  is  maintained  at  this  level  for  some 
weeks.  The  patient,  of  course,  becomes  extremely  emaciated  and  feeble  (it  is 
necessary  to  take  great  care  that  he  does  not  catch  cold),  but  the  number  of  heart- 
beats can  be  reduced  to  forty-two  or  forty-four  in  the  minute  ;  and  not  unfrequently 
it  happens  while  this  is  going  on  that,  owing  to  the  slowness  of  the  current  in  the 
aneurysm,  many  fresh  layers  are  deposited  on  its  wall.  Moreover,  the  improvement 
is  not  only  maintained,  but  often  becomes  much  more  marked  when  the  diet  is 
gradually  raised  again.  In  patients  who  are  feeble  and  anaemic  already,  this,  of 
course,  is  not  advisable.  Not  unfrequently  with  them  a  more  generous  diet,  com- 
bined with  iron,  reduces  the  frequency  of  the  heart-beat,  although  it  may  some- 
what increase  the  force ;  stimulants,  however,  should  always  be  avoided. 

The  bowels  must  be  kept  well  open  ;   if  the  arterial  tension  is  high,  repeated 


-42    DISEASES  AND  IXJ CRIES  OF  SPECIAL  STRUCTURES. 

saline  purges  are  recommended,  and  even  venesection.  Opium  is  of  great  use  in 
controlling  pain  and  procuring  sleep.  Other  drugs  are  recommended  from  time  to 
time,  but  it  is  difficult  to  show  that  any  improvement  that  takes  place  during  their 
administration  is  actually  the  result  of  their  influence.  Iodide  of  potash,  for  ex- 
ample, has  a  distinct  effect  upon  the  blood-pressure,  and  relieves  the  nocturnal 
bone-pain  so  common  in  some  forms  of  internal  aneurysm,  and,  moreover,  is  some- 
times of  benefit  when  there  is  a  decided  history  of  syphilis  :  but  it  certainly  tends 
to  diminish  the  coagulability  of  the  blood.  [Post-mortem  dissection  has 
shown  the  consolidation  of  the  contents  of  the  aneurysmal  sac  too  frequently  to 
admit  of  a  doubt  that  potassium  iodide  does  exercise  a  materially  curative  effect 
on  the  larger  aneurysms.]  Digitalis  may  modify  the  action  of  the  heart,  but  it 
also  tends  to  raise  the  arterial  pressure.  Aconite  and  belladonna  may  be  given 
with  better  reason.  There  is  no  proof  that  either  ergot  or  acetate  of  lead  has  the 
least  effect. 

(b)  Local  Treatment. — The  simplest  method  is  to  raise  the  part  if  it  is  one  of 
the  limbs,  bandage  it.  and  apply  gentle  pressure  over  the  tumor.  This,  however, 
is  rarely  enough,  except  in  the  case  of  the  anterior  tibial  or  other  small  vessels. 
Sometimes  these  are  injured  in  fractures,  and  then  an  aneurysm  may  develop  and 
be  cured  while  the  patient  is  lying  in  bed  with  his  limb  in  splints.  Whatever 
method  is  finally  adopted,  bandaging  and  elevation  always  form  part. 

I.  Compression  of  the  Main  Artery  on  the  Cardiac  Side. — This  may  be  digital 
or  instrumental  :  in  either  case  the  object  is  to  diminish  the  stream  of  blood  flow- 
ing through,  so  that  the  fibrin  may  be  deposited  on  the  walls.  It  is  not  necessary 
to  occlude  the  artery  completely,  all  that  is  required  is  to  prevent  pulsation  in  the 
sac  ,:  and  this  is  especially  to  be  remembered,  as  many  cases  in  which  this  plan  has 
failed  have  been  given  up  because  the  patient  would  no  longer  stand  the  pain,  and 
in  one  or  two  inflammation  of  the  wall  has  been  caused,  and  a  second  aneurysm 
has  developed  later  on. 

The  patient  must  be  placed  in  a  comfortable  position,  and  the  skin  .shaved  and 
powdered  well  with  French  chalk.  Digital  compression  is  to  be  preferred  wherever 
it  is  possible,  but  it  can  only  be  carried  out  where  the  artery  is  superficial  and  rests 
against  a  bone,  as  in  the  case  of  the  femoral  at  Poupart's  ligament,  and  at  least 
three  people  are  required.  Two  fingers  should  be  placed  upon  the  vessel,  care 
being  taken  not  to  include  the  vein,  and  a  weight  of  about  four  pounds  (suspended 
by  a  pulley  from  somewhere  overhead)  allowed  to  come  down  and  rest  upon  the 
dorsum  of  the  last  two  phalanges.  Pressure,  carried  out  simply  by  muscular  exer- 
tion, is  exceedingly  exhausting,  and  can  only  be  kept  up  for  a  short  time.  With 
the  aid  of  a  weight  it  can  be  maintained  with  perfect  uniformity  for  half  an  hour 
without  changing  and  without  fatigue.  When  a  change  is  made,  the  vessel  should 
be  secured  above  or  below  with  the  other  hand,  so  that  no  pulsation  can  take  place 
in  the  aneurysm,  and  the  grasp  should  not  be  relaxed  until  the  new-comer  is  certain 
that  he  has  secured  the  vessel.  One  hand  should  be  kept  upon  the  aneurysm  the 
whole  time,  to  make  sure  that  there  is  no  pulsation.  The  number  of  hours  this 
treatment  has  to  be  maintained  depends  a  great  deal  upon  the  thoroughness  with 
which  it  is  carried  out.  Usually  compression  is  continuous  for  the  first  twelve  or 
fifteen  hours.  If  the  tumor  l:)ecomes  solid  in  that  time  it  is  probably  filled  to  some 
extent  with  laminated  fibrin,  but  much  more  with  recent  soft  coagulum,  and  the 
limb  must  be  elevated  and  firmly  bandaged  with  a  compress  over  the  whole  length 
of  the  artery  for  twenty-four  hours  more,  for  fear  of  the  contents  being  washed 
out  again.  At  the  end  of  that  time  it  is  fairly  safe,  although  no  precaution  may 
be  relaxed  until  the  tumor  has  begun  to  diminish  distinctly.  If  no  change  is  de- 
tected, it  should  be  left  for  a  few  days  and  simply  bandaged  :  perha])s  at  the  end 
of  that  time  a  certain  amount  of  fibrin  will  have  been  laid  down  and  it  is  certainly 
better  to  allow  the  patient  time  to  rest.  Even  when  every  precaution  is  taken  con- 
tinuous compression  becomes  very  painful,  especially  if  there  are  any  enlarged 
glands  round  or  near  the  vessel.  At  the  end  of  a  week  a  second  attempt  may  be 
made,  following  the  same   plan,  or  shorter  sittings  may  be   tried  for  four  or  six 


ANEURYSM. 


243 


hours  a  day,  until  the  cure  is  complete.  When  this  is  successful,  the  fibrin  is 
deposited  in  laminx,  but  it  may  be  a  week  before  there  is  any  distinct  solidifica- 
tion. If  it  ha.s  been  tried  well  and  it  does  not  succeed  at  the  end  of  that  time  it 
should  be  given  uj). 

Instrumental  compression  is  carried  out  on  the  same  plan,  chiefly  with  Carte's 
tourniquet,  which  has  the  advantage  over  others  of  greater  elasticity  of  pressure 
and  of  a  double  pad,  so  that  the  point  of  compression  can  be  varied  without  moving 
the  instrument.  In  some  parts  of  the  body  (the  abdominal  aorta,  for  example) 
only  instrumental  compression  is  possible  ;  but  in  most,  if  it  can  be  managed,  the 
digital  plan  is  to  be  preferred  as  less  likely  to  injure  the  artery  and  more  easy  to 
adjust. 

Opium  is  not  unfrequently  required  to  allay  irritability  and  to  procure  sleep. 
Sometimes,  as  in  the  case  of  the  abdominal  aorta,  an  anesthetic  is  necessary.  If 
compression  fails  or  the  patient  will  stand  it  no  longer,  the  artery  must  be  tied, 
but  not  at  the  spot  at  which  it  has  been  compressed,  for  in  all  probability  the  coats 
of  the  vessel  are  somewhat  thickened  there,  and  perhaps  matted  together  by  adhe- 
sive inflammation.  It  appears  from  statistics  that  ligature  after  compre.ssion  is  not 
so  favorable  as  immediate  ligature — what  this  may  be  due  to  is  not  certain  ;  there 
is  no  doubt  that  the  collateral  circulation  enlarges  from  the  effect  of  continued 
pressure,  and  that  this,  while  it  checks  the  tendency  to  gangrene,  at  the  same  time 
maintains,  perhaps  too  well,  the  current  through  the  sac  ;  but  it  must  be  remem- 
bered that  the  cases  are  not  like  fresh  ones,  they  have  already  failed  once. 

Compression  is  the  plan  of  widest  and  most  general  application  ;  it  avoids 
the  necessity  for  a  wound  and  the  risk  of  secondary  hemorrhage ;  but  it  can  only 
be  employed  in  certain  cases  (fortunately,  the  majority)  ;  it  must  never  be  used 
where,  from  the  presence  of  oedema  or  venous  engorgement,  there  is  reason  to  fear 
obstruction  to  or  pressure  upon  the  main  vein  of  a  limb,  or  where  the  sac  is  enlarg- 
ing rapidly  and  in  danger  of  rupture;  and  it  must  be  admitted  that  sometimes, 
perhaps  from  want  of  intelligence  on  the  part  of  the  patient,  it  is  exceedingly 
difficult  to  carry  out  thoroughly. 

2.  Ligature  of  the  Artery  on  the  Cardiae  Side,  at  a  Distattce from  the  Aneurysm  ; 
the  Hunterian  Operatio7i. — The  object  is  to 
allow  a  slow  stream  of  blood  to  flow  through 
the  sac  and  deposit  layers  of  fibrin  upon 
the  walls,  not  to  cut  off  the  circulation 
completely,  and  fill  the  cavity  with  a  loose, 
soft  coagulum.  Additional  advantages  of 
ligature  at  a  distance  from  the  sac  over 
ligature  close  to  it  are  that  the  operation  is 
easier,  the  best  part  of  the  vessel  being 
selected ;  that  the  artery  is  much  more 
likely  to  be  healthy  ;  that  the  sac  is  less 
interfered  with,  so  that  there  is  less  risk  of 
suppuration  ;  and  that  the  collateral  circu- 
lation is  likely  to  be  better,  and  the  danger 
of  gangrene  less. 

The  immediate  effect  of  tightening 
the  ligature  is  to  stop  the  pulsation  in  the 
aneurysm.  The  blood  pressure  begins  to 
fall  at  once,  the  tissues  around  resume 
their  normal  position,  the  tumor  diminishes 
in  size,  and  its  outline  becomes  less  distinct, 
■when  compression  has  been  tried  before  ligature,  and  the  collateral  circulation  is 
already  established,  coagulation  does  not  take  place  at  once;  the  current  is  not 
shut  off  completely  :  from  the  first  it  flows  through  in  a  gentle,  continuous  stream, 
and  under  its  influence  fibrin  is  deposited  in  layers  on  the  wall  until  the  sac  is 
filled  and  the  artery  blocked  above  and  below.     In  some  cases  slight  but  distinct 


Anel's 


Hunter's.         Brasdor's.     Wardrop's. 


Fig.  53. — Diagram  Showing  the  Different 
Operations  for  Aneurysm. 


In  most  cases,  however,  especially 


244    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


m 


w^ 


pulsation  can  be  detected,  the  stream  is  so  strong  ;  not,  as  a  rule,  for  two  or  three 
days  after  the  operation — not,  that  is  to  say,  until  the  collateral  vessels  are 
thoroughly  expanded ;  then  growing  more  and  more  marked, 
and  finally,  as  the  walls  become  thicker,  fading  away  again. 
In  a  successful  case  the  sac  diminishes  in  size,  until  at  the 
end  of  three  or  four  weeks  it  is  small,  shrunken,  and  hard. 
The  artery  is  obliterated  at  the  seat  of  ligature,  and  again 
opposite  the  aneurysm  ;  in  between  it  not  unfrequently  re- 
mains pervious  (Fig.  54). 

After  the  operation  the  patient  should  be  placed  in  bed 
with  the  limb  arranged  in  an  easy  position,  wrapped  in 
cotton-wool  and  slightly  raised.  It  may  be  surrounded  with 
^j.  hot-water  bottles,  but  none  should  touch  it.  Ligature  is 
liable  to  certain  risks  from  which  compression  is  more  or  less 
exempt. 

\d)  Secondary  hemorrhage  may  occur,  or  the  ligature 
mav  give  way,  or  soften  prematurely,  leaving  an  artery 
bruised  and  partly  divided,  exposed  to  the  full  effects  of 
the  blood-stream.  Not  unfrequently,  in  spite  of  careful 
selection,  it  is  very  difficult  to  make  sure  of  finding  a  part 
of  the  artery  that  is  absolutely  healthy. 

(J})  Pulsation  may  return,  either  from  some  aberrant 
branch  or  because  of  the  development  of  the  collateral  circu- 
lation. If  this  is  only  slight  it  need  not  excite  alarm,  but 
if  it  continues,  and  particularly  if  after  lasting  four  or  five  days 
it  becomes  more  marked,  the  prospect  is  not  good.  Some- 
times, even  then,  if  the  limb  is  kept  carefully  bandaged  it 
subsides  of  itself ;  but  if  it  does  not,  as  soon  as  the  wound 
in  the  artery  is  sound,  means  must  be  taken  to  make  the 
blood  that  is  in  the  sac  coagulate.  Probably,  if  other  things 
are  suitable,  Esmarch's  bandage  is  the  best ;  with  such  perfect 
development  of  the  collateral  vessels  there  can  be  little  fear 
of  gangrene  ;  in  other  cases  flexion,  pressure  on  the  artery 
^'  between  the  aneurysm  and  the  seat  of  ligature,  or  above  the 
latter  point,  and  possibly  even  ligature  of  the  artery  higher 
up,  may  be  required.  Amputation  is  the  last  resource  if  the 
sac  continues  to  increase  in  size  and  threatens  to  give  way. 

{c)  Gangrene  may  occur.  The  aneurysm  itself  is  no 
inconsiderable  obstruction,  although,  if  it  has  formed  slowly, 
the  collateral  supply  round  it  has  usually  had  time  to  enlarge  ; 
the  tissues  beyond  are  frequently  ill-nourished,  the  heart  is 
often  dilated  rather  than  hypertrophied,  and  the  vessels  in 
many  cases  are  atheromatous.  Ligature  of  the  main  trunk 
under  conditions  such  as  these  easily  leads  to  gangrene ;  and 
Fig.  54.— The  Femoral  and  if  the  vciu  is  prcsscd  upon  or  injured,  or  the  sac  has  begun 
to  leak,  or  there  is  any  inflammatory  cedema,  is  almost  sure 
to  do  so.  Usually  it  is  of  the  moist  variety  and  amputation 
is  inevitable ;  sometimes,  when  it  is  dry  and  very  slow  in  its 
course,  a  line  of  demarcation  forms,  and  only  a  part  of  the 
limb  is  lost. 

(d)  Suppuration  round  the  sac.     This  was  not  an  uncom- 

T^r  artrryTetween^ihe   ^0^  occurrence  whcu  the  artery  was  tied  near  the  aneurysm, 

ligature  and  the  sac  is   in  a  great  nicasure  owing  to  the  extent  of  the  manipulation. 

patent. -(Bowiby.)  Sometimes,  especially  when  the  sac  has  rapidly  enlarged,  or 

has  been  much  handled,  it  happens  even  when  the  operation 

is  performed  at  a  distance.     If  the  sac  has  ceased   pulsating  it  should  be  left  as 

long  as  possible  until  the  skin  shows  signs  of  giving  way  ;  with  good  fortune  the 


Popliteal  Vessels,  five 
years  after  ligature  of  the 
superficial  femoral  for  the 
cure  of  a  popliteal  aneu- 
rysm. The  vessel  has 
been  occluded  by  the 
ligature  at  a,  and  again 
at  the  seat  of  aneurj'sm. 
The  aneurj'sm  itself  is 
represented    by  a    small 


ANEURYSM.  245 

ends  of  the  artery  may  become  sealed,  and  turning  out  all  the  clots  would  only 
increase  the  chance  of  hemorrhage  by  opening  them  up  again.  If,  however, 
pulsation  continues,  there  is  no  hope  but  in  amputation,  plugging,  or  placing  a 
tournitjuet  upon  the  artery  higher  up,  laying  the  whole  open  from  one  end  to  the 
other,  turning  out  all  the  sloughs  and  broken-down  clot,  and  securing  everything 
that  bleeds  as  far  from  the  surface  of  the  wound  as  possible.  Afterward,  and  in 
any  case,  watch  must  be  kept  night  and  day  until  the  wound  is  healed. 

3.  Distal  Ligature  after  Wardrop'' s  Method. — This  is  ordinarily  classed  with 
Brasdor's,  and  as  a  matter  of  history  was  a  deduction  from  it,  but  there  is  an 
essential  difference  between  them.  In  Bra.sdor's  the  whole  circulation  is  cut  off, 
the  aneurysm  is  left  full  of  clot,  and  complete  obliteration  is  aimed  at.  In 
Wardrop' s  the  whole  circulation  is  not  cut  off,  large  branches  are  left  either 
between  the  seat  of  ligature  and  the  aneurysm  or  arising  from  the  sac  itself; 
and  these  branches  begin  at  once  to  increase  in  size,  so  that  whatever  benefit  is 
derived  from  the  operation,  and  in  some  instances  it  has  been  shown  to  be  very 
considerable,  it  cannot  be  due  to  immediate  obliteration  of  the  cavity. 

As  a  matter  of  practice  it  is  reserved  almost  entirely  for  aneurysms  at  the 
root  of  the  neck,  whether  springing  from  the  subclavian,  innominate,  or  aorta. 
The  benefit  some  of  those  springing  from  the  arch  itself  have  derived  is  very 
remarkable,  although  in  some  of  the  earlier  cases  the  operation  was  performed 
under  the  erroneous  impression  that  the  innominate  was  concerned.  As  at  first 
practiced,  the  carotid  and  subclavian  were  ligatured  simultaneously  with  a  view 
of  diminishing  the  amount  of  blood  flowing  through  ;  but  that  this  cannot  be  the 
correct  explanation  is  clear  from  the  fact  that  in  some  cases  as  much  benefit 
has  been  derived  from  ligature  of  the  left  carotid  only.  The  result  must  be 
due  either  to  a  coagulum  projecting  back  into  the  sac,  and  acting  as  a  nucleus  for 
the  deposit  of  laminated  fibrin,  or  to  the  fact  that  the  direction  of  the  stream  is 
changed  and  the  pressure  transferred  to  parts  which  not  only  have  not  been  so 
much  weakened,  but  which  even  may  have  been  strengthened  by  the  deposit  of 
fibrin  upon  them  while  they  were  lying  out  of  the  direct  flow.  Possibly  there  is 
something  to  be  said  for  both  views. 

II.   Rapid  Coagulation  of  the  Contents,   such   as  is  produced  naturally  zc>he?i   an 
embolus  is  dislodged  and  blocks  the  distal  orifice. 

The  natural  method  of  cure  may  be  imitated  in  many  ways,  with  varying 
success ;  but  with  the  exception  of  one  (the  use  of  Esmarch's  bandage)  it  is  only 
employed  under  special  conditions  when  ligature  or  compression  is  out  of  the  ques- 
tion.     Constitutional  treatment  must,  of  course,  be  maintained  at  the  same  time. 

I.  Esmarcli  s  Bandage  (Reid' s  Method). — The  aneurysm  is  filled  with  blood 
and  the  circulation  arrested  above  and  below. 

An  elastic  bandage  is  applied  to  the  distal  part  of  the  limb,  either  beginning 
at  the  end  and  carrpng  it  up  to  the  sac  or  leaving  the  fingers  or  toes,  as  the  case 
may  be,  and  commencing  only  a  short  distance  below.  The  sac  is  then  allowed  to 
fill,  the  bandage  either  carried  over  it  very  lightly  or  made  to  skip  it  altogether, 
and  applied  firmly  again  to  the  part  above.  If  there  is  not  sufficient  room,  an 
elastic  strap  may  be  used,  or  an  abdominal  tourniquet,  as  the  case  requires.  The 
bandage  is  usually  applied  for  about  two  hours  (I  have  known  half  an  hour  suc- 
cessful, but  this  was  a  very  exceptional  case)  and  then  digital  or  instrumental 
compression  kept  up  on  the  trunk  above  for  twelve  hours  more,  in  order  to  protect 
the  clot  at  the  entrance  of  the  vessel  from  the  impact  of  the  blood. 

In  a  successful  case  the  whole  of  the  sac  is  filled  with  a  coagulum  which 
extends  into  the  artery  and  occludes  it.  The  hope  is  that  this,  if  not  displaced, 
will  become  organized  where  it  is  in  contact  with  the  intima,  and  be  replaced  by 
fibrous  tissue ;  while  the  rest  of  the  coagulated  blood,  lying  out  of  the  current, 
will  either  be  absorbed  or  dry  up.     Possibly  it  may  become  organized  too. 

An  anaesthetic  is  absolutely  necessary  the  whole  time,  as  the  proceeding  is  very 


2  46    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

painful.  If  the  aneurysm  is  on  one  of  the  limbs,  this  should  be  raised  and  care- 
fully wrapped  with  cotton-wool  before  the  constriction  is  removed. 

The  chief  advantages  of  this  method  are  its  simplicity  and  rapidity.  It  suc- 
ceeds best,  naturally,  with  small  aneurysms  in  young  subjects  free  from  cardiac 
disease  or  extensive  atheroma,  and  should  not  be  used  for  large  ones  or  those  on 
the  point  of  rupture.  At  the  same  time  it  is  practically  the  only  plan  admissible 
for  some  aneurysms  of  the  abdominal  aorta  and  its  branches. 

Failure  is  not  infrequent,  the  aneurysm  appearing  perfectly  solid  when  the 
bandage  is  unwound,  but  becoming  completely  empty  by  the  next  day  in  spite  of 
the  precaution  of  pressure  upon  the  supplying  trunk.  If  this  happens  once  it  is 
nearly  sure  to  happen  a  second  and  a  third  time.  If,  on  the  other  hand,  the  coag- 
ulum  remains  firm  for  twenty-four  hours  the  cure  is  likely  to  be  permanent. 

A  considerable  amount  of  ecchymosis  is  often  noticed  round  the  sac,  but  it 
does  not  appear  that  there  is  any  unusual  danger  of  gangrene.  The  bandage  has 
been  kept  on  for  upward  of  three  hours  and  a  half  in  a  case  of  popliteal  aneurysm 
without  any  ill  effect.  Rupture  has  occurred  on  one  or  two  occasions  from  the 
tension  to  which  the  sac  has  been  subjected,  and  there  is  always  the  possibility,  if 
there  is  any  cardiac  disease  or  atheroma  of  neighboring  vessels,  of  throwing  too 
great  a  strain  upon  them,  but,  provided  the  cases  are  carefully  selected,  it  is  as 
safe  as  any  other  method. 

Where  it  is  possible  the  elastic  strap  tourniquet  should  be  avoided,  and  two 
or  three  turns  of  a  broad  rubber  bandage  made  round  the  part  instead  ;  the  sharp 
construction  of  a  rubber  band  has  l)efore  now  caused  paralysis  of  a  nerve  by  com- 
pressing it  against  a  subjacent  bone. 

The  other  methods  for  obtaining  rapid  coagulation  are  of  very  limited  appli- 
cation. 

2.  Manipulation. — An  attempt  is  made  to  detach  some  of  the  clot  from  the 
interior,  and  plug  the  distal  orifice  with  the  embolus,  as  in  the  natural  method. 
The  artery  should  be  compressed  upon  the  cardiac  side  during  the  manipulation. 
This  has  succeeded  in  a  few  instances  in  which  there  was  practically  no  alternative  ; 
but  it  should  never  be  tried  at  the  root  of  the  neck  if  there  is  the  least  suspicion 
that  the  carotid  is  involved. 

3.  Flexion. — Aneurysms  at  the  knee  and  elbow  may  be  compressed,  and  the 
pulsation  stopped  by  extreme  flexion  of  the  joint,  but  the  process  is  painful,  un- 
certain, and  only  advisable  under  special  circumstances,  when,  for  example,  pulsa- 
tion has  returned  after  ligature.  The  limb  must  be  bandaged  as  high  as  the 
aneurysm,  flexed  until  pulsation  ceases,  and  then  fixed  for  some  hours,  the  patient 
meanwhile  being  kept  under  the  influence  of  morphia.  Afterward  the  same  pre- 
caution must  be  adopted  as  in  Reid's  method. 

4.  Brasdor"  s  Operation  or  Distal  Ligature  of  Trunk  ivithout  Leaving  any  Lnter- 
ve?iing  Branch. — This  is  only  possible  in  aneurysm  of  the  root  of  the  common  caro- 
tid, all  other  large  arteries  having  too  many  branches.  The  cavity  is  filled  at  once,  as 
in  embolism,  but  the  blood-pressure  soon  falls  ;  the  tissues  around  expand  again, 
the  sac  diminishes  in  size,  and  the  blood  that  it  contains  probably  coagulates  at 
once.  Sometimes  the  coagulum  extends  down  into  it  from  the  seat  of  ligature. 
For  aneurysms  in  that  particular  situation  it  is  exceedingly  suitable. 

5.  Distal  compression  has  been  tried  in  imitation,  but,  except  in  a  few  an- 
eurysms of  the  abdominal  aorta,  it  is  of"  very  little  service.  It  throws  the  whole 
strain  upon  the  sac  without  anything  like  the  same  certainty  of  coagulation. 

6.  Introduction  of  Foreign  Bodies  into  the  Sac. — Of  these,  iron  wire  seems  to 
afford  the  best  prospect.  As  yet  it  has  only  been  used  in  desperate  cases  of  inter- 
nal aneurysm,  so  that  it  must  not  be  judged  too  harshly.  In  one  or  two  it  has 
been  partially  successful,  but  in  spite  of  this  it  cannot  be  recommended  until  all 
other  methods  have  been  exhausted. 

The  wire  must  be  sufficiently  fine  and  flexible  to  coil  up  in  the  interior  of  the 
sac  without  exerting  any  degree  of  internal  pressure  ;  and  especial  care  must  be 
taken  to  bury  the  ends  as  effectually  as  possible.     Usually  it  is  passed  in  through 


ANEURYSM.  247 

one  of  Southey's  trocars,  the  puncture  being  sealed  with  strong  carbolic  acid  or 
the  actual  cautery.  In  the  most  successful  case  (I.oreta's,  one  of  abdominal  an- 
eurysm, in  which  the  sac  became  consolidated  and  the  patient  lived  for  92  days 
afterward)  only  six  feet  were  employed,  and  probably  in  some  of  the  first  the 
amount  was  unnecessarily  great.  I' ndoul)tedly  it  causes  coagulation  of  the  blood, 
but  the  result  is  usually  fatal  from  rupture  of  the  sac  at  some  weak  spot,  or  from 
inflanmiation  set  up  by  the  necessary  manipulation. 

It  has  been  proposed  to  connect  the  wire  with  the  positive  pole  of  a  battery 
and  pass  a  continuous  current  through  ;  but  coagulation,  in  all  the  cases  yet  re- 
corded, appears  to  have  been  induced  with  sufficient  rapidity  without  this. 

7.  Galvano-ptincturc. — Coagulation  may  be  started  in  the  interior  of  an  an- 
eurysm by  means  of  galvano-puncture,  provided  the  part  of  the  wall  selected  is  not 
too  thin,  or  the  sac  extending  too  rapidly;  and  possibly  the  clot  so  formed  may 
change  the  direction  of  the  stream  and  lead  to  the  deposit  of  fresh  layers  over  the 
weaker  parts.  The  difficulty  is  that,  especially  in  the  case  of  thoracic  aneurysms, 
for  which  this  is  chiefly  used,  it  is  almost  impossible  to  form  a  definite  idea  as  to 
the  size  of  the  orifice  of  communication,  the  direction  in  which  the  aneurysm  is 
spreading,  or  the  course  of  the  blood-stream  through  it.  Still,  in  some  cases  of 
sacculated  aneurysm  springing  from  the  arch  of  the  aorta,  a  very  decided  im- 
provement has  been  effected  with  very  small  risk.  Unhappily,  accumulation  of 
fibrin  on  the  front  of  the  sac  (often  the  only  part  accessible)  may  be  attended 
with,  or  may  actually  cause,  rapid  extension  in  some  other  direction,  unknown 
and  unsuspected. 

Fine  trocar-shaped  needles  are  the  best,  insulated  up  to  the  neck  with  vulcan- 
ite ;  silk  causes  too  much  irritation,  and  sealing-wax  or  simple  rubber  does  not 
adhere  sufficiently.  They  are  attached  to  the  positive  pole  only ;  the  negative, 
which  should  never  be  introduced  into  the  sac,  is  connected  with  a  large  zinc 
plate,  covered  with  wash-leather  and  soaked  in  salt  solution.  The  patient  can 
rest  his  hand  on  this  and  interrupt  the  current  at  any  moment ;  but  as  the 
strength  never  should  exceed  five  or  six  milliamperes,  there  is  no  pain  or  shock  to 
cause  any  alarm  even  when  the  aneurysm  is  close  to  the  heart.  Two  or  more 
needles  are  introduced  parallel  to  each  other,  well  into  the  interior,  until  their  ex- 
ternal ends  distinctly  vibrate ;  then  the  current  is  turned  on  and  continued  until 
the  movement  ceases  and  the  tissues  around  feel  hard.  The  needles  should  be  left 
in  for  an  hour  or  so  afterward,  in  order  that  the  clot  mayattain  some  degree  of 
firmness  and  become  fixed.  Nothing,  or  at  most  a  little  blood-stained  serum, 
exudes  from  the  punctures,  but  it  is  as  well  to  cover  them  with  collodion.  By 
repeated  applications  of  this  kind,  I  have  succeeded  in  keeping  in  check  an 
aneurysm  of  the  aorta  that  had  already  caused  partial  absorption  of  the  sternum, 
and  with  such  success  that  for  some  time  the  pulsation  disappeared  from  the  inter- 
costal spaces.  Unhappily,  sudden  excitement  one  day  caused  a  rapid  extension 
of  the  tumor,  and  the  skin  became  so  much  stretched  and  thinned  that  nothing 
further  could  be  done. 

8.  Acupuncture. — In  one  or  two  cases,  this  has  been  tried  with  at  least  tem- 
porary benefit.  Three  pairs  of  long,  fine  darning-needles  were  introduced  into 
the  sac,  so  that  each  pair  crossed  in  the  cavity.  They  were  left  in  for  five  days, 
by  which  time  they  had  caused  a  considerable  degree  of  clotting  ;  and  this  gradu- 
ally increased  until  at  length  the  sac  became  almost  solid. 

III.   Exclusion    of  the   Aneurysm. 

This  takes  place  when  suppuration  occurs  round  an  aneurysm  and  the  sac 
sloughs  out.  What  is  known  as  the  old  operation  is  carried  out  on  the  same  plan  ; 
a  free  incision  is  made  into  the  sac,  all  the  clots  turned  out,  and  the  artery  tied 
above  and  below.  With  the  aid  of  tourniquets,  the  primary  hemorrhage  can  be 
fairly  well  controlled  ;  but  as  the  artery  in  idiopathic  or  spontaneous  aneurysm  is 
almost  certain  to  be  extensively  diseased  on  either  side,  the  risk    of  secondary 


248     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

hemorrhage  is  vet}'  great ;  and  even  if  this  does  not  occur,  gangrene  is  exceed- 
ingly likely  to  follow.  Practically  it  is  reserved  for  traumatic  aneurysm,  embolic 
aneurysm  of  the  upper  limb  in  young  p>eople,  and  cases  in  which,  after  ligature 
of  the  artery,  the  sac  has  become  inflamed  and  is  beginning  to  suppurate,  without 
the  pulsation  having  ceased. 

IV.   Amputation. 

This  may  be  required  if  moist  gangrene  sets  in  :  for  rupture  of  the  sac  ;  .sup- 
puration with  threatened  hemorrhage  ;  or  disease  of  a  neighboring  bone  or  joint. 
If  secondary  hemorrhage  occurs  from  the  seat  of  ligature,  an  attempt  may  be  made 
to  secure  the  two  ends  of  the  artery  iji  situ  ;  but  if  it  is  clear  that  the  walls  of  the 
vessels  are  seriously  diseased,  it  is  probable  that  amputation  at  once,  if  it  is  prac- 
ticable, gives  the  patient  a  better  chance  of  life. 


Traum.\tic  Aneurysm. 

The  formation  of  traumatic  aneurysm  has  been  already  described  ;  an  artery 
is  injured  and  the  cicatrix  yields ;  or  one  of  the  coats  is  torn  through,  and  the 
others  are  unable  to  stand  the  strain  ;  or  there  is  a  wound  plugged  withacoagulum 
which  gradually  stretches  under  the  influence  of  the  blood-pressure  ;  in  any  case 
a  circumscribed  sac  containing  fluid  blood  forms  in  connection  with  the  interior 
of  the  vessel  and  grows  larger  and  larger,  the  wall,  as  soon  it  attains  any  consid- 
erable size,  being  formed  of  fibrous  tissue  thrown  out  by  the  inflamed  and  irri- 
tated structures  around,  and  lined  with  laminated  clot. 

Its  progress  and  terminations  are  similar  in  all  respects  to  the  idiopathic 
form  ;  it  may  become  filled  with  laminated  fibrin,  or  with  loose  soft  blood-clot ;  it 
may  cause  suppuration  around  ;  it  may  leak  by  slow  degrees  and  then  suddenly 
rupture  into  the  cellular  tissue ;  sometimes  even  it  forms  a  communication  with  a 
vein  (arterio-venous  aneurysm)  ;  or  it  may  at  length  end  in  gangrene  of  the  part. 

As  a  rule,  the  simpler  methods  of  treatment  succeed  ;  a  bandage  is  often 
enough,  if  the  part  is  kept  at  rest ;  or,  if  this  does  not  answer,  Reid's  method, 
digital  compression,  or  flexion  may  be  tried.  If  these  fail  and  the  aneurysm  is 
superficial,  the  old  ofjeration  may  be  resorted  to  without  hesitation,  as  the  walls 
of  the  vessel  are  healthy ;  but  if  it  is  deeply  seated  proximal  ligature  (the  Hun- 
terian  method)  should  have  the  preference. 

Rupture  or  even  leakage,  unless  of  the  most  trivial  description,  leaves  no 
alternative  ;  then  it  is  simply  a  question  of  a  ruptured  artery,  and  it  must  be 
treated  as  such. 

Special  Aneurysms. 

Aneurysms  at  the  Root  of  the  Neck. 

!Many  forms  of  aneurysm  are  met  with  at  the  root  of  the  neck,  and  the  differ- 
ential diagnosis  is  often  very  difficult.  Roughly,  they  are  divided  into  three  classes, 
although  .sharp  distinctions  are  seldom  possible,  and  the  dilatation  is  rarely  limited 
to  one  part. 

1.  Those  confined  within  the  thorax.  These  spring  usually  from  the  first  part 
of  the  arch  of  the  aorta,  occasionally  from  the  third.  They  may  be  sacculated ; 
but  very  often,  even  when  a  sacculus  is  present,  it  is  only  secondary  to  a  wider 
fusiform  enlargement. 

2.  Those  that  pulsate  in  the  episternal  notch,  or  behind  the  sterno- clavicular 
articulation  or  the  stemo-mastoid,  so  that  part  of  the  outline  of  the  sac  can  be  felt. 

These  include  sacculated  aneurysms  of  the  transverse  portion  of  the  arch  ;  those 
that  spread  from  the  aorta  into  the  base  of  the  innominate ;  and  aneurysms  of  the 
innominate  itself,  involving  more  or  less  of  the  carotid  or  subclavian.  Aneurysms 
springing  from  the  left  extremit)'  of  the  arch,  and  spreading  in  the  direction  of  the 


ANEURYSM. 


249 


left  carotid   or  sulxlavian,  occasionally  jircscnt   in   this  region,  l)ut  only  in  their 
later  stages. 

3.  Those  that  lie  entirely  ont  of  the  thorax,  the  finger  being  able  to  feel  the 
under  surface  of  the  sac.  'I'hese  must  be  either  carotid  or  subclavian  ;  even  the 
high  innominate  form  (so  called  to  distinguish  it  from  that  which  spreads  upward 
from  the  aorta)  descends  too  far. 

The  diagnosis  of  these  different  conditions  rests  upon  the  position  and  extent 
of  the  tumor  with  regard  to  the  surface  of  the  body,  the  evidence  of  pressure  upon 
structures  near,  and  the  alteration  in  the  pulse-wave.  Thorough  examination  must 
always  be  made  of  the  heart,  to  ascertain  whether  there  is  any  mitral  or  aortic 
regurgitation,  and  of  the  other  arteries.  Any  surgical  o]jeration  that  is  undertaken 
must  be  of  the  most  serious  description,  and  should  never  be  attemi)ted  unless 
other  conditions  are  favorable.  Fusiform  dilatation,  aortic  disease,  atheroma  in 
other  vessels,  hypertrophy  or  dilatation  of  any  of  the  cavities  of  the  heart  to  any 
serious  extent,  and  renal  disease,  are  practically  final,  so  far  as  active  treatment  is 
concerned. 

Even  taking  the  small  number  of  cases  left,  those  in  which  there  is  merely  a 
sacculated  aneurysm  springing  from  an  otherwise  healthy  vessel,  active  surgical 
treatment  cannot  be  recommended  until  rest,  diet,  and  simpler  methods  have  been 
thoroughly  tried.  How  long  they  should  be  kept  up  before  adopting  further  meas- 
ures depends  upon  the  amount  of  improvement  in  each  individual  case.  A  certain 
degree  is  almost  invariable  at  hirst  if  a  patient  who  has  been  engaged  in  hard  man- 
ual labor  is  laid  up  in  bed  and  kept  on  low  diet ;  the  heart  beats  less  quickly  and 
less  forcibly  ;  the  tension  in  the  aneurysm  falls  ;  the  surrounding  tissues  empty  it  to 
a  certain  extent  by  their  pressure  ;  and  the  pulsation  becomes  less  distinct.  If  this 
continues,  nothing  better  can  be  wished  for,  and  it  may  be  hoped  that  the  sac  will 
gradually  become  solid.  Too  often,  however,  it  is  only  temporary  ;  all  the  symp- 
toms return  even  after  a  patient  trial  for  months,  and  without  the  patient  undertak- 
ing any  exertion.  For  such  as  these,  if  the  other  conditions  already  enumerated 
are  favorable,  it  is  sometimes  possible  to  adopt  a  more  active  line  with  benefit ; 
but  the  proportion  they  bear  to  the  whole  is  exceedingly  small. 

I.  Aneurysm  of  the  first  part  of  the  arch.  This  lies  for  the  most  part  to  the 
right  of  the  middle  line,  causing  an  area  of  dullness  that  corresponds  chiefly  to  the 
second  rib  and  the  second  interspace,  although  it  may  reach  as  high  as  the  sterno- 
clavicular articulation.  Protrusion  of  the  chest- wall  takes  place  comparatively 
early,  and  is  soon  followed  by  the  formation  of  a  distinct  swelling  which  pulsates 
visibly  and  sensibly.  Over  this  region  the  heart-sounds  are  heard  with  abnormal 
loudness,  the  second  especially.  The  heart  itself  is  often  displaced  outward. 
There  may  be  evidence  of  pressure  upon  the  right  bronchus,  air  not  entering  freely 
into  the  lung,  or  upon  the  superior  vena  cava,  causing  congestion  of  both  arms  and 
both  sides  of  the  head.  The  pulses  are  equal,  carotid  as  well  as  radial,  but  the 
pulse-wave  is  slightly  lower  and  more  sloping  than  natural,  and  the  down-stroke 
prolonged  and  undulating. 

If  rest  and  diet  fail  and  the  other  conditions  are  sufficiently  favorable,  the 
choice  lies  between  galvanopuncture,  acupuncture,  the  introduction  of  foreign  sub- 
stances, simultaneous  distal  ligature  of  the  right  carotid  and  subclavian,  and  liga- 
ture of  the  left  carotid.  Of  these  the  first  three  have  never  strengthened  the  sac 
sufficiently  to  enable  the  patient  to  lead  an  active  life  again,  even  for  a  time,  and 
the  last  of  them  is  very  likely  to  end  in  embolism.  Perhaps  galvanopuncture  is  the 
best,  especially  if  the  current  is  kept  up  for  some  hours  and  the  needles  are  retained 
until  the  clot  is  firm  ;  but  it  has  not  yet  been  proved  that  the  coagulum  is  capable 
of  resisting  for  any  length  of  time  the  immense  force  that  must  fall  upon  it  in  the 
first  part  of  the  aorta.  The  last  two  have  each  succeeded  once  or  twice,  although 
it  was  not  known  at  the  time  that  the  aneurysm  was  situated  in  the  first  part  of  the 
arch.  Ligature  of  the  left  carotid  perhaps  affords  the  best  hope  ;  it  is  not  so  serious 
an  operation  as  the  other,  and  if  the  rest  of  the  aorta  is  not  dilated,  and  the  heart 
17 


250    DISEASES  AND  JXJURIES  OF  SPECIAL  STRUCTURES. 

is  not  diseased,  there  is  a  possibility  of  its  proving  successful.  The  condition  of  the 
other  carotid  must,  however,  be  carefully  investigated  first. 

2.  Aneurysms  that  pulsate  in  the  episternal  notch.  This  is  the  most  difficult 
class  of  all  :  it  does  not  follow  by  any  means  that  a  tumor  originates  upon  the  side 
upon  which  it  projects. 

{a)  The  area  of  dullness  and  the  locality  of  the  pulsation  rarely  reveal  much.  If 
there  is  a  distinct  band  of  resonance  opposite  the  level  of  the  second  costal  carti- 
lage, it  is  probable  that  the  first  part  of  the  arch  is  intact,  but  it  is  not  common  to 
find  this  even  after  the  fullest  inspiration.  Also,  if  the  pulsation  is  limited  to  the 
region  of  the  right  sterno-clavicular  articulation,  the  aneurysm  probably  involves 
the  innominate  artery,  but  it  does  not  show  that  the  dilatation  is  limited  to  this, 
and  it  does  not  exclude  those  varieties  of  sacculated  aneurysm  which  ascend  from 
the  arch  in  front  of  the  other  vessels  and  pulsate  in  exactly  the  same  locality. 

(J))  Pressure  signs  are  more  useful.  Veins  are  often  obstructed,  the  superior 
cava  when  the  first  part  of  the  arch  is  concerned,  the  right  innominate  if  the 
aneurysm  extends  upward  along  the  innominate  artery,  the  right  internal  jugular  if 
the  first  part  of  the  subclavian  is  involved,  and  the  left  innominate  when  there  is  a 
pouch  projecting  upward  from  the  transverse  part  of  the  arch,  along  the  innominate 
or  independently.  This  last  condition,  in  which  the  tumor,  pulsation,  and  accent- 
uated second  sound  of  the  heart  are  most  distinct  upon  the  right  side,  and  the 
congestion  upon  the  left,  is  very  suggestive. 

Nerves  do  not  suffer  so  often.  The  left  recurrent  laryngeal  is  first  irritated 
and  then  compressed  in  aneurysms  of  the  distal  portion  of  the  arch,  causing  a 
peculiar  paroxysmal  cough  with  a  high,  squeaky  voice,  and  in  the  later  stages 
aphonia.  The  right  suffers  in  the  same  way  when  the  first  part  of  the  subclavian 
or  the  innominate  is  dilated.  In  every  case  of  suspected  aneurysm  the  condition 
of  the  vocal  cords  as  regards  position  and  movement  during  phonation  should  be 
carefully  examined. 

The  sympathetic  is  not  affected  unless  the  aneurysm  assumes  a  particular  direc- 
tion or  becomes  very  large.  Vascular  dilatation,  increased  sweating,  and  con- 
traction of  the  pupil  are  the  chief  symptoms. 

Compression  of  the  trachea  or  of  one  of  its  divisions  may  occur  in  almost  any 
of  the  forms  \  the  tone  of  the  voice  is  not  affected  ;  the  breath-sounds  are  changed  ; 
there  is  a  loud,  harsh  blowing,  often  audible  on  both  sides,  even  when  only  one  is 
involved  ;  violent  fits  of  spasmodic  coughing,  ending  in  the  expectoration  of  thick, 
ropy  mucus,  are  of  common  occurrence,  and  the  expansion  of  the  chest  is  often 
unequal. 

In  other  cases  the  oesophagus,  the  lower  cords  of  the  brachial  plexus  on  one 
side,  the  sternal  end  of  the  clavicle,  or  the  sterno-clavicular  articulation  are  affected 
as  the  growth  increases  in  size,  and  give  important  indications  as  to  the  direction 
in  which  it  is  extending. 

(t)  The  condition  of  the  pulse  affords  even  more  valuable  evidence  than  this, 
although  it  must  always  be  remembered  that  the  right  subclavian  sometimes  runs  an 
abnormal  course,  and  may  be  compressed  by  an  aneurysm  springing  from  some  other 
vessel.  It  is  not,  however,  the  absence  of  pulsation,  so  much  as  the  character,  the 
peculiar,  low,  sloping,  aneurysmal  curve,  that  is  important,  and,  to  obtain  satisfac- 
tory evidence  of  this,  tracings  must  be  taken  from  both  radials  and  both  carotids. 
If  those  obtained  from  the  two  sides  are  approximately  equal,  the  aneurysm  proba- 
bly involves  the  first  part  of  the  arch,  though  it  is  by  no  means  certainly  limited 
to  it ;  if  the  right  are  affected,  but  not  the  left,  the  arch  itself  must  be  nearly 
intact ;  if  the  let't  without  the  right,  the  innominate  must  be  sound  ;  and  the  same 
with  regard  to  the  radial  and  carotid  on  either  side. 

If  rest  and  diet  fail,  distal  ligature  is  the  only  active  treatment  advisable  for 
any  of  these,  although  one  case  of  innominate  aneurysm  is  stated  to  have  been 
cured  by  distal  compression  of  the  subclavian  and  carotid.  Galvano-puncture  or 
the  introduction  of  foreign  bodies  does   not  offer  the  least  prospect  of  success. 


ANEURYSM.  251 

Those  cases,  however,  only  are  suitable  for  it  in  which  the  tumor  is  distinctly- 
limited  in  size,  and  in  which  the  presence  of  fusiform  dilatation  of  the  aorta, 
hypertrophy  and  dilatation  of  the  left  ventricle,  etc.,  can  be  excluded.  The 
choice  lies  between  simultaneous  ligature  of  the  right  carotid  and  subclavian  and 
ligature  of  the  left  carotid.  The  former  is  to  be  preferred,  if  from  the  condition 
of  the  pulse  and  the  right  venous  congestion  the  symptoms  point  definitely  to  the 
innominate  ;   the  latter  probably  under  other  conditions. 

3.  Aneurysms  of  the  right  side  of  the  root  of  the  neck,  lying  outside  the 
thorax.  These  are  either  carotid  or  subclavian.  The  reason  for  classing  them 
here  is  the  extreme  difficulty  of  distinguishing  them  from  the  high  innominate 
form. 

In  aneurysm  of  the  first  part  of  the  subclavian  the  swelling  appears  first  behind 
the  clavicle,  pushing  that  bone  forward  and  causing  a  rather  elongated  area  of  pul- 
sation. Paroxysmal  cough  with  alteration  in  the  tone  of  the  voice  from  pressure 
on  the  recurrent  laryngeal,  venous  congestion  and  oedema  of  the  side  of  the  head 
and  neck  from  compression  of  the  internal  jugular,  and  weakening  of  the  radial 
pulse  are  the  chief  distinctive  signs. 

When  the  base  of  the  right  carotid  is  involved  the  shape  and  position  of  the 
tumor  and  the  direction  of  the  pulsation  are  different ;  there  is  no  pressure  upon 
any  nerve  or  vein,  no  dullness  in  the  first  intercostal  space,  and  nothing  in  connec- 
tion with  the  trachea,  cesophagus,  or  recurrent  laryngeal,  until  the  tumor  reaches 
a  considerable  size.  On  the  other  hand,  the  facial  and  temporal  pulses  are  dis- 
tinctly different  from  those  on  the  opposite  side. 

If  these  two  sets  of  symptoms  occur  together,  even  if  they  are  only  slightly 
marked,  it  means  that  the  distal  end  of  the  innominate  is  involved  ;  that  practically 
it  is  a  case  of  innominate  aneurysm  (the  high  form  in  distinction  from  the  low  one, 
which  spreads  upward  from  the  aorta),  and,  as  already  described,  that  it  can  only 
be  treated  by  rest  and  diet,  or  by  simultaneous  double  distal  ligature. 

Aneurysms  of  the  Carotid. 

The  point  of  bifurcation  is  the  most  common  situation,  but  almost  any  part, 
except  that  which  lies  inside  the  thorax  on  the  left  side,  may  be  involved.  The 
internal  carotid  is  seldom  affected,  although  a  few  cases  are  on  record,  and  most 
of  those  in  connection  with  the  external  are  traumatic,  and  extend  along  its 
branches.  It  is  peculiar  that  aneurysms  of  the  common  trunk  are  nearly  as  fre- 
quent among  women  as  among  men. 

Two  varieties  are  distinguished,  the  high  and  the  low  ;  the  latter  is  almost,  if 
not  quite,  confined  to  the  right  side. 

Symptoms. — In  addition  to  the  ordinary  signs,  the  presence  of  a  circum- 
scribed fluid  tumor  with  characteristic  pulsation  and  bruit,  there  are  others  caused 
by  pressure  upon  neighboring  organs  and  by  interference  with  the  cerebral  circu- 
lation. Among  the  former  may  be  classed  dyspnoea,  spasmodic  coughing,  and 
hoarseness  from  pressure  upon  the  trachea,  larynx,  or  recurrent  laryngeal,  dys- 
phagia from  the  sac  projecting  into  the  pharynx  or  oesophagus  (this  is  more  com- 
mon when  the  internal  is  affected),  contraction  of  the  pupil  and  other  symptoms 
from  paralysis  of  the  sympathetic,  and  neuralgia  from  pressure  upon  the  cervical 
nerves.  The  latter  are  due  either  to  loss  of  arterial  tension  in  the  vessels  of  the 
brain,  in  the  same  way  as  in  the  facial  and  temporal  branches  of  the  external 
carotid,  or  to  obstruction  to  the  flow  in  the  internal  jugular.  Giddiness,  syncope, 
noises  in  the  ears,  dimness  of  vision,  headache,  and  violent  throbbing  are  not 
unfrequently  present,  and  in  addition  there  is  always  the  risk  of  embolism,  with 
paralysis  of  smaller  or  larger  centres,  from  some  fragment  of  clot  being  detached. 

The  diagnosis  in  many  cases  is  exceedingly  easy ;  in  a  few,  however,  it  is  a 
matter  of  the  greatest  difficulty.  Aneurysmal  dilatation  is  not  at  all  uncommon 
at  the  bifurcation  and  at  the  origin  of  the  right  common  trunk,  and  if  noticed 
suddenly  for  the  first  time,  or  if  it  accidentally  becomes  more  prominent  from  wast- 


252     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

ing  of  the  tissues  around,  it  may  cause  considerable  uneasiness.  Probably  the 
cases  in  which  carotid  aneurysms  are  recorded  as  having  lasted  unchanged  for 
years  were  really  examples  rather  of  fusiform  expansion  than  anything  else.  At 
the  root  of  the  neck,  even  if  the  diagnosis  of  aneurysm  is  certain,  it  may  be 
impossible  to  prove  that  the  carotid  only  is  involved  ;  aneurysms  of  the  subclavian, 
the  innominate,  and  even  of  the  arch  of  the  aorta,  may  simulate  it  perfectly,  so 
far  as  position  is  concerned.  Glandular  enlargements  are  usually  lobulated  and 
multiijle,  and  the  only  difficulty  occurs  when  the  artery  runs  through  the  centre 
of  a  mass  of  them.  A  few  cases  of  cysts  lying  on  the  artery  are  on  record,  but 
the  character  of  the  pulsation  is  different,  and  although  fluctuation  is  distinct  the 
contents  cannot  be  emptied  out  of  the  sac  by  pressure.  Vascular  growths  of  the 
thvroid,  which  occasionally  pulsate,  move  up  and  down  with  deglutition,  and  can 
be  traced  into  connection  with  the  isthmus.  Abscesses  and  pulsating  malignant 
growths  rarely  give  rise  to  trouble  ;  the  shape  of  the  swelling,  the  relation  it  l:)ears 
to  the  vessel,  the  absence  of  expansile  pulsation,  and  the  effects  of  distal  and 
proximal  compression  are  sufficiently  distinctive.  When  the  aneurysm  is  situated 
on  the  internal  carotid,  pressing  against  the  tonsil  and  causing  it  to  project  into 
the  pharynx,  it  may  be  mistaken  for  an  abscess. 

Spontaneous  cure  is  very  rare.  Some  cases  remain  quiet  for  a  long  time 
without  enlarging,  but  the  general  tendency  is  for  the  tumor  to  increase  until  it 
ruptures  into  the  pharynx,  trachea,  or  externally.  Suppuration  may  occur  round 
it,  especially  after  ligature,  and  embolism  of  the  cerebral  arteries,  leading  to 
hemiplegia,  has  happened  in  several  cases — once,  at  lea.st,  while  the  tumor  was 
being  examined. 

The  only  treatment  possible  is  compression  or  ligature,  proximal  or  distal. 

The  common  carotid  may  be  compressed  with  the  fingers  against  the  trans- 
verse process  of  the  sixth  cervical  vertebra,  or  above  this  by  grasping  the  artery 
behind  the  sterno-mastoid,  between  the  finger  and  thumb,  the  patient's  head  being 
bent  over  to  the  affected  side  so  as  to  relax  the  muscle.  Instrumental  compre.ssion 
is  rarely  successful.  In  any  case,  even  when  the  greatest  care  is  used,  it  is  almost 
impossible  to  stop  the  flow  of  blood  for  more  than  two  minutes,  and  often  not  that 
long  at  first,  vertigo,  faintness,  and  a  sense  of  .sickness  coming  on  almost  at  once. 
Whether  this  is  due  to  the  interruption  of  the  circulation  or  in  part  at  least  to  the 
irritation  of  the  vagus  and  sympathetic  is  uncertain.  It  is  more  important  that 
after  a  number  of  sittings  a  certain  degree  of  tolerance  is  established. 

If  this  fails  proximal  ligature  must  be  tried  if  there  is  room,  distal  if  there  is 
not.  Neither  is  very  successful,  and  it  has  been  proposed,  especially  in  traumatic 
cases  fwhich,  however,  are  too  rare  to  enter  into  the  question),  to  resort  to  the  old 
operation.  There  is  some  rea.son,  however,  to  believe  that  recent  results  are  a 
good  deal  better.  Suppuration  of  the  sac,  and  hemiplegia  and  convulsions  from 
cerebral  anaemia,  are  not  unusual  consequences.  Occasionally  pulmonary  conges- 
tion and  hypostatic  pneumonia  occur,  possibly  from  interference  with  the  blood- 
supply  of  the  base  of  the  brain,  but  more  probably  from  injury  sustained  by  the 
vagus  or  the  cardiac  branches  of  the  sympathetic. 

Aneurysm  of  the  external  carotid  presents  no  special  features.  The  artery 
itself  should  always  be  secured  in  preference  to  the  common  trunk,  if  it  can  pos- 
sibly be  managed,  as  this  avoids  one  of  the  most  common  causes  of  death.  Some- 
times it  is  necessary  to  tie  one  or  more  of  the  branches  as  well,  owing  to  the  special 
freedom  of  the  collateral  circulation. 

Aneurysm  of  the  extra-cranial  portion  of  the  internal  carotid  can  only  be 
treated  by  pressure  or  proximal  ligature. 

Aneurysmal  varix  occasionally  occurs  in  the  neck,  as  a  result  of  stabs  and 
other  wounds,  involving  an  artery  and  a  vein.  It  is  most  frequent  in  connection 
with  the  common  or  internal  carotid  and  the  internal  jugular  ;  but  it  has  been 
known  to  form  between  the  common  carotid  and  the  subclavian  vein,  just  where 
they  cross.  The  immediate  effect  of  such  an  injury  is  an  enormous  extravasation 
of  blood  ;  if  this  does  not  prove  fatal,  or  end  in  suppuration,  the  orifices  in  the 


ANEURYSM.  253 

vessels  lying  opposite  each  other  may  unite  and  prevent  further  loss.  The  symp- 
toms are  those  already  described,  violent  pulsation  in  the  veins  with  dilatation  and 
hypertrophy,  palpitation  arising  from  the  une([ual  pressure  in  the  auricle  and  the 
unusual  character  of  the  l)lood,  and  headache,  giddiness,  noise  in  the  ears,  etc., 
from  interference  with  the  cerebral  circulation.  In  most  cases  there  is  a  distinct 
thrill  along  the  course  of  the  vein  ;  and  a  whizzing  or  purring  noise  can  nearly 
always  be  heard,  more  or  less,  over  the  whole  of  that  side  of  the  head.  Not 
unfrecpiently  it  is  very  distressing  to  the  patient,  even  preventing  sleep.  Treat- 
ment should  be  palliative  only. 

Okiuiai,  Aneurysm. 

Orbital  aneurysm  is  a  clinical  term  used  to  describe  certain  pulsating  tumors 
of  the  orbit,  attended  with  exophthalmos,  without  implying  the  invariable  presence 
of  any  single  pathological  lesion. 

In  those  past  middle  life  it  may  originate  spontaneously  or  after  some  slight 
exertion,  or  at  any  age  from  such  accidents  as  fracture  of  the  base  of  the  anterior 
fossa  of  the  skull,  gunshot  injuries,  or  penetrating  w'ounds  of  the  orbit.  U.sually 
the  symptoms  appear  within  the  first  few  months,  often  within  a  few  days.  At  first 
there  is  merely  a  loud  buzzing  or  roaring  sound  audible  to  the  patient,  then  the 
conjunctiva  becomes  congested  and  perhaps  chemosis  follows.  After  a  while  the 
eyeball  projects  and  begins  to  pulsate,  the  ocular  muscles  lose  their  power,  the 
pupil  becomes  fixed,  the  hollow  under  the  orbital  arch  is  filled  up,  and  a  soft, 
pulsating  mass  makes  its  appearance  at  one  angle  of  the  orbit,  usually  the  upper 
and  inner.  The  veins  of  the  eyelids,  the  bridge  of  the  nose,  and  the  forehead  soon 
become  distended  and  tortuous  ;  a  distinct  thrill  and  a  loud,  rasping  bruit  are 
perceptible  over  the  swelling ;  a  large  pad  of  infiltrated  mucuous  membrane  pro- 
trudes between  the  lids ;  the  pulsation  of  the  eyeball  becomes  more  and  more 
distinct,  and  in  many  cases  the  transparency  of  the  media  is  destroyed. 

Before  this  occurs  it  may  be  noted  with  the  ophthalmoscope  that  the  disc  is 
unduly  prominent  and  the  retinal  veins  enlarged.  Small  hemorrhages,  too,  may 
be  present.  Finally  the  opposite  eye  and  orbit  may  become  affected  in  the  same 
way,  and  in  extreme  cases  the  dilatation  of  the  veins  may  extend  over  a  great  part 
of  the  face. 

The  noises  in  the  head  and  the  bruit  cea.se  as  soon  as  pressure  is  applied  to  the 
carotid  on  the  corresponding  side  ;  if  it  is  kept  up  the  globe  recedes  and  the  pulsa- 
tion diminishes  or  stops  altogether. 

It  has  been  clearly  demonstrated  by  Rivington  that  the  pathological  lesion 
underlying  this  condition  is  probably  always  a  communication  between  the  internal 
carotid  artery  and  the  cavernous  sinus,  sometimes  caused  by  injury,  sometimes  due 
to  the  rupture  of  an  aneurysm  or  the  giving  way  of  the  floor  of  an  atheromatous 
ulcer.  The  immediate  effect  is  the  rush  of  arterial  blood,  under  high  pressure,  into 
the  ophthalmic  vein,  causing  at  first  merely  pain  and  a  peculiar  buzzing  noise 
audible  to  the  patient ;  but  later,  as  the  vein  becomes  enlarged  and  distended,  and 
as  with  its  increasing  size  the  pressure  in  its  interior  becomes  greater  and  greater, 
giving  rise  to  the  exophthalmos  and  the  signs  of  aneurysmal  varix  extending  on  to 
the  face.  The  communication  between  the  two  cavernous  sinuses  explains  the  fact 
that  one  eye  may  become  affected  after  the  other. 

Aneurysm  of  the  ophthalmic  artery  may  cause  exophthalmos,  but  cannot 
produce  a  pulsating  tumor  at  the  angle  of  the  orbit  or  the  distention  and  thrill 
in  the  veins.  The  venous  sinuses  of  the  cranium  notunfrequently  become  throm- 
bosed,but  do  not  of  themselves  lead  to  the  development  of  pulsating  tumors, although 
they  may  cause  some  degree  of  proptosis  with  passive  congestion  of  the  eyeball, 
dilated  pupil,  restricted  movements,  and  diminished  vision.  Aneurysms  of  the 
internal  carotid  (unruptured)  may  project  into  the  cavernous  sinus  without  giving 
rise  to  the  essential  symptoms  of  this  disorder.  The  rare  examples  of  erectile 
and  cavernous  tumors  met  with  in  the  orbit  might  produce  something  of  the  same 


254    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

character,  but  without  pulsation  or  bruit.  Cirsoid  aneurysms  undoubtedly  could, 
but  it  has  never  yet  been  found  in  this  locality,  and  Rivington  suggests  that  in 
many  cases,  in  other  parts  of  the  body,  especially  where  it  has  followed  injury,  it 
is  really  a  form  of  aneurysmal  varix  itself  rather  than  true  cirsoid  aneurysm. 

The  greatest  difficulty  occurs  with  pulsating  sarcomata  growing  from  the  back 
of  the  orbit.  For  a  time  at  least  they  may  cause  symptoms  of  an  almost  identical 
character,  but  the  bruit  is  usually  absent,  and  when  it  is  present  is  of  a  very  different 
description  ;  and  extension  of  the  grow^th  always  takes  place  very  rapidly. 

Treatment. — The  only  treatment  at  all  satisfactory  in  its  results  is  compres- 
sion or  ligature  of  the  common  carotid.  The  former  has  seldom  been  tried,  owing 
to  the  difficulty  of  maintaining  it  for  more  than  a  minute  or  two ;  but  probably  it 
deserves  more  attention  than  it  has  received.  The  latter  has  been  very  successful 
both  in  the  traumatic  and,  though  to  a  less  extent,  in  the  spontaneous  variety.  In 
one  or  two  instances  both  vessels  have  been  tied,  though  not  at  the  same  time, 
owing  to  persistence  or  recurrence  of  the  symptoms.  This  may  have  been  cau.sed 
by  the  clot  being  wa.shed  away  before  organization  had  rendered  it  sufficiently 
firm,  or  by  unusual  freedom  of  communication  between  the  two  cavernous  sinu.ses, 
or  by  the  blood  having  found  its  way  into  the  orbit  through  other  veins  as  well  as 
the  ophthalmic.  Vision  is  lost  in  a  large  number  of  cases,  chiefly  from  ulceration 
of  the  cornea  and  collapse  of  the  eyeball.  This  may  sometimes  be  checked  by 
early  operation,  certainly  it  is  favored  by  delay  ;  but  it  is  impossible  to  predict 
what  will  result  in  any  given  case,  as  the  ligature  of  the  vessel  itself  under  these 
circumstances  may  so  interfere  with  the  circulation  through  the  eye  as  to  impair 
the  transparency  of  the  media. 

Aneurysms  of  the  Subclavian. 

These,  like  aneurysms  of  the  carotid  and  innominate,  may  be  divided  into 
two  classes  :  those  which  are  limited  to  the  third  part  of  the  arter\%  that  which 
descends  beneath  the  clavicle,  terminating  at  the  lower  border  of  the  first  rib  ;  and 
those  which  implicate  the  first  part,  whether  they  are  limited  to  this  or  extend  over 
the  rest  as  well.  Like  aneurysms  elsewhere  (with  the  exception  of  the  carotid), 
they  are  much  more  common  in  men  than  in  women,  and,  for  the  most  part,  occur 
upon  the  right  side. 

Subclavian  aneurysms  rarely  attain  large  size  before  rupture  takes  place.  They 
usually  form  an  elongated  swelling  behind  and  above  the  clavicle,  with  all  the 
characteristic  signs  of  aneurysm,  pulsation,  bruit,  etc.  The  pressure  symptoms 
vary  according  to  the  locality  ;  when  the  inner  part  is  concerned,  the  recurrent  laryn- 
geal nerve  and  the  internal  jugular  vein  are  compressed  ;  when  the  outer,  the  sub- 
clavian vein,  the  external  jugular,  and  some  of  the  cords  of  the  brachial  plexus. 
In  general,  the  prominence  is  chiefly  upward,  but  occasionally  the  sac  enlarges  in 
the  direction  of  the  pleura,  and  it  may  become  adherent  to  it ;  and  sometimes  the 
phrenic  nerve,  the  trachea,  and  the  oesophagus  are  compressed. 

Enlarged  glands  may,  as  in  the  case  of  the  carotid,  surround  the  vessel  and 
lead  to  a  certain  amount  of  difficulty  in  diagnosis  ;  and  chronic  abscess  may  occur 
in  connection  with  them  or  with  other  structures,  and  produce  at  first  sight  a  closely 
similar  appearance ;  but  the  effect  of  compression  upon  the  artery  or  upon  the  sac 
is  conclusive.  The  difficulty  of  determining  how  far  inward  the  dilatation  extends 
is  often  very  great,  especially  on  the  right  side  ;  but,  as  a  rule,  the  comparison  of 
the  pulse  in  the  branches  of  the  carotid  on  the  two  .sides  is  enough  to  determine 
whether  the  innominate  is  involved  or  not. 

Spontaneous  cure  is  said  to  have  occurred  in  a  few  cases  from  embolism.  As  a 
rule,  the  sac  enlarges  very  slowly  for  a  time,  and  then  suddenly  gives  way,  causing 
an  immense  extravasation,  which  may  prove  fatal  from  pressure,  or  may  burst  into 
the  pleura,  the  trachea,  or  externally. 

The  treatment  of  subclavian  aneurysm  is  most  unsatisfactory.  Proximal  liga- 
ture, unless  the  aneurysm  is  really  axillary  rather  than  subclavian,  is  practically 


ANEURYSM.  255 

hopeless.  Ligature  of  the  innominate  or  of  the  first  part  of  the  siil)clavian  on  the 
right  side  has  proved  ahiiost  invariably  fatal  from  secondary  hemorrhage  ;  while  on 
the  left  side  ligature  of  the  corresponding  trunk  is  out  of  the  question.  Proximal 
compression  is  ecpially  impossible,  except  in  the  case  of  some  rare  anatomical 
abnormality. 

Distal  ligature  has  not  proved  any  better,  i)robal)ly  owing  to  the  very  large 
collateral  l)ranches  coming  off  from  the  sac  itself  or  its  immediate  vicinity.  Am- 
putation at  the  shoulder  joint  has  been  performed  on  one  or  two  occasions  with 
the  view  of  meeting  this,  but  without  sufficient  success  to  justify  repetition. 

Rest  and  diet  should  be  thoroughly  tried  in  every  case  first.  If  they  do  not 
succeed,  and  the  sac  contains  sufficient  fibrin,  direct  pressure  with  manipulation 
affords  the  best  hope,  always  provided  the  carotid  is  not  involved.  Under  other 
circumstances,  prolonged  galvano-puncture  would  prol)ably  answer  better ;  or  an 
attempt  might  be  made  to  procure  solidification  by  the  introduction  of  a  short 
length  of  iron  wire  ;  but  the  prognosis  in  all  such  cases  is  very  grave,  and  the  risk 
of  suppuration  setting  in  very  great. 

Axillary  Aneurysm. 

This  is  chiefly  remarkable  for  the  rapidity  of  its  development  and  the  fre- 
quency with  which  it  can  be  traced  to  a  definite  injury.  As  might  be  expected,  it 
is  much  more  common  among  men  than  women,  and  nearly  always  occurs  upon  the 
right  side.  Any  part  of  the  artery  may  be  involved,  and  it  may  project  downward 
into  the  axilla,  inward  toward  the  thorax,  so  that  the  ribs  become  absorbed  ;  or 
upward  under  the  clavicle,  raising  the  shoulder.  The  movements  of  the  arm  are 
naturally  restricted,  the  head  is  inclined  to  that  side,  the  elbow  is  abducted,  and 
not  un frequently  there  is  great  pain  running  down  the  arm  from  pressure  upon  the 
brachial  plexus,  or  oedema  from  occlusion  of  the  axillary  vein. 

Spontaneous  cure  is  very  rare,  if  it  ever  happens.  If  left  to  itself  the  sac 
rapidly  enlarges  and  either  becomes  inflamed  and  suppurates  (to  which  it  is  espe- 
cially prone)  or  ruptures  into  the  loose  cellular  tissue  of  the  axilla,  the  shoulder 
joint,  or  the  thorax. 

The  treatment,  if  the  aneurysm  is  limited  to  the  axilla,  is  comparatively  .simple. 
Compression  of  the  third  part  of  the  subclavian  should  be  tried  first ;  but  after  a 
short  time  it  usually  becomes  exceedingly  painful,  and  if  it  is  kept  up  is  not  with- 
out danger  to  the  brachial  plexus.  If  it  cannot  be  borne,  Esmarch's  bandage  may 
be  used  under  an  anaesthetic,  the  circulation  above  being  controlled  with  a  rubber 
cord  arranged  round  the  axilla  in  a  figure-of-eight,  as  high  as  possible  ;  or  a  liga- 
ture maybe  placed  round  the  third  part  of  the  subclavian.  When,  however,  the 
clavicle  is  pushed  up  by  an  immense  tumor,  and  it  is  doubtful  how  far  the  aneurysm 
is  subclavian  and  how  far  it  is  axillary,  the  question  becomes  much  more  difficult. 
Rest  and  diet  may  succeed,  but  usually  the  tumor  continues  to  increase  unchecked. 
Direct  pressure  and  manipulation  are  not  suitable,  owang  to  the  thinness  of  the 
sac  and  the  rapidity  of  its  growth,  while  galvano-puncture  and  the  introduction  of 
foreign  substances  are  almost  sure  to  excite  inflammation  and  very  possibly  sup- 
puration. The  best  chance  lies  in  ligature  of  the  subclavian  as  far  away  as  pos- 
sible, dividing  the  scalenus  anticus,  and  drawing  the  phrenic  nerve  inward  out  of 
the  way,  if  it  appears  necessary.  Any  branch  that  comes  off  from  the  main  trunk 
near  the  seat  of  ligature  should  be  tied  too,  to  diminish  as  much  as  possible  the 
risk  of  secondary  hemorrhage  ;  but  the  operation  is  one  of  extreme  difficulty,  and, 
owing  to  the  manipulation  necessary,  is  very  likely  to  be  followed  by  inflammation 
either  of  the  sac  or  of  the  pleura  and  its  contents. 

Aneurysms  of  arteries  below  the  axillary  are  rare  except  as  a  result  of  embo- 
lism or  injury.  There  is  nothing  special  either  in  their  symptoms  or  their 
treatment. 


256    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Abdominal  Aneurysm. 

Fusiform,  dissecting,  and  sacculated  aneurysms  are  described  in  connection 
with  the  abdominal  aorta  and  its  branches.  The  last  is  the  most  common  and  is 
the  only  one  capable  of  treatment. 

It  may  occur  at  any  part  and  may  either  involve  the  roots  of  some  of  the 
large  branches,  such  as  the  cteliac  axis,  or  may  cause  their  obliteration  by  its  pres- 
sure. Usually,  it  projects  forward  in  the  direction  of  least  resistance  ;  but  instances 
have  been  known  of  aneurysms  originating  on  the  posterior  surface,  and  eating 
their  way  into  the  bodies  of  the  vertebrae.  Generally  there  is  a  distinct  history  of 
injury,  or,  if  not,  of  some  especially  laborious  occupation  ;  when  there  is  not, 
when  the  dilatation  is  apparently  spontaneous,  it  is  probable  that  the  vessel  is 
seriously  diseased.  One  or  two  instances  of  spontaneous  recovery  are  recorded, 
the  condition  not  having  been  even  suspected  during  life. 

The  svmptoms  are  very  obscure  until  the  sac  has  attained  a  considerable  size. 
Pain  is  usually  present,  but  it  varies  very  much  in  character  ;  in  some  cases  it  is 
continuous,  in  others  paroxysmal  ;  sometimes  it  radiates  along  the  course  of  the 
nerves,  at  others  it  is  fixed  and  localized;  and  the  character  is  equally  vague. 
Pulsation  of  the  typical  expansive  description  with  a  distinct  systolic  bruit,  audible 
behind  as  well  as  in  front,  is  nearly  always  present  from  the  first,  but  often  it 
is  not  noticed  until  it  compels  attention.  Dyspnoea  may  occur  from  pressure 
upward  toward  the  diaphragm  ;  dyspepsia,  colic,  constipation,  and  other  troubles 
from  interference  with  the  stomach  and  intestines.  Jaundice  has  been  known  from 
compression  of  the  bile-duct.  The  liver  may  be  displaced,  or  the  left  kidney  ; 
but  uriemia,  anasarca,  ascites,  and  other  troubles  that  arise  from  pressure  upon 
veins  are  seldom  met  with.  The  tumor  is  generally  fixed,  not  moving  with  the 
diaphragm  ;  and  the  pulsation  is  usually  most  marked  a  little  to  the  left  of  the 
middle  line ;  but  especially  when  the  upper  part  of  the  vessel  is  concerned  it  may 
require  very  deep  pressure  to  feel  it  at  all. 

Diagnosis. — The  chief  difficulty  occurs  in  connection  with  a  form  of  dila- 
tation which,  especially  in  thin  subjects,  may  be  so  striking  and  so  distinctly  ex- 
pansive as  to  simulate  aneurysm  very  closely.  Lumbar  and  psoas  abscess,  solid 
tumors  resting  on  the  front  of  the  aorta,  and  pulsating  growths  in  connection  with 
the  vertebrae  mav  be  mistaken  for  it.  Aneurysm  of  the  coiliac  axis  usually  pro- 
jects forward  toward  the  right  side  under  the  liver ;  when  the  sui)erior  mesenteric 
is  involved  the  tumor  is  more  movable,  but  this  does  not  hold  good  when  the  origin 
is  affected.  The  character  of  the  pulse-wave  in  the  lower  extremities  should 
always  be  carefully  investigated,  although  it  does  not  give  very  clear  indications, 
owing  to  the  difficulty  of  comparison. 

As  a  rule,  the  course  of  the  disease  is  very  rapid  ;  the  structures  round  yield 
readily  and  there  is  nothing  to  restrain  the  growth  of  the  tumor.  Death  is  usually 
sudden  from  rupture  into  the  peritoneal  cavity,  but  occasionally  leakage  is  more 
slow  and  an  ill-defined  swelling  forms  in  the  iliac  or  lumbar  region,  and  delays  the 
end  for  a  few  days.  A  very  marked  degree  of  emaciation  is  not  uncommon  ;  and 
the  loss  of  strength  and  exhaustion,  partly  from  the  interference  with  the  circula- 
tion, partly  from  digestive  troubles,  want  of  sleep,  and  pain,  may  be  so  great  as  to 
prove  fatal  before  the  sac  gives  way. 

Treatment. — Although  one  or  two  instances  of  spontaneous  cure  are  known 
to  have  occurred,  the  treatment  by  rest  and  diet  holds  out  a  very  slender  chance. 
Probably  this  is  due  in  great  measure  to  the  absence  of  support  from  the  tissues 
around,  and  to  the  high  degree  of  pressure  in  the  sac.  If  there  is  no  material  im- 
provement within  a  fortnight  or  three  weeks,  there  is  not  likely  to  be  any  afterward; 
and  then  it  becomes  a  question  whether  something  fiirther  should  be  attempted. 

This  depends  upon  the  position  of  the  aneurysm,  whether  it  is  above  or  below 
the  renal  arteries ;  on  its  shape,  whether  it  is  sacculated  or  not;  on  its  origin, 
whether  it  was  spontaneous  or  distinctly  traumatic ;  and  on  the  condition  of  the 
heart,  the  kidneys,  and  the  other  vessels. 


ANEURYSM.  257 

If  everything  is  fiivorable,  the  choice  lies  l)et\veen  proximal  or  distal  jiressure 
and  opening  the  abdomen  and  introducing  foreign  substances  into  the  sac,  as  in 
Loreta's  case  already  mentioned.  Proximal  pressure  is  undoubtedly  the  best  of 
these;  but,  without  opening  the  abdomen,  it  cannot  be  effected  above  the  renal 
arteries  ;  the  aorta  lies  too  deeply  and  is  covered  with  structures,  especially  the 
pancreas,  which  may  not  be  bruised.  If  the  abdomen  is  opened,  as  has  recently 
been  done  by  Keetley,  pressure  can  be  applied  almost  directly  to  the  vessel,  but  of 
course  in  such  a  case  this  itself  is  a  serious  matter.  The  bowels  must  be  thoroughly 
cleared  out  with  aperients  and  enemata,  the  l)ladder  emj)tied,  and  care  taken  that 
the  stomach  contains  no  solid  food.  Then  the  patient  must  be  placed  under  an 
anaesthetic,  and  Lister's  or  Carte's  tourniquet  carefully  adjusted  above  the  swelling, 
and  slowly  screwed  down  until  the  pulsation  of  the  aneurysm  is  checked.  It  need 
not  be  said  that  this  is  only  possible  in  a  very  limited  number  of  cases.  Once 
fixed,  no  current  should  be  allowed  to  flow  through  until  it  is  determined  to  bring 
the  procedure  to  an  end  ;  any  rush  of  blood,  such  as  would  ensue  from  relaxing 
the  pressure  too  soon,  would  at  once  sweep  the  coagulum  away.  How  long  com- 
pression can  be  maintained  depends  upon  the  condition  of  the  patient.  If  there  is 
no  sign  of  shock,  it  may  be  kept  up  for  three  or  perha])s  four  hours  ;  and  possibly  at 
the  end  of  that  time  pulsation  may  be  so  much  diminished  that  consolidation  will 
follow  of  itself.  In  several  cases,  however,  peritonitis  has  occurred,  and  proved 
fatal  from  the  amount  of  l)ruising.  Afterward,  and  for  some  time,  the  patient 
must  be  kept  as  quiet  as  possible  in  the  hope  that  the  coagulum  will  remain  firm. 

Where  this  cannot  be  carried  out,  distal  compression  may  be  tried.  In  a  few 
instances  the  two  have  been  used  together  so  as  to  ensure  complete  cessation  of  the 
circulation  through  the  sac.      By  itself  it  is  certainly  not  so  effectual. 

Cessation  of  pulsation  is  attended  by  great  loss  of  power  with  coldness  and 
deficient  sensibility  in  the  parts  below.  After  a  time,  if  they  are  kept  warm  and 
protected  from  injury,  this  passes  off  and  pulsation  can  be  detected  in  the  larger 
trunks  again  ;  but  naturally  the  collateral  circulation,  in  man  at  least,  can  scarcely 
become  sufficiently  developed  to  replace  the  aorta. 

Iliac  Aneurysm. 

Aneurysm  of  the  common,  external,  or  internal  iliac  artery  forms  a  soft,  cir- 
cumscribed swelling  in  the  line  of  the  vessel,  with  characteristic  expansive  pulsa- 
tion and  bruit  continued  along  its  course.  The  pain  is  rarely  severe  unless  the 
obturator  or  genito-crural  nerve  is  involved  ;  and  owing  to  the  space  around,  other 
signs  are  often  wanting  until  the  tumor  has  reached  a  large  size.  If  left  it  usually 
ends  in  rupture  ;  but  in  one  or  two  instances  oedema  and  gangrene  have  occured 
from  venous  obstruction. 

Diagnosis. — Aortic  aneurysm,  springing  from  just  above  the  bifurcation,  has 
been  known  to  spread  down  as  low  as  Poupart's  ligament.  Enlarged  glands  round 
the  artery  may  cause  a  momentary  doubt.  Tumors  growing  from  the  bones, 
especially  pulsating  sarcomata,  are  much  more  difficult ;  but  in  most  cases  they  may- 
be distinguished  by  their  extent,  position,  attachment  to  the  bone,  feeble,  ill-defined 
bruit,  and  different  pulsation.  Moreover,  they  cannot  be  emptied  by  pressure  ; 
they  do  not  alter  the  pulse-tracing  in  the  same  way  ;  and  the  bruit  (when  there  is 
one)  is  not  carried  along  the  artery.  Abscesses  in  the  same  region  require  careful 
examination,  as  aneurysms  not  unfrequently  send  outlying  pouches,  which  scarcely 
pulsate,  under  Poupart's  ligament.  In  every  case  the  rectum  should  be  thoroughly 
explored. 

Treatment. — This  depends  upon  the  position,  whether  the  common  trunk  is 
affected,  or  merely  that  part  of  the  external  branch  which  lies  near  Poupart's  liga- 
ment. In  the  former  case,  if  rest  and  diet  do  not  soon  effect  a  decided  improve- 
ment, the  same  treatment  must  be  adopted  as  for  aneurysm  at  the  bifurcation, 
proximal  pressure  with  or  without  distal.  If  low  down,  either  the  same  plan  may 
be  tried,  or  the  common  or  external  iliac  may  be  ligatured  according  to  the  height 


258    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

to  which  the  sac  ascends.  Where  neither  of  these  methods  is  practicable,  galvano- 
piincture  affords  the  best  hope  ;  distal  ligature  has  never  proved  successful,  and  the 
injection  of  coagulants  (although  perchloride  of  iron  once  very  nearly  succeeded) 
is  almost  certain  to  give  rise  either  to  gangrene  of  the  limb  or  suppuration  of  the  sac. 

Aneurysm  of  the  Branches  of  the  Internal  Iliac. 

The  gluteal,  and  less  frequently  the  sciatic  and  pudic  arteries,  are  occasionally 
the  seat  of  aneurysms,  the  majority  being  traumatic  in  origin.  In  some  cases, 
especially  when  the  sciatic  is  concerned,  the  sac  lies  partly  inside  the  pelvis,  partly 
outside  ;  in  most  it  is  altogether  extra-pelvic.  The  mode  of  origin  gives  no  clue 
to  this,  as  either  of  the  arteries  may  be  wounded  in  the  sacro-sciatic  foramen  and 
then  retract ;  the  only  way  in  which  it  can  be  ascertained  is  by  rectal  or,  in  the 
female,  vaginal  examination. 

Symptoms. — When  the  aneurysm  is  small,  these  are  very  vague,  owing  to 
the  dejjth  at  which  it  is  situated.  There  is  jiain  along  the  course  of  the  sciatic 
nerve  ;  the  movements  of  the  hip  are  limited,  especially  in  the  direction  of  flexion  ; 
and  usually  there  is  a  hard,  deep,  ill-defined  swelling.  Pulsation  and  a  bruit  are 
rarely  absent  when  it  has  reached  any  size,  but  so  long  as  the  sac  is  small  it  is  very 
difficult  to  make  certain.  If  left,  spontaneous  cure  is  possible,  but  very  rare  ;  much 
more  often  the  sac  continues  to  enlarge  ;  the  muscle  and  the  tissues  over  it  waste  ; 
and  at  length  rupture  takes  place.  There  is  no  means  of  telling  sciatic  from 
gluteal  aneurysm,  although  the  former  is  more  })robable  if  the  sac  can  be  felt  inside 
the  pelvis. 

Diagnosis. — Pulsating  Sarcoma. — In  its  early  stages  this  is  very  difficult ; 
later,  rectal  examination  or  puncture  with  a  fine  trocar  and  cannula  will  give 
sufficient  evidence.  A  bruit  is  greatly  in  favor  of  the  tumor  being  aneurysmal, 
as  it  is  rarely  present  in  a  sarcoma  until  this  has  attained  a  consideral)le  size,  and 
even  then  it  is  much  softer  in  tone. 

Abscess. — The  absence  of  pulsation  and  bruit  is  usually  sufficient  in  chronic 
abscesses,  the  signs  of  suppuration  in  acute  ones,  but  it  must  be  remembered  that 
gluteal  aneurysms  not  unfrequently  suppurate. 

Enlarged  Bursa. — The  subgluteal  bursa  may  become  distended  with  blood  or 
serous  fluid,  but  there  is  no  bruit  or  pulsation,  in  spite  of  the  thinness  of  the  walls, 
and  there  is  no  tension  ujjon  the  contents. 

Arterial  Hcematoma. — Unless  there  is  a  distinct  history  of  injury,  or  a  cicatrix 
or  some  other  evidence,  a  definite  diagnosis  may  be  impossible.  The  rapidity  of 
formation  and  extension,  the  absence  of  pulsation  and  bruit,  the  tension  and  inflam- 
mation of  the  parts  around  are  equally  sugge.stive  of  abscess,  arterial  haematoma, 
and  ruptured  aneurysm.  Of  these  the  first  can  be  excluded  by  means  of  an  ex- 
ploratory puncture  ;  the  other  two  are  identical  and  require  the  same  treatment. 

Treatment. — Constitutional  treatment  should  be  tried  in  these  as  in  all 
other  kinds  of  aneurysm  first  ;   if  they  fail,  resort  must  be  had  to  operation. 

Pressure  cannot  be  carried  out,  unless  applied  to  the  l)ifiir(;ation  of  the  ab- 
dominal aorta.  Perhaps  this  might  be  worth  a  trial  first,  under  an  anaesthetic.  In 
the  intrapelvic  form  ligature  of  the  internal  or  common  iliac  is  very  serious,  as  an- 
eurysm rarely  involves  this  part  of  the  vessel  without  extensive  atheroma.  In  the 
extra-pelvic  one,  the  old  operation,  laying  the  whole  sac  open,  necessitated  an  in- 
cision in  Syme's  case  nearly  two  feet  long,  and  this  was  followed  by  extensive  ne- 
crosis and  suppuration.  Probably,  therefore,  unless  the  sac  has  already  given  way 
these  aneurysms  are  best  treated  by  galvano-puncture,  or  even  the  injection  of  co- 
agulants such  as  perchloride  of  iron.  If  supi)uration  occurs  and  bleeding  follows 
the  opening  of  the  abscess,  the  cavity  must  be  packed  from  the  bottom.  Embo- 
lism would  not  be  so  serious  a  matter  as  in  most  other  parts  of  the  body. 


ANEURYSM. 


Fkmokai,  ANr:uRvsM. 


259 


Aneurysm  may  occur  in  the  course  of  the  common,  the  superficial,  or  the  deep 
femoral  artery.  Usually  it  is  sacculated,  hut  occasionally  fusiform  ;  sometimes  in 
Hunter's  canal  it  is  rather  flattened. 

As  a  rule  there  is  no  difficulty  in  the  diagnosis,  all  the  characteristic  signs  be- 
ing present,  but  not  unfrequently  it  is  almost  impossible  to  distinguish  whether  the 
dilatation  is  on  the  superficial  or  the  deep  branch  ;  the  former  of  the  two  is  much 
the  more  common,  and  affects  the  pulse  below  to  a  greater  extent,  but  this  cannot 
always  be  relied  ujjon.  Of  course  if  the  pulsation  of  the  superficial  trunk  can  be 
distinctly  made  out  overlying  the  deep  one,  there  is  no  difficulty. 

The  treatment  consists  in  proximal  pressure,  instrumental  or  preferably  digi- 
tal, and  if  this  fails,  ligature.  If  the  aneurysm  is  in  Hunter's  canal,  the  same 
artery  may  be  tied  higher  up  ;  if  in  Scarpa's  triangle,  or  if  the  profunda  is 
involved,  the  choice  lies  between  ligation  of  the  external  iliac  or  of  the  common 
femoral.  The  former  is  usually  preferred,  owing  to  its  freedom  from  branches  at 
the  seat  of  ligature,  the  better  development  of  the  collateral  circulation,  and  the 
fact  that  it  is  less  frequently  atheromatous  ;  but  the  latter  has  been  shown  to  be 
very  successful  in  actual  practice. 

PoPLiTE.AL   Aneurysm, 

The  popliteal  artery  is  the  most  common  seat  of  aneurysm,  except  the  aorta 
itself.  It  is  peculiarly  liable  to  atheroma  ;  it  is  not  supported  by  the  structures 
around  ;  it  is  compressed  more  or  less  in  flexion  of  the  knee,  stretched  out  in  over- 
extension, sometimes  even  ruptured  ;  and  immediately  below  it  breaks  up  into  a 
number  of  branches,  so  that  an  embolus,  if  it  comes  down  the  vessel,  is  almost 
certain  to  lodge  there.  That  constitutional  causes  are  of  very  great  importance 
is  shown  by  the  fact  that  it  sometimes  occurs  on  both  sides,  and  that  it  may  even 
develop  upon  the  second  while  the  patient  is  lying  in  bed  being  treated  for  the 
first. 

Fusiform  dilatation  is  occasionally  met  with,  but  sacculated  aneurysm  is  much 
more  common.  In  some  cases  it  springs  from  the  anterior  surface  of  the  artery 
and  grows  forward  against  the  bone  or  the  posterior  ligament  of  the  knee  joint, 
and  then  it  is  usually  slow  in  its  course,  rarely  attaining  a  large  size.  In  others  it 
extends  backward,  and,  meeting  with  little  to  oppose  it,  becomes  immense,  form- 
ing a  thin-walled  sac  within  comparatively  a  short  space  of  time. 

Symptoms. — Occasionally  the  onset  is  sudden,  dating  from  some  exertion  ; 
more  frequently,  the  patient  suffers  from  obscure  rheumatic  pain  down  the  leg  with 
stiffness  of  the  joint  and  a  sense  of  weakness,  and  then  suddenly  discovers,  or  has 
discovered  for  him,  the  presence  of  a  pulsating  swelling.  Usually  the  expansive 
pulsation,  the  bruit  conducted  down  the  leg,  and  the  way  in  which  the  sac  empties 
upon  compression  and  fills  again  on  relaxation  of  the  vessel  are  distinctive.  Oc- 
casionally the  tumor  is  harder  and  cannot  be  emptied,  the  pulsation  is  that  of  an 
artery  only,  and  the  bruit  is  indistinct  and  faint ;  and  in  some  very  rare  instances 
there  is  no  pulsation  at  all.  Probably,  in  the  former  case,  the  sac  is  already  partly 
filled  with  fibrin,  and  possibly  in  the  latter  it  is  completely  solid  ;  but  as  pulsation 
sometimes  makes  its  appearance  later,  this  explanation  is  hardly  satisfactory. 

If  the  sac  grows  forward,  synovitis  of  the  knee  joint  sets  in,  the  pain  is  very 
severe,  and  movement  greatly  restricted.  If  it  takes  a  direction  backward,  the 
popliteal  vein  may  be  compressed  and  congestion  and  oedema  follow  ;  or  the  in- 
ternal popliteal  nerve  may  be  stretched  so  that  there  is  severe  neuralgia  extending 
down  the  side  of  the  limb  into  the  sole  of  the  foot.  Sometimes  a  distinct  differ- 
ence can  be  made  out  in  the  two  tibial  pulses. 

Left  to  itself  it  occasionally  undergoes  spontaneous  cure.  Much  more  fre- 
quently it  grows  larger  and  larger,  leaks,  and  ruptures  either  into  the  knee  joint,  or 
more  usually  into  the  cellular  tissue  of  the  leg.     In  either  case  the  patient  is  con- 


2  6o    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

scions  of  something  having  given  way,  and  becomes  sick  and  faint  with  the  pain 
and  loss  of  blood.  If  the  rupture  takes  place  through  the  posterior  ligament  the 
knee  becomes  immensely  distended  at  once,  but  the  bruit  and  pulsation  do  not 
altogether  cease,  and  the  pulse  can  still  be  felt,  though  feebly,  in  the  posterior 
tibial.  If  it  is  into  the  cellular  tissue,  a  tense  swelling  forms  rapidly  in  the  popli- 
teal space,  filling  it  completely  and  causing  the  most  severe  pain  ;  the  limb  below 
becomes  cold  and  livid,  the  tibials  cannot  be  felt,  and  in  a  very  short  time  gan- 
grene sets  in.  Occasionally  inflammation  breaks  out  round  the  sac,  the  skin 
becomes  red,  oedematous,  and  exceedingly  painful,  and  sometimes  this  is  followed 
by  suppuration. 

The  diagnosis  must  be  made  from  sarcoma  growing  either  from  the  bones,  the 
posterior  ligament  of  the  knee  joint,  or  the  lymphatic  glands ;  abscess ;  bursal 
cyst,  or  diverticulum  from  the  knee  joint ;  and  solid  tumors  resting  upon  the 
artery.  Arterial  haematoma  from  perforation  of  the  popliteal  artery  gives  rise  to 
the  same  symptoms  as  a  leaking  or  a  ruptured  aneurysm,  according  to  the  size  of 
the  opening.  In  one  case  under  my  care  there  was  a  distinct  bruit  with  faint  pul- 
sation along  the  course  of  the  vessel. 

Treatment. — Rest  and  diet  are  employed  here  only  as  adjuncts,  but  they 
should  never  be  neglected,  and  unless  the  sac  is  enlarging  rapidly,  so  that  there  is 
fear  of  rupture,  it  is  always  advisable  to  submit  the  patient  to  a  few  days'  prepara- 
tion before  employing  any  active  treatment. 

If  the  aneurysm  is  of  moderate  size  only,  and  there  is  no  fear  of  immediate 
rupture,  Reid's  method  with  Esmarch's  bandage,  or  digital  compression,  is  the 
best,  preference  being  given  to  the  latter  if  there  is  much  evidence  of  atheroma 
or  of  heart-disease  ;  to  the  former  if,  other  things  being  suitable,  there  are  enlarged 
glands  in  the  groin.  Flexion  succeeds  well  with  those  that  are  small  or  already 
partially  solidified. 

If  these  measures  fail,  or  if  the  sac  is  enlarging  rapidly  and  perhaps  leaking, 
or  if  inflammation  has  set  in,  or  if  there  is  any  oedema  of  the  foot  from  pressure 
upon  the  popliteal  vein,  the  artery  should  be  tied  at  once  at  the  apex  of  Scarpa's 
triangle,  and  the  limb  well  wrapped  in  cotton-wool  and  raised. 

Moist  gangrene  after  ligature,  rupture  of  the  sac  into  the  cellular  tissue  or 
into  the  knee  joint,  disease  of  the  knee  joint,  caries  of  the  lower  end  of  the 
femur,  and  suppuration  round  the  sac,  require  amputation.  If  dry  gangrene 
occurs,  the  parts  may  be  covered  with  some  antiseptic  powder,  raised,  and  wrapped 
in  cotton-wool,  in  the  hope  that  a  line  of  demarcation  will  form.  Recurrent 
pulsation  after  ligature  must  be  treated  by  compression,  Esmarch's  bandage,  or 
flexion  ;  if  these  fail  and  the  patient  is  a  young  man  with  the  rest  of  his  arteries 
healthy,  the  external  iliac  may  be  tied  ;  if  old,  it  would  probably  be  better  to 
amputate  at  once.  If  secondary  hemorrhage  occurs  from  the  seat  of  ligature,  the 
wound  must  be  opened  and  both  ends  tied  ;  if  this  does  not  succeed,  or  the  wound 
is  in  such  a  condition  that  success  is  improbable,  amputation  should  be  performed. 


OPERATIONS  ON  ARTERIES.  261 


SECTION  IV.— OPERATIONS  ON  ARTERIES. 

Arteries  may  require  to  be  compressed  so  as  to  check  the  flow  of  blood  for  a 
time,  or  Hgatured.  In  either  case  it  is  usual  to  select  certain  points,  owing  to  their 
being  more  accessible,  or  i'urther  removed  from  important  structures,  or  because  of 
the  condition  of  the  collateral  circulation.  Wounds  of  arteries  have  been  already- 
dealt  with. 

Gener.\l  Rules  for  Lkjatuke. 

The  position  of  the  patient  must  be  such  as  to  bring  the  artery  as  near  the 
surface  as  possible,  and  at  the  same  time  make  the  various  anatomical  features  of 
the  limb  stand  out  distinctly. 

The  e.xact  course  of  the  vessel  must  be  made  out  by  feeling  for  its  pulsation 
where  this  is  possible,  and  by  making  use  of  the  ordinary  anatomical  guides.  In 
many  cases  it  is  advisable  to  mark  it  out  upon  the  skin  with  an  aniline  pencil. 
Careful  examination  must  be  made  for  any  abnormality  either  of  the  trunk  itself 
or  of  its  branches. 

Other  things  being  equal,  the  sjjot  selected  should  always  be  far  away  from 
any  large  branch.  If  this  is  impossible,  or  if  when  the  artery  is  exposed  it  is  found 
that  one  is  near,  it  should  be  tied  as  well. 

As  a  rule,  the  incision  should  be  in  the  course  of  the  vessel,  over  it  (excep- 
tions will  be  mentioned  later  on),  the  middle  corresponding  to  the  spot  at  which 
the  artery  is  to  be  tied,  and  the  length  depending  upon  the  amount  of  fat  that  is 
present  and  the  depth  of  the.vessel. 

The  first  incision  should  divide  the  skin  and  the  superficial  fascia,  taking  care 
to  avoid  any  large  subcutaneous  veins,  such  as  the  internal  saphena  or  the  external 
jugular. 

The  deep  fascia  should  be  divided  on  a  director  to  the  same  extent,  and  this 
holds  good  for  every  other  incision  ;  the  bottom  of  the  wound,  that  is  to  say,  should 
be  kept  throughout  in  the  same  plane,  not  deeper  in  one  part  than  in  another. 

Each  anatomical  structure  should  be  recognized  as  it  is  exposed,  the  operator 
carefully  making  out  the  various  landmarks  in  turn. 

Muscles,  when  identified,  should  be  drawn  to  one  side,  the  fascia  which  binds 
them  down  being  divided  if  necessary,  and  the  position  of  the  limb  being  changed 
if  they  are  too  tense. 

The  sheath  of  the  vessel  is  recognized  by  its  position,  by  the  pulsation  of  the 
artery,  and  by  the  sensation  the  finger  receives.  When  an  artery  is  compressed  it 
feels  like  a  flattened  band  with  thick  and  rounded  edges,  and  it  empties  beyond 
the  finger  ;  a  vein  can  hardly  be  felt  at  all,  while  a  nerve  is  round  and  solid. 

The  sheath  is  formed  of  dense  fibrous  tissue,  and  in  the  larger  arteries  is 
separated  from  the  outer  wall  of  the  vessel  by  more  or  less  of  a  space  traversed  by 
minute  blood-vessels  and  delicate  connefctive  tissue.  In  many  cases  the  vein  is 
enclosed  with  it,  in  a  separate  compartment,  and  sometimes  a  nerve  as  well.  The 
nutrition  of  the  coats  of  the  artery  depends  almost  entirely  upon  the  vessels  it 
receives  in  this  way,  and  consequently  the  opening  must  be  as  small  as  is  con- 
veniently possible,  the  sheath  must  be  separated  as  little  as  can  be,  and  care  must 
be  taken  to  open  the  right  compartment.  The  loose  areolar  tissue  that  covers  the 
sheath  is  lifted  up  with  a  pair  of  forceps  at  one  spot,  so  as  to  form  a  small  cone  ; 
the  side  of  this  is  cut  with  a  scalpel  held  upon  the  flat,  so  that  the  edge  does  not 
at  any  time  face  the  artery,  and  an  opening  made  sufficiently  wide  to  see  thebluish- 
Avhite  external  coat  of  the  vessel  beneath.      One  edge  of  this  opening  is  held  up 


262    DISEASES  AND  INJURIES  OF  SEE  CIA  I  STRUCTURES. 


with  a  ])air  of  fine  forceps,  to  make  it  tense,  and  the  vessel  gently  separated  from 
its  sheath  with  an  aneurysm-needle  or  a  director.     The  other  edge  is  then  laid 

hold  of  and  tlie  process  repeated  on  that 
side,  until  the  whole  circumference  is 
detached  for  a  very  short  distance.  The 
aneurysm-needle  is  then  passed  round 
(unthreaded),  keeping  as  close  to  the 
wall  of  the  vessel  as  possible,  and  begin- 
ning on  the  side  that  faces  the  most 
important  structure,  whether  it  is  vein  or 
nerve.  As  the  needle  passes  round,  the 
opposite  edge  of  the  opening  in  the 
sheath  should  be  seized  with  forceps  and 
drawn  outward  in  order  to  straighten  out 
the  route.  Sometimes  a  few  strands  of 
tissue  covering  the  point  of  the  needle 
require  division  with  the  finger-nail,  or 
even  with  the  scalpel,  but  great  care 
should  be  taken  to  keep  the  edge  and  the 
point  away  from  the  vessel  as  far  as  pos- 
sible (Fig.  55). 

When  the  needle  has  been  passed, 

Fig.  55.— This  diagram  represents  three  distinct  opera-     the  VeSSel  is    COmpreSSCd    agaiust    it    with 
tions.     A.  Opening  the  Sheath.     B.  Drawing  Ligature      .^         r-  ^  ^  ^^      ^     •  ^    •       ,-\ 

round  the  Artery,  c  Tying  Artery.  the  finger,  to   make  surc  that   it  IS  the 

artery  (pulsation  ceasing  beyond)  and 
that  nothing  else  is  included  with  it. 
Then  the  needle  is  threaded  and  with- 
drawn. 

A  reef-knot  should  always  be  used. 
A  few  attempts  have  been  made  to  sub- 
stitute a  loop  or  hitch  to  avoid  the  pro- 
jection, but  the  same  reliance  cannot  be  placed  upon  it.  The  amount  of  pressure 
should  be  sufficient  to  draw  the  inner  coat  well  together.  AVhether  this  will  divide 
it  in  the  middle  depends  upon  the  shape  and  material  of  the  ligature.  With  a 
flat  band  (such  as  Barwell's  ox  aorta)  it  certainly  will  not ;  with  stout  catgut  it  is 
very  doubtful ;  with  fine  gut,  kangaroo  tendon,  or  silk,  there  is  no  question.  In 
any  case,  the  greatest  care  should  be  taken,  in  tying  the  knot,  not  to  lift  the  vessel 
unnecessarily  from  its  bed  ;  the  fingers  must  be  brought  down  to  it. 

When  a  double  ligature  is  used  and  the  artery  divided  in  between,  it  must  be 
separated  from  its  sheath  for  some  little  distance ;  how  far  depends  upon  its  size. 
The  object  is  to  enable  the  two  ends  to  retract  thoroughly.  The  portions  that  lie 
beyond  the  ligatures  are  practically  cut  off  from  the  circulation,  in  the  same  way 
as  the  end  of  an  artery  that  is  tied  or  twisted  on  the  face  of  a  stum]),  and  like  it 
either  slough  or  become  infiltrated  with  organizing  lymph,  according  to  the  behavior 
of  the  wound  and  the  addition  or  not  of  suppuration.  This  plan  should  be  adopted 
in  every  case  in  which  a  sufficient  length  of  artery  can  be  exposed  without  inter- 
fering with  the  part  too  much. 


Fig.  56. — Aneurysm-needle. 


Ligature  of  the  Innominate. 

The  line  of  the  artery  runs  from  the  middle  of  the  manubrium  to  the  right 
sterno-clavicular  articulation  ;  the  point  of  bifiircation  is  usually  just  below  the 
upper  border  of  the  joint. 

The  patient  lies  on  his  back  with  the  shoulders  slightly  raised  and  the  head 
turned  toward  the  left.     The  operator  stands  upon  the  right  side. 

The  incision  is  triangular  ;  one  side  extends  for  three  inches  along  the  inner 
border  of  the  right  sterno-mastoid  [in  Smyth's  case  the  incision  was  made  along 


OPERATIONS  ON  ARTERIES.  263 

the  A// sterno-cleido  mastoid],  entling  on  the  .sternum,  the  other  outward  from 
the  lower  end  of  this  along  the  ui)per  border  of  the  clavicle  ;  the  flap  so  formed  is 
reflected  outward  on  its  base. 

The  sternal  head  of  the  sterno-mastoid  and  the  greater  portion  of  the  clavicular 
one  are  divided  upon  a  director,  close  to  their  origin,  and  reflected  in  the  same 
direction  as  the  skin.  The  anterior  jugular  vein  is  drawn  on  one  side  or  tied,  as 
the  case  requires.  The  sterno-hyoid  and  the  sterno-thyroid  muscles  are  divided 
as  far  as  they  are  exposed.  The  third  layer  of  the  cervical  fascia  is  now  laid  bare. 
An  incision  is  made  in  this  over  the  common  carotid  ;  the  artery  is  followed  down- 
ward with  the  finger  until  the  origin  of  the  subclavian  can  be  felt  and  seen  ;  the 
internal  jugular  vein  and  the  pneumogastric  nerve  are  drawn  to  the  other  side,  and 
the  anterior  surface  of  the  sheath  cleared  by  gently  separating  the  loose  fat  and  the 
numerous  thyroid  and  other  veins  lying  in  it.  The  pleura  is  pushed  to  the  right, 
the  veins  to  the  left,  the  sheath  opened  in  between,  and  the  needle  pas.sed  from  right 
to  left. 

A  very  great  deal  depends  upon  the  length  of  the  vessel.  If  possible  there 
should  be  at  least  half  an  inch  between  the  bifurcation  and  the  ligature,  and,  to 
obtain  this,  part  of  the  sternum  and  clavicle  may  be  cut  away  if  necessary.  If 
there  is  not  so  much  the  base  of  the  carotid  should  be  tied  as  well,  but  there  is 
never  sufficient  of  the  subclavian.  The  operation  has  succeeded  only  once  in 
eighteen  times,  secondary  hemorrhage  having  nearly  always  occurred  from  the 
distal  end ;  but  possibly  with  more  suitable  animal  ligatures  of  sufficient  size  and 
strength  better  results  may  be  obtained.  Several  patients  lived  for  long  periods, 
notably  Thomson's,  of  Dublin. 

Sedillot  recommends  a  single  longitudinal  incision  between  the  two  heads  of 
the  sterno-mastoid,  as  enabling  a  better  examination  to  be  made  of  the  bifurcation 
and  the  branches. 

Ligature  of  the  Common  Carotid. 

The  line  of  the  artery,  whatever  the  position  of  the  head,  runs  from  the  sterno- 
clavicular articulation  to  the  lobule  of  the  ear.  It  extends  from  the  joint  as  high 
as  the  upper  border  of  the  thyroid  cartilage,  and  is  crossed  opposite  the  cricoid 
cartilage  by  the  omo-hyoid.  It  may  be  tied  at  the  root  of  the  neck,  below  the 
omo-hyoid  or  above  it.  If  a  choice  is  allowed  the  point  selected  is  at  the  upper 
border  of  the  muscle. 

I.  At  the  Root  of  the  Neck. — The  position  of  the  patient  at  first  is  the  same 
as  for  ligature  of  the  innominate.  Afterward  the  head  is  slightly  raised  and 
rotated  to  relax  the  sterno-mastoid  muscle. 

Either  the  angular  incision  may  be  used  or  Sedillot's  longitudinal  one  between 
the  two  heads  of  the  muscle.  The  preliminary  steps  are  the  same  as  tho.se 
described  already,  the  sternal  head  of  the  sterno-mastoid  being  divided  on  a  direc- 
tor if  sufficient  room  cannot  be  obtained  without.  The  sterno-hyoid  and  sterno- 
thyroid muscles  are  drawn  inward  with  a  retractor  or  notched,  the  cervical  fascia 
divided,  great  care  being  taken  not  to  wound  the  numerous  thyroid  and  other 
veins  that  lie  beneath,  and  the  sheath  of  the  vessel  exposed.  This  must  be 
opened  well  to  the  inner  side  and  the  needle  passed  from  without  inward.  On 
the  right  side  the  pneumogastric  and  the  jugular  recede  somewhat  from  the  artery, 
and  they  may  be  drawn  still  further  away  by  applying  a  retractor  to  the  clavicular 
part  of  the  sterno-mastoid  ;  on  the  left  the  vein  may  overlap  it,  and  the  thoracic 
duct  lies  immediately  behind.  The  ligature  should  always  be  placed  on  the 
artery  as  far  as  possible  from  its  origin,  and  this  operation  should  not  be  selected 
unless,  from  the  presence  of  aneurysm  or  from  other  cause,  no  choice  is  left. 
If  it  is  attempted  the  artery  will  be  found  to  lie  much  deeper  than  is  generally 
expected. 

2  and  3.  Ligature  Imtnediately  Above  or  Below  the  Omo-hyoid  Muscle. — The 
position  of  the  patient  is  the  same,  the  head  being  turned  to  the  opposite  side. 
An  incision  two  inches  and  a  half  in  length  is  made  along  the  inner  border  of  the 


264    niSEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

sterno-mastoid  ;  usually  its  centre  lies  opposite  the  cricoid  cartilage,  but  it  may  be 
higher  or  lower  as  the  case  requires.  The  skin,  superficial  fascia,  and  platysma  are 
divided  first;  the  deep  fascia  is  slit  up  on  a  director,  exposing  the  inner  border 
of  the  sterno-mastoid,  and  avoiding,  if  possible,  the  sterno-mastoid  artery,  thyroid 
veins,  and  a  communicating  vein  that  often  runs  down  along  the  inner  l)order  of 
the  muscle  from  the  facial  to  the  anterior  jugular.  If  this  cannot  be  done  the  ves- 
sels must  be  tied.  The  head  is  now  slightly  raised,  the  sterno-mastoid  drawn  out- 
ward, the  sterno-hyoid  and  sterno-thyroid  inward,  the  deep  fascia  divided,  and 
the  omo-hyoid  exposed  lying  upon  the  sheath,  with  usually  some  filaments  of  the 
descendens  noni  nerve.  The  sheath  is  opened  on  the  inner  side,  avoiding  the 
veins  which  often  cross  the  upper  part,  and  the  needle  introduced  from  without 
inward. 

This  operation  may  be  required  for  wound  of  tlie  artery,  for  liemorrhage  from 


—-\j>tsccndc7is 
^cni  neri'e 

-—Omc-Jiycid 
■X    inusric 


Mastoid  Muscle 


Fig.  57. — Ligature  of  the  Common  Carotid  and  Facial  Arteries. 


or  aneurysm  of  either  the  trunk  or  any  of  the  branches  of  the  internal  or  external 
carotid,  or  as  part  of  the  distal  operation  for  aneurysm  of  the  innominate  of  the 
aorta.  Owing  to  the  effect  upon  the  circulation  through  the  brain  the  two  carotids 
should  never  be  tied  simultaneously,  and  if  one  is  blocked  the  effect  of  temporary 
pressure  should  be  tried  upon  the  other  before  a  permanent  ligature  is  a])plied. 
Life  has  been  maintained  after  both  carotids  and  one  vertebral  have  been  ob.structed  ; 
but,  on  the  other  hand,  symptoms  of  cerebral  an?emia  have  occasionally  followed 
ligature  of  one,  and  not  unfrequenlly  that  of  both,  even  when  the  operations  were 
performed  with  a  considerable  interval. 

The  common  carotid  can  be  com])ressed  against  the  tuljercle  on  the  transverse 
process  of  the  sixth  cervical  vertebra  (the  cricoid  is  opposite  the  fifth)  by  pre.ssure 
backward,  or  a  little  above  this  by  grasping  the  artery  between  the  finger  and 
thumb,  behind  the  sterno-mastoid  when  it  is  relaxed.  Both  are  very  painful  and 
liable  to  cause  syncope  if  kept  up  for  more  than  a  minute  or  two. 


OPERATIONS  ON  ARTERIES.  26 q 


LKiATl'KK    OK    THE    Ex'I  F.KNAl.    C'aKOTID. 

The  line  of  the  artery  runs  from  the  back  of  the  thyroid  cartilage  almost 
directly  upward  to  the  posterior  part  of  the  condyle  of  the  lower  jaw.  The  posi- 
tion of  the  jiatient  is  the  same,  with  the  face  turned  rather  more  to  the  opposite 
side. 

An  incision  is  maile  from  behind  the  angle  of  the  lower  jaw  to  a  short  distance 
below  the  upi)er  border  of  the  thyroid  cartilage,  dividing  the  skin,  superficial  fascia 
and  platysma,  and  watching  carefully  for  the  anterior  division  of  the  temporo-max- 
'illary  vein.  This  emerges  from  the  lower  border  of  the  parotid  and  runs  to  join 
the  facial,  piercing  the  fa.scia  either  just  below  the  gland  or  some  little  distance 
down.  The  anterior  margin  of  the  sterno-mastoid  is  then  defined,  its  sheath  laid 
open,  and  the  deep  fascia  beneath  carefully  divided  upon  a  director.  The  artery 
is  usually  tied  opposite  the  cornu  of  the  hyoid  bone,  the  sheath  being  opened  a 
little  below  and  the  needle  passed  from  without  inward.  Any  veins  that  come  in 
the  way — thyroid,  lingual,  or  facial — are  either  pulled  on  one  side  or  tied  with  a 
double  ligature  and  divided.  If  the  temporal  i)ulse  is  watched  there  is  no  fear  of 
mistaking  the  trunk  of  the  internal  for  that  of  the  external,  although  it  often  lies 
more  superficially  at  its  origin. 

The  usual  seat  of  ligature,  at  the  level  of  the  cornu  of  the  hyoid  bone,  lies  be- 
tween the  superior  thyroid  and  lingual  arteries.  When,  however,  the  object  is  to 
cut  off  the  blood -supply  from  the  middle  meningeal  or  some  other  branch  of  the 
internal  maxillary,  the  vessel  may  be  secured  immediately  under  the  margin  of  the 
parotid. 

Ligature  of  the  external  carotid  is  a  very  much  more  favorable  operation  than 
that  of  the  common,  partly  because  it  avoids  one  of  the  great  sources  of  collateral 
circulation  and  secondary  hemorrhage,  partly  because  it  does  not  interfere  with 
the  blood-supply  of  the  brain.  It  should  always  be  adopted  in  preference  where  it 
can  be  shown  that  one  of  its  branches — the  middle  meningeal,  for  example — has 
been  injured,  or  where  this  is  exceedingly  probable,  as  in  stabs  and  other  injuries 
in  the  region  of  the  parotid.  On  the  other  hand,  in  punctured  wounds  of  the 
tonsil,  in  cases  of  sloughing  diphtheritic  and  scarlatinal  ulcers,  and  when  the  seat  of 
the  injury  is  in  the  region  of  the  greater  cornu  of  the  hyoid  bone,  where  the  internal 
carotid  is  more  superficial  than  the  external,  ligature  of  the  common  trunk  affords 
the  better  prospect,  always  provided  that  the  bleeding  point  cannot  be  secured  in 
situ.  It  must  be  remembered,  with  regard  to  injuries  of  the  tonsil,  that  wounds  of 
the  ascending  pharyngeal  are  no  less  fatal  than  those  of  the  carotid  ;  when  a  small 
branch  arises  from  a  main  trunk  the  pressure  in  it  near  its  point  of  origin  is  scarcely 
less  than  that  in  the  trunk  itself. 

Ligature  of  the  Internal  Carotid. 

This  can  be  done  through  the  same  incision,  the  external  carotid  being  drawn 
forward  and  the  internal  jugular  vein  backward.  The  needle  is  passed  from 
without  inward.  The  operation  has  been  performed  in  a  fair  number  of  cases  with 
success. 

Ligature  of  the  Lingual  Artery. 

The  chief  landmark  is  the  greater  cornu  of  the  hyoid  bone.  The  artery 
arises  from  the  external  carotid  opposite  this  (when  the  body  is  in  the  position  for 
ligature),  and  runs  some  little  distance  along  its  upper  border.  It  may  be  tied 
either  before  or  after  it  passes  beneath  the  posterior  belly  of  the  digastric. 

[It  should  be  remembered  that  occasionally  this  artery  is  given  off  from  the 
superior  thyroid  instead  of  the  external  carotid.] 

The  head  of  the  patient  is  thrown  well  back  and  turned  toward  the  opposite 
side. 

I.  Behind  the  Digastric. — The  incision,  two  inches  in  length,  starts  from  the 
18  '  * 


266     i:>/SEAS£S  AND   J.Y/ CRIES    OF  SPECIAL   STRC/CIXIiES. 

margin  of  the  sterno-mastoid.  and  runs  slightly  curving  upward  immediately  above 
the  greater  cornu.  The  skin,  superficial  fascia,  and  i)latysma  are  divided,  watch 
being  kept  for  the  facial  vein  toward  the  posterior  angle  of  the  wound.  If  it  is 
seen  it  must  be  pulled  on  one  side.  The  projection  of  the  submaxillary  gland  fills 
the  upper  portion  of  the  incision  and  overlaps  the  other  structures  ;  the  deep  fascia 
is  divided  on  a  director  along  its  lower  border,  the  gland  pushed  up,  out  of  the 
way,  the  tip  of  the  greater  cornu  drawn  down  with  a  hook,  and  the  posterior 
margin  of  the  digastric  defined.  The  angle  between  this  and  the  upper  margin 
of  the  hyoid  is  then  carefully  cleaned,  the  hypoglossal  nerve  pushed  upward,  the 
ranine  vein  avoided,  and  the  posterior  fibres  of  the  hyoglossus  exposed.  These" 
are  either  divided  on  a  director,  pushing  it  between  them  and  the  middle  con- 
strictor ;  or  by  picking  them  up  with  a  pair  of  forceps  and  cutting  through  them 
layer  by  layer.  The  artery  lies  with  one,  and  sometimes  two  veins,  close  above  the 
bone. 

2.  After  it  Juts  Passt-i1  tiic  Dii^^astric. — The  position  is  the  .same,  but  the  inci- 
sion starts  half  an  inch  below  and  external  to  the  symphysis,  runs  downward  to  the 
junction  of  the  greater  cornu  and  the  body,  and  then  turns  upward  to  a  little  below 
the  angle  of  the  jaw.  The  structures  are  divided  in  the  same  way,  the  submaxillary 
gland  pushed  up,  and  a  triangle  exposed  formed  by  the  two  bellies  of  the  digastric 
and  the  hypoglossal  nerve,  dipping  under  the  mylohyoid  in  front.  The  fat  and 
loose  cellular  tissue  which  fill  this  space  are  removed,  care  being  taken  not  to  in- 
jure the  ranine  vein  ;  the  fibres  of  the  hyoglossus,  which  form  the  floor,  divided 
layer  by  layer  :  and  the  lingual  artery,  with  its  one  or  two  veins,  exposed,  lying 
parallel  to  the  upper  border  of  the  bone. 

T.IGATURE    OF    THE    F.-VCIAL    ArTERV. 

This  may  be  tied  at  the  anterior  border  of  the  masseter,  where  it  is  oijly 
covered  by  skin,  platysma,  and  fascia.  A  short  transverse  incision  along  the  lower 
margin  of  the  jaw  is  all  that  is  required.  The  vein  lies  behind.  It  can  easily  be 
compressed  in  the  same  situation. 

LlG.JiTURE    OF    THE    TeMPOR.AL    ArTERV. 

A  short  vertical  incision  immediately  in  front  of  the  ear  over  the  root  of  the 
zygoma  is  all  that  is  required.  The  artery  lies  in  some  rather  dense  cellular  tissue 
at  this  spot,  with,  as  a  rule,  a  single  vein. 

The  occipital  artery  may  require  to  be  ligatured  in  the  scalp,  midway  between 
the  mastoid  process  and  the  external  occipital  protuberance  ;  but  in  most  cases, 
like  the  branches  of  the  temporal,  it  can  readily  be  controlled  by  pressure.  In  its 
deeper  part, where  it  lies  under  the  mastoid,  it  is  almost  inaccessible  and  is  i>ractically 
out  of  the  reach  of  injury. 

Ligature  of  the  Subclavian  Artery. 

The  first  part  of  the  right  subclavian  has  been  tied  fourteen  times  with  a  uni- 
formly unsuccessful  result,  and,  except  in  the  case  of  some  abnormality  among  its 
branches,  it  is  difiicidt  to  see  how  it  could  be  otherwise.  The  first  part  of  the  left 
is  quite  out  of  the  question.  On  the  other  hand,  ligature  of  the  third  part,  on  either 
side,  is  a  very  succcssfitl  operation. 

I.  Ligature  of  the  First  Part  of  the  Fight  S///>e/a7'ia;/. — The  artery  extends 
forward,  upward,  and  outward  from  the  bifurcation  of  the  innominate  behind  the 
sterno-clavicular  articulation . 

The  position  of  the  patient  and  the  line  of  the  incision  are  the  same  as  for  ligature 
of  the  innominate  ;  the  inner  border  of  the  clavicular  origin  of  the  sterno-mastoid 
is  divided  as  far  as  required,  and  the  outer  of  the  sterno-hyoid  and  sterno-thyroid, 
exposing  the  anterior  jugular  vein  and  the  deep  layer  of  the  cervical  fascia.     The 


OPERATIONS  ON  ARTERIES. 


■67 


f(jriner  is  tied  or  pulled  on  one  side,  the  latter  divided  very  cautiously  ;  the  internal 
jugular  vein,  with  the  vertebral,  running  down  to  join  the  innominate,  drawn  out- 
ward ;  the  innominate,  if  it  rises  too  high,  jjressed  downward,  and  the  connective 
tissue  gently  separated  until  the  bifurcation  of  the  innominate  artery  is  exposed  on 
one  side  and  the  origin  of  the  vertebral  on  the  other.  The  vagus  should  be 
recognized  and  pressed  inward  toward  the  carotid,  so  as  to  avoid  any  injury  to  the 
recurrent  laryngeal.  If  there  is  sufficient  space  between  the  origin  of  the  vertebral 
anil  the  point  of  bifurcation,  the  sheath  is  opened  midway  and  the  needle  i)assed 
from  below  upward  and  inward,  remembering  that  the  artery  rests  upon  the  ])leura 
behind  as  well  as  below  :  if  the  length  is  too  short,  the  vertebral  should  be  tied  as 
well. 

2.  Ligature  of  the  Third  Part  of  the  Subclavian.  —  The  patient  lies  on  the  back 
with  the  shoulders  slightly  raised,  the  head  turned  to  the  opposite  side,  and  the  arm 
drawn  downward  to  depress  the   clavicle  as  much  as  possible.     The    height  to 


O-Jiyoid  la. 


Fig.  5S. — Ligature  of  Subclavian  and  Lingual  Arteries. 


which  the  artery  ascends  above  the  clavicle  is  very  variable,  particularly  on  the 
right  side  ;  it  may  be  almost  concealed  behind  the  bone,  especially  when  the  neck 
is  short  and  the  curves  well  marked  ;  or  it  may  rise  an  inch  and  a  half  above  it. 
The  pulsation  can  always  be  felt  upon  the  first  rib  between  the  trapezius  and  the 
sterno-mastoid. 

The  course  of  the  external  jugular  vein  should  be  ascertained  first.  Usually 
it  pierces  the  deep  fascia  an  inch  above  the  clavicle,  just  po.sterior  to  the  sterno- 
mastoid.  The  incision,  two  inches  and  a  half  or  three  inches  in  length,  is  parallel 
to  the  clavicle,  immediately  above  it,  with  its  centre  corresponding  to  the  interval 
between  the  sterno-mastoid  and  trapezius  ;  the  skin,  superficial  fascia,  platysma, 
and  descending  branches  of  the  cervical  plexus  are  divided;  there  is  no  need  to 
draw  the  skin  down  on  to  the  bone.  If  the  external  jugular  vein  is  exposed  it 
should  be  drawn  to  one  side.  The  deep  fascia  is  cut  through  upon  a  director,  and 
if  the  interval  between  the  muscles  is  very  small,  the  edge  of  one  or  other  or  both 


268    DISEASES  AND  IXJUKJES  OE  SPECL4L  STRUCTURES. 

may  be  notched.  The  space  thus  exposed  is  filled  with  loose  cellular  tissue  con- 
taining a  venous  plexus  formed  by  the  terminations  of  the  external  jugular,  su])ra- 
scapular.  and  transverse  cervical  veins,  a  branch  from  the  cephalic,  and  sometimes 
the  anterior  jugular  as  well.  To  avoid  wounding  these,  the  tissues  must  be  care- 
fully separated  with  a  director  behind  the  margin  of  the  sterno-mastoid,  until  the 
edge  of  the  scalenus  anticus  is  felt  with  the  finger.  If  this  is  traced  down  to  the 
tubercle  on  the  rib,  the  artery  is  made  out  at  once,  unless  there  is  the  rare  abnor- 
mality in  which  it  follows  the  course  of  the  vein.  As  a  rule,  the  sensation  of  the 
flattened  band  with  rounded  edges  is  characteristic,  even  if  the  pulsation  cannot 
be  felt.  The  chief  difficulty  arises  with  the  lowest  cord  of  the  brachial  plexus,  but 
if  care  is  taken  to  include  only  that  structure  which  lies  next  to  the  scalene  tubercle, 
and  to  feel  the  radial  pulse  before  the  ligature  is  tightened,  it  is  scarcely  likely  to 
be  mistaken. 

The  artery  in  this  situation  is  surrounded  by  a  d.ense  funnel-shaped  sheath 
prolonged  from  the  cervical  fa.scia ;  this  is  opened  by  a  small  incision,  and  the 
needle  passed  from  above,  downward,  behind  the  artery,  so  as  to  avoid  taking  the 
lowest  cord  of  the  plexus. 

The  posterior  belly  of  the  omo-hyoid,  the  subclavian  vein,  and  the  transverse 
cervical  artery  are  rarely  seen.  The  supra-scapular  branch  maybe  in  the  way, 
running  parallel  to  the  clavicle,  but  it  can  always  be  drawn  on  one  side.  The  third 
part  of  the  artery  is  just  free  from  the  pleura.  In  many  cases  the  posterior  scapular 
or  some  other  large  branch  arises  almost  from  the  spot  at  which  the  artery  is  usually 
tied  ;  if  there  is  sufficient  room  the  ligature  is  placed  as  far  as  possible  on  the  dis- 
tal side  ;  if  there  is  not,  the  branch  is  tied  as  well.  In  some  few  ca-ses,  chiefly 
where  the  operation  is  done  for  aneurysm  of  the  axillary,  extending  upward  under 
the  clavicle,  the  outer  margin  of  the  scalenus  anticus  must  be  divided,  and  the 
second  part  ligatured.  In  doing  this,  care  must  be  taken  to  avoid  the  pleura, 
which  lies  behind  and  below  it ;  the  transverse  cervical  and  supra-scapular  arteries, 
which  not  unfrequently  cross  it ;  and  the  phrenic  nerve,  which  runs  down  upon 
the  scalenus  anticus,  but  usually  leaves  it  just  before  it  reaches  the  level  of  the 
artery.  In  any  case  it  is  advisable  to  keep  the  line  of  division  low  down,  but  the 
position  of  the  subclavian  vein  must  be  recollected. 

The  third  part  of  the  subclavian  artery  is  easily  compressed  against  the  first 
rib,  unless  the  neck  is  exceedingly  short  and  thick.  The  operator  stands  behind 
the  patient's  shoulder  and  uses  the  thumb  of  the  same  hand  (right,  that  is  to  say, 
for  the  right  subclavian)  pressing  downward,  inward,  and  backward.  If  there  is 
any  difficulty,  it  is  probably  because  the  artery  makes  rather  a  higher  curve  than 
is  expected.  Sometimes  a  compressor  is  used,  but  the  brachial  plexus  cannot 
then  be  so  well  avoided. 


Ligature  of  the  Vertebral  Artery. 

This  has  been  performed  for  secondary  hemorrhage  after  ligature  of  some  of 
the  larger  trunks,  and  for  epilepsy.  The  operation,  however,  so  far  as  this  last- 
mentioned  affection  is  concerned,  has  been  practically  abandoned,  although  some 
of  the  cases  derived  considerable  temporary  benefit. 

The  position  is  on  the  back,  with  the  head  slightly  turned  to  the  opposite  side. 
There  is  no  line  for  the  artery  ;  the  guide  to  it  is  either  the  transverse  process  of 
the  sixth  cervical  vertebra,  or  the  interspace  between  the  scalenus  anticus  and  the 
longus  colli. 

The  incision  is  three  inches  in  length,  down  the  posterior  margin  of  the  sterno- 
mastoid  ;  the  external  jugular  vein  must  be  avoided  and  drawn  inward  with  the 
muscle.  The  fa.scia  beneath  is  carefiiUy  divided  until  the  scalenus  anticus,  with  the 
phrenic  nerve  and  the  transverse  cervical  artery,  are  recognized.  Avoiding  these, 
the  inner  border  of  the  scalenus  anticus  is  to  be  made  out,  and  next  to  this,  lying 
between  it  and  the  longus  colli,  is  the  artery.  The  transverse  process  of  the  sixth 
cervical  is  a  further  guide  to  the  division  if  it  is  required.      The  vein  lies  almost 


OPERATJOXS  ON  ARTJ-IR/ES.  269 

always  in  front  of  the  artery.  Alexander,  who  has  had  the  chief  experience  in 
this  operation,  recommends  that  it  should  be  drawn  inward  or  outward,  whichever 
is  most  convenient,  with  an  aneurysm-needle.  Another  needle  is  then  passed  from 
without  inward,  behind  the  artery,  threatled,  and  withdrawn. 

The  pleura  lies  on  the  inner  side  of  the  wound,  the  subclavian  artery  below. 
If  the  vertebral  enters  the  fifth  foramen  instead  of  the  sixth  it  generally  runs 
slightly  more  to  the  inner  side. 

LiG.ArURE    OF    THE    INTERNAL    Ma.MM.\RV    ArTKKV. 

The  internal  mammary  runs  downward  behind  the  costal  cartilages  to  the 
margin  of  the  sternum  in  the  sixth  interspace,  where  it  divides.  At  its  origin  it  is 
crossed  by  the  phrenic  nerve  and  by  the  junction  of  the  internal  jugular  and  sub- 
clavian veins ;  in  the  first  three  interspaces  ligature  is  fairly  easy  ;  after  that,  it 
becomes  more  and  more  difficult.  The  incision  is  oblique,  with  its  centre  corre- 
sponding to  the  middle  of  the  intercostal  space  concerned  ;  the  skin,  superficial 
fascia,  aponeurosis  of  the  pectoralis  major,  and  the  intercostal  fa.scia  are  successively 
divided  and  the  artery  exposed,  with  a  vein  on  either  side.  If  there  is  not  suffi- 
cient room,  part  of  the  costal  cartilages  or  of  the  sternum  should  l)e  removed  as 
well. 

Ligature  of  the  Axillary  Artery. 

The  axillary  artery  is  tied  either  on  the  front  of  the  thorax  in  the  first  part  of 
its  course,  or  from  the  axilla  in  the  third.  The  line  of  the  ve.ssel,  when  the  arm 
is  abducted  from  the  side,  is  from  the  middle  of  the  clavicle  outward  to  the  inner 
side  of  the  prominence  caused  by  the  coraco-brachialis. 

1.  I?i  the  First  Part  of  its  Course. — The  patient  is  placed  on  the  back  with  the 
shoulder  unsupported,  hanging  over  the  edge  of  a  pillow,  and  the  arm  by  the  side. 
Later,  after  the  muscle  is  divided,  a  greater  amount  of  space  can  be  obtained  by 
pushing  the  elbow  somewhat  upward.  Various  incisions  have  been  used,  but  the 
most  simple  is  one  running  parallel  to  the  clavicle,  half  an  inch  below  it,  from 
just  inside  the  coracoid  process  to  within  an  inch  of  the  sternal  end.  The  skin, 
superficial  fascia,  and  some  fibres  of  the  platysma  are  divided  ;  the  clavicular 
portion  of  the  pectoralis  major  is  cut  through  in  successive  layers,  any  vessel  that 
bleeds  being  clamped  at  once  ;  and  the  costo-coracoid  membrane  exposed,  with 
the  cephalic  vein  crossing  inward  and  the  acromio-thoracic  artery  (some  branches 
of  which  have  already  been  divided)  coming  forward  through  it.  The  layer  of 
fascia  is  cut  through  on  a  director,  parallel  to  the  clavicle,  above  the  perforation  of 
the  cephalic  vein,  and  the  axillary  sheath  exposed,  covered  with  a  little  loose  fat. 
The  sheath  is  opened  above  ;  the  vein  lies  almost  in  front  of  the  artery,  but 
it  can  usually  be  pressed  down  with  the  finger  out  of  harm's  way.  The  needle 
should  be  passed  from  below  upward,  avoiding  the  long  thoracic  nerve  which  lies 
behind  the  artery  on  the  serratus  magnus,  and  the  lowest  cord  of  the  brachial 
plexus,  which  lies  immediately  above. 

This  operation  can  readily  be  performed  upon  the  dead  subject,  but  it  is  very 
doubtful  if,  in  the  living,  it  has  any  advantage  over  ligature  of  the  third  part  of 
the  subclavian  ;  and  certainly  it  has  several  grave  disadvantages.  Its  branches  are 
numerous,  the  vein  is  seriously  in  the  way,  very  large  abnormal  branches  not 
unfrequently  arise  from  it,  and  the  operation  is  much  more  difficult. 

2.  In  the  Third  Part  of  its  Course. — The  arm  is  abducted  from  the  side  and 
rotated  outward  to  bring  the  folds  of  the  axilla  and  the  head  of  the  bone  into 
prominence.  The  line  of  the  artery  is  parallel  to  the  margins  of  the  axilla,  but 
nearer  the  anterior  than  the  posterior.  When  operating  on  the  left  side,  the  sur- 
geon stands  between  the  arm  and  the  thorax  ;  on  the  right,  it  is  more  convenient 
for  him  to  place  himself  on  the  outer  side  (Fig.  59). 

The  incision,  three  inches  in  length,  runs  down  the  inner  border  ot  the 
coraco-brachialis  from  the  highest  point  of  the  axilla.     The  skin  and  superficial 


270    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

fascia  only  are  divided.  The  deep  fascia  is  slit  u])  on  a  director,  the  inner  border 
of  the  muscle  defined,  the  median  nerve  which  lies  next  to  it  (excei)t  the  musculo- 
cutaneous which  perforates  it)  pulled  slightly  to  the  outer  side,  and  the  artery 
exposed  behind  it.  The  sheath  is  opened  in  front  and  the  needle  passed  from 
within  outward. 


r'  "tyz-ri  linrZinl/s  m/isclf- 


2;it '.  /^u/an£ous  nerfe . 


Fig.  59. — Ligature  of  Axillary  Artery. 


If  the  axillary  vein  is  single  and  occupies  the  normal  relation  to  the  artery,  it 
may  not  be  seen  at  all  or  only  indistinctly  through  the  sheath  ;  but  often  there  are 
two,  and  sometimes  they  lie  on  opposite  sides  and  are  united  by  transverse 
branches  across  it.  Abnormal  branches  are  not  at  all  uncommon,  the  radial,  for 
example,  arising  high  up. 

Ligature  oy  the  Brachial  Artery. 

The  brachial  artery  may  be  tied  in  any  part  of  its  course.  The  line  is  from 
the  inner  margin  of  the  coraco-brachialis  in  the  axilla,  down  the  inner  margin  of 
the  biceps  to  the  middle  of  the  bend  of  the  elbow. 


BSce/is    muscle 


Median,  nerve 
Fk;.  60. — Ligature  of  Brachial  Artery. 


The  arm  is  abducted,  extended,  and  rotated  outward.  In  the  later  steps  of 
the  operation,  if  the  biceps  overlaps  the  artery,  the  elbow  may  be  flexed  to  relax  it 
(Fig.  60). 

I.  In  the  Upper  and  Middle  Part  of  its  Course  an  incision  two  inches  long 
is  made  over  the  inner  margin  of  the  muscle,  dividing  the  skin  and  the  superficial 


OPE  RAJ  JONS  OX  AJ<TERIES.  271 

fascia  only.  The  deep  fascia  is  cut  tiirou^h  upon  a  director,  the  muscle  drawn 
outward,  anil  the  median  nerve,  which  usually  lies  upon  the  anterior  surface  of  the 
artery,  drawn  either  outwartl  or  inward  according  to  its  position.  The  artery  lies 
to  the  inner  side  of  the  muscle,  with  a  vein  on  either  side  of  it  ;  and  the  needle 
may  be  passed  in  either  direction.  Occasionally  the  median  nerve  lies  on  the  deep 
surface  of  the  vessel,  not  the  sui)erficial,  and  sometimes  a  certain  amount  of  diffi- 
culty arises  from  abnormalities,  the  brachial  winding  round  the  internal  condyle 
of  the  humerus,  or  dividing  into  two  branches  high  up.  It  is  said  that  a  large  in- 
ferior profunda  has  been  mistaken  for  the  artery,  and  that  difficulty  has  been  caused 
by  the  median  nerve  resting  upon  the  vessel  and  receiving  an  impulse  from  it. 

The  brachial  artery  may  be  compre.ssed  against  the  shaft  of  the  humerus  in  any 
jxirt  of  its  course,  the  direction  of  the  pressure  varying  with  the  part  of  the  artery 
concerned.  In  many  cases  it  is  rather  nainful.  nrobably  owing  to  the  fact  that  the 
nerves  are  pressed  upon  as  w-ell. 

2.  Ligature  at  the  Bend  of  the  Elbow. —  The  arm  is  abducted,  the  elbow  ex- 
tended and  supinated.  An  incision  an  inch  and  a  half  in  length  is  made  obliquely 
at  the  bend  of  the  elbow,  parallel  and  close  to  the  inner  border  of  the  tendon  of 
the  biceps,  avoiding  the  median  basilic  vein,  which  lies  to  the  inner  side,  and  the 
metlian  cephalic,  which  lies  below.  As  it  is  deepened  the  median  basilic  vein  can 
be  drawn  inward,  and  with  it  the  internal  cutaneous  nerve.  The  strong  semilunar 
fascia  from  the  biceps  is  then  divided  upon  a  director,  and  the  artery  with  its  venae 

Tciifhrious .  Ijwucurosis 
.       di  rid  eel 


'^'w-*  ^ 


Fig.  61. — Ligature  of  Brachial  Artery  at  the  Bend  of  the  Elbow. 

comites  exposed,  lying  surrounded  by  a  small  amount  of  cellular  tissue  and  fat. 
The  needle  may  be  passed  from  either  side,  the  median  nerve  being  some  little 
distance  off  (Fig.  61). 

Forced  flexion  and  forced  extension  can  control  and  even  stop  the  pulsation 
in  the  brachial  at  the  elbow,  the  former  by  compressing  it  between  muscular 
ma.sses,  the  latter  by  the  tension  exerted  on  it. 

Ligature  of   the   Radial  Artery. 

The  line  of  the  vessel  is  almost  straight  from  the  inner  side  of  the  tendon  of 
the  biceps  to  just  internal  to  the  base  of  the  styloid  process  of  the  radius  ;  it  may 
be  tied  in  any  part  of  its  course  (Fig.  62). 

The  arm  is  extended  and  supinated  ;  later,  when  the  upper  part  of  the  artery 
is  to  be  tied,  the  elbow  joint  is  flexed  to  relax  the  supinator  longus. 

I.  In  the  Upper  Part. — The  line  of  the  incision  varies  with  the  condition  of 
the  muscles.  When  they  are  only  moderately  developed  it  may  correspond  to  that 
of  the  artery  ;  but  in  cases  in  which  the  prominence  of  the  supinator  longus  reaches 
beyond  the  middle  of  the  limb,  it  is  placed  more  to  the  inner  side.  The  skin  and 
superficial  fa.scia  are  divided  for  from  two  to  three  inches,  avoiding  as  far  as  jjos- 
sible  the  large  cutaneous  veins  often  present  in  the  course  of  the  vessel ;  the  deep 
fascia  is  cut  through  upon  a  director,  the  edge  of  the  muscle  raised   (while    the 


2  7-'     DISEASES  AND   INJURIES   OE  SPECIAL   STRUCTURES. 

elbow  is  flexed),  and  the  under  surface  followed  until  the  artery  is  exposed,  sur- 
rounded by  a  little  loose  fascia  and  lying  upon  the  pronator  radii  teres.  The 
veins  lie  on  either  side  of  it,  the  nerve  is  not  seen  (Fig.  63). 

2.  At  the  wrist  i\i\?.  artery  is  quite  superficial,  and  all  that  is  required  is  a  very 
short  incision  on  the  radial  side  of  the  tendon  of  the  flexor  carpi  radialis,  between 
it  and  the  supinator  longus.  The  deep  fascia  must  be  very  cautiously  cut  through 
upon  a  director.  Two  veins  accompany  the  artery  ;  the  nerve  lies  adjacent  to  it 
for  part  of  its  course,  but  leaves  it  before  it  reaches  the  wrist  (Fig.  64). 

3.  The  radial  artery  may  also  be  tied  on  the  outer  side  of  the  wrist,  where 


Fig.  62.— Line  of  Incision  for  Ligature. 

its  pulsation  can  easily  be  felt.     The  hand   should  be  abducted  and  slightly  ex- 
tended to  relax  the  extensor  tendons  of  the  thumb. 

Ligature  of  the  Ulnar  Arierv. 

The  line  of  the  ulnar  artery  extends  from  the  inner  side  of  the  biceps  tendon 
in  the  middle  of  the  bend  of  the  elbow,  inward  to  about  the  middle  of  the  ulna, 
and  then  straight  down  to  the  outer  side  of  the  pisiform  bone.  The  arm  is  ex- 
tended and  the  forearm  supinated  ;  but  after  the  interval  between  the  muscles  is 
found  the  wrist  is  flexed  to  relax  the  stuctures  on  the  front  of  the  limb. 

r.   The  artery  can  be  tied  in  the  upper  third  of  its  course,  although  it  is  diffi- 


Su/iinator  lonr/iis 


Fig.  63. — Ligature  of  Radial  Artery. 

cult  to  understand  what  circumstances  could  give  rise  to  such  an  operation.  The 
line  of  incision  is  not  that  of  the  artery,  it  runs  from  the  front  of  the  internal 
condyle  to  the  outer  border  of  the  pisiform  bone,  and  is  at  least  three  inches  in 
length.  The  skin  and  superficial  fascia  are  divided,  and  the  deep  fascia  thor- 
oughly exposed  in  order  to  find  the  white  line  that  marks  the  tendinous  edge  of 
the  flexor  carpi  ulnaris.  This  is  divided  for  the  whole  length  of  the  wound  ;  the 
hand  is  flexed  to  relax  the  muscle,  and  the  fibres  separated  until  the  ulnar  nerve  is 
laid  bare  lying  upon  the  flexor  profundus.  External  to  this  is  the  edge  of  the 
flexor  sublimis,  which  must  be  divided,  and  then  carefully  lifted  up  from  the  flexor 
profundus  beneath,  until  the  vessel  is  exposed  with  the  veins  on  each  side.  Lower 
down,  where  it  approaches  the  nerve,  it  is  much  more  easy. 


OPERATIONS  ON  ARTERIES. 


273 


2.  At  the  wrist  all  that  is  required  is  a  short  incision  along  the  radial  side  of 
the  flexor  carpi  ulnaris  tendon.  As  soon  as  this  is  exposed  the  wrist  is  flexed  and 
the  tendon  raised  with  the  handle  of  the  scalpel,  laying  bare  the  deep  fascia  which 
covers  in  the  artery  as  it  lies  upon  the  flexor  profundus  or  the  annular  ligament. 
The  nerve  lies  to  the  inner  side,  and  is  slightly  deeper  (Fig.  64). 

Ligature  of  the  Abdominal  Aorta. 

The  abdominal  aorta  divides  opposite  the  left  side  of  the  body  of  the  fourth 
lumbar  vertebra,  on  a  level  with  the  umbilicus  and  the  highest  point  of  the  crest 
of  the  ilium.  The  line  of  the  iliac  arteries  runs  from  this  to  a  point  on  Poupart's 
ligament,  midway  between  the  anterior  superior  spine  of  the  ilium  and  the  jjubic 
symphysis.  The  upper  third  corresponds  roughly  to  the  common  iliac,  the  lower 
two-thirds  to  the  external. 

The  abdominal  aorta  has  been  tied  ten  times  in  all,  one  patient  surviving  ten 
days  after  the  operation.  Cooper's  incision  was  in  the  middle  line  of  the  abdo- 
men, the  intestines  being  pushed  on  one  side  and  the  peritoneum  scratched  through 
with  the  finger  nail.  The  other  method  is  post-peritoneal,  the  incision  being 
similar  to  that  employed  for  ligature  of  the  common  iliac,  but  prolonged  at  least 
as  high  as  the  umbilicus.     The  needle  should  be  passed  from  left  to  right. 

Compression  of  the  abdominal  aorta  is  easily  managed  at   the  umbilicus  by 


T)r<'}i  j'fisrin 

7 


Fig.  64. — Ligature  of  the  Radial  and  Ulnar  Arteries. 


means  of  Lister's  tourniquet,  and  may  be  kept  up  under  an  anaesthetic  for  an  hour 
and  more  \vithout  any  serious  con.sequences.  In  thin  people  the  artery  may  be 
controlled  with  the  thumbs.  The  tourniquet  should  be  placed  upon  the  right  side 
and  wTth  the  upper  pad  rather  beyond  the  middle  line,  as  the  aorta  lies  on  the  left. 


Ligature  of  the  Common  Iliac. 

Abernethy's  incision  for  ligature  of  the  external  iliac  commences  one  inch 
above  Poupart's  ligament,  half  an  inch  outside  the  external  abdominal  ring,  runs 
upward  curving  round  parallel  to  Poupart's  ligament,  and  terminates  a  short  dis- 
tance above  and  internal  to  the  anterior  superior  spine.  How  far  it  should  be 
prolonged  upw-ard  in  a  case  of  ligature  of  the  common  iliac  depends  upon  the 
condition  of  the  abdominal  wall.  Certainly  it  must  be  continued  at  least  tw'o 
inches  above  the  anterior  spine,  and  not  unfrequently  as  high  as  the  umbilicus 
(Fig.  65).  The  skin  and  superficial  fascia  are  divided  first ;  then  the  external  ob- 
lique, internal  oblique,  and  transversalis  muscle  in  order  (some  of  the  branches  of 
the  circumflex  ilii  being  cut  between  the  two  last)  and  the  transversalis  fascia  ex- 
posed. This  can  always  be  distinguished  from  the  peritoneum  by  its  being  attached 
to  Poupart's  ligament.  A  small  incision  is  carefully  made  in  it,  at  the  lower  angle 
of  the  wound,  w-here  it  is  thickest,  and  where  the  sub-peritoneal  fat  collects  most, 
and  then  it  is  divided  for  the  whole  length  upon  a  broad,  flat  director.  The  peri- 
toneum is  pushed  inward,  not  stripped  up.  the  patient  being  turned  over  slightly 


2  74    DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

to  the  opposite  side,  the  sheath  of  the  artery  exposed  and  cleaned,  and  the  needle 
passed  round  it  from  within  outward.  The  spermatic  vessels  and  the  ureter  adhere 
to  the  peritoneum  and  so  escape  danger. 

On  the  left  side  the  veins  do  not  give  much  trouble  ;  the  left  common  iliac 
lies  to  the  inner  side  of  the  artery  the  whole  way.  On  the  right,  however,  the 
relation  is  much  closer.  The  inferior  vena  cava  begins  on  the  right  side  of  the 
artery,  over  the  body  of  the  fifth  lumbar  vertebra  ;  the  left  common  iliac  passes 
behind  the  commencement ;  the  right  behind  the  end,  winding  round  as  it  ascends 
until  it  comes  to  lie  upon  the  outer  side.  As  the  artery  cannot  be  seen  the  diffi- 
culty can  easily  be  imagined. 

The  operation  has  been  performed  according  to  Lidell  sixty-eight  times  with 
only  sixteen  recoveries,  and  it  is  a  matter  of  question  whether  it  would  not  be  ad- 
visable to  adopt  Cooper's  method  and — especially  if  it  is  the  right  side — deliber- 
ately open  the  abdomen. 

The  common  iliac  arteries  can  be  controlled  at  their  point  of  bifurcation  by 
means  of  Davy's  lever.  It  is  simply  a  smooth,  straight  bar  of  wood,  which  is  intro- 
duced through  the  anus  and  passed  up  the  bowel  until  it  rises  out  of  the  cavity  of 


Fig.  65. — Incision  for  the  Application  of  Ligature  to  the  Aorta  or  Common  Iliac  .\rterj'. 


the  true  pelvis.  By  raising  the  outer  end  and  turning  it  to  one  side  or  the  other, 
the  opposite  artery  is  easily  compressed  against  the  bone,  just  at  or  above  its  bifur- 
cation. It  controls  the  branches  of  the  internal  as  well  as  of  the  external  iliac, 
but  it  is  in  many  cases  very  difficult  of  introduction  ;  when  a  large,  loose  rectum 
falls  into  folds  it  is  sometimes  no  easy  matter  for  the  hand  to  find  its  way  up  ;  per- 
foration has  been  caused  by  it,  and  the  mucous  membrane  of  the  bowel  is  liable  to 
slough  if  the  pressure  is  continued. 


Ligature  of  the  Internal  Iliac. 

The  position  of  the  patient  and  the  line  of  the  incision  are  the  same  as  for 
ligature  of  the  common  trunk.  The  peritoneum  must  be  pushed  inward  in  the 
same  way,  and  the  finger  passed  down  over  the  external  branch  to  find  the  internal. 
The  needle  is  passed  from  within  outward,  the  internal  iliac  vein  lying  behind  it 
and  to  its  inner  side,  the  termination  of  the  external  and  the  commencement  of 
the  common  behind,  and  to  the  outer  side  at  its  origin.  There  is  usually  a  little 
more  than  an  inch  available. 


OPERATIOyS  OX  ARTERIES. 


275 


LlGAllRF.    OF    THE  (IlAIEAL  ARTERY. 

The  line  of  the  ghiteal  artery  extends  from  the  posterior  superior  spine  of  the 
ilium  to  the  apex  of  the  great  trochanter  ;  it  emerges  from  the  pelvis  at  the  junc- 
tion of  the  upper  with  the  micklle  third.  The  position  of  the  patient  is  face 
downward  with  the  thigh  extended. 

The  incision  is  in  the  line  of  the  artery,  four  inches  in  length.  The  skin  and 
superficial  fascia  are  divided,  the  fibres  of  the  gluteus  maximus  exposed  and  sepa- 
rated, and  the  upper  margin  of  the  great  sacro-sciatic  foramen  felt  for  with  the 
finger.  The  artery  emerges  through  this  between  the  margins  of  the  jjyriformis 
and  the  gluteus  medius. 


'i  j-Peritcneank 
S/iermaOc  Cent 


■Occ/iyaseia 
SarCcriua  mitsrlc/ 


Jjony.  Sa/i/tena      \-M$, 


Fig.  66. — Ligature  of  External  Iliac  and  Superficial  Femoral  Arteries.     In  this   figure  the  incision  for  the 
Femoral  Artery  is  placed  too  low. 

The  spot  at  which  the  sciatic  artery  is  found  lies  internal  to  and  below  this, 
in  the  middle  of  the  line  drawn  from  the  posterior  superior  sjjine  to  the  tuberosity  ; 
the  incision  is  vertical. 

The  internal  pudic  lies  about  half  an  inch  internal  to  this,  under  the  cover 
of  the  great  sacro-.sciatic  ligament. 


Ligature  of  the  External  Iliac. 

The  line  of  the  artery  is  the  continuation  of  that  for  the  common  iliac  ;  excep- 
tionally in  old  people  with  tortuous  ves.sels  it  is  thrown  into  curves,  the  most 
marked  of  which  usually  dips  down  into  the  pelvis.  The  position  of  the  patient 
is  the  same,  the  limb  being  extended  and  slightly  abducted. 

There  are  two  methods — .\bernethv's.  which  has  been  described  already,  and 


2  76    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Cooper's  (Fig.  66).  The  incision  in  the  latter  is  shghtly  concave  upward,  about 
half  an  inch  above  Poupart's  ligament,  commencing  to  the  inner  side  of  the  centre 
and  running  toward  the  anterior  superior  spine  for  about  three  inches.  The  skin, 
superficial  fascia,  and  a  few  small  vessels  ])assing  over  Poupart's  ligament  are 
divided  ;  the  aponeurosis  of  the  external  oblique  is  incised  for  the  same  distance 
upon  a  director  ;  the  internal  oblique  and  transversalis  muscle  drawn  upward  and 
outward,  or  if  necessary  divided  to  a  slight  extent,  and  the  transversalis  fascia  with 
the  internal  abdominal  ring  and  the  spermatic  cord  exposed.  The  deep  epigastric 
artery  and  the  cord  are  then  pulled  upward  and  inward,  the  transversalis  fascia 
cautiously  divided  sufficiently  to  admit  the  finger,  and  the  sheath  of  the  artery 
exposed,  overlapped  to  a  very  slight  extent  by  the  peritoneum.  The  needle  is 
passed  from  the  side  of  the  vein,  taking  care  not  to  include  the  genito-crural  nerve. 
Cooper's  operation,  there  is  no  doubt,  interferes  with  the  strength  of  the 
abdominal  wall  less  than  Abernethy's,  although,  if  buried  sutures  are  used  and 
the  layers  carefully  united  to  each  other  in  their  proper  order,  it  suffers  very 
slightly  in  either.  The  peritoneum  is  less  exposed,  and  perhaps  is  in  less  danger 
of  being  injured,  but  the  difference  is  not  a  material  one.  The  deep  epigastric, 
on  the  other  hand,  is  distinctly  in  very  great  danger  and  has  been  wounded  ;  the 
circumflex  ilii  vein  almost  crosses  the  seat  of  ligature,  and  if  the  lower  part  of  the 
artery  is  diseased,  it  is  impossible  to  reach  the  upper,  much  less  the  common  iliac, 
without  enlarging  the  wound  very  seriously.  Abernethy's,  therefore,  is  to  be 
preferred  for  all  cases  except  aneurysms  situated  below  Poupart's  ligament  in  which 
the  artery  can  be  shown  to  be  healthy  where  it  crosses  the  pubes. 


Ligature  of  the  Femoral  Artery. 

The  line  of  the  artery  begins  at  the  mid-point  between  the  pubic  symphysis 
and   the  anterior  superior  spine,  and  Avhen  the  limb   is  straight  runs  down   to 
the  inner  border  of  the  patella,  the  vessel  extending  two-thirds  of  the  distance. 
If,  on  the  other  hand,  the  limb  is  flexed,  abducted,  and  rotated  outward — the  posi- 
tion in  which  it  is  placed  for  operation — the  lower  point 
is  the  adductor  tubercle  on  the  internal  condyle  (Fig.  67). 
The   common    femoral    is   tied  immediately  below 
Poupart's  ligament,  the  superficial  one  either  at  the  apex 
of  Scarpa's  triangle  or  in  Hunter's  canal. 

I.  The  Common  Femoral. — The  incision  may  be 
either  longitudinal  or  transverse.  The  former  is  two 
inches  in  length  in  the  line  of  the  artery,  beginning 
immediately  below  Poupart's  ligament ;  the  latter  is 
parallel  to  the  ligament,  half  an  inch  below  it,  and  across 
the  vessel.  .  The  skin,  superficial  fascia,  and  fascia  lata  are 
very  carefully  divided  in  either  case  ;  the  sheath  of  the 
vessel  exposed,  avoiding  the  genito-crural  nerve,  and  the 
compartment  that  contains  the  artery  opened  on  the  inner 
side.  The  needle  is  passed  from  within  outward  about 
half  an  inch  below  the  ligament. 

The  objections  urged  against  this  operation  are  the 
uncertain  length  of  the  artery — the  origin  of  the  profinida 
is  u.sually  an  inch  and  a  half  below  Poupart's  ligament, 
Ijut  it  may  be  very  much  higher  or  very  much  lower,  and 
then  one  of  the  large  circumflex  branches  frequently 
comes  off  from  the  main  trunk  by  itself — and  the  fact  that 
this  part  is  frequently  diseased.  But  in  carefully  selected 
cases  it  has  been  shown  to  be  very  successful. 

The  comon  femoral  is  easily  controlled  by  digital  or 
instrumental  compression  where  it  passes  under  the  ligament,  resting  upon  the 
bone. 


Fig.  67. — Line  of  Incision  for  Liga- 
ture of  the  Femoral  Artery. 


OPERATIONS  ON  ARTERIES.  277 

2.  TJif  Siipfrjicial  Femoral  in  Scarl^a  s  Triangle. — The  jioint  selected  is  at 
the  apex,  just  before  it  is  crossed  by  the  sartoriiis,  usually  four  or  five  inches  below 
the  ligament  and  two  or  three  below  the  origin  of  the  jjrofunda. 

The  limb  is  slightly  flexed,  abducted,  and  laid  upon  its  outer  side,  the  line  of 
the  artery  marked  out  (if  possible  the  pulsation  should  be  felt),  and  the  course  of 
the  internal  saphena  vein  ascertained.  The  incision  is  three  inches  in  length, 
with  its  centre  opposite  the  point  selected.  The  skin  and  superficial  fascia  are 
divided,  the  fascia  lata  exposed,  and  the  edge  of  the  sartorius  made  out  as  it  runs 
downward  and  inward  past  the  lower  margin  of  the  wound.  The  fascia  is  divided 
along  the  edge  of  the  muscle,  which  is  then  drawn  outward  and  raised  with  a 
retractor;  another  thinner  layer  cut  through  beneath,  and  the  sheath  of  the  vessel 
exposed,  with  perhaps  the  internal  cutaneous  nerve  crossing  it.  A  small  opening 
is  made  in  the  sheath  and  the  needle  passed  round  the  artery  from  within  outward, 
care  being  taken  not  to  injure  the  vein  which  lies  almost  immediately  behind. 

3.  The  Superficial  Femoral  in  Hunter  s  Canal. — Hunter's  canal  occupies  the 
middle  third  of  the  thigh  measured  upon  the  inner  side;  the  point  selected  for 
ligature  is  in  the  middle' of  this  or  midway  between  the  groin  and  the  knee.  The 
line  of  the  incision,  when  the  limb  is  flexed,  abducted,  and  rotated  outward,  is  a 
finger's  breadth  internal  to  the  line  of  the  artery,  and  should  be  three  or  four 
inches  in  length. 

The  skin  and  superficial  fascia  are  divided,  avoiding  the  internal  saphena  vein, 
and  exposing  the  fascia  lata  covering  the  sartorius.  The  muscle  is  recognized  by 
the  almost  vertical  direction  of  the  fibres.  The  fascia  is  divided  upon  a  director 
along  its  outer  or  anterior  border,  the  muscle  pulled  inward  with  a  retractor,  and 
the  fibrous  tissue  forming  the  roof  of  Hunter's  canal  and  stretching  from  the  vastus 
internus  to  the  adductors  exposed.  The  aponeurosis  is  slit  up  on  a  director,  some 
branches  of  the  anastomotica  perhaps  being  divided  at  the  inferior  angle,  the 
sheath  of  the  vessel  exposed,  with  the  long  saphenous  nerve  lying  upon  it  just 
before  it  perforates  the  adductor  magnus,  a  small  opening  made  in  it,  and  the 
needle  passed  from  without  inward,  the  vein  lying  to  the  outer  side  and  slightly 
behind. 

Ligature  of  the  Popliteal  Artery. 

The  popliteal  extends  from  the  opening  in  the  adductor  magnus  to  the  level 
of  the  tubercle  of  the  tibia.  It  may  be  tied  in  the  upper  or  in  the  lower  part  of 
its  course. 

1.  In  the  Upper  Part. — The  position  of  the  limb  should  be  the  same  as  for  liga- 
ture of  the  femoral  in  Hunter's  canal,  with  the  knee  flexed.  The  operator  stands  on 
the  outer  side.  An  incision  three  inches  in  length  is  made  immediately  behind  the 
tendon  of  the  adductor  magnus,  commencing  or  ending,  as  the  case  may  be,  oppo- 
site the  adductor  tubercle.  The  skin  and  superficial  fascia  are  divided,  taking 
care  not  to  cut  the  internal  saphena  vein,  and  the  fascia  lata  separated  from  the 
anterior  margin  of  the  sartorious,  some  of  the  branches  of  the  anastomotica  prob- 
ably requiring  to  be  twisted  or  clamped.  The  adductor  tendon  is  drawn  forward, 
the  sartorius  and  the  inner  hamstrings  backward  (the  long  saphenous  nerve  wall 
probably  follow  the  adductor  tendon,  and  with  it  the  main  superficial  branch  of 
the  anastomotica),  and  search  made  with  the  finger  and  a  director  in  the  fat  that 
protrudes.  The  depth  of  the  artery  varies  according  to  the  distance  down  the 
limb ;  the  vein  is  not  seen  at  all. 

2.  In  the  Lower  Part. — The  patient  lies  upon  the  face,  or  in  what  is  known 
as  the  three-quarter  prone  position,  with  the  knee  at  first  extended.  Afterward  it 
may  be  bent  to  relax  the  gastrocnemius  if  it  is  required.  The  incision  is  vertical, 
three  inches  in  length  in  the  line  of  the  vessel  and  outside  the  external  saphena 
vein  if  this  is  seen.  The  skin,  superficial  fascia,  and  deep  fascia  are  divided  suc- 
cessively, the  internal  popliteal  nerve  pulled  outward,  the  semi-membranous  inward 
if  it  is  exposed,  and  the  dissection  carried  very  carefully  through  the  loose  fat  that 


2  78    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

fills  the  space.  The  separation  from  the  vein,  which  lies  superficial  to  the  artery 
and  rather  to  the  outside,  is  often  very  difficult,  and  j^aeat  care  must  be  taken  not 
to  mistake  one  for  the  other,  as  the  coats  of  the  vein  are  unusually  thick  and  rigid 
for  its  size.     The  needle  should  be  passed  from  without  inward. 


Ligature  ok  the  Posterior  Tibial. 

The  line  extends  from  the  middle 
of  the  knee  joint  to  midway  between 
the  internal  malleolus  and  the  pro- 
jection of  the  heel,  commencing  at  the 
lower  border  of  the  popliteus  muscle, 
just  below  the  level  of  the  tubercle  of 
the  tibia.  It  may  be  tied  in  the  mid- 
dle of  the  leg,  low  down,  or  behind 
the  internal  malleolus  (Fig.  68). 

I.  In  the  Upper  Part. — The  pa- 
tient lies  on  the  back  with  the  knee 
well  flexed  and  laid  on  its  outer  side. 
The  incision  is  four  inches  in  length, 
parallel  to  the  inner  border  of  the 
tibia  three-quarters  of  an  inch  behind, 
and  exactly  in  the  middle  of  the  leg. 
The  internal  saphena  must  be  avoided. 
The  skin,  superficial,  and  deep  fa.sciae  are  divided,  the  gastrocnemius  pulled  to 
one  side,  the  tibial  origin  of  the  soleus  cut  through  in  the  same  line  until  the 
glistening  tendinous  layer  on  the  deep  surface  and  the  fibres  that  arise  from  it  are 
recognized,  and  the  superficial  muscles  pulled  away  from  the  deeper  ones.  Between 
them  there  is  a  sheet  of  fascia,  anterior  to  which  are  the  vessels  resting  upon  the 
tibialis  posticus.  There  is  a  vein  on  either  side,  while  the  nerve  at  this  point 
usually  rests  upon  the  artery  (Fig.  69). 


Fig.  68. — Lines  of  Incision  for  Ligature  of  the  Posterior 
Tibial  Arterj-. 


\ 


\ 


Fig.  69. — Ligature  of  Posterior  Tibial  Artery. 


2.  In  the  Lower  Part. — The  position  of  the  foot  and  the  patient  is  the  same. 
The  incision  is  much  shorter  midway  between  the  border  of  the  tibia  and  the 
tendo-Achillis.  The  deep  fascia,  which  has  been  prolonged  down  from  the 
interspace  between  the  muscles,  is  stouter  here  than  it  is  above.  The  nerve  lies 
more  to  the  inner  side. 

X.   Behind  the  Internal  Malleolus. — A  short,  curved  incision  two  inches  in 


OPK RATIONS  ON  ARTERIES. 


279 


length   is   made   ])ehiiul  ami   below  the  internal  malleolus,  the  jjiilsation  of  the 
vessel  being  the  best   guide.     The  deep  fascia  iiere  is  thicker  still,  forming  the 

internal  annular  ligament  that  binds 
the  tendons  down.  Care  should  be 
taken  not  to  open  any  of  the  syno- 
\  ial  sheaths  (Fig.  70). 


f 


Fig.  70. 


-Ligature  of  ihe  Posterior  Tibial  Artery 
Betiind  the  Internal  Malleolus. 


Fig.  71. —  Line  of  Incision  for  Ligature  of  tlie  Ante- 
rior Tibial. 


LiGATURK    OF    THE    ANTERIOR    TiBIAL. 

The  artery  extends  from  a  i)oint  midway  between  the  head  of  the  fibula  and 
the  external  tuberosity  of  the  tibia  to  another  which  lies  midway  between  the  two 
malleoli,  and  from  thence  to  the  base  of  the  space  between  the  two  first  metatar- 
sal bones.  At  first  it  is  very  deep ;  lower  down  its  pulsation  can  be  easily  felt. 
The  leg  is  extended  and  the  foot  held  in  position  of  the  plantar  flexion  (Fig.  71). 


Tihuilis    (inLirus 


^iir  lonfju 
cJiaitoriiht 

Fig.  72. —  Ligature  of  the  Anterior  Tibial  Artery. 


I.  In  the  Upper  Third. — An  incision  from  three  to  four  inches  in  length  is 
made  in  the  line  of  the  artery  and  deepened  until  the  deep  fascia  is  reached.  If 
the  separation  between  the  extensor  communis  digitorum  and  the  tibialis  anticus 
cannot  be  seen  when  the  foot  is  bent  upward,  a  transverse  or  oblique  cut  is  made 
through  the  aponeurosis.  The  line  of  division  then  is  usually  evident  at  once. 
The  two  muscles  are  separated  with  the  handle  of  a  scalpel,  and  the  artery  is  found 
lying  with  the  nerve  superficial  to  it  and  a  vein  on  each  side. 


2  8o     DISEASES  AND  INJURIES    OF  SPECIAL   STRUCTURES. 


2.  In  the  Lower  Part  of  the  Leg. — The  incision  is  three  inches  in  length  in 
the  line  of  the  artery.     The  skin  and  superficial   fascia  are  divided,  and  careful 

search  made  with  the  finger  for  the  gap 
between  the  extensor  hallucis  and  the 
common  extensor.  If  this  is  found  the 
aponeurosis  is  slit  up  on  a  director,  and 
search  made  under  the  former  of  the  two  ; 
even  a  short  distance  above  the  ankle  joint 
the  tendon  often  has  not  yet  crossed  to  the 
inner  side.  If  there  is  no  indication  the 
fascia  is  slit  up  in  the  same  way,  and  all  the 
structures  that  lie  on  the  inner  side  pulled 
Tendon  o/'   Outward  away  from  the  tibia  with  the  fore- 

^ -' finger;  the  innermost  cord,  which  consists 

of  th6  tibialis  anticus  and  the  extensor  hal- 
lucis, is  now  allowed  to  slip  back  and  search 
made  for  the  vessel  next  to  it.  The  nerve 
lies  upon  the  outer  side  (Fig.  72). 

3 .  The  Dorsalis  Pedis. — The  guide  to 
the  artery  is  the  inner  slip  of  the  extensor 
brevis  digitorum.  The'  incision  is  made 
over  this  in  the  line  of  the  vessel,  the  tendon 
drawn  to  one  side,  and  search  made  beneath 
(Fig-  73> 


,,  JEjctensor 
i/rr-pis  cligUoruiin 
nmscle 


(yfensor 
/iro/irius 
/lollicis 


Fig.  73. — Ligature  of  Dorsalis  Pedis  Artery. 


DISEASES  OE  LYMPHATICS. 


CHAPTER  III. 

IXJLRIES  AND  DISEASES  OE  THE  LYMPI/ATJCS. 

INJURIES  OF  LYMPHATICS. 

The  lymphatics  are  so  widely  distributed  that  they  must  i)e  severed  or  torn  in 
every  cut  or  bruise  to  a  greater  or  less  extent  ;  but  as  a  rule  they  collapse  at  once 
and  give  no  trouble.  Persistent  escape  or  collection  of  lymph,  unless  there  is 
some  obstruction  higher  up,  causing  (edema  of  the  ])art,  is  very  rare  ;  but  probably 
a  great  deal  of  the  early  discharge  from  wounds  conies  from  the  divided  lymphatics, 
and  certainly  the  poisons  that  cause  the  various  kinds  of  wound  fever  (sei>tic  and 
traumatic),  are  chiefly  absorbed  through  them. 

The  thoracic  duct  has  occasionally  been  wounded,  leading  to  the  di.scharge 
through  a  fistulous  opening  of  a  spontaneously  coagulating  liquid,  milky  during 
digestion  ;  and  in  one  case  its  opening  is  stated  to  have  healed  under  a  plug.  In 
another  instance  the  duct  was  ruptured  opposite  a  fracture  of  the  spine,  and  the 
contents  were  poured  out  into  the  pleural  cavity,  compressing  the  lung  and  ulti- 
mately causing  death. 

DISEASES  OF  LYMPHATICS. 

Lymphangitis. 

Acute  inflammation  of  the  lymphatic  vessels  is  always  secondary,  and  is  usually 
caused  by  the  entrance  of  an  irritant  poison  through  the  connective-tissue  rootlets. 
Exceptionally  it  follows  sprains,  or  the  inflammation  spreads  from  surrounding 
structures  and  involves  the  wall  directly.  In  most  cases  the  immediate  source  is  a 
poisoned  wound,  often  a  mere  pin-prick  or  scratch,  sometimes  so  small  that  it  is 
overlooked  altogether  ;  and  consequently  it  is  of  frequent  occurrence  among 
butchers,  cooks,  and  those  engaged  in  post-mortem  work.  In  the  case  of  the 
throat  it  may  perhaps  originate  without  an  abrasion,  the  poison  entering  through 
the  spaces  between  the  epithelial  cell ;  but  naturally  this  is  incapable  of  proof. 
Recent  wounds  are  much  more  likely  to  be  attacked  than  granulating  ones,  and 
those  which  are  not  kept  at  rest  or  in  which  there  is  any  discharge  confined  under 
high  tension,  and  above  all,  pustules,  are  the  most  likely  of  all. 

Whatever  the  irritant  may  be,  it  probably  does  not  cause  inflammation  of  the 
w^all  of  the  vessel  unless  it  is  arrested  by  clotting.  If  this  does  not  take  i)lace,  it  is 
hurried  on  to  the  neighboring  lymphatic  glands,  and  sets  up  inflammation  there. 

Pathology. — The  changes  are  best  seen  in  larger  trunks.  The  delicate 
cellular  tissue  that  surrounds  the  vessel  and  forms  its  outer  wall  is  swollen,  softened, 
and  congested  ;  the  intima  becomes  cloudy,  the  endothelial  plates  lose  their  dis- 
tinctness of  outline,  and  the  lymph  that  fills  the  vessel  and  the  plasma  that  circu- 
lates through  and  around  its  walls  coagulate.  They  are  no  longer  in  contact  with 
healthy  structures.  Outside  the  vessel  altogether,  some  distance  away  from  the 
irritant,  the  blood-vessels  dilate,  and  the  blood  and  the  plasma  circulate  more 
rapidly  and  in  greater  quantity  ;  immediately  around  the  exciting  cause,  the 
stream  either  ceases  or  is  carried  on  very  slowly,  and  the  lumen  of  the  vessel,  the 
interstices  in  its  wall,  and  the  cellular  sheath  become  filled  with  a  coagulating 
exudation. 

The  future  course,  whether  resolution,  organization,  or  suppuration  sets  in, 

depends  upon  the  cause.     Resolution  begins  at  once,  if  the  irritant  is  slight  and 

transient ;  the  fibrin  disappears,  the  walls  of  the  vessel  recover,  the  endothelium  is 

regenerated,  and  the  circulation  is  re-established.     Organization  is  probable  if  its 

19 


282     DISEASES  AND  INJURIES    OF  SPECIAL   STRUCTURES. 

action  is  persistent,  as  in  syphilis  ;  and  the  coats  of  the  vessels,  and  the  celhilar 
tissue  in  Avhich  they  lie,  become  hard,  dense,  and  sclerosed.  Suppuration  only  takes 
place  when  pyogenic  micro-organisms  are  the  exciting  cause,  coagulation-necrosis 
setting  in,  and  the  solid  tissues  becoming  liquefied  and  melting  away.  As  a  rule, 
it  is  circumscribed,  but  if  the  tissues  are  badly  nourished  from  intemperance  or 
starvation,  or  if  there  is  septic  decomposition  as  well  to  assist,  it  may  be  diffuse  and 
boundless. 

Symptoms. — These  are  plainest  when  the  superficial  vessels  are  involved. 
Red  lines  mark  out  their  course  upon  the  skin — wavy,  irregular,  very  tender  to  the 
touch,  slightly  raised  above  the  surface,  and  hardened  from  thrombosis.  Some- 
times they  are  quite  narrow  ;  sometimes,  when  the  poison  is  very  active,  an  inch 
or  more  in  breadth.  At  the  same  time  the  glands  are  swollen  and  tender,  and  if 
the  affection  is  extensive  the  limb  below  may  be  oedematous.  With  the  deeper 
trunks  most  of  these  signs  naturally  are  wanting  ;  but  usually,  even  in  the  deepest, 
faintly  outlined  patches  of  redness  are  visible  here  and  there  upon  the  skin,  where 
the  superficial  plexuses  communicate  with  the  deep  ones. 

A  rigor  is  not  uncommon  at  the  beginning,  and  if  the  inflammation  is  widely 
spread  there  may  be  a  very  considerable  degree  of  fever  and  prostration.  Simple 
lymphangitis  is  rarely  serious  ;  if,  however,  suppuration  sets  in  it  may  be  attended 
by  very  grave  illness,  and  if  the  vessels  (which  run  in  groups)  are  extensively  de- 
stroyed, a  condition  of  solid  cedema  is  very  likely  to  persist,  leaving  the  limb 
more  or  less  crippled.  When  it  occurs  as  part  of  a  diffuse  inflammation  of  the 
cellular  tissue  its  significance  is,  of  course,  altogether  different ;  it  is  part  then  of  a 
general  suppurative  infection,  not  unlikely  to  end  in  pyaemia,  the  chief  safeguard 
against  the  constitutional  affection  spreading  through  the  lymphatics  being  the 
arrest  of  the  pyogenic  micrococci  in  the  neighboring  glands. 

Treatment. — The  cause  should  be  removed  at  once  or  rendered  innocuous 
by  the  free  use  of  antiseptics  ;  tension  immediately  relieved  by  incision,  drainage, 
warmth,  or  other  measures,  as  the  case  requires  ;  absolute  rest  enforced  ;  and  the 
limb  raised  to  diminish  the  amount  of  blood  entering  it  as  well  as  to  facilitate  the 
return  of  the  lymph.  Cold  evaporating  lead  lotion  is  the  best  local  application. 
Quinine  may  be  given  internally  if  the  temperature  is  high  ;  and  the  bowels 
usually  require  to  be  opened. 

If  suppuration  occurs  the  abscess  should  be  incised  at  once.  Afterward,  when 
the  inflammation  has  subsided  and  the  wound  healed,  if  there  is  any  oedema  left 
it  may  be  relieved,  if  not  cured,  by  the  proper  application  of  massage  and  band- 
aging. 

Lymphadenitis. 

Inflammation  of  lymphatic  glands  always  accompanies  inflammation  of  the 
vessels  ;  but  in  a  very  much  larger  number  of  instances  it  occurs  independently  of 
them,  the  irritant  having  been  carried  along  by  the  lymph  stream  without  causing 
any  symptoms  until  arrested  in  the  gland.  It  may  be  simple  {acute,  ending  in 
resolution  or  suppuration,  and  chronic)  or  specific,  as  in  tubercle,  syphilis,  glanders, 
and  perhaps  some  chancroids. 

I.   Simple  Adenitis  or  Bubo. 

The  pathological  changes  are  similar  to  those  that  occur  in  inflammation  else- 
where. The  cortex  is  the  part  first  involved  ;  it  becomes  more  vascular,  soft,  and 
swollen  ;  the  lymph-paths  are  filled  ;  the  corpuscles  are  packed  in  the  follicles  as 
tightly  as  they  can  be  ;  the  reticulum  loses  its  distinctness  ;  and  here  and  there, 
where  stasis  occurs  and  the  capillaries  give  way,  masses  of  red  blood-corpuscles 
can  be  seen.  In  recent  acute  cases  the  gland  is  a  deep  purple  throughout,  and  the 
connective  tissue  around  is  swollen  and  infiltrated  with  lymph  almost  to  the  same 
extent.  This  may  terminate  in  resolution;  or  the  inflammation  may  become 
chronic  ;  or  suppuration  may  occur. 


DISEASES  OF  LYMPJf.l TICS.  2S3 

(I.  Resolution. — The  process  is  exceedingly  simple;  the  hyperemia  diininishes  ; 
the  excess  of  lym])h-corpuscles  is  gradually  removed  ;  the  lymph-paths  are  opened 
up  again  ;  old  extravasations  are  (piietly  absorbed  ;  and  the  whole  gland  resumes, 
or  nearly  so,  its  normal  condition.  A  certain  degree  of  enlargement  is  very  com- 
monly left,  especially  if  the  attack  is  repeated. 

/'.  Chronic  Inflanunation. — This  termination  is  almost  as  common.  The 
cellular  exudation,  insteatl  of  being  absorbed  or  undergoing  fatty  degeneration, 
becomes  organized ;  the  cai)sule  is  thickened,  hard,  and  adherent  to  the 
structures  round  ;  the  adenoid  tissue  of  the  follicles  is  indurated ;  and  occa- 
sionally, when  the  glands  are  extensively  involved,  the  circulation  is  seriously 
impeded,  leading  to  dilatation  of  the  lym]ihatics  and  even  solid  cedema  in  the 
parts  below. 

c.  Suppuration. — This  may  begin  either  in  the  gland  itself,  yellow  foci  of 
coagulation- necrosis  occurring  in  the  various  parts  of  the  cortex  and  enlarging 
until  they  fuse  ;  or  more  generally  as  periadenitis.  In  the  latter  case,  when  the 
abscess  is  opened,  the  gland  is  found  lying  in  a  more  or  less  sloughing  condition, 
attached  to  one  side  of  the  cavity.  Residual  abscesses  are  of  common  occurrence 
in  connection  with  lymphatic  glands  ;  inflammation  subsiding  and  remaining  quiet 
perhaps  for  years,  and  then,  from  some  slight  additional  irritant,  suddenly  break- 
ing out  again  and  running  on  to  suppuration. 

Causes. — x\  moderately  acute  form  of  inflammation  not  unfrequently  follows 
over-exertion  or  exposure  to  cold,  esjjecially  if  there  has  been  at  any  time  a  pre- 
vious attack.  The  glands  become  swollen  and  painful ;  the  skin  over  them  is 
tender  on  pressure  ;  the  neighboring  muscles  are  stiff,  and  movement  is  much 
restricted.  As  a  rule,  this  subsides  without  any  serious  result  as  soon  as  the  cause 
ceases  to  act ;  its  importance  is  due  to  the  fact  that  the  tissues,  enfeebled  by 
inflammation,  form  the  most  suitable  soil  for  the  development  of  any  germs  that 
may  reach  them.  Suppuration  may  occur,  especially  in  those  whose  health  is 
broken  down  ;  tubercular  disease  may  follow  ;  I  have  known  it  to  develop  rapidly 
in  the  femoral  glands  after  a  strain  in  jumping ;  and  in  children  it  is  probable 
this  often  happens.  The  eruption  of  the  teeth,  for  example,  is  attended  with  a 
considerable  degree  of  enlargement  and  some  inflammation  of  the  submaxillary 
glands.  In  most  cases  this  subsides  of  itself  as  soon  as  the  parts  become  quiet 
again,  but  occasionally  it  forms  the  starting  point  for  suppuration  or  tubercular 
disease,  the  micrococci  or  bacilli,  as  the  case  may  be,  gaining  access  to  the  damaged 
tissue  through  the  mucous  membrane  of  the  mouth.  When  the  glands  are  healthy 
these  germs  are  practically  inert. 

Acute  inflammation  of  the  glands  arises  from  the  same  causes  as  acute  lymph- 
angitis, especially  poisoned  w^ounds  in  which  there  is  friction  or  tension  to  facili- 
tate absorption.  In  rare  cases  it  is  said  that  there  is  no  breach  of  surface,  but  it 
is  proverbially  impossible  to  prove  a  negative.  Specific  forms  of  inflammation 
can  only  arise  from  specific  causes,  and  these  are  rarely  limited  to  the  gland  first 
involved  ;  tubercle,  syphilis,  glanders,  etc.,  all  tend  to  spread  from  one  to  another, 
although  there  may  be  at  first  a  temporary  arrest.  This  is  not  so  with  the  micro- 
cocci of  suppuration.  Against  these  the  adenoid  tissue  seems  to  possess  an  unusual 
power  of  resistance ;  not  only  does  the  mischief  rarely  extend  beyond  the  glands 
first  attacked,  but  these  themselves  appear  capable  of  holding  out  for  an  excep- 
tionally long  period.  Inflamed  glands  are  exceedingly  common  as  the  result  of 
gonorrhoea,  soft  sores,  pustules,  poisoned  wounds,  and  many  other  injuries  ;  but 
although,  of  course,  many  instances  do  occur,  suppuration  is  by  no  means  invariable. 
The  pyogenic  micrococci  must  be  carried  to  the  glands  in  abundance  by  the 
lymph  corpuscles  and  the  lymph  stream  ;  but  if  the  adejioid  tissue  is  fairly  well 
nourished,  and  protected  from  injury,  in  many  cases  they  are  only  able  to  excite  a 
certain  degree  of  inflammation. 

Chronic  adenitis,  if  not  of  specific  origin,  usually  results  from  the  frequent 
repetition  of  acute  attacks.  The  glands  are  left  slightly  enlarged,  hardened,  and 
infiltrated  with  fibrous  tissue ;  and  they  may  persist  in  this  condition  without 


284     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 

change  and  without  causing  any  symjjtoms  for  years.  \\\  many  instances  it  is 
impossible  to  say  how  tar  this  is  due  to  syphilis. 

Symptoms. — When  the  attack  is  acute,  and  the  gland  is  tightly  bound 
down  by  fascia,  the  symptoms  are  severe.  On  the  other  hand,  if  there  is  a  large 
amount  of  loose  cellular  tissue  around,  so  that  there  is  but  little  tension,  they  may 
be  very  slight ;  in  the  axilla  even  suppuration  may  occur  without  the  patient  com- 
plaining of  it.  Pain,  heat,  and  swelling  are  the  most  i)rominent ;  the  first  esj)e- 
cially,  when  the  deeper  glands  are  involved  ;  the  last  when  the  structures  round  are 
soft  and  yielding.  Tenderness  on  pressure  is  always  present ;  and  if  the  gland  can 
be  felt,  it  is  fixed  in  its  bed,  partly  from  its  size,  partly  from  the  cellular  exuda- 
tion around  binding  it  down.  The  constitutional  disturbance,  like  the  pain, 
depends  largely  upon  the  tension  ;  in  the  slighter  cases  it  is  scarcely  noticeable  ; 
in  the  more  acute  ones,  especially  when  the  deep  glands  are  inflamed,  it  is  often 
very  marked. 

Suppuration  may  begin  very  quietly  when  the  tissues  around  are  loose  and 
yielding,  or  there  may  be  high  fever  and  even  a  rigor.  The  part  begins  to  throb, 
the  skin  is  red,  glazed,  and  cedematous,  the  swelling  rapidly  increases  in  size,  and 
the  outline  becomes  ill-defined.  If  the  pus  forms  in  the  interior  fluctuation  is 
often  very  indistinct ;  if  around  the  gland  it  may  be  apparent  almost  at  once. 

There  is  rarely  any  difticulty  in  the  diagnosis  of  acute  inflammation  ;  the 
locality,  the  nodular  character  of  the  swelling,  and  the  evidence  of  an  exciting 
cause  (which  may,  however,  have  already  disa])peared)  indicate  at  once  the  struc- 
ture concerned.  Chronic  enlargement  is  more  difficult,  especially  in  the  groin, 
where  it  is  easily  mistaken  for  epii)locele  and  vice  versa.  The  shape  of  the  swell- 
ing, the  direction  it  takes,  and  the  fact  that  it  is  rarely  single,  but  nearly  always 
involves  the  neighboring  glands,  are  the  most  important  distinctions.  The  ques- 
tion of  suppuration  is  very  difficult ;  in  a  large  proportion  of  cases  it  is  practically 
impossible  to  say,  without  exploration,  whether  it  has  commenced  or  not. 

Treatment. — The  exciting  cause  should,  if  possible,  be  removed  at  once. 
Absolute  rest,  cold,  uniform  compression,  and  elevation  are  the  most  effectual 
measures  for  preventing  suppuration  ;  heat  and  counter-irritants  only  encourage  it. 
When  pus  forms  the  shortest  way  is  to  open  up  the  abscess  freely,  allow  the  con- 
tents to  escape  of  themselves,  and  apply  boracic  fomentations,  with  a  considerable 
degree  of  pressure,  in  order  to  keep  the  surfaces  at  rest.  If  the  gland  has  been 
destroyed  and  remains  adherent  to  the  inner  surface  of  the  abscess  it  should  be 
removed  at  the  time  of  the  operation.  In  the  groin,  if  the  redness  and  oedema 
are  very  well  defined,  showing  that  there  is  not  much  infiltration  of  the  cellular 
tissue  round,  two  punctures  with  a  drainage-tube  or  a  bundle  of  horse-hair  passed 
across  may  succeed,  and  in  very  slight  cases  even  a  single  one  ;  but  unless  the 
patient  is  kept  in  bed  with  such  an  amount  of  dressing  on  that  the  limb  is  practi- 
cally fixed  it  is  very  likely  to  end  in  the  formation  of  a  chronic  sinus. 

1 1 .    Tubercular  A  denitis . 

The  lymphatic  glands  are  one  of  the  most  common  seats  of  tubercular  dis- 
ease. The  bacilli  enter  through  the  mucous  membrane  of  the  respiratory  or 
alimentary  canal,  or  through  the  skin  (after  wounds,  abrasions,  attacks  of  eczema, 
and  the  like),  and  at  once,  if  there  is  the  least  predisposition,  or  if  the  resistance 
of  the  tissues  is  lowered  by  inflammation,  lead  to  the  deposit  of  miliary  tubercle. 
In  a  few  cases  infection  may  take  ])lace  through  the  blood.  No  glands  in  the 
body  are  exempt ;  but  naturally  those  in  certain  localities — the  neck,  the  mes- 
entery, and  the  mediastina — are  more  often  affected  than  others,  and  it  may  occur 
at  any  age,  although  it  is  by  far  the  most  common  in  children  and  during  young 
adult  life. 

Pathology. — The  changes  are  characteristic ;  gray  miliary  nodules  develop, 
usually  in  the  centre  of  the  adenoid  masses,  with  typical  giant  and  epithelioid 
cells,  and  outside  these  an  infiltration  of  smaller  ones,  lying  in  a  zone  of  hyper- 


D/SEASJ'.S  OF  f.YMPHATJCS.  285 

femia,  and  caseation  soon  begins  in  the  middle.  Several  of  these  small  nodules 
form  near  each  other  and  fuse,  so  that  when  the  gland  is  cut  across  there  is  a  dead 
white  caseous  spot  surrounded  by  a  soft,  pinkish  gray  areola.  (Gradually,  as  these 
increase  and  multiply,  fresh  tubercles  forming  round  their  margin,  the  whole  gland 
becomes  enlarged,  the  capsule  grows  thicker,  partly  from  the  irritation  and  ten- 
sion to  which  it  is  subjected,  partly  from  the  condensation  on  it  of  the  loose 
cellular  tissue  around,  and  at  length,  if  it  is  cut  across  when  the  disease  is 
advanced,  the  only  trace  of  normal  adenoid  tissue  left  is  a  thin  layer  immediately 
under  the  capsule;  the  whole  of  the  rest  is  converted  into  a  dense  white  caseous 
mass,  many  times  the  size  of  the  original  gland,  but  still  showing  its  origin  by  its 
shape  and  by  the  relation  it  bears  to  the  trabecular. 

The  subseijuent  changes  are  the  same  as  those  that  occur  elsewhere.  If  the 
tubercle-bacilli  spread  and  the  whole  gland  becomes  involved,  the  central  portion 
breaks  (jown  into  a  greenish-yellow  puriform  fluid,  the  surrounding  cellular  tissue 
is  invaded  through  the  hiluni,  and  sujiiHiration  follows,  forming  an  irregularly- 
shaped  abscess  (often  extending  long  distances  under  the  fascia)  with  the  remains 
of  a  lymphatic  gland,  consisting  chiefly  of  the  capsule  lined  with  caseating  tuber- 
cle, still  adherent  to  one  ])art  of  the  wall.  If,  on  the  other  hand,  they  perish, 
either  calcification  or  fibroid  induration,  or  both  together,  follow. 

Symptoms, — The  characteristic  feature  is  a  chronic,  painless  enlargement, 
affecting  usually  several  glands  in  the  same  locality,  although  often  one  more  than 
the  rest.  At  first  they  are  freely  movable,  but,  after  a  time,  they  become  matted 
together  and  adherent  to  the  surrounding  structures.  Later,  after  a  very  variable 
period,  softening  may  occur,  the  swelling  enlarges  in  size  and  becomes  more  ill- 
defined,  the  skin  becomes  reddened  at  one  point,  grows  thinner  and  thinner,  and 
finally  gives  way,  leading  to  the  discharge  of  a  thin  oily  pus,  mixed  with  caseous 
debris,  and  leaving  a  sinus  which  nearly  always  pursues  a  most  irregular  and  devious 
course.  Healing,  if  these  cases  are  left  to  themselves,  is  always  very  protracted  ;  the 
growth  of  the  tubercle  must  cease,  the  whole  of  the  caseous  material  come  away, 
and  the  sinus  close  from  the  bottom,  and  as  the  skin  is  usually  undermined  in  all 
directions,  and  it  is  exceedingly  difficult  to  keep  the  parts  at  rest,  it  may  be  many 
years  before  it  is  complete. 

General  infection  from  superficial  caseating  glands  is  rare,  although  it  may 
take  place  from  mediastinal  ones.  Local  recurrence  again  and  again  is  not 
uncommon  ;  but  at  length,  in  the  vast  majority  of  cases,  the  patient  lives  down 
the  bacillus  and  recovers,  bearing  the  traces  of  his  illness  in  the  deep  seams  and 
cicatrices  left. 

Treatment. — The  constitutional  treatment  of  tubercular  adenitis  is  of  the 
greatest  importance  :  sea  air,  tonics,  cod-liver  oil,  good  feeding,  and  careful  pro- 
tection against  cold,  exposure,  and  irritants  of  all  kinds.  In  many  instances  the 
balance  between  caseation  and  liquefaction  on  the  one  hand,  and  absorption  and 
organization  on  the  other,  turns  entirely  upon  this. 

The  local  treatment  depends  largely  upon  the  amount  of  inflammation  present 
and  the  number  of  glands  involved.  If  there  are  only  two  or  three  and  they  are 
perfectly  quiet  and  painless,  without  any  evidence  of  adhesion  to  the  tissues  round 
them,  they  should  be  left  altogether  alone,  or  the  skin  may  be  thickly  covered  over 
with  ung.  plumbi  iodidi  and  oiled  silk  at  night.  Rubbing  and  counter-irritants, 
such  as  tincture  of  iodine,  are  only  too  likely  to  precipitate  an  acute  attack.  If  in 
spite  of  this  the  enlargement  continues  to  increase,  or  signs  of  softening  or  of 
inflammatory  adhe.sion  begin  to  appear,  excision  may  be  performed,  provided  there 
is  a  reasonable  hope  of  removing  the  whole  ;  either  caseation  has  taken  place 
already  in  spite  of  all  that  has  been  done  to  check  it,  or  it  will  very  shortly,  and 
undoubtedly  the  best  and.  most  effectual  method,  when  the  disease  is  limited  and 
superficial,  is  free  removal.  It  leaves  a  linear  cicatrix  in  a  situation  chosen  because 
it  is  concealed,  and  the  wound  is  sound  within  a  week,  in  place  of  a  sinus  that 
may  continue  to  discharge  for  years,  and  invariably  causes  a  depressed,  seamed, 
and  irregular  scar.      Even  when  the  skin  is  involved  the  same  plan  may  be  tried 


-86     DISEASES  AND  INJURIES    OE  SPECIAI    STRUCTURES. 


with  success.  It  must  always  l)e  remembered,  however,  that  the  real  number  of 
the  glands  concerned  is  probably  far  in  excess  of  the  apimrent,  and  that  removing 
the  more  superficial  ones  is  very  likely  to  expose  many  more  that  lie  deeper.  The 
operator,  therefore,  must  always  be  prepared,  as  unle.ss  the  whole  affected  area  is 
cleared  little  good  is  likely  to  result.  Even  such  extreme  measures  as  division  of 
the  sterno-mastoid  and  dissecting  out  the  great  vessels  and  nerves  of  the  neck 
have  been  recommended. 

If  softening  and  suppuration  have  already  taken  place  the  actual  cautery  may 
be  used  to  perforate  the  inflamed  structures  and  destroy  the  interior  of  the  gland  ; 
or  it  may  be  freely  incised,  the  interior  thoroughly  scraped  out  with  Volkmann's 
spoon,  and  packed  with  iodoform.      Unhappily,  in  most  cases  the  number  of  glands 

involved  precludes  anything 
like  radical  treatment  of  this 
kind  ;  and  all  that  can  be  done 
is  to  open  any  abscesses  that 
are  pointing  ;  slit  up  or  enlarge 
and  drain  any  devious  sinuses 
running  beneath  the  fascia  ; 
scra])e  out  all  the  caseous  debris 
that  is  accessible  ;  and  try  by 
means  of  constitutional  treat- 
ment to  improve  the  general 
health,  so  that  cicatrization  may 
take  place. 

It  not  uncommonly  ha])- 
pens  in  the  neck  that  chronic 
sinuses  with  purple  overhang- 
ing edges  are  left  for  years, 
similar  to  those  met  with  in  the 
groin.  In  many  cases  these 
can  only  be  cured  by  cutting 
away  all  the  overhanging  tissue, 
scraping  out  the  interior,  thor- 
oughly stimulating  the  base, 
and  making  the  route  direct. 
Hilton,  however,  has  shown  what  it  is  possible  to  do  to  these  by  the  judicious  appli- 
cation of  trusses  in  the  groin  ;  that  the  chief  reason  of  failure  of  union  is  the 
perpetual  motion  to  which  the  part  is  subjected  ;  and  that  repair  can  take  place, 
even  in  advanced  cases,  if  alisolute  rest  is  enforced  ;  and  Treves  has  strongly 
advocated  the  same  thing  in  the  neck.  There  is  no  doubt  that,  although  the  pre- 
sence of  caseous  gland  tissue  and  the  indirect  burrowing  under  the  fascia  have  much 
to  do  with  the  delayed  union  and  unsightly  cicatrices  so  common  after  tubercular 
adenitis,  want  of  rest  is  almost  if  not  quite  as  important ;  and  in  every  case  in 
which  this  cannot  be  ensured  in  other  ways  some  appliance,  such  as  Treves'  s])lint 
or  a  gutta-percha  stock,  should  be  used  after  operations. 


Aiohne  d    '^•rbi  inann. 


Fig.  74. — Treves'  Cervical  Splint. 


LvMPHAiic  Glandular  Ti:iM()ks. 

All  forms  of  carcinoma  and  many  of  sarcoma  involve  the  lymphatic  glands 
sooner  or  later ;  these,  however,  are  secondary  growths,  and  derive  their  signifi- 
cance entirely  from  the  primary  one  elsewhere.  In  addition  there  are  others  which 
originate  in  the  glands  themselves. 

Primary  lymphatic  glandular  tumors  form  an  exceedingly  difficult  group  ;  it  is 
impossible  to  classify  them  satisfactorily  either  by  their  pathological  structure  or 
their  clinical  history.  Microscopical  examination  fails  to  show  any  definite 
distinction  between  normal  gland  tissue,  inflammatory  hypertrophy,  simple  tumors, 
or  malignant  ones  ;  and  clinical  symptoms  are  no  more  successful,  at  any  rate  in 


DISEASES  OF  LYMPHATICS. 


287 


the  earlier  stages  when  the  diagnosis  is  of  importance.  Certain  varieties  that  are 
fairly  well  characterized  can  be  described  ;  the  rest  must  be  grouped  round  them, 
nearer  or  further  away,  according  to  the  sum  of  the  features  they  present. 


I.   Lymphoma. 
;iven  to  a  perfectly  simple  form  of  overgrowth  affecting  one  or, 


As  such,  it  is  decidedly 


ouL    ^^ 


This  name  is 
at  the  most,  two  or  three  glands  in  one  part  of  the  body 
rare  (Fig.  75). 

No  cause  is  known  ;  the  gland  steadily  but  persistently  increases  in  size  with- 
out undergoing  the  least  change  in  structure.  It  is  not  inflamed  or  ])ainful  ;  it 
does  not  contract  adhesions  to  the  parts  around  ;  it 
does  not  degenerate  or  decay  in  any  way  ;  and  it  is 
not  attended  with  any  form  of  cachexia.  On  section 
it  is  ai)solutely  normal,  or  at  the  most  slightly  lighter 
in  color  than  the  other  glands.  It  may  attain  a  fair 
size  and  cause  considerable  annoyance,  but  it  is 
seldom  very  large. 

Lymphatic  glandular  tumors  answering  this 
description  are  certainly  exceptional.  In  the  vast 
majority  of  instances,  if  they  are  excised  (the  only 
treatment  suitable  for  them)  and  divided  in  two,  it 
is  found  either  that  they  contain  a  caseous  focus  in 
the  middle,  or  that,  without  aiiy  change  visible  to  the 
naked  eye,  they  are  full  of  miliary  tubercles ;  in 
other  words,  that  they  are  really  examples  of  tuber- 
cular adenitis,  which  from  some  unknown  cause,  pos- 
sibly an  unusual  power  of  resistance  on  the  part  of 
the  patient,  have  followed  an  unusual  course ;  the 
tubercles  have  continued  to  increase,  but  the  lym- 
phatic tissue  has  increased  at  a  faster  rate,  without 
sufficient  inflammation  to  make  the  capsule  contract 
adhesions.  In  other  cases  it  is  probable  that  they 
are    really    the   beginning    of    lymphadenoma,   for 

sometimes,  if  they  are  left,  they  suddenly  change  their  character  and  begin  to 
grow  rapidly. 

II.   Lymphadenoma. 

Two  forms  of  this  are  described  by  some,  according  to  whether  leukaemia  is 
present  or  not  ;  but,  as  it  is  impossible  to  say  upon  what  this  depends,  why  it 
should  occur  in  one  case  and  not  in  another,  it  does  not  seem  a  sufficient  reason 
for  separating  them.  It  is  sometimes  known  as  Hodgkin's  disease  or  malignant 
lymphoma. 

The  pathological  changes  that  occur  in  the  glands  in  the  earlier  stages  are 
identical  with  those  met  with  in  lymphoma  or  in  chronic  inflammation.  In  some 
instances  the  adenoid  tissue  is  in  excess  and  the  glands  are  soft  and  juicy  ;  in  others 
there  is  a  large  amount  of  fibrous  tissue,  the  size  is  smaller,  and  the  consistence 
firmer.  The  difference,  however,  does  not  appear  to  be  anything  more  than  a 
physical  one  ;  clinically  the  two  forms  are  precisely  alike. 

Lymphadenoma,  at  its  commencement,  may  be  confined  to  the  lymphatic 
glands  ;  or  it  may  occur  in  the  spleen  before  the  glands  are  involved  ;  and  deposits 
of  adenoid  tissue,  w^hich,  however,  may  be  secondary,  are  not  uncommonly  found 
in  the  alimentary  canal,  the  liver,  kidneys,  the  medulla  of  bone,  and  elsewhere. 
It  is  evidently,  therefore,  a  di-sease  of  an  entirely  different  character  from  true 
lymphoma  ;  but  when  it  is  primarily  glandular,  it  may  be  impossible  to  distinguish 
one  from  the  other,  until,  by  the  appearance  of  secondary  growths,  it  is  too  late. 
Nothing  is  known  with  regard  to  its  etiology  ;   it  is  most  common  in  )Oung  adult 


Fig.  75. 


Lymphoma,  from  the  Cervical 
Glands. 


288     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 

life,  and  in  the  cervical  region  ;  but  it  may  begin  in  the  inguinal,  or  axillary,  or 
even,  though  rarely,  in  some  of  the  internal  glands. 

The  growth  is  more  rapid  than  that  of  lymphoma,  sometimes  so  rapid  as  to 
cause  a  certain  degree  of  tenderness  from  the  stretching  of  the  fascia  round. 
Gland  after  gland  is  involved,  and  instead  of  remaining  isolated  from  each  other, 
they  become  matted  together  into  smooth,  bossy,  prominent  tumors,  which,  how- 
ever, remain  for  some  time  encapsuled.  In  this  condition  they  may  last  unchanged 
for  several  years,  or  they  may  even  diminish  in  size,  although  they  very  rarely 
disappear  ;  but  at  any  moment  they  may  suddenly  begin  to  grow  again,  spread  into 
the  cellular  tissue  that  surrounds  them,  forming  enormous  masses  from  which  all 
trace  of  the  original  glands  is  lost,  and  start  in  other  parts  of  the  body  as  well. 
When  this  takes  place  the  end,  as  a  rule,  is  not  far  off.  The  patient's  health 
begins  to  fail,  emaciation  is  rapid,  sometimes  hectic  and  profuse  night-sweats  occur, 
the  appetite  is  lost,  diarrhoea  or  epistaxis  sets  in,  dropsy  makes  its  appearance,  and 
the  sufferer  usually  dies  of  exhaustion.  In  other  cases  the  trachea  or  oesophagus  is 
compressed,  even  the  action  of  the  heart  may  be  interfered  with  ;  masses  in  the 
abdomen  may  cause  jaundice,  and  toward  the  end  more  or  less  leukaemia,  though 
not  sufficient  in  every  case  to  give  a  distinct  white  tinge  to  the  blood,  is  a  very 
usual  feature. 

Instances  are  sometimes  met  with  in  which  the  whole  of  the  tissues  of  the  neck 
seem  to  be  involved.  The  skin  is  red,  as  if  inflamed,  soft,  and  almost  fluctuating, 
and  from  the  head  to  the  thorax  is  simply  a  gigantic,  shapeless  mass  of  adenoid 
tissue,  growing  rapidly,  exceedingly  vascular,  and  enclosing  the  blood-vessels, 
nerves,  and  all  the  important  structures  of  the  part. 

III.   Sarcoma. 

Lymphatic  glands  are  occasionally  the  seat  of  an  intensely  malignant  form  of 
sarcoma,  round-celled,  spindle-celled,  or  lymphoid.  It  differs  from  lymphadenoma 
in  the  extreme  rapidity  of  its  growth,  in  the  fact  that  (until  quite  late  in  the  course 
of  the  disease)  only  one  tumor  is  formed,  that  it  remains  limited  for  a  much  longer 
time  to  one  .set  of  glands,  that  it  tends  to  invade  the  skin  and  all  the  structures 
round,  and  that  it  is  not  accompanied  by  leuksemia.  Sometimes  it  is  so  soft  and 
attended  with  such  a  degree  of  pyrexia  that  it  may  be  mistaken  for  an  abscess,  and 
I  have  known  it,  springing  from  the  mediastinal  glands,  displace  the  heart  and 
lungs,  cause  pressure  upon  the  recurrent  laryngeal  and  other  nerves,  and  from  its 
extreme  va.scularity  pulsate  so  forcibly  as  to  raise  the  .suspicion  of  an  aneurysm. 

Treatment. — The  treatment  of  lymphatic  glandular  tumors  is  very  unsatis- 
factory, chiefly  on  account  of  the  great  difficulty  of  diagnosis  in  the  earlier  stages. 
Simple  lymphoma,  if  it  does  not  rajjidly  subside  under  tonics  and  cod-liver  oil, 
should  be  excised,  whether  it  is  true  lymphoma  or  a  caseous  gland  (as  it  u.sually  is) 
or  the  beginning  of  lymphadenoma ;  only,  as  already  mentioned  in  tubercular 
adenitis,  the  operator  must  be  prepared  to  remove  the  whole,  and  often  it  is  much 
more  extensive  than  it  appears  to  be. 

Lymphadenoma,  if  it  has  once  passed  this  stage,  is  better  left  alone  ;  comj)lete 
removal  is  practically  hopeless  ;  no  sooner  is  one  ma.ss  taken  away  than  another 
appears  beneath,  more  difficult  of  access  still ;  and  the  presence  of  leukemia  is  an 
absolute  bar  to  any  surgical  operation  not  of  imperative  necessity — such,  for 
instance,  as  tracheotomy  :   the  hemorrhage  is  uncontrollable. 

Arsenic,  with  iron  and  cod-liver  oil,  is  of  undoubted  value  in  many  cases, 
although,  unfortunately,  the  improvement  is  rarely  permanent.  It  is  usually  given 
in  the  form  of  Fowler's  solution  after  meals,  and  the  dose  must  be  increased  by 
about  a  minim  a  week  until  the  patient  can  take  no  more ;  other  drugs  do  not 
seem  to  have  any  effect,  and  no  local  application  of  any  kind  is  of  any  use. 


DISEASES  OF  LYMPJIATICS. 


289 


Lymph ANciEiF.CTAsis  and  Ly.mphangkioma. 

'I'hc  lymi)hatics  are  liable  to  dilatation  and  distention  in  the  same  way  as  the 
capillaries  and  veins.  Sometimes  this  is  congenital,  like  naivus,  sometimes  it  is 
caused  by  obstruction.  Ihe  minor  form,  affecting  especially  the  smaller  vessels,  is 
known  as  lymphangeiectasis,  the  more  pronounced  as  lymphangeioma. 


I.    Coih^ciiital  Dilatation. 

This  niav  appear  under  various  shapes.  In  the  simplest  there  is  merely  an 
irregular  expansion  of  the  lymphatic  vessels,  generally  in  the  skin,  forming  am- 
pullar and  cavities  of  various  sizes,  lined  with  the  characteristic  endothelium.  In 
those  that  are  more  severe  the  dilatation  is  greater,  the  partition  walls  between  the 
cavities  are  thinner,  so  that  they  break  down,  and  enormous,  irregularly  branching 
spaces  are  formed,  sometimes  spreading  among  the  deeper  structures  to  a  distance 
of  which  the  outside  appearance  gives  no  conception. 

The  most  exaggerated  form  of  the  cavernous  lymphangeioma  is  known  as 
hydrocele  of  the  neck,  congenital  cystic  tumor,  or  sim])ly  hygroma.  It  may  be  pres- 
ent at  birth,  or  it  may  be  so  small  that  at  that  time  it  does  not  attract  attention, 
and  then  later,  when  it  begins  to  enlarge,  it  may  be  mistaken  for  an  acquired 
growth.  The  most  common  situation  for  it  is  the  neck,  but  it  may  occur  in  the 
axilla  or  the  back,  or  even  in  the  region  of  the  kidney.  Sometimes  it  is  apparently 
a  single  cyst,  extending  an  enormous  distance  under  the  fascia  ;  more  frequently  it 
is  polycystic  with  cavities  of  all  sizes,  in  some  of  which  the  fluid  is  clear  and  watery, 
in  others  greenish,  and  in  others  again  distinctly  and  perhaps  deeply  blood-stained. 
The  favorite  locality  is  the  posterior  triangle  of  the  neck,  or  just  behind  the  angle 
of  the  ja\v,  whence  they  may  extend  into  the  mouth,  over  to  the  opposite  side  ot 
the  body  in  front  or  behind  the  trachea,  down  into  the  thorax,  or,  in  short,  almost 
everywhere.  The  w'alls  vary  in  strength,  though  never  very  thick.  Occasionally 
they  contain  here  and  there  portions  of  njevoid  tissue,  which  can  be  detected  when 
superficial  by  the  bluish  tint  they  give.  Much  more  rarely  there  is  a  considerable 
amount  of  solid  growth,  so  as  even  to  give 
rise  to  the  suggestion  of  sarcoma  (Fig.  76). 

A  similar  pathological  condition  prob- 
ably underlies  macroglossia,  macrocheilia, 
and  some  at  least  of  the  varieties  of  con- 
genital overgrowth  of  the  limbs.  Whether 
the  enlargement  of  the  breast,  which, 
though  not  congenital,  sometimes  develops 
at  puberty,  is  to  be  attributed  to  the  same 
cause  is  uncertain.  It  appears  at  least  to 
affect  only  the  cellular-tissue  elements  of  the 
gland,  not  the  secreting  structure. 

The  treatment  of  any  of  these  con- 
genital affections  recjuires  to  be  carried  out 
very  circumspectly.  Single  cysts  may  be 
tapped,  and,  if  they  refill,  injected  with 
iodine  or  with  Morton's  fluid.  Larger 
ones  may  be  drained,  or  a  seton  passed  through  them,  but  it  must  be  remembered 
that  very  often  they  have  very  deep  connections,  and  that  if  suppuration  occurs  the 
fever  that  follows  is  likely  to  prove  exceedingly  serious  or  even  fatal.  Polycystic 
growths  may  be  drained  seriatim,  a  deeper  part  being  opened  only  when  the  super- 
ficial has  contracted  to  a  sinus.      Excision  is  rarely  practicable. 

In  cases  of  congenital  giant  growth,  if  the  size  is  excessive,  or  if  sarcomata 
develop  from  the  imperfectly  organized  tissues,  as  sometimes  occurs  later  in  life, 
amputation  is  the  only  resource.      Macroglossia  and  macrocheilia,  when  they  are 


Fig.  76. — Serous  Cyst  of  the  Neck. 
(Birkett's  case.) 


290     DISEASES  AND   INJURIES    OE  SPECIAL   STRUCTURES. 

small,  can  sometimes  be  kept  in  check  by  astringents,  but  usually  inOannnatory 
hypertrophy  is  added  to  the  congenital  form,  antl  the  only  hojje  is  partial  excision. 

II.    Obstructive  Dilatation. 

Long-continued  obstruction  to  the  lymphatics  causes  a  certain  degree  of 
varicosity  similar  to  that  which  occurs  in  the  veins,  only  much  more  rarely,  because 
of  the  greater  freedom  of  anastomosis.  Sometimes  the  smaller  vessels  are  affected 
most,  so  that  the  superficial  parts,  skin,  or  mucous  membrane,  as  the  case  may  be, 
are  channeled  in  all  directions  by  a  reticular  network,  which  may  even  raise  up 
the  epidermis  in  the  form  of  minute  vesicles  ;  sometimes  the  larger  ones,  tubular . 
lymphangeiectasis.  The  same  thing  occurs  in  connection  with  the  veins,  but  in 
neither  is  the  reason  for  the  difference  obvious.  After  a  time  the  condition  known 
as  solid  oedema  follows  :  the  part  becomes  hard  and  brawny  ;  the  skin  and  the  sub- 
cutaneous tissue  are  thickened  and  indurated  ;  an  enormous  growth  of  lowly 
organized  connective  tissue  takes  place  throughout  the  limb  ;  the  muscles  waste  ; 
the  veins  are  compressed,  making  matters  worse  ;  the  part  becomes  so  heavy  and 
stiff  that  the  patient  can  hardly  use  it ;  and  at  length  it  develops  into  a  state  prac- 
tically identical  with  elephantiasis.  At  first  the  outline  is  smooth,  uniform,  and 
rounded  ;  but  after  a  time  local  inflammation  occurs  from  some  trivial  cause, 
owing  to  the  poor  nutrition  of  the  part ;  and  then  it  becomes  irregular  and  nodu- 
lated all  over.  Finally,  in  some  cases,  rupture  of  the  lymphatics  takes  place  ;  a 
thin  clear  fluid,  coagulating  more  or  less  perfectly,  continues  to  drain  away 
{lyniphorrhoea')  ;  the  patient's  health  fails  ;  and  the  continued  moisture  of  the  part 
leads  to  an  eczematous  condition  of  the  skin,  which  again  in  its  turn  makes  the 
inflammation  worse. 

Causes. — Obstruction  may  be  due  to  various  causes,  and,  according  to  the 
part  of  the  l)ody  affected,  leads  to  very  various  results. 

The  simplest  variety  is  that  which  follows  repeated  attacks  of  erysipelas  (in- 
fective capillary  lymphangitis).  If  this  recurs  often,  partly  from  the  obstruction 
to  the  lymphatic  vessels,  partly  perhaps  from  the  chronic  induration  of  the  glands, 
the  skin  remains  permanently  thickened,  and  when  the  face  is  concerned  a  very 
serious  degree  of  disfigurement  is  left. 

In  phlegmasia  alba  dolens,  the  form  of  white  leg  that  occurs  so  commonly 
after  pregnancy,  it  is  probable  that  the  veins  are  involved  as  well  as  the  lymphatics, 
sometimes  one,  sometimes  the  other  being  the  worst.  It  is  rarely  serious,  although 
it  often  assists  in  the  production  of  chronic  ulcers  of  the  leg  ;  but  I  have  known  it, 
when  frequently  repeated,  end  in  the  most  enormous  nodular  enlargement  of  the 
whole  limb  (except  the  foot)  and  lead  to  very  serious  lymi)horrhoea  from  an  open- 
ing in  Scarpa's  triangle. 

Cancerous  enlargement  of  the  lymphatic  glands  in  the  axilla  leads  to  the  same 
condition  in  a  very  short  space  of  time.  The  axillary  vein  may  be  ligatured  and 
cut  away  with  impunity  ;  there  will  scarcely  be  even  transient  oedema ;  but  when 
the  cancerous  growth  involves  the  glands,  the  hand  and  arm  enlarge  to  such  an 
extent  that  the  patient  is  unable  to  lift  the  limb  from  the  bed. 

The  presence  of  parasites,  especially  the  filaria  sanguinis  hominis,  produces 
even  a  more  striking  series  of  symptoms.  The,  parent  worm  usually  resides  in  one 
of  the  larger  central  lymphatics,  and  from  this  locality  discharges  into  the  stream 
myriads  of  ova  or  embryos.  Some  of  the  main  channels  become  obstructed  by 
the  inflammation  that  takes  place  around  them  ;  dilatation  sets  in,  and  in  many 
cases  rupture  follows,  most  frequently  into  the  bladder  (probably  because  of  the 
very  variable  degree  of  support  the  mucous  membrane  receives),  causing  chyluria, 
but  occasionally  into  the  cavity  of  the  tunica  vaginalis  (chylous  hydrocele),  and 
sometimes  even  externally.  The  same  thing  has  been  known  to  occur  from  the 
pressure  of  tumors,  and  from  other  causes  leading  to  obstruction  of  the  thoracic  duct. 

It  is  ])robal)le  that  the  disease  known  as  Elephantiasis  Arabian  really  origi- 


DISEASES  OF  LYAfPI/ATICS.  291 

nates  in  the  same  way.  Essentially  it  is  a  chronic  h)'i)crtn)])hy  of  the  skin  and 
the  subcutaneous  tissue,  usually  of  the  leg  or  the  scrotum,  causing  enormous 
enlargement  and  deformity,  and  resulting  from  rejieated  attacks  of  inilammation  ; 
but  though  thus  far  it  resembles  the  worst  cases  of  solid  cjedema,  it  differs  consid- 
erably in  other  respects,  especially  in  the  peculiar  form  of  fever  and  the  acute 
inflammatory  attacks  that  accompany  it. 

The  fever  is  of  a  remittent  type  and  is  known  locally  as  elephantoid.  Some- 
times it  is  exceedingly  severe,  and  attended  with  great  pain  ;  more  often  it  is 
only  moderate  in  degree  and  as  the  diseases  advances  tends  to  die  out.  The 
intervals  between  the  attacks  may  be  as  long  as  a  month  ;  with  each  there  is  an 
outbreak  of  acute  inflammation,  the  limb  becoming  tense  and  hot,  the  skin  red- 
dened, and  even  covered  over  with  vesicles  as  in  erysipelas.  In  a  few  days  the 
symptoms  subside,  but  the  limb  never  regains  its  former  size  ;  and  one  attack 
follows  another  until  the  condition  becomes  hopeless.  In  the  early  stages  the 
skin  is  but  little  affected  ;  later  it  becomes  pigmented,  covered  with  eczema, 
ulcerated,  scarred,  roughened,  and  nodulated  in  proportion  to  the  severity  of  the 
local  inflammation. 

The  legs  and  the  external  genitals  are  the  parts  most  often  affected  ;  the 
scrotum  in  particular,  from  the  looseness  of  its  natural  texture  and  the  ease  with 
which  it  borrows  skin  from  the  abdomen,  may  be  enlarged,  so  that  it  sweeps  upon 
the  ground.  Very  often  enormous  hydroceles,  or  dilatations  of  the  lymphatics 
(varix)  and  lymphorrhtca  are  associated  with  it. 

Treatment. — Much  can  be  done  to  relieve  the  symptoms  in  the  milder 
cases  of  lymphatic  obstruction,  even  when  the  cause  is  beyond  control ;  rest  in  an 
elevated  position,  massage,  bandaging,  support  when  the  limb  hangs  down,  and, 
according  to  some,  the  constant  current  (the  positive  pole  always  nearest  the  sound 
parts)  often  effect  material  improvement  in  a  very  short  space  of  time.  Cancerous 
obstruction,  however,  of  the  axilla,  and  obstructions  to  the  abdominal  lymphatics 
and  lacteals  rarely  admit  even  of  relief. 

Elephantiasis  in  its  milder  forms  should  be  treated  in  t\it  same  way.  Rest, 
pressure,  and  elevation  succeed  best  during  the  acute  stage,  combined  with  suitable 
constitutional  measures.  Afterward  either  support  and  pressure  must  be  used, 
Martin's  elastic  bandage  being  of  especial  service,  or,  if  the  mass  is  such  as  to 
disable  the  patient,  it  must  be  removed,  by  amputation  in  the  case  of  the  leg  (it 
rarely  extends  far  up  the  thigh)  or  incision  if  it  is  the  scrotum.  In  either  case, 
the  part  should  be  well  bandaged  and  elevated  first,  in  order  to  reduce  the  amount 
of  blood  it  contains  as  much  as  possible,  and  careful  examination  made  so  that  no 
hernia  is  overlooked. 

An  attempt  should  always  be  made  to  dissect  out  the  penis  from  the  enor- 
mously hypertrophied  prepuce  ;  and  sometimes  at  least  the  testes  can  be  preserved, 
their  position  being  easily  ascertained  by  the  amount  of  the  hydrocele  fluid  that 
surrounds  them. 

Ligature  of  the  main  artery  of  the  limb  has  been  practiced  with  temporary 
alleviation  ;   possibly  compression  deserves  a  further  trial. 


292     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 


CHAPTER    IV. 
INJURIES  AXD  DISEASES  OF  NERVES. 

INJURIES. 

Xerves  may  be  divided,  wholly  or  in  part;  torn  across,  or  torn  out  of  the 
spinal  cord  ;  bruised  from  external  violence  ;  or  compressed  against  some  resisting 
structure.  The  immediate  effect  is  an  interference  with  the  conducting  power  of 
greater  or  less  extent  and  duration,  according  to  the  kind  of  injury  sustained. 

I.   Wounds  of  Nerves. 

Pathological  Changes  Folloioing  Division. — A  nerve  that  is  cut  across  begins 
to  degenerate  at  once.  The  whole  of  the  peripheral  part  is  involved  simultan- 
eously ;  the  myelin  runs  into  cylindrical  masses  which  become  granular  and  fatty, 
and  at  last  disappear.  The  axis-cylinders  split  up  into  fibrils  and  disintegrate,  so 
that  they  can  scarcely  be  recognized  at  the  end  of  a  week ;  and  the  nuclei  of  the 
sheath  increase  in  size  and  begin  to  multiply.  In  two  or  three  weeks  the  whole 
of  the  peripheral  segment  is  atrophied.  The  central  end  changes  in  a  similar 
manner,  but  only  for  the  distance  of  one  or  two  nodes ;  above  this  it  remains 
practically  unaltered,  it  may  be  for  years. 

The  subsequent  course  depends  upon  the  proximity  of  the  two  ends,  and 
upon  the  possibility  of  union  taking  place  between  them. 

{(i)  WHien  they  are  in  Apposition  and  the  Wound  Heals  by  the  First  Inten- 
tion.— Union  takes  place  by  what  is  known  as  nerve-callus,  vascular  granulation- 
tissue  developed  from  the  nuclei  of  the  sheath  and  perineurium  as  well  as  from 
the  ordinary  sources.  In  animals  newly-formed  axis-cylinders  grow  from  these 
nuclei,  connecting  one  end  with  the  other,  within  three  or  four  days.  In  man  this 
has  not  been  proved  ;  but  in  all  probability  the  same  mode  of  union  does  occur, 
though  rather  more  slowly,  as  occasionally,  when  placed  under  very  favorable 
conditions,  the  conducting  power  of  a  divided  nerve  returns  within  a  few  days. 
Such  a  result,  however,  is  exceptional ;  immediate  suture,  even  when  apposition 
is  accurate,  usually  requires  weeks. 

(Ji)  When  the  Ends  are  Not  in  Apposition. — The  changes  that  follow  are  more 
complex  and  depend  largely  upon  the  distance  between. 

Bowlby  has  described  a  process  of  spontaneous  regeneration  as  taking  place 
in  the  distal  segment  six  or  seven  months  after  section.  The  nuclei  of  the  sheath 
increase  in  number,  become  spindle-shaped,  range  themselves  in  rows  in  the 
spaces  of  the  perineurium,  and  gradually  transform  themselves  into  fibrils,  round 
which  a  myelin  sheath  develops.  How  far  this  takes  place  in  all  cases,  even 
whether  it  occurs  in  all,  is  uncertain.  That  it  must  materially  assist  the  restora- 
tion of  function  in  the  case  of  secondary  union  there  can  be  no  question. 

Repair  may  occur  when  there  is  an  inch  between  the  ends  ;  and  a  few  cases 
are  recorded  in  which  even  greater  distances  than  this  have  been  bridged  ;  but 
they  are  few  and  far  between  ;  and  the  restoration  of  function  in  most  of  them  is 
very  imperfect,  even  after  a  long  period  of  time  has  elapsed.  As  a  rule  only  a 
fibrous  band  is  found,  sometimes  not  that. 

If  union  fails,  the  regeneration  of  the  distal  segment  dies  away  again,  per- 
manent degeneration  sets  in,  and  the  nerve  is  reduced  to  a  small  fibrous  cord,  the 
structure  of  which  can  still  be  recognized  on  cross  section,  owing  to  the  peculiar 
nature  of  the  perineurium.  The  central  end  may  remain  almost  unchanged,  or 
grow  out  into  a  rounded  expansion  of  variable  size — a  nerve  bulb.     These  are  met 


INJURIES  OF  NERVES.  293 

with  chielly  in  ainpiitation-stiinips.  hut  they  may  occur  anywlierc  ;  they  consist  for 
the  most  part  of  fibrous  tissue  ;  but  in  the  end  nearest  the  nerve-trunk  a  consider- 
alile  production  of  new  nerve-fibres  takes  place,  although  their  size  is  small  and 
there  is  only  a  limited  amount  of  myelin  round  them. 

In  very  old  cases  atrophic  changes  are  met  with  in  the  spinal  cord  as  well, 
affecting  especially  the  intermedio-lateral  coluniii  on  that  side,  the  posterior  very 
little. 

Symptoms. — The  immediate  symi)toms  are  due  to  interruption  in  the  func- 
tion of  the  nerve  ,  the  remote  ones  are  the  pathological  lesions  that  follow. 

1.  Immediate. — Loss  of  sensation  over  the  region  supplied  by  the  nerve  is 
definite,  provided  it  is  complete.  On  the  other  hand,  persistence  of  sensation 
does  not  in  any  way  negative  division.  Very  little,  scarcely  anything,  indeed,  is 
known  about  nerve-anastomosis,  either  the  coarse  blending  that  can  be  shown  by 
dis.section,  or  the  finer  union  that  probably  takes  place  in  the  nerve  plexuses;  and 
there  are  many  instances  in  which  nerves  have  been  divided,  and  have  even  had 
pieces  excised  from  them,  without  leaving  the  expected  area  of  anaesthesia.  A 
considerable  length  of  the  musculo-spiral,  for  example,  has  been  excised  without 
any  loss  of  sensation  corresponding  to  the  radial.  Further,  in  many  cases  the 
area  of  anaesthesia,  if  time  is  allowed  to  elapse,  very  often  becomes  smaller,  as  if 
collateral  branches  grew  in  all  round  the  margin.  The  sen.sation  that  persists  after 
nerve-section  is  sometimes  almost  perfect  :  more  frequently  localization  is  inexact, 
especially  at  first  ;  anci  occasionally  analgesia  occurs  without  anc'esthesia. 

In  any  case  of  suspected  injury  the  examination  must  be  made  with  the 
greatest  care.  The  patient  should  be  blindfolded  ;  the  part  well  supported,  so 
that  there  is  no  communicated  vibration  ;  and  various  kinds  of  stimuli  u.sed,  ther- 
mic, for  instance,  as  well  as  tactile.  In  no  case  may  a  conclusion  be  drawn  either 
as  to  the  non-division  of  a  nerve,  or  its  union  after  suture,  without  taking  into 
consideration  other  effects  as  well  as  loss  of  sensation. 

Loss  of  muscular  power  is  equally  definite,  provided  it  continues  and  is  fol- 
lowed by  other  signs,  such  as  rapid  wasting  and  disappearance  of  faradic  excita- 
bility. Temporary  paralysis  may  occur  from  shock,  contusion,  or  compression, 
and  be  indistinguishable  for  two  or  three  days.  The  atrophy  is  of  the  most 
extreme  kind  ;  the  fibres  lose  their  striation,  degenerate  and  shrink  ;  the  nuclei 
multiply  ;  the  interstitial  connective  tissue  increases,  until  in  a  very  short  time  the 
whole  muscular  substance  disappears,  and  nothing  is  left  but  a  rigid,  inextensible 
mass  of  fibrous  tissue.  Faradic  excitability  disappears  very  soon ;  there  is  often  a 
distinct  diminution  by  the  third  day ;  galvanic,  on  the  other  hand,  continues 
longer,  but  rarely  or  never,  according  to  Bowlby,  shows  the  increase  that  usually 
occurs  after  nerve-section  in  animals  ;  and  the  anodal  closure  contraction  precedes 
or  occurs  as  soon  as  the  cathodal. 

2.  Later  Changes. — In  addition  to  the  muscular  wasting,  the  joints,  the  skin, 
and  the  connective  tissues  exhibit  after  a  time  very  distinct  alterations.  The  car- 
tilages undergo  fibroid  degeneration,  the  capsule  and  the  connective  tissue  round 
shrink  and  grow  hard  and  rigid,  the  joints  becoine  stiiT,  fibrous  ankylosis  sets  in, 
and  osseous  union  has  been  known  to  follow.  The  skin  becomes  smooth  and 
glossy.  If  the  hand  is  involved  the  fingers  assume  a  peculiar  tapering  shape,  the 
hairs  fall  off,  the  natural  wrinkles  and  folds  disappear,  and  the  color  becomes  a 
pinkish  red.  Sometimes,  especially  when  the  weather  is  cold,  there  is  a  constant 
burning  pain — causalgia.  Vesicular  and  bullous  eruptions,  herpes,  subcuticular 
whitlow,  and  ulceration  are  not  uncommon.  In  rarer  cases  the  end  of  the  finger 
is  slowly  eaten  away,  or  dry  gangrene  sets  in  and  involves  the  w^hole  anaesthetic 
area.  The  nails  are  often  affected  ;  they  may  be  short,  stunted,  and  fibrous,  or 
curved  either  across  or  longitudinally,  so  that  their  edges  and  angles  bite  deeply 
into  the  flesh.  The  connective  tissue  disappears,  the  secretion  of  sweat  ceases, 
and  generally  (after  the  first  few  days  at  least)  the  temperature  of  the  part  falls 
one  or  two  degrees.  In  exceptional  instances  it  has  been  known  to  continue 
higher  than  that  of  the  corresponding  part  on  the  opposite  side  of  the  body. 


294     DISEASES  AND  INJURIES   OE  SPECIAL    STRUCTURES. 

These  changes  are  noted  more  or  less  regularly  after  section  of  any  nerve, 
though,  owing  to  the  frequency  with  which  the  ulnar  and  median  are  divided  at 
the  wrist  and  the  musculo-spiral  damaged  in  the  arm,  they  are  more  commonly 
seen  in  connection  with  the  hand  than  in  all  the  other  parts  of  the  body  put 
together.  Other  affections,  however,  are  occasionally  met  with  of  a  more  special 
character. 

Perforating  Ulcer  of  the  Eoot  is  the  most  common  and  in  some  respects  the 
most  striking.  It  occurs  chiefly  in  connection  with  locomotor  ataxy  and  the 
chronic  form  of  nerve-degeneration  that  is  associated  with  it  ;  but  it  is  also  met  with 
in  the  anaesthetic  form  of  lei)rosy,  after  fracture  of  the  spine  with  partial  paralysis, 
and  after  degeneration  of  the  nerves  without  the  spinal  cord  being  affected  at  all. 
In  most  cases  it  is  situated  on  the  ball  of  the  great  toe,  but  it  may  occur  on  the 
outer  side  of  the  tread  or  in  any  part.  A  corn  forms  first ;  after  a  time  the 
epidermis  in  the  centre  softens  and  breaks  down,  and  an  opening  is  left  in  the 
middle,  which  at  first  sight  appears  altogether  insignificant,  but  if  a  probe  is  passed 
into  it,  it  is  usually  found  to  extend  far  into  the  substance  of  the  foot,  and  not 
unfrequently  to  involve  the  bone  or  the  metatarso-phalangeal  articulation.  There 
is  little  or  no  pain,  the  edges  of  the  sore  are  usually  whitened  and  callous,  and  in 
many  cases  the  skin  around  it  is  entirely  anaesthetic.  Not  unfrequently  it  is 
present  on  both  feet  at  the  same  time. 

In  the  majority  of  cases  perforating  ulcer  heals  readily  as  soon  as  the  foot  is 
raised,  protected  from  injury,  and  kept  warm.  Very  often  it  breaks  out  again  if 
the  part  is  used.  The  nutrition  of  the  tissues  is  so  enfeebled  that,  though  they 
can  repair  the  effects  of  an  injury  when  very  favorably  placed,  they  are  unable  to 
withstand  the  slightest  pressure  or  irritation. 

How  far  these  changes  are  due  to  lesions  of  trophic  nerves,  and  how  far  they 
are  simply  the  result  of  malnutrition  from  disuse,  is  undetermined.  In  any  case 
injury  plays  an  important  part  in  causing  them.  Sensation  is  lost,  the  immediate 
effect  of  any  violence  is  unperceived,  and  fresh  injury  inflicted  before  the  first  has 
a  chance  of  getting  well.  Ulceration  and  gangrene  of  the  fingers,  for  example, 
which  attain  their  climax  in  anaesthetic  leprosy,  and  perforating  ulcer  of  the  foot 
are  directly  excited  by  injury,  although  they  would  not  occur  without  the  nutrition 
of  the  part  being  defective ;  the  point  at  issue  is  whether  this  arises  simply  from 
disuse  and  anaesthesia,  from  the  interruption  of  trophic  nerves,  or  from  their  irri- 
tation. 

There  is  no  evidence  that  partial  division  of  a  nerve  is  followed  by  trophic  or 
inflammatory  disturbances  more  frequently  than  complete  section.  On  the  other 
hand,  when  it  does  occur,  the  consequences  are  limited  to  the  distribution  of  the 
divided  fibres,  and  they  follow  regardless  of  the  manner  in  which  the  interruption 
is  effected,  whether  by  section,  rupture,  compression,  or  chronic  inflammation, 
provided  only  it  lasts  a  sufficient  length  of  time. 

II.  Subcutaneous  Injuries  of  Nerves. 

Contusion. — Section  of  a  nerve  is  followed  by  the  most  characteristic  conse- 
quences, other  injuries  differ  according  to  their  severity.  If,  for  example,  the 
force  of  the  blow  is  only  slight  the  conductive  power  of  the  nerve  is  suspended 
for  the  moment,  there  is  a  certain  amount  of  dull  aching  at  the  injured  spot, 
tingling  is  felt  at  the  periphery,  and  often  there  is  a  subjective  sense  of  heat,  with 
at  times  actual  flushing.  When  the  injury  is  more  severe  and  the  nerves  are  badly 
crushed,  loss  of  sensation  and  of  muscular  power  may  be  complete  and  followed 
by  wasting  and  disappearance  of  the  faradic  excitability  over  the  whole  area  sup- 
plied. As  a  rule,  the  prognosis  in  these  cases  is  good,  or  at  least  better  than  in 
section,  because  the  physical  continuity  is  not  destroyed,  and  although  trophic 
lesions  may  follow  they  usually  disappear  again  of  themselves,  but  occasionally 
they  persist.  Some  of  the  worst  cases  occur  in  connection  with  the  upper  cords 
of  the  brachial  plexus,  one  or  all  of  them  being  crushed  in  falls  upon  the  shoul- 


INJURIES  OF  NERVES.  295 

ders,  and  leaving  paralysis,  perhaps  permanent,  of  a  corresponding  portion  of  the 
arm.  When,  on  the  other  hand,  the  jjlexus  is  torn  out  from  the  cord  (as  when  a 
man  in  foiling  from  a  height  catches  hold  of  something  in  the  hope  of  saving 
himself)  the  lower  cords  suffer  most  and  with  them  the  symj^athetic  of  the  eye, 
leading  to  narrowing  of  the  palpebral  fissure  and  permanent  contraction  of  the 
pupil. 

The  diagnosis  of  the  extent  of  the  damage  sustained  in  subcutaneous  injuries 
is  very  difficult.  If  the  faradic  excitability  of  the  muscles  persist,  the  hurt  is 
probably  slight.  If  it  rapidly  disappears  and  this  is  followed  by  wasting  and  the 
reaction  of  degeneration,  there  is  no  doubt  that  the  physiological  continuity  of 
some  of  the  nerve-fibres  is  interrupted,  and  if  the  whole  of  the  muscles  supplied 
by  the  trunk  are  affected  in  this  way  it  is  highly  probable  that  the  nerve  itself  is 
torn  across. 

Compression. — The  same  s}'mptoms  are  caused  b}'  gradual  compression, 
whether  this  is  due  to  the  growth  of  a  tumor  (a  cervical  exostosis,  for  instance, 
})ressing  on  the  brachial  plexus),  the  enlargement  of  an  aneurysm,  the  growth  of 
callus,  the  contraction  of  a  cicatrix,  or  some  external  agent.  Paralysis  of  the 
musculo-spiral  is  not  uncommonly  caused  by  a  person  going  to  sleep  with  the  arm 
hanging  over  the  back  of  a  chair,  the  nerve  in  this  particular  position  being 
caught,  almost  unprotected,  between  the  wood  and  the  bone.  When  the  cause  is 
slight  and  only  temporary,  there  is  merely  tingling  or  pricking,  followed  by 
numbness  and  a  sense  of  warmth,  with  some  loss  of  power  over  the  movements 
of  the  part ;  in  more  severe  cases,  the  anc^sthesia  and  paralysis  are  complete,  but 
the  prognosis,  if  the  cause  can  be  removed,  is  usually  favorable.  Crutch  paralysis 
is  perhaps  the  most  common  form,  sensation  being  less  affected  than  movement, 
but  both  varying  very  greatly  in  distribution.  Whether  the  curious  instances  of 
paralysis  of  one  or  more  of  the  nerves  of  the  arm  (sometimes  of  the  whole 
brachial  plexus)  occurring  during  sleep  are  to  be  accounted  for  in  this  way,  or, 
as  Duchenne  tried  to  prove,  by  cold  draughts  at  night,  is  doubtful.  The  absence 
of  any  evidence  of  neuritis  renders  the  latter  explanation  very  difficult  to  under- 
stand. 

Stretching. — The  effect  of  violent  strain  upon  a  healthy  nerve  is  closely  simi- 
lar, the  pathological  lesion  probably  being  of  the  same  character — interruption  of 
the  medullary  sheaths,  with  extensive  disturbance  of  the  axis-cylinders  (rupture 
only  in  very  severe  cases),  minute  hemorrhages,  and,  subsequently,  congestion. 
The  worst  instances  occur  in  connection  with  dislocations,  the  injury  being  caused 
sometimes  by  the  pressure  of  the  displaced  bone,  sometimes  by  the  tension  to 
which  the  nerves  are  subjected  at  the  time  of  the  accident  or  in  subsequent 
attempts  at  reduction. 

Treatment, — {a)  When  a  nerve  is  divided  in  an  open  wound,  the  two  ends 
should  be  found,  brought  together  as  accurately  as  possible,  and  sutured  with 
chromic  gut  or  fine  kangaroo  tendon.  There  is  no  objection  to  passing  the  suture 
through  the  nerve  itself;  indeed,  in  the  case  of  small  ones,  it  is  the  only  way  in 
which  it  can  be  effected  ;  but  the  needle  used  should  be  flattened  from  side  to  side, 
so  as  to  inflict  the  minimum  of  injury.  In  the  case  of  large  ones  the  sheath  should 
be  sutured  as  well.  The  rest  of  the  wound  is  treated  according  to  the  condition  it 
presents ;  the  limb  placed  upon  a  splint  to  prevent  tension  upon  the  sutures,  and 
every  endeavor  made  to  procure  union  by  the  first  intention. 

As  already  mentioned,  perfect  recovery  may  take  place  within  a  fortnight,  so 
that  no  difference  is  perceptible  to  the  patient  or  to  others.  This,  however,  is 
exceptional.  In  the  majority,  trophic  lesions  begin  to  show  themselves,  and  then, 
slowly,  after  some  months,  disappear  again,  sensation  returning  before  movement 
and  voluntary  power  before  electric  excitability.  No  case  should  be  considered  a 
failure  until  at  least  a  year  has  elapsed  ;  sometimes  no  improvement  can  be  de- 
tected for  months,  then  it  sets  in  and  progresses  rapidly ;  sometimes  it  is  steady 
and  gradual  from  day  to  day.  Bowlby  explains  the  differences,  in  part  at  least, 
by  the  independent  regeneration  of  the  distal  segment,  which   is  no  doubt  has- 


296     DISEASES  AND   INJURIES    OE  SPECIAL   STRUCTURES. 

tened  very  considerably  as  soon  as  connecting  axis-cylinders  develop  in  the  inter- 
vening splice. 

The  ultimate  prognosis  is  fairly  good,  but  complete  failure  occurs  in  a  certain 
number  of  cases,  partial  failure  in  many  more,  delicacy  of  touch  and  accuracy  of 
movement  being  impaired  ;  and  in  all,  or  nearly  all,  the  sense  of  localization  re- 
quires re-educating.  The  presence  of  suppuration  distinctly  diminishes  the 
chance  ;  in  one  or  two  instances,  indications  of  commencing  recovery  have  suddenly 
disappeared  again,  probably  owing  to  the  onset  of  inflammation  checking  repair. 

{b')  When  the  injury  is  a  subcutaneous  one  from  the  commencement,  or  the 
wound  (if  there  was  one)  has  healed,  every  endeavor  must  be  made  to  assist  the 
natural  process  of  repair.  Rest,  pressure,  bandages,  splints,  cold,  position,  and 
elevation  may  all,  or  some  of  them,  be  required,  according  to  the  nature  of  the 
injury.  Everything  else  must  wait  until  time  has  been  given  for  the  parts  to  be 
restored  to  their  natural  condition. 

The  only  exception  is  in  those  cases  in  which  the  compression  is  progressive, 
due  to  some  internal  cause;  for  these,  naturally,  something  further  is  required; 
callus,  for  example,  if  it  does  not  soon  become  absorbed,  must  be  cut  away  and 
the  nerve  dissected  out ;  a  cicatrix  in  the  soft  tissues  must  be  treated  according  to 
circumstances;  an  exostosis  removed,  or  perhaps  the  nerve  displaced  a  little  to 
one  side  to  avoid  the  offending  body. 

If  the  faradic  excitability  of  the  muscles  persists,  recovery  takes  place  rapidly; 
if  it  disappears  and  is  succeeded  by  wasting  and  the  reaction  of  degeneration  (as 
always  occurs  after  section)  the  prognosis  should  be  more  guarded,  and  means 
must  be  taken  to  maintain  the  nutrition  of  the  part  as  soon  as  the  fear  of  inflam- 
mation is  past.  Warmth,  friction,  massage,  stimulating  liniments,  galvanism, 
everything,  in  short,  that  can  improve  circulation  and  nutrition  is  beneficial ;  and, 
especially  if  there  is  any  anaesthesia,  great  care  must  be  taken  to  protect  it  from 
injury.  The  galvanic  excitability  increases  in  animals  for  some  time  after  the 
faradic  is  lost :  but  by  the  end  of  four  months  the  muscles  refuse  to  react  to 
either.  In  man  it  is  doubtful  whether  the  increase  takes  place,  but  the  galvanic 
excitability,  at  any  rate,  lasts  very  much  longer  than  the  faradic,  and  for  this 
reason  galvanism  is  preferred,  as  treatment,  to  faradism.  The  sittings  should  not 
be  too  long  or  too  frequently  repeated  ;  every  other  day  for  a  quarter  of  an  hour 
is  usually  enough,  the  time,  of  course,  being  chiefly  determined  by  the  extent  of 
the  paralysis  and  the  number  of  muscles  concerned.  Massage  should  be  applied 
afterward,  and  a  weak  ascending  current  used  at  the  end  to  diminish  the  sense  of 
fatigue.  The  skin  is  thoroughly  well  soaked  with  salt  and  water  first ;  and  care 
must  be  taken  not  to  irritate  an  insensitive  part  by  using  a  current  that  is  too 
strong.  An  occasional  interruption  now  and  then,  reversing  the  direction,  is  said 
to  be  very  beneficial. 

Increased  sensitiveness  of  skin  is  the  first  sign  of  recovery.  If  this  is  noted, 
the  treatment  is  continued  in  the  same  way  ;  in  some  cases  improvement  is  very 
rapid  :  the  muscles  soon  regain  their  shape,  although  their  strength  and  size  and 
the  accuracy  of  their  movements  may  be  defective  for  a  long  period  ;  in  others  it 
is  much  more  slow.  After  section,  voluntary  power  returns  before  electric  excita- 
bility, but  this  is  not  invariable  in  subcutaneous  injuries. 

How  long  this  should  be  continued,  supposing  there  is  no  improvement, 
varies  with  each  case.  In  a  child,  for  example,  repair,  if  it  is  going  to  take  place, 
begins  earlier  than  in  an  adult ;  probably  six  months  may  be  taken  as  the  limit. 
If,  at  the  end  of  this  time,  there  is  no  sign  of  improvement,  it  does  not  follow 
that  there  never  will  be  any ;  but  it  is  almost  certain  that  it  never  will  be  very 
perfect,  and  that  while  secondary  suture  does  not  add  any  material  risk,  it  offers 
the  possibility  of  considerable  benefit.  If  a  neuroma  has  developed  upon  the 
central  end,  repair  is  hardly  possible. 

Secondary  Suture. — This  may  be  performed  at  any  time  after  failure  of 
primary  union.  If  an  attempt  was  made  to  secure  this  at  the  time  of  the  injury, 
it  is  advisable  to  wait  for  some  months ;  conductivity  does  not  return  equally  soon 


INJURIES  OF  NERVES.  297 

in  all  cases.  If  no  attempt  was  made,  the  sooner  secondar)-  suture  is  jjcrformed 
the  better.  According  to  IJowlby,  so  long  as  the  case  is  of  less  than  a  year's 
duration,  the  amount  of  time  does  not  influence  materially  either  the  rapidity 
with  which  union  takes  i)lace  or  its  perfection.  After  two  years,  however,  perfect 
recovery  is  very  doubtful,  although  a  certain  degree  of  improvement  has  been 
noted  even  at  the  end  of  twelve.  As  in  primary  suture,  the  period  at  which  sen- 
sation and  motion  return  is  exceedingly  variable.  The  former  has  been  known 
to  appear  again  within  twenty-four  hours,  or  two  or  three  days  (and  sometimes  in 
these  cases,  probably  owing  to  changes  taking  place  in  the  wound,  it  fails  later)  ; 
while  in  other  instances  it  has  been  months  and  even  a  year  before  there  was 
decided  improvement.  The  latter,  as  might  be  expected  from  the  change  the 
muscles  have  undergone,  and  the  necessity  for  them  almost  to  grow  again,  is 
longer  still,  months  and  even  years  not  being  uncommon.  No  case,  therefore, 
should  be  given  up  as  a  failure  until  at  least  two  years  have  elapsed. 

The  method  of  performing  the  operation  is  very  simple,  although  in  carrying 
it  out  great  difficulties  may  be  encountered.  Esmarch's  bandage  should  be 
applied,  so  that  everything  may  be  seen  without  confusion.  An  inci.sion  is  made 
over  the  seat  of  division,  frequently  traversing  a  scar,  and  the  ends  of  the  nerves 
sought.  The  upper  one,  especially  if  it  is  bulbous,  usually  presents  but  little  diffi- 
culty ;  the  lower,  on  the  other  hand,  may  be  so  shrunken,  fibrous,  and  matted  to 
the  structures  around  that  it  can  scarcely  be  recognized. 

The  bulb  on  the  upper  one  should  be  cut  away  and  no  more ;  the  less  of  the 
lower  one  that  is  sacrificed  the  better  ;  it  may  appear  hopelessly  atrophied,  but  it 
is  not  in  a  more  favorable  condition  further  away. 

If,  after  they  are  freed  from  adhesions,  the  ends  can  be  brought  together 
without  much  traction,  they  should  be  sutured  wdth  chromic  gut,  as  already  men- 
tioned. In  many  instances,  however,  there  is  a  great  gap  between,  and  sometimes 
this  is  the  case  in  primary  operations  when  a  considerable  portion  of  the  nerve 
has  been  lost  or  is  too  much  bruised  to  live. 

An  additional  inch  or  more  may  be  obtained  by  stretching  the  ends,  having 
first  removed  the  bandage.  If  this  fails  there  are  various  methods  which  have 
been  recommended  and  some  of  which  have  been  tried  successfully. 

1.  Nerve-splicing  is  said  to  have  succeeded  (Despres),  the  distal  end  of  the 
divided  median  having  been  implanted  between  the  separated  fibres  of  the  un- 
injured ulnar. 

2.  Flaps  have  been  used.  An  incision  partly  through  the  trunk  of  the  nerve 
is  made  some  little  distance  from  the  end,  and  a  flap  of  nerve-tissue  reflected 
downward  from  it,  leaving  it  attached  at  its  base,  so  as  to  bridge  across  the  gap. 
This,  too,  is  said  to  have  been  of  use,  sensation  returning  in  four  weeks  and  com- 
plete recovery  in  one  year. 

3.  In  a  dog,  the  sciatic  nerve  was  resected,  the  two  ends  sutured  at  some  dis- 
tance, and  inclosed  in  one  of  Neuber's  decalcified  drainage-tubes.  Union  fol- 
lowed, but  such  a  proceeding  would  be  hardly  likely  to  succeed  in  man. 

4.  The  humerus  has  been  resected  in  order  to  bring  the  ends  together. 

5.  Grafts  from  animals  have  been  used,  portions  of  freshly  excised  nerves 
being  imbedded  in  the  gap  and  fixed.  In  one  case  in  which  a  rabbit's  nerve  was 
employed  to  replace  part  of  the  ulnar  and  median,  sensation  returned  in  four 
weeks  and  movement  in  nine,  although  the  gap  was  more  than  two  and. a  half 
inches  in  width  (Tilleman's).  In  another  case,  in  which  the  sciatic  nerve  of  a 
dog  was  used,  the  result  was  doubtful. 

6.  Finally,  Mayo  Robson,  in  a  girl  fourteen  years  of  age,  removed  two  inches 
and  a  quarter  of  the  median  nerve  for  a  neuroma,  and  two  days  later  transplanted 
into  the  gap  a  portion  of  the  posterior  tibial  from  a  recently  amputated  leg. 
Sensation  began  to  return  within  thirty-six  hours,  and  within  four  months  was 
almost  complete,  although  some  of   the  muscles  were  still  much  wasted. 

There  is  no  doubt  that  any  of  these  measures  would  be  much  more  likely  to 
succeed  in  a  case  of  primary  suture  than  where  the  distal  end  has  been  already 
20    • 


29S    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

long  separatetl  from  the  proximal  one.  It  is  possible,  of  course,  that  they  show 
nothing  more  than  that  the  nuclei  of  the  sheath  multiply  more  rapidly,  and 
arrange  themselves  more  readily  in  rows  when  mechanical  assistance  is  given  them, 
and  they  are,  as  it  were,  directed  into  one  particular  line,  instead  of  being  allowed 
to  coil  up  indiscriminately  into  a  ball. 

Complications . 

Injuries  of  nerves  as  a  rule  heal  readily,  whether  the  nerve  fibres  unite  or 
not.  Occasionally  they  are  followed  by  sequelae,  some  of  which  are  very  perplex- 
ing. 

1.  Reflex  Paralysis. — By  this  is  meant  paralysis  of  one  part  of  the  body 
consequent  on  injury  to  another  with  which  the  paralyzed  one  has  no  direct  con- 
nection.    It  may  occur  immediately  after  the  accident,  or  some  time  may  elapse. 

a.  Imviediate. — Most  of  the  instances  recorded  are  the  result  of  gunshot 
wounds  ;  a  very  severe  injury  is  suddenly  inflicted  and  a  distant  part  of  the  body 
is  paralyzed  almost  at  once.  In  all  probabilities  these  cases  are  due  to  shock, 
although  it  is  an  open  question  how  this  produces  such  a  result. 

b.  Secondarx. — These  are  of  a  total  different  character.  A  slight  injury  is 
inflicted  upon  one  of  the  peripheral  nerves,  the  muscles  supplied  by  it  gradually 
lose  their  power,  anaesthesia,  muscular  cramp,  and  trophic  lesions  follow ;  other 
nerves  become  involved,  first  those  distributed  to  the  same  limb,  then  the 
corresponding  ones  on  the  opposite  side,  and  subsequently  similar  changes  in 
nutrition  make  their  appearance  there.  In  short,  the  symptoms  are  those  of 
progressing  chronic  neuritis. 

2.  Reflex  Spasms. — Trivial  wounds  of  cutaneous  nerves  are  occasionally  fol- 
lowed by  a  peculiar  series  of  symptoms  of  which  tonic  muscular  spasm  alternating 
with  violent  contraction  is  the  most  prominent  feature. 

In  many  cases  it  is  distinctly  traceable  to  neuritis  ;  shortly  after  the  injury 
the  track  of  the  nerve  becomes  exceedingly  painful,  the  wound  is  exquisitely 
tender,  and  the  least  touch  throws  all  the  muscles  around  into  a  state  of  rigid  spasm. 
In  course  of  time  as  the  wound  heals  this  subsides ;  but  the  scar  often  remains 
painful  and  tender,  and  the  least  touch  at  one  particular  spot  may  bring  all  the 
symptoms  back.  In  other  cases,  however,  there  is  no  evidence  of  any  inflamma- 
tory affection  at  any  time  ;  the  whole  trouble  appears  to  arise  from  a  nerve-fila- 
ment being  entangled  in  the  cicatricial  tissue  and  irritated  when  the  part  is 
moved.  This  was  apparently  not  infrequent  in  days  gone  by  after  the  operation 
for  venesection  ;  some  of  the  cutaneous  filaments  at  the  bend  of  the  elbow  were 
caught  in  the  cicatrix,  and  the  biceps  and  the  other  flexor  muscles  were  thrown 
into  a  state  of  spasmodic  cramp  if  the  scar  was  touched  or  an  attempt  made  to  use 
the  arm. 

Reflex  spasmodic  contraction  of  an  apparently  similar  description  is  common 
in  children  after  slight  injuries,  especially  those  affecting  joints.  In  them  it  is 
doubtful  how  far  the  disorder  is  due  to  the  as  yet  imperfect  development  of  volun- 
tary control,  and  when  there  is  no  evidence  or  past  history  of  neuritis  spreading 
along  the  nerve,  this  should  not  be  lost  sight  of  in  older  patients,  especially  if 
there  is  a  suggestion  of  hysteria.  The  treatment,  if  this  factor  can  be  eliminated, 
consists  simply  in  excision  of  the  cicatrix,  or  of  the  painful  spot  in  it,  as  soon  as 
the  acute  symptoms  have  subsided. 

3.  Epilepsy. — A  few  cases  of  epilepsy  have  been  definitely  traced  to  a 
peripheral  lesion  as  the  exciting  cause  ;  the  aura  originates  in  the  scar-tissue  and 
the  least  pressure  is  immediately  followed  by  an  attack.  In  any  such  case,  or 
where  there  is  the  least  possibility  of  such  a  thing,  the  scar  should  be  thoroughly 
excised,  or  the  nerves  coming  from  it  freely  divided.  The  sooner  this  is  done 
the  better,  for  there  is  evidence  to  show  that  the  constant  repetition  of  an  irritation 
of  this  kind  may  at  length  lead  to  a  condition  in  which  an  exciting  cause  is  no 
longer  required. 


DISEASES  OF  NERVES.  299 

4.  Tetanus. — Whether  this  disease  is  ever  produced  by  i^eripheral  irritation 
is  open  to  question.  It  certainly  is  one  of  the  rarest  of  all  rare  complications,  if 
the  number  of  accidents  and  operations  in  which  nerves  are  injured  is  taken  into 
consideration.  On  the  other  hand,  its  distinctly  epidemic  occurrence,  the  period 
of  incubation,  and  the  general  course  of  its  symptoms  strongly  favor  its  microbic 
origin,  even  if  no  weight  is  attached  to  the  somewhat  contradictory  results  of 
experiment.  Probably  the  only  valid  reason  for  including  it  here  is  the  occasional 
occurrence  of  tetanic  contractions  after  subcutaneous  injuries  (simple  fracture,  for 
examijle)  in  which  nerves  had  been  strained  or  stretched. 

It  must  be  remembered  that  tetanus,  the  disease,  is  a  very  different  thing  from 
spasmodic  muscular  contraction,  even  though  this  is  tetanic  in  character. 


DISEASES    OF    NERVP:S. 
Neuritis. 

Inflammation  of  the  peripheral  nerves  may  be  acute  or  chronic  ;  in  either 
case  the  active  changes  are  limited  to  the  connective  tissue  ;  the  medulla  and  the 
axis-cylinders  are  only  involved  secondarily. 

Acute  Neuritis. —  The  whole  nerve  is  swollen,  softened,  and  intensely  con- 
gested. The  sheath  and  the  septa  of  cellular  tissue  are  thickened  and  infiltrated 
with  lymph,  and  in  severe  cases  the  section  is  strained  with  minute  extravasations  ; 
but  suppuration  is  rare.  The  myelin  breaks  up  and  disap[)ears,  the  axis-cylinders 
become  indistinct,  the  nuclei  of  the  sheath  are  said  to  increase  in  number,  and  in 
the  worst  cases  the  whole  appearance  of  a  nerve  is  lost.  Such  extensive  changes 
as  this,  however,  are  very  rarely  met  with. 

Chronic  Neuritis. — In  this  there  is  an  increase  of  all  the  connective-tissue 
elements  of  the  part.  The  sheath  is  thickened  and  adherent  to  the  structures 
around  ;  the  nerve  itself  becomes  hard  and  dense,  shrinking  after  a  time  to  less 
than  its  normal  diameter,  and  the  fibres  are  atrophied  and  in  great  measure  dis- 
appear. The  term  chronic  neuritis  is,  however,  applied  in  a  very  general  way 
either  to  a  true  chronic  inflammation,  with  increased  cellular  exudation  and 
organization,  or  to  a  simple  process  of  degeneration,  in  which  the  nerve  fibres 
atrophy  in  much  the  same  manner  as  after  section.  In  many  of  the  forms  of 
so-called  neuritis  there  is  no  evidence,  past  or  present,  of  inflammation  of  any 
kind. 

Causes. — Inflammation  occasionally  follows  injury,  even  when  the  skin  is 
unbroken  :  why,  it  is  difficult  to  understand.  Acute  or  chronic  inflammation  of 
the  cellular  tissue  in  or  round  a  nerve  can,  of  course,  be  caused  by  the  presence  of 
foreign  bodies  or  of  micro-organisms ;  but  the  result  is  very  rarely  proportionate 
to  the  cause,  either  as  regards  severity  or  persistence  of  the  symptoms,  and  the 
worst  cases  not  uncommonly  follow  such  accidents  as  sprains.  There  must  be 
some  other  factor  as  well,  very  likely  a  personal  one. 

The  influence  of  cold  is  variously  estimated.  The  sciatic  and  facial  nerves 
are  the  most  often  affected,  the  latter,  it  is  said,  being  compressed  by  eff"usion  in 
the  bony  canal,  so  that  facial  paralysis  results  ;  but,  according  to  Duchenne.  neuritis 
is  much  more  common  than  is  usually  believed  ;  certainly  many  cases  of  paralysis, 
especially  of  the  musculo-spiral,  commence  during  sleep,  whether  they  are  caused 
by  cold  or  pressure. 

Neuritis  is  not  uncommon  in  gouty  and  rheumatic  subjects  as  a  result  of 
exposure  to  cold  and  wet,  especially  after  great  fatigue.  The  fibrous  sheath  is 
filled  with  inflammatory  exudation  which  compresses  the  nerve  filaments  and  in 
all  probability  the  nervi  nervorum  as  well,  judging  from  the  intense  local  pain 
and  tenderness. 

In  syphilis  degeneration  of  peripheral  nerves  is  not  uncommon,  and,  of 
course,  gummata  occasionally  develop  in  connection  with  them.  In  anaesthetic 
leprosy  a  chronic  form  of  inflammation  is  the  essential  lesion.     The  abuse  ot 


300    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

alcohol  is  stated  to  be  the  main  element  in  the  production  of  what  is  known  as 
progressive  multiple  neuritis.  Degeneration  akin  to  inflammation,  if  not  depend- 
ent upon  it,  occurs  sometimes  in  locomotor  ataxy,  Pott's  disease,  chronic  myelitis, 
etc.  But  even  when  full  allowance  is  made  for  all  of  these  there  is  a  very  large 
residue  for  which  no  explanation  is  forthcoming.  Some  of  the  cases  are  distinctly 
inflammatory  ;  others  (those,  for  instance,  associated  with  herpes  zoster  and 
sloughing  bed-sores)  only  exhibit  degenerative  changes  ;  there  is  no  evidence  of 
true  neuritis  ;  but  the  changes  are  so  much  more  marked  and  so  much  more  rapid 
than  those  that  follow  simple  section  that  it  does  not  appear  advisable  to  separate 
them. 

Symptoms. — i.  Constitutional. — These  depend  upon  the  severity,  and 
extent  of  the  inflammation  ;  rigors,  high  fever,  and  delirium  are  present  in  the 
worst  cases,  but  these  are  very  rare.  In  chronic  ones  constitutional  signs  may  be 
altogether  wanting. 

2.  Local. — These  vary  with  the  character  and  connections  of  the  nerve, 
whether  it  is  motor  or  sensory.  In  acute  inflammation  the  trunk  is  enlarged, 
excessively  tender,  and  the  skin  over  it  is  reddened  and  hyper^esthetic.  There  is 
the  most  intense  pain,  radiating  over  the  whole  area  of  distribution,  sometimes  of 
a  burning  character  (causalgia),  sometimes  dull  and  aching,  with  numbing,  prick- 
ing, and  tingling  sensations.  Muscular  twitching  and  fibrillar  contraction  may 
be  present  in  the  earlier  stages,  but  tonic  spasm  is  more  common,  and  in  a  little 
while  this  gives  way  to  loss  of  power,  with  rapid  wasting  and  diminished  faradic 
excitability.  Paralysis,  more  or  less  complete,  trophic  changes  of  the  most 
varied  character,  and  anaesthesia  are  the  final  stages,  the  pain  frequently  con- 
tinuing the  whole  time  ;  but  naturally  the  extent  to  which  these  occur  differs  in 
every  case. 

Traumatic  neuritis  is  always  local  at  first,  but  in  many  instances  it  spreads 
upward  along  the  nerve  trunks  until  it  meets  other  branches,  involves  these  as  well, 
and  may  finally  implicate  the  whole  of  a  limb.  Then  at  length  it  subsides  or 
becomes  chronic,  leaving  the  muscles  wasted,  the  joints  stiffened,  the  nerves 
thickened  and  tender  on  pressure,  and  the  general  health,  both  of  mind  and  body, 
impaired  from  prolonged  suffering. 

Other  forms  of  neuritis  are  seldom  very  acute,  although  many  of  them,  espe- 
cially the  rheumatic,  are  often  severe  ;  pain,  tenderness,  swelling  along  the  course 
of  the  nerves,  wasting  of  the  muscles,  and  diminished  faradic  excitability  are  rarely 
absent ;  sometimes  they  are  marked  as  in  the  traumatic  variety  ;  sometimes,  on  the 
other  hand,  as  when  the  facial  nerve  is  paralyzed  from  cold,  the  effect  is  compara- 
tively slight,  consisting  merely  of  temjjorary  loss  of  power  without  any  very 
perceptible  alteration  in  the  electric  reaction. 

A  peculiar  form  of  multiple  neuritis  is  described  as  occurring  in  connection 
with  alcohol  and  syphilis,  although  it  is  doubtful  whether  these  are  to  be  regarded 
as  the  sole  cause.  In  some  cases  it  is  stated  to  have  originated  from  cold.  The 
hands  and  feet  are  first  involved,  the  extensor  muscles  on  the  front  of  the  leg  suf- 
fering so  often  that,  according  to  Buzzard,  this  of  itself  is  diagnostic.  The  pain 
is  intense  ;  numbness  with  formication  and  a  sen.se  of  fearful  burning  are  nearly 
always  present.  The  nerves  are  swollen  and  tender  ;  the  skin  red  and  glazed  ; 
other  trophic  lesions  follow  and  rapidly  spread  up  the  limb.  Muscular  power  is 
lost  almost  from  the  beginning  ;  reflex  phenomena  disa])pear  ;  the  reaction  of  de- 
generation sets  in  ;  wasting  is  extreme,  the  muscles  remaining  flaccid,  without  be- 
coming fibroid  ;  and  the  movements  resemble  those  of  locomotor  ataxy.  In  some 
cases  there  is  a  considerable  degree  of  fever  as  well,  and  the  general  health  usually 
fails  rapidly.  The  course  of  the  disease  is  very  variable  ;  in  a  few  cases  it  has  con- 
tinued to  spread,  commencing  at  the  extremities  and  rapidly  advancing  until  the 
spinal  cord  became  involved  ;  in  some  it  has  remained  stationary  for  a  long  period, 
often  at  the  level  of  the  hands  or  feet,  and  then  di.sappeared  again,  recovery  taking 
place  often  imder  anti-syphilitic  treatment  ;  while  in  others  again  it  has  steadily 
progressed  from  bad  to  worse,  until  the  patient  died  from  exhaustion  or  was  carried 


DISEASES  OF  NERVES.  301 

off  by  some  intercurrent  disorder.  Some  of  these  cases  are  difficult  to  distini^aiish 
from  tal)es  dorsalis  ;  the  gait  is  ataxic  ;  there  are  girdle  pains,  and  not  unfre(iuently 
lightning  ones  as  well  ;  but  as  a  rule  in  spinal  ataxy  the  electric  reaction  of  the 
muscles  continues  normal. 

Treatment. — Constitutional  measures  are  most  imjjortant.  In  the  vast 
majority  of  instances,  even  if  the  inflammation  is  excited  by  cold  or  injury,  its  ])er- 
sistence  and  severity  are  due  to  some  other  cause,  whether  gout,  rheumatism, 
syphilis,  malaria,  chronic  alcoholism,  or  debility,  and  by  itself  local  treatment  is  not 
likely  to  succeed. 

\w  acute  neuritis  the  first  thing  is  to  relieve  the  almost  intolerable  pain  ; 
warmth,  belladonna,  fomentations,  injections  of  morphia,  Indian  hemp,  and  other 
anodynes  are  the  most  useful.  Afterward,  when  the  first  severity  of  the  attack  is 
past,  narcotics,  and  opium  in  particular,  should  be  employed  as  little  as  possible. 
Counter-irritants,  leeches,  blisters,  iodine,  and  even  acupuncture  are  of  decided 
benefit  ;  warm  and  Turkish  baths  frequently  give  great  relief,  particularly  before 
going  to  bed  ;  the  constant  current  interrupted  occasionally  and  preferably  weak, 
but  long  continued,  is  often  most  successful,  and  in  the  later  stages,  when  the  ex- 
treme tenderness  has  subsided  in  some  measure,  massage  does  more  good  than  any- 
thing else,  in  all  probability  by  causing  absorption  of  the  inflammatory  exudation 
and  preventing  the  formation  of  adhesions  and  dense  cicatricial  tissues. 

Quinine  and  salicylic  acid  are  sometimes  very  useful.  Stretching  the  nerve 
itself,  paralyzing  the  nervi  nervorum  and  freeing  the  sheath  all  round,  has  proved 
of  great  benefit,  even  in  such  diseases  as  multiple  neuritis  and  anesthetic  leprosy, 
and  in  the  worst  cases  is  almost  certain  to  give  temporary  relief. 

Neuralgia. 

By  neuralgia  in  the  general  sense  of  the  term  is  meant  an  acute  paroxysmal 
pain  in  the  course  of  a  nerve.  In  many  cases  it  is  really  a  symptom  of  neuritis,  or 
of  disease  of  the  brain  or  spinal  cord,  and  the  treatment  must  be  guided  by  the 
cause.  Sometimes,  however,  it  does  occur  with  great  severity  without  there  being 
any  perceptible  change  in  the  nerv^e  or  the  centre  from  which  it  springs. 

Neuralgia  of  this  type  is  nearly  always  due  to  some  constitutional  disorder, 
although  it  may  be  started  by  a  local  cause.  Neuralgia  of  the  testes,  for  example, 
arising  from  irritation  of  the  kidney,  or  of  the  face  from  the  presence  of  a  carious 
tooth,  is  seldom  severe  except  in  those  who  are  predisposed  to  it  by  a  constitu- 
tional affection,  whether  it  is  mental  or  physical,  hereditary  or  acquired.  It  is 
especially  common  among  members  of  what  may  be  called,  for  want  of  a  better 
term,  neurotic  families.  Anaemia,  dyspepsia,  over-lactation,  mental  worry  or  over- 
work, malaria,  gout,  debilitating  influences  of  all  kinds,  may  induce  it ;  but  the 
worst  form  of  all,  that  which  is  known  as  epileptiform  neuralgia,  or  when  it  involves 
the  fifth  nerve,  as  tic,  has  so  far  eluded  every  attempt  at  finding  a  reason.  It  may 
occur  in  both  sexes,  in  the  young  as  well  as  the  old,  the  robust  as  w-ell  as  the 
weakly,  and  it  may  so  completely  destroy  strength  and  health,  both  of  mind  and 
body,  as  to  drive  the  patient  to  commit  suicide. 

This  peculiar  variety  of  neuralgia  is  usually  met  with  in  the  face,  affecting  one 
of  the  branches  of  the  fifth  pair,  or  in  severe  cases  all  of  them.  The  pain  is  parox- 
ysmal, of  the  most  intense  description,  coming  on  instantaneously  from  the  slight- 
est cause — a  touch,  a  breath  of  cold  air,  an  attempt  at  mastication,  or  even  from 
no  cause  at  all  ;  it  may  last  a  few  seconds  or  some  minutes  ;  and  it  may  come  on  at 
frequent  intervals,  or  not  for  days  and  even  weeks.  Whenever  it  occurs  the  suf- 
ferer describes  it  as  the  most  intolerable  agony,  usually  comparing  it  to  something 
burning.  There  may  be  convulsive  spasm  with  it  {tic  convulsif)  or  not ;  in  many 
cases  there  is  profuse  lachrymation,  in  others  the  mucous  membrane  of  the  nose  and 
mouth  is  hot  and  dry,  occasionally  the  whole  side  of  the  face  flushes,  and  in  many 
instances  the  hair  is  affected  too.  Usually  in  its  earlier  stages  it  is  traceable  to 
some  tooth  as  its  starting-point,  but  in  the  true   epileptiform  variety  it  is  not 


302    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

uncommon  to  find  that  the  patient  has  had  every  tooth  on  that  side  of  the  head 
removed  without  experiencing  even  a  temporary  cessation. 

Closely  akin  to  this  is  a  variety  of  neuralgia  that  is  occasionally  met  with  after 
amputations,  different  altogether  from  that  which  is  due  to  the  nerve-ends  having 
become  bulbous  or  entangled  in  the  scar.  It  does  not  begin  until  the  wound  is 
sound.  The  whole  of  the  stump  is  the  seat  of  a  fearful  burning  pain,  though  to  the 
touch  it  is  intensely  cold.  The  skin  is  red,  glazed,  and  congested,  the  color 
returning  very  slowly  after  pressure.  The  muscles  of  the  joint  above,  and  some- 
times of  the  whole  limb,  are  in  a  state  of  constant  spasmodic  twitching,  and  the 
pain  radiates  not  only  through  the  amputated  part  but  over  the  whole  of  the  limb. 
This  (though,  like  tic,  it  may  have  commenced  as  a  local  affection  from  a  local 
source  of  irritation)  when  once  established  is  only  too  liable  to  become  permanent, 
in  the  same  way  that  local  epilepsy  sometimes  does,  either  from  constant  repetition 
only,  or  from  a  peculiar  unstable  condition  of  the  central  nervous  system  ;  and  I 
have  known  it  return  after  four  successive  amputations,  and  even  after  the  nerves 
had  been  stretched  on  the  face  of  the  stump  as  far  as  they  could  be  without  being 
torn  out.  No  single  one  appeared  to  be  involved,  the  disease,  whether  central  or 
not,  was  general. 

Treatment. — The  ordinary  form  of  neuralgia  is  only  a  symptom  of  an  affec- 
tion either  of  the  nerve  itself  (neuritis)  or  of  another  part  of  the  body,  and  the 
treatment  essentially  consists  in  finding  the  cause,  whether  local  or  constitutional. 
If  nothing  is  discovered,  all  that  can  be  done  is  to  relieve  the  symptoms  by  large 
doses  of  quinine,  salicylic  acid,  croton-chloral  hydrate,  or  tincture  of  gelseminum 
internally,  and  anodynes — belladonna,  veratria,  aconite  or  menthol — locally. 
Naturally,  as  the  constitutional  condition  that  underlies  the  case  may  be  of  the 
most  different  description,  the  line  of  treatment  required  for  one  patient  is  often 
diametrically  opposed  to  that  advisable  for  another.  Purgatives,  colchicum,  iodide 
of  potash,  and  alkalies  may  suit  one  ;  while  complete  change  of  air,  often  to  the 
seaside,  rest,  tonics,  iron,  quinine,  arsenic,  strychnia,  or  phosphorus  may  be 
required  for  another.  Very  great  care  is  essential  in  advising  stimulants  or 
morphia. 

Epileptiform  neuralgia  is  rarely  benefited  except  by  operation,  and  even  then 
in  too  many  instances  only  temporarily.  As  a  rule,  by  the  time  the  neuralgia  has 
assumed  this  type  all  the  teeth  on  that  side  of  the  head  have  been  extracted  in  the 
hope  of  obtaining  relief.  Sometimes  this  is  successful,  but  in  the  worst  form 
either  the  patient  is  entirely  unable  to  state  from  what  particular  spot  the  neuralgia 
starts,  or  else,  if  there  clearly  is  one  offending  tooth,  no  sooner  is  it  removed  than 
the  pain  transfers  itself  to  another.  Careful  examination,  however,  should  never 
be  omitted  ;  there  is  more  than  one  case  on  record  in  which  excision  of  part  of 
the  gum  or  of  the  alveolar  border  succeeded  after  all. 

Quinine  seems  to  have  no  control  over  it  ;  anodynes  soon  lose  their  effect ; 
morphia,  if  persisted  in,  only  makes  the  condition  of  the  patient  worse.  Gal- 
vanism is  sometimes  beneficial.  If  this  fails,  nerve-stretching  may  be  tried,  and 
as  a  final  effort  the  whole  nerve  may  be  removed  with  its  branches  as  far  as  possi- 
ble, up  to  its  exit  from  the  cranium.  The  trunk  most  commonly  affected  is  the 
superior  maxillary,  and  there  is  a  sufficient  number  of  cases  in  which  excision  of 
Meckel's  ganglion  has  succeeded,  to  justify  the  operation.  It  is  true,  relief  has 
not  been  permanent  in  all  or  nearly  all,  but  in  most  it  has  lasted  some  months,  in 
many  one  or  two  years,  and  that  alone  would  be  sufficient. 


OPERATIONS    ON    NERVES. 

Nerve-stretching. 

The  great  sciatic  may  be  stretched  subcutaneously  without  a  wound,  and  with 
almost  as  great  success  ;  in  the  case  of  other  nerves  an  incision  is  required.  If  the 
cord  is  a  large  one,  one  or  more  fingers  may  be  placed  beneath  it  and  steady 


OPERATIONS  ON  NERVES.  303 

traction  exercised  upon  it,  first  in  one  direction,  then  in  the  other  ;  as  it  yields  a 
sensation  as  of  crackling  or  snapping  is  transmitted  to  the  finger,  and  the  length 
and  flexibility  of  the  part  exposed  are  distinctly  increased.  Small  nerves  should 
be  lifted  upon  a  rounded  hook,  sharp  edges  being  avoided  as  much  as  possible. 

The  immediate  effect  is  to  loosen  the  sheath,  separating  it  from  all  the  struc- 
tures around,  and  tear  across  the  smaller  vessels,  so  that  its  section  is  stained  with 
minute  ccchymoses.  The  myelin  of  the  more  superficial  fibres  is  broken  up  into 
segments,  many  of  the  tubules  are  ruptured,  and,  unless  the  force  is  very  extreme, 
the  excitability  is  increased  for  a  time.  In  a  little  while  the  part  becomes  more 
vascular,  some  of  the  fibres  degenerate  and  disappear,  the  nuclei  of  the  sheath 
multiply,  all  the  interstices  are  filled  with  lymph,  and  the  fibrous  tissue  becomes 
swollen  and  softened.  At  this  stage,  after  its  temporary  increase,  the  excitability 
of  the  nerve  diminishes,  anaesthesia  and  loss  of  power  follow,  corresponding  to 
the  fibres  affected,  and  the  faradic  excitability  of  the  muscles  is  greatly  depressed. 
Gradually  this  gives  way  in  turn  to  regeneration  ;  new  nerve  tubules  are  formed, 
the  hyperemia  subsides,  and  at  length  all  the  functions  of  the  part  are  restored. 

It  is  especially  noteworthy  that  the  effect  of  nerve-stretching  is  not  limited  to 
the  spot  at  which  the  traction  is  applied.  It  extends  for  long  distances  up  and 
down  the  trunk,  involves  the  branches  that  come  off  from  it,  and  occasionally 
produces  a  considerable  effect  upon  the  spinal  cord.  It  is  probable  that  no  degree 
of  traction  that  can  be  safely  exercised  upon  a  nerve  during  life  moves  the  cord  to 
any  appreciable  extent ;  but  whether  this  is  the  case  or  not  there  is  no  doubt  that 
hyperaimia  of  the  colunms  of  Goll  may  follow,  and  that  sometimes,  in  animals  at 
least,  sclerosis  of  the  posterior  columns  makes  its  appearance  afterward. 

The  effect  varies  with  the  force,  and  this,  of  course,  is  regulated  by  the  size 
and  the  condition  of  the  nerve.  In  some  people  the  cords  naturally  stand  a  much 
higher  strain  than  in  others.  The  greater  the  length  exposed  the  less  the  risk,  as 
the  force  is  more  distributed.  There  is  not  so  much  fear  of  the  nerve  giving  way 
as  of  its  being  pulled  out  from  its  spinal  attachment,  and  great  care,  therefore, 
must  be  used  when  the  part  exposed  is  situated  near  the  intervertebral  foramina 
and  the  traction  is  from  the  centre.  In  any  case  the  pull  must  increase  uniformly 
without  the  least  jerk. 

To  stretch  the  sciatic  nerve  subcutaneously  the  patient  is  placed  under  an 
anaesthetic,  and  the  hip  flexed  while  the  knee  is  kept  in  rigid  extension,  until  a 
sufficient  effect  is  produced.  The  hamstring  muscles  suffer  to  a  certain  extent  at 
the  same  time,  the  ischial  tuberosity  being  very  tender  for  days  afterward.  I  have 
done  this  with  temporary  benefit  on  more  than  one  occasion,  but  it  does  not  free  the 
sheath  of  the  nerve  from  surrounding  adhesions  in  anything  like  the  same  degree. 

Neither  operation  is  devoid  of  risk,  especially  in  the  case  of  the  sciatic. 
Paralysis  of  other  nerves  coming  up  from  the  same  region  of  the  cord  has  been 
known  to  follow,  and  even  the  corresponding  one  on  the  opposite  side  of  the  body 
may  suffer.  Meningeal  hemorrhage,  meningitis,  and  myelitis  have  all  occurred 
and  have  proved  fatal,  and  in  other  cases  sloughing  bed-sores,  cystitis,  suppurative 
nephritis,  and  other  trophic  lesions  have  followed.  Whether  the  frequency  with 
which  these  occur  after  operations  upon  the  sciatic  is  simply  due  to  the  fact  that 
this  nerve  is  more  often  affected  than  others,  or  to  the  exceptional  amount  of  force 
that  is  sometimes  used,  as  there  is  so  little  danger  of  tearing  the  trunk,  is  not 
known. 

The  good  effect  that  follows  the  operation  in  so  many  different  diseases  has 
been  accounted  for  in  many  ways.  There  is  no  doubt  that  old  adhesions  are 
broken  across  and  the  cord  freed  from  constricting  bands.  In  other  cases,  when 
the  neuralgic  pain  is  local,  not  referred  to  the  periphery  of  the  nerve,  the  benefit 
may  be  due  to  the  effect  upon  the  nervi  nervorum.  Something,  perhaps,  may  be 
said  for  the  increased  vascularity  that  follows  ;  the  fibres  are  better  supplied  with 
blood  and  better  nourished.  But  in  all  probability  the  chief  good  is  due  to  the 
actual  interruption  of  the  fibres,  both  of  the  trunk  and  its  branches,  securing 
physiological  rest  for  the  centre  until  its  normal  nutrition  is  restored. 


304     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

The  effect  (except  where  there  is  some  local  reason,  such  as  chronic  inflam- 
mation or  the  presence  of  adhesions)  is  usually  temporary.  When  the  nerves  are 
regenerated  the  old  symptoms  return  again  ;  either  the  original  cause  still  remains 
at  work,  or  the  effect  upon  the  centre  has  been  repeated  so  frequently  and  for 
such  a  length  of  time  that  habit  has  become  second  nature.  Sometimes,  however, 
the  interval  is  sufficiently  long,  the  vicious  circle  is  broken,  and  the  patient 
remains  free. 

Nerve-stretching  has  almost  superseded  nerve-section  :  it  produces  the  same 
effect  without  interrupting  the  physical  continuity  of  the  cord  ;  it  acts  upon  the 
branches  as  well  as  the  trunk  ;  a  longer  section  of  the  nerve  is  examined,  and 
adhesions,  if  there  are  any,  are  broken  across.  The  wound  is  a  larger  one,  it  is 
true,  but  that  is  scarce4y  a  serious  objection. 

Its  chief  use  is  in  connection  with  all  forms  of  neuralgia  and  chronic  neuritis, 
even  that  which  occurs  in  anaesthetic  leprosy.  In  many  of  these  cases  it  is  extra- 
ordinarily successful.  Epileptiform  neuralgia,  however,  is  usually  only  relieved  ; 
it  is  almost  certain  to  return.  In  addition,  it  has  been  used  with  varying  success 
in  tabes,  both  to  relieve  the  pain  and  for  the  ataxic  .symptoms,  and  in  facial  tic. 
In  spastic  spinal  paralysis,  tetanus,  paralysis  agitans,  and  spasmodic  wry-neck  its 
value  is  very  doubtful ;  sometimes  it  is  said  to  have  procured  temporary  relief,  but 
it  is  not  probable  that  the  whole  number,  or  even  a  large  proportion,  of  the  cases 
in  which  it  has  failed,  has  been  published. 

Neurecto.mv  and  Nerve- EVULSION'. 

The  former  of  these  signifies  merely  the  removal  of  a  portion  of  a  nerve-tnink  ; 
the  latter,  etc.,  complete  separation  from  the  highest  point  that  can  be  reached,  as 
a  rule,  the  orifice  of  a  bony  canal. 

Neurectomy  is  practiced  upon  the  spinal  accessory  for  uncontrollable  spasmodic 
wry-neck,  and  occasionally  upon  the  nerves  of  the  head  and  face  for  neuralgia. 
Nerve-evulsion  is  rarely  tried  except  in  the  case  of  the  second  and  third  branches 
of  the  fifth  for  epileptiform  neuralgia. 

Meckel's  ganglion  may  be  excised,  either  from  the  side  or  in  front.  In  the 
former  operation  the  zygoma  with  the  attachment  of  the  masseter  is  separated  and 
reflected  ;  in  the  latter  the  anterior  wall  of  the  antrum  is  trephined.  If  the  light  is 
good  (an  electric  light  or  at  least  a  reflector  attached  to  the  forehead  of  the  operator 
is  essential;  the  anterior  operation  is  quite  feasible,  and,  though  permanent  cure  is 
rare,  may  be  relied  upon  to  give  relief  for  at  least  one  or  two  years.  A  crucial 
incision  is  made  down  to  the  bone  over  the  infra-orbital  foramen  ;  a  half-inch 
circle  is  removed  with  a  trephine  from  immediately  below  it,  and  the  nerve  traced 
back,  cutting  away  the  floor  of  the  infra-orbital  canal  and  groove  until  the  posterior 
wall  is  reached.  A  second  trephine  opening  is  made  in  this,  taking  care  not  to 
wound  the  soft  tissues  beyond,  and,  as  a  rule,  Meckel's  ganglion  is  exposed  at 
once,  and  can  be  removed  with  its  posterior  dental  branches  and  the  whole 
length  of  the  infra-orbital,  thus  securing  complete  anaesthesia  of  that  side  of  the 
palate. 

The  inferior  dental  nerve  may  be  exposed  through  the  vertical  ramus  of  the 
jaw,  a  circle  of  bone  being  excised  with  the  trephine ;  but  in  most  cases  it  can  be 
reached  as  satisfactorily  through  the  mouth,  and  a  disfiguring  scar  avoided.  A  gag 
should  be  placed  between  the  teeth  on  the  opposite  side,  and  the  mouth  opened  as 
widely  as  possible  ;  the  incision  runs  along  the  projecting  fold  of  mucous  membrane, 
fjassing  from  one  jaw  to  the  other  behind  the  last  molar  teeth,  and  the  finger  is 
pushed  between  the  internal  pterygoid  muscle  and  the  ramus  until  the  sharp  spine 
of  bone  that  marks  the  orifice  of  the  dental  canal  is  reached.  The  nerve  may  then 
be  hooked  forward  with  an  aneurysm  needle,  and  separated  from  its  connections 
for  some  little  distance  by  the  finger.  Care  must  be  taken  not  to  mistake  the  long 
internal  lateral  ligament  of  the  lower  jaw  for  it. 


OPERATIONS  ON  NERVES. 


305 


Nkuromata. 

True  neuromata — that  is  to  say,  tumors  composed  of  nerve-tissue — are  very 
rare.  A  few  cases  are  recorded  in  which  nerve-fibres  (usually  small  and  without 
much  myelin)  have  been  found,  and,  in 
one  or  two,  nerve-ganglion  cells  as  well ; 
but  the  total  number  is  very  small,  and 
there  is  no  means  l5y  which  they  can  be 
distinguished  from  false  ones  during  life. 
The  nerve-fibres  are  not  arranged  in  any 
definite  order,  and  do  not  conminnicate 
with  those  of  the  trunk  ui)on  which  they 
grow. 

False  neuromata  are  fibromata,  sarco- 
mata, or  cysts  developed  in  connection  with 
the  fibrous  tissue  of  the  nerve.  They  may 
attain  any  size  and  grow  either  on  the  side 
of  the  nerve  or  in  among  the  fibres,  dis- 
placing them.  Sometimes  they  are  multi- 
ple, as  many  as  two  thousand  having  been 
counted  in  one  individual,  and  these  are 
not  unfrequently  associated  with  moUuscimi 
fibrosum.  Occasionally  their  section  pre- 
sents a  plexiform  appearance:  The  symp- 
toms naturally  vary  with  the  kind  of  nerve 
from  which  they  grow  and  the  extent  to 
which  they  interfere  with  its  functions. 
Shooting  pains,  especially  when  the  growth 
is  handled  in  a  particular  way,  neuralgia, 
paralysis,  spasm,  trophic  lesion,  and  even 
paraplegia  (when  the  tumor  is  situated  in 
the  spinal  canal)  have  been  described  in 
connection  with  them. 

Neuromata  must  not  be  confused  with 
the  bulbous  enlargements  which  make  their 
appearance  upon  the  ends  of  nerves  after 
section,  although  the  microscopic  appear- 
ance is  closely  similar. 

Excision  is  the  only  treatment.  If  the 
growth  proceeds  from  one  side  of  the 
trunk  there  is  no  difficulty  ;  if,  however,  it 
is  interstitial  this  may  be  impossible. 
Under  these  conditions  the  only  course 
open  is  to  excise  a  portion  of  the  nerve  and  brin 
sible,  by  means  of  sutures. 


Fig.  77, — False  Neuroma.  A  large  oval  tumor,  six 
inches  long  by  four  wide,  implicating  the  sciatic 
nerve  and  its  posterior  tibial  branch.  The  tumor 
is  hollow,  presenting  a  large  central  cavity  with 
sofi,  shreddy  walls.  The  trunk  of  the  nerve,  a,  is 
seen  passing  into  the  tumor  above  and  emerging 
below  at  a  point  below  the  popliteal  space.  Vari- 
ous filaments  are  represented  spread  out  on  the 
walls  of  the  tumor,  bb,  and  many  other  nerves  can 
be  detected  by  examination  in  the  central  cavity. 
For  about  one  and  one-half  inches  above  the  tumor 
the  nerve  is  much  thickened  and  indurated.  All 
that  is  known  of  the  history  is  that  the  limb  was  . 
amputated.  The  chief  mass  of  the  tumor  was 
found,  on  microscopical  e.xamination,  to  consist  of 
fibrous  tissue  of  various  consistence,  granular 
amorphous  material,  round  and  oval  cells  of  the 
size  of  pus-globules  for  the  most  part,  elongating 
fibre-cells,  and  remnants  cf  nerve  tubes.  (Holmes.) 


the  two  ends  together,  if  pos- 


p6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  V. 
INJURIES  AND  DISEASES  OF  MUSCLES,   TENDONS,  ETC. 

Sprains  and  Contusions. 

Contusions  of  muscles  are  rarely  serious,  although  they  may  cause  consider- 
able effusion  of  blood,  with  pain  and  loss  of  power.  In  a  itw  instances,  however 
(especially  in  the  case  of  the  quadriceps  femoris),  permanent  atrophy  has  followed. 
I  have  known  the  same  thing  occur  after  a  violent  sprain,  and  that,  too,  without  the 
fibres  being  torn  to  any  extent. 

Tendons  themselves  seldom  suffer ;  the  soft  delicate  sheath  that  surrounds 
them  receives  the  brunt  of  the  violence.  Repeated  strains,  however,  are  not 
unfrequently  followed  by   chronic  inflammation,  which  may  end  in  ossification. 


a.     Hyaline 
cartilage. 


i.  Proliferat- 
ing cartilage. 

c.  Remains 
of  old  matrix 
of  cartilage, 
with  enclosed 
medullary 
spaces. 

d.  New  bone 
developed 
from  the  car- 
tilage and 
arranged  in 
irregular  tra- 
becular 


w         a.      Lacunae 
and  canaliculi. 


6.   Lamellae. 


C  c.  Haversian 

artery. 


Fig.  78. — Rider's  Bone  seen  in  Section,  with  its  Microscopical  Appearance. 


The  best  known  e.xample  is  what  is  called  rider's  bone,  developing  in  the  tendon  of 
the  adductor  longus  in  those  who  are  accustomed  to  rough  riding,  but  I  have  met 
with  similar  ones  in  the  tendons  of  the  psoas,  (piadriceps,  and  biceps.  In  chronic 
rheumatic  myositis  the  tendinous  expansions  attached  to  the  bones  often  become 
ossified,  so  that  the  intermuscular  ridges  stand  out,  covered  with  irregular  osteo- 
phytes.    This  condition,  however,  is  rarely  diagnosed  during  life. 


RUPTURE    OF  TENDONS. 


307 


Rri'l  LIKE. 

Muscles  are  torn  by  external  violence,  by  sudden  spasm,  as  in  tetanus,  or  by 
splinters  of  bone  being  driven  into  them  in  fracture,  and  the  injury  may  be  either 
simple,  with  the  skin  unbroken,  or  comijound.  In  cases  of  external  violence 
the  rupture  may  of  course  involve  any  part  ;  the  sheath  only  may  be  torn,  or  the 
whole  thickness  of  the  muscle.      When  it  is  due  to  sudden  contraction   the  fibres 


SUorl    cAc„,,r 


— ^-^raWft^,!^"^'^-—^^"^ 


Fig.  79. — Thumb,  with  'rendons,  etc.,  Torn  out  by  Machinery. 


are  usually  wrenched  out  from  the  tendons,  the  line  of  junction  being  the  weakest 
part.  If,  for  example,  the  last  phalanx  of  one  of  the  fingers  or  the  thumb  is  pulled 
off,  it  brings  with  it  the  whole  length  of  the  flexor  tendons  (Fig.  79). 

The  signs  of  such  an  accident  are  very  conspicuous.  There  is  a  sudden  sharp 
pain  followed  by  a  dull  sense  of  aching  and  of  helplessness,  and  a  feeling  as  if 
fluid  were  trickling  down  the  skin.  The  ends  retract  immediately  as  far  as  they 
can  ;  an  immense  amount  of-  blood  is  poured  out ;  and  the  separation  grows  more 
distinct  with  every  attempt  to  use  the  part.  By  degrees  the  blood  is  absorbed  ;  the 
swelling  becomes  less  prominent,  the  lymph  that  is  thrown  out  becomes  organized, 
and,  if  the  interval  is  not  too  wide,  a  slice  of  cicatricial  ti.ssue  is  developed. 
Later  it  appears  that  this  is  in  some  measure  replaced  by  muscular  elements  again. 
If  only  the  investing  fascia  gives  way  the  muscle  substance  is  squeezed  out  through 
the  rent,  and  forms  a  mushroom-shaped 
swelling  known  as  muscle  hernia. 

The  adductor  longus  often  suffers  in 
this  way  in  the  almost  involuntary  grip 
upon  the  saddle  when  a  horse  swerves  ; 
and  full  power  is  seldom  regained.  The 
biceps  in  the  arm ;  the  quadriceps  in  the 
leg ;  and  the  rectus  abdominis,  among 
the  flat  muscles,  are  ruptured  almost  as 
frequently.  Others  are  seldom  injured  ; 
but  the  lower  part  of  the  pectoralis  major 
may  be  torn  (when,  for  instance,  a  person 
tries  to  save  himself  from  falling  by 
clutching  at  something)  ;  the  sterno- 
mastoid  may  give  way  from  vomiting,  or  (probably  from  excessive  traction)  during 
birth  ;  and  the  biceps  femoris,  the  semi-membranosus,  and  many  others  occasion- 
ally suffer.  Whether  the  plantaris  ever  does  is,  I  think,  open  to  question.  There 
is  a  well-known  form  of  accident,  the  symptoms  of  which  are  always  strikingly 
alike,  known  as  lawn-tennis  leg,  or  as  the  "coup  de  fouet."  It  is  rare  among 
women  and  hospital  patients,  but  exceedingly  common  in  men  past  middle  life 
and  of  a  somewhat  gouty  tendency.  There  is  a  sudden  violent  pain  in  the  calf  of 
the  leg,  like  a  whip-stroke,  and  the  patient  stops  involuntarily,  whatever  he  may  be 
doing,  with  his  leg  perfectly  helpless.  In  a  few  minutes  a  little  extravasation 
makes  its  appearance  behind  the  inner  malleolus  ;  a  certain  amount  of  puffiness 
and  oedema  may  occur  as  well ;  and  then  the  pain  subsides.  The  toe  is  placed  upon 
the  ground,  but  not  the  heel  ;  all  the  resolution  the  patient  is  capable  of  cannot 
bring  it  down  ;    the  weight  cannot  be  borne  upon  the  leg  ;  and  walking  is   out  of 


Fig.  80.^ — Ruptured  Tendon  of  Biceps. 


3oS    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  i]uestion.  In  some  cases  a  sHl^^Iu  degree  of  eversion  of  the  foot  has  been 
noticed.  This  peculiar  accident  is  always  attributed  to  rupture  of  the  plantaris 
tendon,  but  I  am  not  aware  of  any  instance  in  which  this  lesion  has  been  demon- 
strated. On  the  other  hand,  I  know  of  at  least  one  case  in  which  the  same 
accident  occurred  twice  in  the  same  leg  at  a  different  spot  within  the  month.  From 
the  symptoms,  the  class  of  person  in  whom  it  occurs,  and  the  rapidity  with  which 
recovery  takes  place,  if  proper  measures  are  taken  (not  without),  I  am  inclined  to 
think  that  it  is  rather  a  rupture  of  some  one  of  the  deep-seated  veins,  which  are 
so  often  varicose,  than  of  that  exceedingly  long  tendon. 

Treatment. — 'i"he  limb  must  be  placed  in  the  position  tliat  secures  the 
maximum  degree  of  relaxation,  and  the  extravasation  checked  as  far  as  possible 
by  cold  and  pressure.  Firm  bandaging  assists  in  keei)ing  the  muscle  from  con- 
tracting and  helps  to  press  the  broken  surfaces  somewhat  nearer.  Afterward  the 
])art  must  be  kept  absolutely  at  rest  until  organization  is  complete.  If  union 
takes  place  the  nutrition  will  soon  recover  under  the  influence  of  massage  and  gal- 
vanism. When  the  tendo-.A.chillis  is  ruptured  a  high-heeled  shoe  must  be  worn 
for  two  or  three  months  afterward. 

If  the  ends  cannot  be  brought  into  fair  apposition,  union,  of  course,  is  impos- 
sible. The  gap  grows  wider  and  more  distinct  as  the  blood  that  fills  it  is  absorbed  ; 
the  ends  of  the  muscle  atrophy  ;  and  its  use  is  entirely  lost.  In  many  cases  some 
appliance  is  needed  afterward — an  abdominal  .support,  for  example,  to  prevent 
ventral  hernia,  or  a  thigh-belt  if  the  adductor  is  ruptured. 

In  open  wounds  an  attem])t  may  be  made  to  draw  the  surfaces  together  by 
deei)ly-buried  catgut  sutures  passed  through  the  whole  thickness  of  the  muscle,  or 
through  its  investing  layer  only,  but  it  rarely  succeeds.  With  tendons,  on  the 
other  hand,  primary  suture  is  very  successful  and  should  always  be  practiced. 
Chromic  gut  is  the  best  material,  the  sutures  being  passed  through  the  thickness 
of  the  tendon,  and  the  wound,  if  necessary,  enlarged  for  the  purpose.  At  the 
wrist,  where  deep  transverse  cuts  are  of  common  occurrence,  this  is  specially 
important  ;  but  the  tendo-Achillis  and  many  others  have  been  joined  again  in  this 
way.  Even  secondary  suture,  freeing  the  ends  from  the  cicatricial  tissue  around, 
freshening  them,  and  fastening  them  together,  is  very  often  successful ;  but  the 
greatest  care  must  be  taken  to  secure  union  by  the  first  intention,  and  the  limb 
must  be  held  rigidly  fixed  for  some  little  time  upon  a  splint,  to  avoid  the  smallest 
accidental  movement. 

Where  the  interval  is  too  great  the  tendon  may  be  split  and  the  two  ends 
spliced,  as  described  in  speaking  of  nerve-suture.  In  one  or  two  instances  resec- 
tion of  the  shaft  of  the  bone  has  been  performed  to  reduce  the  size  of  the  gap  ; 
and  transplantation  of  a  muscle  from  a  dog  into  the  biceps  is  said  to  have 
succeeded. 

Rupture  of  the  plantaris  tendon  recpiires  an  entirely  different  method.  The 
limb  must  be  raised  for  a  few  minutes  in  order  that  the  oedema  may  subside  ;  and 
then  carefully  strapped  and  bandaged  from  the  foot  upward.  As  soon  as  this  is 
accomplished -the  patient  is  to  walk  with  his  heel  well  down  upon  the  ground  ;  the 
sooner  it  is  done,  the  more  speedy  is  recovery  ;  prolonged  rest  always  leaves  a 
most  serious  degree  of  stiffness,  probably  from  the  organization  of  the  extravasated 
blood  tying  together  all  the  planes  of  cellular  tissue  between  the  muscles.  The 
bandage  should  be  renewed  as  soon  as  it  becomes  loo.se,  and  should  be  kept  on  for 
eight  or  ten  days.  Any  stiffness  that  is  left  disapi)ears  rapidly  under  massage  and 
hot  douching.  Reunion  of  the  tendon,  if  it  is  really  ruptured,  does  not  appear  to 
be  material. 

Dislocations. 

The  peronei  tendons  are  occasionally  displaced  from  behind  the  external 
malleolus  in  severe  sprains  of  the  ankle,  in  spite  of  the  tough  fibrous  sheath  that 
binds  them  down.     Reduction  is  easy,  but  often  it  is  almost  impossible  to   retain 


MUSCULAR  ATROPHY.  309 

them  in  position.  Tlie  foot  should  be  carefully  bandaged,  with  firm  pressure 
behind  the  bony  projection,  and  passive  motion  commenced  at  the  end  of  the 
first  week  at  the  latest.  It  often  happens,  however,  in  spite  of  every  care,  that 
repair  is  not  perfected,  antl  that  some  trivial  slip,  even  months  later,  tears  the  old 
wound  open  again. 

The  extensor  tendons  on  the  back  of  the  wrist  suffer  in  the  same  way,  but 
rarely  give  rise  to  more  than  temporary  inconvenience.  There  is  a  moment's  pain  ; 
the  tendon  slips  back,  and,  beyond  a  certain  feeling  of  soreness  and  weakness,  the 
use  of  the  hand  does  not  suffer. 

The  long  tendon  of  the  biceps  may  be  displaced  from  its  groove,  although  no 
doubt  many  of  the  cases  in  which  this  accident  has  been  diagnosed  are  really  the 
result  of  rheumatoid  arthritis.  There  is  a  sudden  twist  with  a  sensation  of  sicken- 
ing pain,  and  the  use  of  the  arm  is  restricted  in  certain  directions  ;  it  cannot  be 
raised  above  the  level  of  the  shoulder,  and  the  head  of  the  bone  is  too  prominent 
in  front ;  then,  suddenly,  after  a  little  manipulation,  a  snap  is  felt,  and  full  power 
is  regained  almost  immediately.  In  one  case  under  my  care  this  occurred  on 
several  occasions,  the  patient  being  able  to  throw  the  head  of  the  bone  out  of  gear. 
as  it  were,  almost  at  will ;  and  although  the  diagnosis  was  not  verified,  it  is  difficult 
to  understand  what  other  kind  of  lesion  could  have  given  rise  to  so  peculiar  and 
constant  a  train  of  symptoms. 

Similar  accidents  have  been  recorded  in  connection  with  other  tendons.  Thus 
the  tibialis  posticus  may  be  displaced  from  behind  the  internal  malleolus  in  the 
same  way  as  the  peronei  on  the  outer  side  of  the  foot  ;  and  the  sartorius  may  be 
forcibly  wrenchecl  from  its  'surroundings  at  the  knee-joint  (especially  when  the 
knee  is  flexed)  ;  but  these  are  all  rare.  Displacement  of  the  tendon  of  the  quad- 
riceps in  cases  of  genu  valgum  is  regarded  rather  as  a  dislocation  of  the  patella. 

The  slender  muscular  slips  that  lie  packed  side  by  side  in  the  neck  and  in  the 
loins  are  sometimes  displaced  ;  but  it  is  doubtful  whether  this  should  be  called  a 
dislocation.  It  usually  occurs  in  some  sudden  awkward  action,  when,  for  example, 
the  head  is  twisted  round  to  look  upward.  There  is  a  sensation  of  something 
giving  way,  or  of  a  snap,  with  acute  pain  ;  and  the  head  is  either  fixed,  or  is  very 
slowly  and  painfully  brought  into  a  straight  position  again.  In  some  instances 
this  is  caused  by  the  momentary  locking  of  the  articular  processes,  or  strain  of  the 
capsular  ligaments  ;  but  occasionally  a  distinct,  elongated,  and  very  tender  swelling 
has  been  noted,  and  complete  relief  has  followed  rapid  manipulation,  the  muscle 
being  pressed  back  into  position  while  the  patient  endeavors  by  some  sudden 
action  to  make  it  contract.  Many  of  these  cases,  however,  are  probably  due  to 
tearing  of  the  membranous  fascia  enclosing  the  muscle  and  partial  hernia,  or  to 
rupture  and  extravasation  in  its  substance.  Either  of  these  hypotheses  would 
explain  the  facts  equally  well. 

Atrophy. 

Muscular  atrophy  may  be  due  to  the  supply  of  blood  being  insufficient ;  to 
affections  of  the  nerves  or  nerve  centres  ;  or  to  both  together. 

Deficient  supply  of  blood,  such  as  arises  from  disuse,  the  pressure  of  an  elastic 
stocking,  or  the  ligature  of  the  main  artery  of  a  limb,  causes  simple  wasting,  with 
or  without  fatty  degeneration.  The  electric  reaction  is  not  affected  ;  the  size  and 
strength  of  the  muscles  diminish  ;  they  lose  tone  and  feel  soft  and  flabby  to  the 
touch,  but  it  requires  nothing  more  than  increased  vigor  of  circulation  to  restore 
them.  As  soon  as  the  cause  is  removed,  they  begin  to  improve  at  once  with 
massage  and  galvanism. 

Atrophy  due  to  affections  of  the  nervous  system  is  more  serious.  If  the 
nerves  are  divided,  faradic  excitability  diminishes  from  the  first,  and  may  disappear 
altogether  in  the  course  of  a  few  days.  The  same  thing  occurs  with  the  slowly 
interrupted  current ;  but,  for  a  little  while  (at  any  rate  in  animals),  the  irritability 


3IO    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

appears  to  l)e  increased,  and  a  peculiarly  slow  and  continuous  contraction  is  caused 
by  stimulation  that  is  not  strong  enough  to  make  any  im])ression  upon  a  healthy 
structure.  This  may  last  for  a  week  or  two,  but  rarely  for  much  longer  ;  and  at 
the  end  of  three  or  four  months,  if  the  separation  is  complete,  the  muscles  are 
insensitive  to  stimuli  of  all  kinds.  The  atrophy  that  occurs  in  connection  with 
neuritis  is  almost  as  rapid;  but  the  worst  examples  of  all  are  .seen  in  infantile 
paralysis,  and  progressive  muscular  atrophy,  when  the  centres  in  the  anterior 
cornua  of  the  spinal  cord  are  destroyed.  In  these  disea.ses  the  corresponding 
muscular  fibres  may  waste  so  completely  that  no  trace  of  them  can  be  found. 

Muscular  atrojjhy  following  lesions  of  the  motor  area  of  the  brain  is  not 
accompanied  by  the  reaction  of  degeneration  ;  the  fibres  simply  waste  away  from 
want  of  use.  Rigidity,  tremors,  and  contraction,  however,  follow  if  secondary 
descending  sclerosis  sets  in  and  involves  the  motor  tracts  in   the  sjjinal  cord. 


Functional  Disorders. 

Loss  of  power,  with  or  without  spasmodic  contraction,  is  sometimes  met  with 
in  muscles  that  are  constantly  overworked  ;  and,  as  no  definite  lesion  is  known  to 
exist,  it  is  usually  described  as  functional  impotence  and  functional  spasm.  It 
may  affect  a  single  muscle  by  itself  (the  peroneus  longus  for  example),  so  that  it 
cither  remains  powerless  or  in  a  state  of  rigid  contraction,  instead  of  shortening 
and  relaxing  in  harmony  with  the  rest ;  or  more  frequently  it  involves  a  group 
associated  together  for  some  particular  action,  and  only  when  that  action  is  being 
carried  out  ;   for  all  other  purposes  they  are  as  strong  as  they  were  before. 

The  most  common  example  is  known  as  writer'' s  cramp,  the  muscles  of  the 
hand  being  affected  only  when  an  attempt  is  made' to  grasp  and  direct  a  pen  ;  but 
it  is  frequently  met  with  in  other  occupations  (so  that  it  is  sometimes  known  as  a 
professional  neurosis),  especially  those  in  which  finely  adjusted  movements  are  kept 
up  without  intermission  for  a  great  length  of  time.  At  first  there  is  little  more 
than  a  sense  of  fatigue  ;  the  pen  is  grasped  more  tightly,  or  is  held  in  some  unusual 
way;  then  involuntary  contractions  set  in;  at  the  beginning  they  are  only  of 
momentary  duration  ;  soon  they  become  more  persistent  and  exaggerated  ;  the 
more  attention  that  is  paid  to  them,  and  the  greater  the  effort,  the  worse  they 
grow ;  the  muscles  of  the  forearm  become  involved  as  well  as  those  of  the  hand  ; 
even  those  of  the  head  and  neck  may  suffer  ;  then  they  spread  to  the  opposite  side 
of  the  body  ;  and  finally,  the  least  attempt  at  placing  the  hand  in  position  is 
sufficient  to  throw  it  into  a  state  of  the  most  violent  and  painful  agitation. 

The  electric  excitability  of  the  muscles  is  usually  slightly  depressed  ;  the 
nerves,  especially  the  median,  are  tender  on  pressure;  neuralgic  pains  are  very 
frequent,  at  first  only  when  the  one  ])articular  action  is  attempted,  but  later  more 
constantly  ;  and  partly  from  this,  partly  from  the  mental  distress,  the  general  health 
fails  and  the  nutrition  of  the  muscles  becomes  still  more  impaired  ;  but  there  is  no 
evidence  of  neuritis  or  of  any  gross  pathological  lesion.  It  may  occur  even  in 
those  who  are  strong  and  healthy  ;  but  it  is  distinctly  more  frequent  in  members 
of  neurotic  families  ;  and  in  a  few  cases  it  can  be  traced,  in  part  at  least,  to  slight 
hemiplegic  attacks  occurring  at  an  earlier  period  of  life  ;  recovery  is  perfect  for 
all  ordinary  actions,  only  unusually  delicate  combinations  such  as  these  are  carried 
out  at  a  disadvantage,  and  foil  in  jierfection  sooner  than  they  otherwise  would. 
The  style  of  writing  is  probably  of  some  importance.  Those  who  rely  upon  their 
fingers  only,  who  do  not  use  the  wrist  or  forearm,  appear  especially  subject  to  it. 
Short-hand  writers,  Avhose  style  is  necessarily  very  free,  are  seldom  affected. 

It  is  probable,  as  Vivian  Poore  suggests,  that  these  disorders  (or  at  least 
writer's  cramp,  which  may  be  taken  as  the  type  of  the  rest)  are  due  to  neuro-muscular 
fatigue,  the  tenderness  along  the  course  of  the  nerves,  the  tremors,  and  the  dimin- 
ished  excitability  all  being  susceptible  of  the  same  explanation.      Certainly  the 


MYOSITIS.  3t. 

most  successful  remedies  are  those  which  tend  to  improve  muscular  nutrition. 
Massage,  combined  with  passive  motion  and 
suitably  arranged  exercises,  has  met  with  the 
most  conspicuous  success,  cases  of  many  years' 
duration  having  begun  to  improve  almost  at 
once,  and  having  been  at  length  completely 
cured,  so  that  full  power  of  writing  was  regained. 
At  the  same  time  tonics,  galvanism,  and  local 
injection  of  strychnia  are  of  very  great  assist- 
ance. Rest  alone  effects  but  slight  alleviation, 
and  that  only  of  a  temporary  character. 

II  .1  1-  ■  t      1     u  tic.  8i. — Nussbaiim's  Instnimer.t  for 

n   early    cases  the  appliance  invented  by  Writer's  Cramp. 

Nussbaum    may    be    used    with    benefit.      It    is 

framed  to  exercise  the  extensors  and  abductors  of  the  fingers,  so  that  they  may  be 

better  able   to    resist   and  overcome   the  spastic    contraction  of  the  flexors  and 

adductors  (Fig.  8i). 


Contracture  or  Permanent  Shortening. 

This  is  distinguished  from  ordinary  muscular  rigidity  (such  as  occurs  in  the 
early  stages  of  inflammation  of  a  joint  and  in  hysteria),  by  its  not  relaxing  under 
an  ancesthetic.  The  change  is  in  the  sheath  and  the  connective  tissue  of  the 
muscle  ;  the  fibres  atrophy,  the  cross  section  is  very  much  diminished  in  size,  and 
in  some  of  the  more  extreme  cases  scarcelv  anv  trace  of  true  muscle  substance  is 
left. 

It  is  produced  in  various  ways.  A  mild  form  of  it  may  be  caused  by  pro- 
longed rest  in  one  position,  as  in  the  case  of  the  gastrocnemius,  when  the  patient  is 
confined  to  bed  ;  the  worst  cases  are  usually  the  result  of  chronic  inflammation  of 
the  muscle  itself,  descending  neuritis,  or  persistent  irritation  along  some  portion 
of  the  motor  tract.  Hence  its  frequency  in  descending  sclerosis  following  lesions 
of  the  cortex. 

Slight  cases,  provided  the  cause  is  not  a  persistent  one,  can  be  cured  by  mas- 
sage and  passive  motion  ;  tenotomy,  however,  is  often  necessary  in  old  joint  dis- 
ease, before  the  parts  can  be  restored  to  their  natural  position.  Section  should 
always  be  subcutaneous,  and  performed  at  the  spot  at  which  the  muscle  (or  prefer- 
ably its  tendon)  is  most  superficial  and  farthest  away  from  important  structures. 


Myositis. 

Subacute  inflammation  of  muscles  usually  occurs  in  connection  with  gout, 
rheumatism,  and  exposure  to  cold  and  wet,  or  it  follows  prolonged  overwork,  or  a 
sudden  strain  rupturing  some  of  the  fibres.  The  pain  is  often  severe,  especially 
at  night,  and  when  an  attempt  is  made  to  move  the  part ;  and  this,  combined 
with  stiffness,  is  the  most  conspicuous  feature.  Fever,  swelling,  and  local  pyrexia 
are  seldom  present.  Inflammation  due  to  other  causes  is  more  rare,  although  it 
sometimes  extends  into  the  muscles  from  the  surrounding  structures,  and  occasion- 
ally arises  from  direct  infection  through  a  wound  or  through  the  blood. 

In  chronic  inflammation  the  exudation  becomes  organized  and  contracts  while 
the  muscular  substance  itself  wastes  and  degenerates.  In  many  cases  this  ends  in 
a  condition  of  rigid  contracture,  requiring  prolonged  massage  and  even  tenotomy 
before  use  of  the  part  is  regained  ;  and  ossification  is  not  uncommon,  spreading 
from  the  insertions  of  the  muscles  into  the  tendons  and  along  the  fibrous  septa, 
until  the  bones  are  covered  with  irregular  osteophytes. 

Suppirative  myositis  may  either  occur  as  a  local  affection  (an  abscess  forming 
in  the  substance  of  the  muscle,  from  injury,  or  the  impaction  of  a  foreign  body), 


iiSiVi, 


312    DISEASES  AXD  INJURIES  OF  SPECIAL  STRUCTURES. 

or  as  part  of  a  general  infective  disorder.      Diffuse  suppurative  myositis,  for  exam- 
ple, sometimes  breaks  out  under  the 
same  conditions  as  diffuse  inflamma- 
/'^  y  '■  ,  tion  of  the  cellular  tissue,  or  diffuse 

/        "    '  _    '  .  suppurative  periostitis,  although  it  is' 

y  C  ■, '         much   more  rare;    the  pyogenic  or- 

,^  >  '  ,'       ganisms    gain    access    to    the    i)art 

1%^  A,  .  '/I        through  a  wound,  or  when  the  skin 

y*^,  ■•  ]k/      is  unbroken  through  one  of  the  mu- 

Mj  ^"^  r,l      cous  surfaces,   and    owing    to    their 

"^^  being  accidentally  favored  in  some 

/V.-rioir-^""-    -      •  ^  ,■   -'    way  (by  extreme  fatigue,  for  instance") 

\:^  /^^o^X'  ^-f^^    give  rise  to  wide-spreading  suppura- 

(  '    v'^;^;'  ■  '-^^  tion. 

v^  In  addition  to  this,  a  few  cases 

'  V'   "."•» V^'^ii/ji'  i'iV'P'V'         are  recorded  of  an  a(7//(f //■<7^/r.y.f/?'(f 

'  fUr-'  I  I  ffiyositis,  involving  all  the  voluntary 

T-     „     c-L     •      1.  TT   1      r-     „      -.,    ,  r-..       muscles  of  the  bodv,  and  generally 

FiG.  82. — Showing  the  Early     Fig.  83 — 1  he  Late  or  Fibrous  .  ^        ,    ^  -     ,         .    °  ■' 

or  Cellular  Stage.  Stage.  proving  fatal  from  asphvxia  or  pneu- 

From  a  case  of  sterno-mastoid  induration  in  an  infant.  mOnia.      It  appears  tO  reseillblc  trich- 

inosis  in  many  of  its  features,  and  in 
all  probability  is  parasitic,  although  as  yet  no  actual  evidence  is  at  hand.  Inflam- 
matory swelling  of  the  muscles,  with  the  most  intense  pain,  so  that  the  patient  can 
barely  move ;  an  urticarial  or  papular  eruption  upon  the  skin,  followed  by  cedema, 
and  rapidly  increasing  weakness,  have  been  noted  in  all ;  while  in  some  there  was 
cramp,  or  a  tonic  contraction  of  the  muscles,  with  insomnia  and  profuse  sweating. 
The  diaphragm,  heart,  and  bladder  appear  to  escape. 

In  all  the  cases  examined  evidence  of  acute  inflammation  has  been  found, 
sometimes  parenchymatous,  the  fibres  being  pale,  rigid,  friable,  and  infiltrated 
with  serum  ;  sometimes,  on  the  other  hand,  interstitial,  with  hemorrhages  scattered 
everywhere  among  the  fibres. 

Gummata  are  not  uncommon,  especially  in  the  tongue  and  the  sterno- 
mastoid.  In  the  latter  muscle  a  peculiar  firm  and  hard  nodule,  which  is  certainly 
not  always  due  to  syphilis  (Figs.  82  and  83),  is  sometimes  noted  shortly  after  birth. 
In  most  instances  it  appears  to  be  traumatic. 

Leprosy,  tuberculosis,  and  other  similar  diseases  give  rise  at  times  to  specific 
deposits  among  muscular  fibres,  as  in  other  tissues. 

A  very  peculiar  form  of  inflammation  is  occasionally  met  with  {jttyositis  ossifi- 
cans), in  which  large  plates  of  bone  are  developed,  chiefly  in  the  dorsal  region, 
but  also  all  over  the  body,  in  the  substance  of  the  muscles,  so  that  the  bones 
become  united  together  by  osseous  sheets  of  the  most  fanciful  shapes.  Nothing 
is  known  as  to  its  pathology. 

Teno-svxovitis. 

The  synovial  sheaths  of  tendons  resemble  the  deeper  bursas  and  the  lining 
membranes  of  joints  in  structure  and  pathology.  Inflammation  may  be  caused  by 
any  continued  irritant,  organized  or  unorganized.  The  simplest  form  is  that  due 
to  mechanical  injury,  such  as  tension  or  overwork  ;  others,  more  severe,  are  the 
result  of  specific  ailments,  gout  and  rheumatism,  for  example,  or  of  infection,  as 
in  tubercle  and  syphilis  ;  suppuration  never  occurs  without  the  presence  of  pyo- 
genic micro-organisms,  whether  they  come  through  a  wound,  through  the  blood, 
as  in  pyaemia,  or  directly  from  surrounding  structures. 

I.  Acute. — Simple  acute  teno-synovitis  is  caused  by  strains  or  prolonged  over- 
work. The  course  of  the  tendon  is  marked  out  by  an  ill-defined  swelling,  the  skin 
over  it  is  tender  and  sensitive,  the  temperature  is  slightly  raised,  the  action  of  the 
muscle  is  painful,  and  whenever  the  part  is  used  or  moved   in   any  way  there  is  a 


TEN  OS  YNO  VITIS. 


l^^l 


peculiar  soft  crepitus,  as  of  two  pieces  of  silk  gently  rubbed  together.  The  endo- 
thelial lining  is  detached,  the  surface  covered  with  lymph,  and  the  least  movement 
causes  friction.  In  more  severe  cases  the  exudation  involves  the  loose  cellular 
tissue  around  as  well  as  the  tendon  sheet  itself;  often  it  is  mixed  with  blood,  and 
the  pain,  heat,  and  tension  are  more  severe.  The  whole  of  tiie  dorsum  of  the 
hand  and  forearm,  for  exami)le,  may  be  swollen  and  (edematous,  and  the  bruising 
extend  far  above  the  elbow,  after  a  fall  ujn^n  tlie  back  of  the  hand,  doubling  the 
wrist  upon  itself. 

The  subsecjuent  changes  are  the  same  as  those  that  occur  in  other  parts  under 
.similar  conditions.  The  whole  of  the  exudation  may  be  absorbed  without  leaving 
after-trouble  of  any  kind.  I'art  of  it  may  undergo  organization  (especially  if 
there  is  .some  constitutional  ailment  jjresent,  keeping  up  a  persistent  though  slight 
degree  of  irritation),  so  that  the  attack  becomes  chronic;  or  supjjuration  may 
follow. 

2.  Chronic  Tenosynovitis. — Chronic  inflammation  may  begin  as  such,  or  follow 
an  acute  attack,  kept  up  either  by  a  constitutional  cause,  such  as  gout  or  rheuma- 
tism, or  by  the  presence  of  adhesions.  This  is  a  frequent  result  of  over-caution 
and  the  fear  of  passive  motion  in  the  treatment  of  sprains  and  other  injuries.  The 
tendon-sheath,  after  some  slight  accident,  is  filled  with  lymph,  which  becomes 
organized  and  forms  bands  extending  between  contiguous  structures,  tying  them 
together.  At  first  these  are  thin  and  delicate,  and  break  down  at  once  ;  but  if  the 
parts  are  kept  at  rest  too  long,  they  grow  firm  and  rigid,  and  then,  unless  they  are 
torn  right  in  two,  or  at  least  are  stretched  to  such  an  extent  that  no  more  tension 
falls  upon  them,  they  become  the  cause  of  fresh  attacks.  Every  contraction  of 
the  muscle  strains  them,  and  gives  ri.se  to  pain  ;  fresh  effusion  follows,  and  this  in 
its  turn  becomes  organized,  and  makes  them  stronger  still.  The  frequent  repeti- 
tion only  makes  matters  worse,  while  one  sudden,  and  sufficiently  vigorous,  well- 
directed  wrench  would  remove  the  cause,  once  for  all. 

The  pain  in  chronic  tenosynovitis  is  very  variable  ;  usually  it  is  rather  of  a 
dull,  aching  character,  with  a  sen.sation  of  soreness  ;  it  is  never  intense  and  throb- 
bing, as  in  the  acute  form.  The  temperature  is  only  .slightly  raised,  there  is  little 
or  no  redne.ss  of  skin,  Ixit  the  swelling  is  generally  conspicuous,  involving  the  loose 
tissue  around  as  well  as  the  sheath  it.self,  and  attended  with  great  impairment  of 
power.  In  many  cases  the  effusion  is  simply  serous,  but  it  may  be  thickened, 
almost  gelatinous,  or  mixed  with  myriads  of  melon-seed  bodies,  all  practically  the 
same  size  and  shape,  consisting  of  concentric  laminae  of  fibrin,  developed  from  the 
lymph  poured  out  on  the  walls  and  septa.  The  inner  surface  may  retain  its  normal 
smooth  character,  but  not  unfrequently,  especially  in  rheumatism  and  in  the  neigh- 
borhood of  joints  affected  with  osteo-arthritis,  it  is  rough,  irregular,  and  covered 
over  with  ma.sses  of  dendritic  outgrowths,  which  can  be  felt  rnstling  and  crepitating 
with  every  movement. 

Tubercular  inflammation  is  met  with  most  frequently  in  the  large  sheaths 
which  spread  along  the  flexor  tendons  under  the  annular  ligament  of  the  wrist. 
The  walls  and  mesotena  are  enormously  thickened  and  converted  into  granulation- 
tissue,  similar  to  that  met  with  in  tubercular  synovitis  of  joints.  The  fluid  in  the 
interior  may  be  gelatinous,  like  that  found  in  ganglions,  or  turbid  from  the  exuda- 
tion mixed  with  it ;  but  it  is  rarely  much  increased  in  quantity.  The  lining 
membrane  is  softened  and  rough,  the  movements  of  the  tendons  impaired,  and 
the  use  of  the  part  greatly  limited.  The  most  prominent  symptom  is  a  chronic, 
painless  swelling,  occurring,  as  in  compound  palmar  ganglion,  above  and  below 
the  annular  ligament  of  the  wrist,  .soft  and  elastic  to  the  touch,  but  not  fluctuating, 
and  not  admitting  of  its  contents  being  driven  from  one  compartment  to  another. 

3.  Suppuration. — This  may  be  caused  by  direct  infection,  as  after  amputation 
of  the  toes  when  long  open  channels  are  left,  placed  vertically  in  the  most  con- 
venient position  for  receiving  all  the  discharges  of  the  wound  ;  or  by  pyaemia,  or 
by  extension  from  inflammation  near.  The  most  common  situation  is  on  the 
fingers  {thecal  abscess  or  tuhitlow),  owing  to  the  frequency  with  which  poisoned 

21 


314    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

wounds  occur,  and  the  jjcculiar  distribution  of  the  lymphatics.  Instead  of  the 
loose,  horizontal  arrangement  which  prevails  in  the  subcutaneous  tissue  of  other 
parts,  the  general  direction  of  all  the  fibres  and  lymphatic  spaces  in  the  fingers  is 
from  the  skin  toward  the  periosteum  or  the  tendon-sheath,  and  any  poison  that 
is  inoculated  on  the  surface  is  carried  down  to  the  deeper  structures,  causing 
inflammation,  which  is  all  the  more  severe  because  of  the  dense,  unyielding  char- 
acter of  the  tissues.  This  is  the  explanation  of  the  frc<iucncy  with  which  j)eriostitis 
of  the  last  phalanx  and  acute  suppuration  in  the  tendon-sheath  occur.  The  poison 
spreads  down  to  the  bone,  which  speedily  becomes  inflamed  and  perishes  (the 
proximal  end  and  the  joint  often  remaining  intact),  the  tendon  sloughs,  and  the 
finger  is  left  distorted,  stiffened,  and  useless.  Fortunately  the  sheath,  in  the  case 
of  the  first  three  fingers,  does  not  communicate  with  the  general  one,  but  extends 
no  further  than  the  heads  of  the  metacarpal  bones.  In  the  thumb  and  little 
finger,  however,  it  does,  and  if  acute  supi)uration  occurs  in  connection  with  them 
the  sloughing  is  very  likely  to  involve  the  whole  of  the  flexor  tendons,  the  hand 
may  be  riddled  with  abscesses,  and  the  pus  may  spread  into  the  carpal  joints,  or 
even  in  the  deep  planes  of  the  cellular  tissue  up  the  forearm,  and  endanger  life 
itself. 

Owing  to  the  extreme  tension,  acute  suppuration  in  the  tendon-sheaths  of  the 
fingers  is  attended  with  very  severe  symptoms.  There  may  be  a  rigor  ;  the  tem- 
perature is  raised  many  degrees,  the  finger  throbs  and  burns,  especially  if  it  is 
allowed  to  hang  down,  the  skin  is  hot,  glazed,  and  exquisitely  tender,  and  move- 
ment is  impossible.  For  the  same  reason,  the  dense  character  of  the  tissue  on  the 
])almar  surface,  the  swelling  is  usually  slight.  Often  it  is  more  marked  upon  the 
back  of  the  hand,  the  poison  i)assing  from  the  sheath  into  the  cellular  tissue  around  ; 
and  in  severe  instances  it  is  accompanied  by  lymphangitis  and  deep-seated,  brawny 
infiltration  of  the  tissue  of  the  forearm. 

On  the  other  hand,  in  pyasmia,  suppuration  may  make  its  appearance  in  some 
loose  and  large  sheath  as  insidiously  as  in  the  ca.se  of  joints,  without  tension, 
redness,  or  pain.  The  consequences,  however — the  extension  into  the  cellular 
tissue  round,  and  the  implication  of  neighboring  synovial  cavities — are  no  less 
certain  when  once  the  resisting  power  of  the  tissues  is  overcome  by  the  continued 
action  of  pyogenic  germs. 

Treatment. — The  general  principles  are  the  same  as  in  the  case  of  joints. 
When  the  symptoms  are  acute  the  limb  should  be  placed  upon  a  splint,  kept  at 
perfect  rest,  raised  to  check  hyperemia,  and  carefully  and  evenly  bandaged,  the 
line  of  the  sheath  being  covered  with  many  layers  of  cotton-wool.  If  this  is  not 
practicable,  cold  or  lead  lotion  may  be  used.  Passive  motion  should  be  com- 
menced as  soon  as  there  is  a  sensible  reduction  in  the  quantity  of  the  effusion  ; 
moving  the  tendon  once  or  twice  each  day  quietly  and  steadily  will  prevent  the 
formation  of  adhesions  without  making  the  inflammation  more  severe. 

As  the  attack  subsides,  counter-irritation  may  be  used  with  benefit.  Massage, 
owing  to  the  peculiar  situation  of  the  tendon-sheaths,  is  of  especial  service.  Hot 
douching,  steaming,  fomentations,  friction,  and  passive  motion  are  of  very  great 
use  as  soon  as  the  temperature  of  the  part  is  normal.  Sometimes,  particularly  when 
there  is  one  very  tender  spot,  an  adhesion  can  be  ruptured  under  an  anaesthetic  and 
the  tendon  released.  In  most  of  the  cases,  however,  in  which  there  is  persistent 
stiffness,  it  depends  not  .so  much  upon  the  presence  of  bands  and  adhesions  as  upon 
the  defective  state  of  nutrition.  The  tendons  and  their  sheaths  have  been  injured 
and  kept  at  rest  for  weeks  together  ;  the  circulation  through  them  has  been  reduced 
as  low  as  possible  ;  the  plasma  upon  which  their  nutrition  depends  has  been  allowed 
to  remain  stagnant  in  the  interstices,  and  active  work  is  out  of  the  (piestion.  Under 
these  conditions,  when  once  the  acute  inflammation  has  subsided,  and  the  tempera- 
ture of  'the  i)art  has  fallen  to  normal  (very  often  it  is  lower  than  this,  and  the  skin 
is  blue  and  congested),  everything  is  beneficial  that  encourages  the  flow  of  blood 
through  it ;   the  more  it  is  used  the  sooner  it  recovers. 

If  there  is  a  suspicion  of  suppuration,  an  exploratory  puncture  should  be  made 


GANGLION.  315 

without  delay,  and  if  pus  is  found,  the  incision  should  be  very  free,  so  that  there 
can  be  no  possibility  of  tension  or  accumulation  of  decomposing  fluid.  Otherwise 
the  tendon  is  sure  to  slough,  and  the  neighboring  l:)ones  and  joints  very  likely 
become  involved  as  well.  A  median  incision  may  be  made  down  the  centre  of 
each  finger  on  the  ]xilmar  surface,  as  far  as  the  first  deeiJ  transverse  groove  that 
forms  on  the  palm  when  the  fingers  are  flexed  ;  the  radial  and  ulnar  compartments 
of  the  i)almar  fascia  may  be  freely  opened,  and  even  the  anterior  annular  ligament 
•divided  in  preference  to  allowing  the  pus  to  spread,  under  high  tension,  up  the 
deep  fascia  of  the  limb.  Fortunately,  in  most  cases,  the  inflammation  passes  over 
this,  following  the  course  of  the  superficial  vessels  and  the  tendon  of  the  palmaris 
longus,  and  free  exit  can  be  given  without  such  an  extensive  wound. 

Tubercular  disease  of  the  synovial  sheaths  of  tendons  should  be  treated  at  first 
by  rest  and  pressure,  in  the  hope  that  if  all  sources  of  irritation  are  avoided  the 
tissues  may  gain  the  upper  hand  and  the  tubercles  undergo  retrogressive  changes. 
If  this  does  not  succeed,  excision  may  be  practiced  with  success,  even  in  the  case 
of  the  compound  palmar  ganglion.  The  whole  sheath  has  been  laid  open  from 
one  end  to  the  other,  the  anterior  annular  ligament  divided,  and  the  thickened, 
softened,  gelatinous  tissue  carefully  dissected  out,  as  in  arthrectomy.  The  structures 
are  then  sutured  together  in  their  proper  order,  an  opening  left  at  each  end  for 
drainage,  and  passive  motion  begun  on  the  .second  day. 

Ganglion. 

Tendon-sheaths  normally  contain  a  small  amount  of  fluid  which  is  practically 
identical  with  ordinary  synovia.  Under  certain  circumstances,  however,  its  char- 
acter alters,  the  quantity  increases,  and  a  dilatation  like  a  cyst  is  formed.  Some- 
times the  whole  tendon  sheath  is  affected  ;  the  walls  are  stretched  ;  the  cavity 
becomes  irregular,  the  weaker  parts  yielding  most  ;  mesothenar  and  lining  mem- 
brane are  thickened  and  swollen  ;  the  interior  is  covered  over  with  irregular  pro- 
cesses similar  to  those  found  in  joints  ;  and  the  fluid  is  thick,  semi-gelatinous,  and 
mixed  with  thousands  of  melon-seed  bodies  formed  from  the  fibrin  poured  out  in 
the  walls.  Much  more  fretpiently  a  small  pouch  is  developed,  probably  as  a  hernial 
protrusion  through  or  between  the  fibrous  walls  of  the  sheath  ;  and  this  becomes 
filled  with  a  gelatinous  material  so  thick  that,  though  it  can  be  squeezed  out  through 
a  cannula,  it  retains  for  some  time  the  shape  of  the  bore.  In  most  cases  the  com- 
munication persists,  and  the  diverticulum  continues  to  enlarge,  fluid  being  squeezed 
into  it  with  every  movement  of  the  tendon  ;  in  some,  however,  it  becomes  closed. 
or  contracts  to  such  a  degree  that  the  two  appear  distinct.  Dilatation  of  a  com- 
plex synovial  sheath,  such  as  that  which  surrounds  the  flexor  tendons  of  the  fingers, 
is  known  as  compound  ganglion  ;  when  there  is  merely  a  cyst  developed  from  one 
side  it  is  distinguished  as  simple  or  cystic.  Similar  cysts,  containing  the  same  kind 
of  fluid,  although  it  is  usually  more  liquid,  are  developed  in  connection  with  the 
synovial  cavities  of  joints,  and,  particularly  when  they  occur  at  the  wrist,  render 
the  diagnosis  very  difficult. 

Causes. — In  some  instances  the  formation  of  a  ganglion  is  sudden,  and  can 
be  traced  to  a  single  strain.  More  often  they  appear  to  result  from  over-u.se,  or 
repeated  slight  injury.  Simple  cysts  are  exceedingly  common  upon  the  dorsa! 
surface  of  the  wrist,  in  connection  with  the  extensor  tendons,  especially  that  of 
the  second  j^halanx  of  the  thumb  ;  but  they  are  met  with  occasionally  on  the 
palmar  surface,  and,  though  not  so  often,  they  are  found  on  the  dorsum  of  the 
ankle,  by  the  head  of  the  fibula,  in  the  popliteal  space,  and,  in  short,  in  connection 
with  almost  any  sheath.  Distention  of  the  sheath  itself  is  less  common  ;  the 
typical  example  is  the  compound  palmar  ganglion  ;  but  it  is  met  with  elsewhere, 
in  the  fingers  themselves,  for  example,  limited  to  the  phalangeal  sheath,  and  in 
the  tendons  round  the  ankle. 

A  simple  ganglion  forms  a  round,  tense  swelling,  which  stands  out,  white  and 
prominent,  beneath  the  skin  when  the  tendon  is  put  upon  the  stretch.     As  a  rule. 


3i6    DISEASES  AND  JNJUIUES  OE  SPECIAL  STRUCTURES. 

they  are  too  small  for  fluctuation  ;  many  of  them  feel  as  dense  and  clastic  as  carti- 
lage, but  not  unfretiuently  their  consistence  varies  from  time  to  time;  those,  for 
example,  that  occur  by  the  head  of  the  fibula  are  distinctly  softer  when  the  knee 
is  bent  than  when  it  is  extended.  They  are  not  ])ainful  and  there  is  no  sign  of 
inflammation  about  them,  but  they  may  cause  considerable  suffering  from  pressing 
upon  a  cutaneous  nerve  ;  and  very  often  they  are  attended  by  a  sensation  of 
weakness,  although  there  is  no  i)roof  of  actual  loss  of  i)Ower  and  no  wasting  of 
the  muscle. 

No  definite  line  can  be  drawn  between  these  and  those  that  are  due  to  disten- 
tion of  the  synovial  sac  itself.  Many  of  the  cystic  ones  are  large,  thin-walled, 
and  lobulated,  evidently  occupying  a  considerable  portion  of  the  general  cavity; 
and  as  thev  grow  they  become  even  more  irregular  in  shape.  The  most  important 
is  that  which  involves  the  sheaths  of  the  flexor  tendons  of  the  fingers  (Fig.  84). 
The  arrangement  of  these  sheaths  is  subject  to  great  variety,  not  only  in  different 
persons  (arising  possibly  from  different  occupations)  but  at  different  ages.  There 
is  a  separate  sac  for  the  flexor  longus  poUicis,  which,  after  childhood,  opens  up  a 
communication  with  the  phalangeal  one,  so  that  one  long  cavity  extends  from  the 
last  phalanx  to  some  distance  above  the  wrist.  Similarly  in  the  adult  there  is  a 
common  sheath  for  all  the  flexors  of  the  fingers,  but  this  opens  into  the  phalangeal 
sheath  of  the  little  one  only.     In   old  age,  especially  in  those  whose  hands  have 


Fig.  84.— Ganglion  Involving  all  the  Flexor  Tendons  of  Hand  and  Wrist. 


been  subjected  to  much  work,  the  barrier  between  these  two  sheaths  breaks  down, 
and  a  very  irregular  space  is  left,  with  numerous  septa  dividing  it  into  imperfect 
compartments.  According  to  other  observers  (Rosthorn  in  particular)  in  child- 
hood and  fre<iuently  in  adult  life  the  index  and  middle  finger  tendons  are  devoid 
of  a  sheath  altogether,  and  there  is  but  one  for  the  ring  and  the  fifth.  However 
this  may  be,  it  is  not  uncommon  as  a  result  of  repeated  strains  to  find  an  enormous 
swelling  filling  up  the  palm  of  the  hand,  .so  that  the  fingers  cannot  be  closed, 
extending  along  the  little  one,  and  sometimes  the  thumb  as  well,  right  to  the  end, 
and  communicating  freely  with  another  swelling  above  the  annular  ligament  of  the- 
wrist,  reaching  upward  for  two  or  three  fingers'  breadth.  If  the  wrist  is  flexed 
and  pressure  is  made  alternately  above  and  below,  the  fluid  can  be  squeezed  from 
one  part  to  the  other,  and  not  unfrequently  with  it  numerous  melon-seed  bodies 
which  can  be  felt  crepitating  among  the  tendons  as  they  pass  across.  This  is 
known  as  compound  palmar  ganglion.  It  may  be  caused  by  a  single  strain  ;  but 
in  most  instances  it  is  of  gradual  formation.  There  is  no  heat  or  redness,  but 
there  is  a  certain  amount  of  chronic  inflammation  which  leads  to  the  irregular  thick- 
ening of  the  walls  and  mesotena,  and  to  the  deposit  of  the  lym])h  out  of  which 
the  melon-seed  bodies  are  formed  ;  and  occasionally  when  the  irritation  is  kept  up 
it  ends  at  length  in  suppuration. 

Similar  chantres  occur  in  connection  with  other  tendon-sheaths,  the  synovial 


DUPUYTREN'S   CONTRACTION.  317 

sac  of  tlic  iicioiiL'i,  for  example,  or  that  for  the  extensors  of  the  toes,  but  mucli 
more  rarely. 

Treatment.— ("ystic  ganglion,  if  it  gives  rise  to  any  inconvenience,  may 
be  treated  in  various  ways.  Subcutaneous  rupture  is  often  resorted  to,  but  the 
cyst  generallv  refdls,  and  when  it  does  not  it  leaves  behind  a  thickening  which 
may  persist  f<.>r  vears.  l^mcture  with  a  trocar  and  cannula  is  not  more  satisfac- 
tory. Subcutaneous  section  with  a  tenotomy-knife,  dividing  the  .sac  in  two  with 
a  single  horizontal  sweep,  answers  better;  but  if  the  cyst  causes  any  real  trouble 
•or  is  unsightly,  the  most  efficient  plan  is  to  cut  down  upon  it  and  excise  it.  The 
cure  is  effectual,  and  a  linear  cicatrix  only  is  left.  I'he  limb  should  be  placed 
upon  a  splint  afterward,  until  the  wound  is  sound,  as  not  unfrequently  the  tendon 
is  exposed,  and  sometimes  the  cyst  communicates  indirectly  with  a  neighboring 
joint. 

Comi)Ouncl  ganglion  is  much  more  serious,  and  if  the  walls  of  the  synovial 
sac  and  the  septa  are  thickened  and  irregular,  or  if  they  are  covered  over  with 
lymph,  and  the  cavity  is  full  of  melon-seed  bodies,  a  very  guarded  prognosis  must 
be  given.  Pressure  is  of  no  use.  A  free  incision  may  be  made  into  it  above  and 
below  the  wrist,  and  the  whole  cavity  emptied  and  drained  as  thoroughly  as  pos- 
sible ;  but  though  the  fluid  is  removed,  and  most  of  the  melon-seed  bodies,  many 
are  sure  to  be  left,  the  condition  of  the  lining  membrane  is  untouched,  and  the 
drainage  is  very  imperfect.  Syme  laid  the  whole  sheath  open,  dividing  the  annu- 
lar ligament ;  and  it  is  a  question  whether  this  would  not  be  the  best  proceeding 
now,  at  least  for  those  cases  in  which  melon-seed  bodies  are  present  and  the  walls 
are  much  altered  in  character. 

The  greatest  care  must  be  taken  to  avoid  suppuration.  If  this  occurs,  the 
tendons  are  almost  sure  to  slough  ;  and  if  there  is  the  least  tension,  or  if  the  vitality 
of  the  tissues  is  lowered  by  the  poisonous  products  of  decomposition,  it  is  almost 
certain  to  become  diffuse  and  to  spread  to  the  wrist  joint,  or  to  the  deep  planes  of 
cellular  tissue  in  the  forearm,  and  cause  the  most  extensive  destruction. 


Dupuytren's  Contraction. 

The  palmar  fascia,  and  the  prolongations  of  it  which  run  by  the  side  of  the 
fingers  and  are  attached  to  the  periosteum  of  the  first  phalanx,  not  unfrequently 
become  the  seat  of  a  peculiarly  obstinate  form  of  contraction,  tying  the  fingers 
rigidly  down  into  the  palm  of  the  hand.  It  rarely  occurs  under  thirty  years  of 
age,  and  is  much  more  common  among  men  than  women  ;  indeed,  according  to 
some,  the  latter  are  entirely  exempt,  but  this  is  not  the  case.  Usually  its  begin- 
ning can  be  traced  to  some  slight  injury,  such  as  the  pressure  of  a  round-headed 
stick  in  the  palm  of  the  hand  during  convalescence  from  severe  illness  ;  or  a 
sudden  strain,  pulling  the  finger  back; 
but  there  is  no  doubt  that  it  is  depend- 
ent, to  a  very  large  extent,  upon  gout, 
although  I  am  not  aware  that  deposits 
of  urate  of  soda  are  ever  found  in  it ; 
and  it  is  much  more  common  among 
the  well-to-do  than  among  hospital 
patients.  Certain  classes  of  the  latter, 
however,  engineers'  fitters,  for  example, 
are  often  affected  (Fig.  85). 

The  ring  finger  is  usually  attacked 
the  first,  but  in  many  cases  all  the  three 
on  the  ulnar  side  are  involved  more  or 
less  ;   the  index  only  suffers  in  the  worst. 


Fig.  85. — Dupuytren's  Contraction. 


The  first  thing  to  attract  attention  is  a 


small,  hard  nodule  in  the  palm  of  the  hand,  at  a  point  corresponding  to  the  lowest 
of  the  transverse  creases  into  which  the  skin  is  thrown  and  to  the  interval  between 
the  ring  and  the  little  fingers.     It  is  not  painful  unless  roughly  handled,  and  does 


3i8    DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 

not  at  first  give  rise  to  any  inconvenience.  Soon,  however,  the  skin  begins  to 
waste  and  lose  its  flexibility  ;  the  fat  disappears,  and  the  cutis  becomes  tied  down 
so  firmly  to  the  fascia  beneath  that  it  is  practically  incorporated  with  it.  Then 
prolongations  make  their  appearance,  running  from  this  upward  toward  the  wrist 
and  downward  to  the  fingers.  The  skin  becomes  adherent  in  other  ]iarts  ;  the 
bands  of  fascia  stand  out  more  rigidly,  and  gradually  the  fingers  are  flexed  and 
tied  down  into  the  palm  of  the  hand  in  an  altogether  hopeless  way.  Extension 
has  not  the  least  influence  over  them. 

The  flexor  tendons  take  no  share  in  the  deformity,  although  at  first  sight  it  is 
easy  to  mistake  the  rigid  bands  that  stand  out  in  the  hollow  of  the  palm  for  them. 
The  disease  is  entirely  due  to  the  contraction  of  the  fascia,  the  deep  as  well  as 
the  superficial  layer,  and  the  vertical  bands  that  pass  between  them  and  the  skin. 
It  affects  the  fingers  on  the  inner  side  of  the  hand  more  than  the  rest,  because  in 
all  probability  they  are  weaker  and  less  able  to  stand  a  strain  than  the  others ; 
and  if  they  are  bent  backward  the  prolongations  of  the  fascia  over  the  metacarpo- 
phalangeal articulations  are  stretched  and  hurt.  It  is  the  peculiarly  obstinate 
and  progressive  character  of  the  contraction  that  makes  it  so  serious.  When 
once  it  has  commenced,  it  tends  steadily  to  grow  worse  and  worse,  tying  one 
finger  down  after  another;  and  although  in  the  earlier  stages  it  may  be  relieved 
or  even  cured  without  great  difficulty,  in  the  later  ones  this  is  impossible  without 
operation. 

Treatment. — Systematic  massage,  with  the  finger  well  extended,  will  often 
check  the  contraction,  if  not  too  far  advanced,  and  cause  absorption  of  the 
inflammatory  exudation.  If  this  does  not  succeed  a  splint  may  be  worn  at  night, 
fitted  on  to  the  dorsum  of  the  hand  and  firmly  strapped  to  the  wrist.  Little 
caps  of  metal  are  adjusted  to  the  phalanges  and  attached  to  the  dorsal  splint 
by  means  of  elastic  bands,  the  strength  of  which  the  patient  can  regulate  for 
himself. 

In  other  cases  a  more  complicated  appliance  is  required.  A  broad,  well- 
padded  metal  plate  is  fitted  to  the  back  of  the  hand  and  wrist,  w-ith  extension 
racks  lying  over  the  fingers  bent  at  an  angle  to  suit  the  degree  of  flexion. 
Improvement,  however,  in  this  way  is  very  slow,  and  it  rarely  happens  that  patients 
can  be  induced  to  take  the  trouble  before  the  deformity  is  too  far  advanced  and 
the  bands  too  rigid.  If  the  angle  of  flexion  approaches  90°,  it  is  almost  impossi- 
ble to  straighten  it  without  operation. 

Dupuytren  himself  merely  made  a  transverse  incision  through  the  skin  and 
fa.scia  at  the  most  resisting  point,  so  that  when  the  finger  was  straightened  out  a 
lozenge-shaped  woimd  was  left,  the  sides  of  which  might  in  successful  cases  grow 
together.  Modern  treatment,  however,  resolves  itself  either  in  subcutaneous 
section  with  a  fine  tenotomy-knife  at  many  points  (after  Adams),  or  into  a  modi- 
fication of  Goyrand's  original  plan,  dissecting  out  the  whole  of  the  contracted 
portion.  Whatever  is  done,  it  must  be  recollected  that  unless  immediate  union 
is  obtained  the  result  is  likely  to  be  very  far  worse  afterward  than  it  was  before. 

When  the  bands  extend  far  down  the  sides  of  the  fingers,  there  is  no  doubt 
that  Adams's  method  is  jjreferable.  The  hand  should  first  be  thoroughly  soaked 
in  an  antiseptic  bath  and  well  raised,  so  as  to  limit  the  amount  of  hemorrhage. 
The  palm  is  dealt  with  first,  selecting  those  points  where  the  skin  is  still  movable 
over  the  subjacent  tissue ;  then  each  side  of  the  fingers  by  itself,  as  many  punc- 
tures being  made  as  are  necessary  to  allow  them  to  come  out  perfectly  straight. 
The  little  wounds  are  then  covered  with  iodoform-collodion  and  cotton-wool,  a 
palmar  si)lint  adjusted  to  keep  the  hand  at  rest,  a  bandage  j^laced  over  the  whole, 
and  everything  left  for  three  days.  By  that  time  all  the  punctures  should  be 
healed,  and  extension  may  be  commenced  with  an  appliance  similar  to  that  already 
described.  The  more  rapidly  this  is  carried  out  the  better;  to  be  successful  the 
fingers  should  be  perfectly  straight  within  the  fortnight. 

Excision  is  only  practicable  where  the  contraction  is  of  limited  extent,  and 
such  cases,  of  course,  succeed  the  best  with  tenotomy  as  well.     The  incision  is 


BURS.^.  319 

made  down  the  length  of  the  band  ;  the  skin,  which  is  usually  very  much  atrophied 
and  closely  adherent,  detached  from  the  fascia  beneath  without  bruising;  and 
then  ^  the  hard,  contracted  band  isolated  and  removed.  The  advantage  of  this 
metliod  is  that  the  straightening  is  more  perfect  and  the  risk  of  recurrence  is 
less  ;  but  it  is  very  questionable  whether  this  is  real.  Certainly  some  of  the  cai>es 
which  have  apparently  succeeded  have  relap.sed  again  in  an  altogether  hoi)eless 
manner. 

AVhichever  method  is  adopted  the  apparatus  must  be  worn  at  night  for  some 
considerable  time  to  prevent  recurrence.  During  the  day  it  may  be  disjjensed 
with  as  soon  as  the  fingers  are  straight.  Massage,  warm  bathing,  deep  friction, 
and  everything  that  can  encourage  absorption  should  be  thoroughly  practiced 
from  the  moment  that  the  wounds  are  sufficiently  sound.  Nodules  and  deep 
bands  of  the  fascia  are  always  left  behind,  even  when  the  attempt  at  excision  is 
fairly  successful ;  and  every  endeavor  should  be  made  to  promote  their  absorjjtion, 
to  limit  the  amount  of  inflammatory  exudation,  and  to  restore  as  soon  as  possible 
the  suppleness  of  the  skin. 

BURS/E. 

Bursae  are  spaces  developed  in  the  cellular  tissue  by  friction.  The  deei)er 
ones,  lying  between  tendons  and  bones,  are  present  at  birth,  and  are  lined  with  a 
definite  endothelium  similar  to  that  in  tendon-sheaths  and  joints.  Subcutaneous 
ones,  on  the  other  hand,  do  not,  for  the  most  part,  make  their  appearance  until 
later,  and  are  less  regular  in  shape  and  structure.  Many  are  constant  in  occurrence, 
and  are  reckoned  among  the  normal  structures  of  the  part ;  but  they  may  be  devel- 
oped anywhere  by  friction,  and  throughout  life  they  have  a  tendency  to  grow, 
until  in  many  cases  they  form  communications  with  neighboring  synovial  cavities. 
The  fluid  in  the  subcutaneous  ones  is  more  serous  than  joint  synovia,  but  that  in 
the  deeper  ones  is  identical  with  it. 

Bursas  that  communicate  with  joint-cavities  naturally  possess  a  special  impor- 
tance. Very  often  the  channel  between  the  two  is  so  narrow  that  no  fluid  can  be 
made  to  traverse  it ;  but  where  there  is  the  least  ground  for  suspicion,  the  swelling 
should  always  be  given  the  benefit  of  the  doubt,  and  treated  as  if  it  were  an  out- 
lying part  of  the  synovial  sac. 

Injuries. — Incised  and  punctured  wounds  inflicted  with  a  clean  instrument 
heal  readily.  The  latter  are  the  more  serious,  owing  to  their  tendency  to  become 
valvular.  Lacerated  ones  may  cause  considerable  trouble,  owing  to  the  fact  that 
the  part  is  the  seat  of  constant  friction.  For  the  same  reason  contusions  are 
frequently  followed  by  slight  inflammation.  No  special  treatment,  however,  is 
required  ;  if  there  is  a  wound  it  must  be  thoroughly  cleansed  and  drained  ;  a  large 
extravasation  of  blood  may  be  aspirated  ;  and  in  any  case  careful  pressure  must 
be  used  to  prevent  tension  and  to  keej)  the  parts  at  rest. 

Inflammation  of  Biirsce. — Simple  inflammation  is  very  common.  It  may  be 
acute  or  chronic,  and  subside  or  end  in  suppuration.  Specific  diseases  are  more 
rare,  but  superficial  bursae  in  particular  are  liable  to  be  affected  in  syphilis,  gout, 
and  tubercle,  probably  owing  to  the  frequency  with  which  they  are  injured. 

[a)  Acute  hiflammatioti. — This  is  nearly  always  due  to  injury.  The  symptoms, 
if  the  bursa  is  superficial,  are  plain  at  once.  Swelling  is  very  conspicuous  ;  and 
redness  and  local  pyrexia  are  well  marked  ;  but  owing  to  the  presence  of  a  cavity 
in  which  the  exudation  can  collect  the  tension  at  first  is  not  very  high,  and  the 
pain  and  constitutional  disturbance  not  severe.  In  deeper  ones,  on  the  other  hand, 
the  diagnosis  is  more  difficult ;  swelling  cannot  be  detected  ;  the  pain  is  often  very 
great,  especially  on  movement ;  and  the  fever  may  be  such  as  to  lead  to  the  suspi- 
cion that  other  even  more  important  neighboring  structures  are  involved. 

In  these  cases  the  diagnosis  often  rests  almost  entirely  upon  a  knowledge  of 
the  action  of  the  muscles  that  surround  the  part.  Thus,  if  the  bursa  under  the 
deltoid  is  inflamed,  rotation  of  the  humerus  is  fairly  free  when  the  arm  is  moder- 


320     DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 

ately  abducted  from  the  side;  in  adduction  or  great  abduction  it  is  very  painful, 
owing  to  the  tension  upon  the  sac.  So  with  that  under  the  psoas  ;  if  the  thigh  is 
flexed  the  head  of  the  femur  rotates  without  pain.  On  the  other  hand,  th^limb 
is  kept  extended  when  either  the  bursa  l^etween  the  quadriceps  and  the  femur,  or 
that  l.)etween  the  ligamentum  patella;  and  the  tibia,  is  affected.  In  other  cases  the 
position  of  the  swelling  is  the  most  significant  sign.  If,  for  instance,  the  bursa 
between  the  os  calcis  and  the  tendo-Achillis  is  enlarged  there  is  a  swelling  on 
either  side  behind  the  limb,  but  none  in  front,  as  when  the  I)one  or  the  ankle  joint 
is  inflamed  ;  and  unless  the  bursa  on  the  front  of  the  pouur  communicates  with  the 
knee  joint  there  is  no  distention  of  the  synovial  fccmhes  on  either  side  of  the 
patella,  even  if  it  suppurates. 

{b)  Chronic  Inflammation. — This  may  either  be  the  re.sult  of  an  acute  attack, 
or  be  chronic  from  the  first.  Usually  it  is  caused  by  some  slight  but  frequently 
repeated  injury,  or  by  a  more  severe  one  (a  contusion,  for  example,  filling  it  with 
blood),  the  effects  of  which  are  perpetuated  by  constant  friction. 

The  pathological  appearance  varies  very  considerably.  Sometimes  the  wall  is 
thin  and  the  cavity  immensely  distended  with  a  fluid  which  at  first  is  blood-stained, 
but  which  in  course  of  time  loses  its  color  and  becomes 
clear  and  serous.  In  other  cases  the  wall  is  thickened 
(whether  there  is  fluid  present  or  not)  either  by  the  deposit 
of  fibrin  in  laminae  on  the  inner  surface  or  by  the  formation 
of  dense  inflammatory  tissue  around,  or  by  both  together, 
until  it  is  an  inch  or  more  in  diameter,  and  the  central 
cavity  is  reduced  to  a  cleft  (Fig.  86).  It  rarely  disappears 
altogether.  Not  unfrequently  the  interior  is  rough  and 
irregular,  covered  with  warty  nodules,  or  traversed  by 
thickened  bands,  some  of  which,  as  in  the  case  of  the  prai- 
patellar  bursa,  may  be  the  remains  of  the  septa  between  the 
different  cavities,  while  others  are  new  formations  altogether. 
Occasionally  melon-seed  bodies  are  found  in  numbers, 
either  white  or  stained  with  blood,  as  if  they  were  formed  from  blood-clot. 
More  rarely  there  are  definite  pedunculated  outgrowths  with  floating  cartilaginous 
ends,  similar  to  those  found  in  joints.  This,  however,  is  not  common  except  in 
osteo-arthritis,  when  the  bursre,  even  though  they  do  not  communicate  with  the 
neighboring  joint,  not  unfrequently  undergo  a  similar  transformation.  Finally, 
sometimes,  in  very  old  cases,  calcification  takes  place. 

Tubercular  inflammation  is  characterized  chiefly  by  a  slow,  painless  enlarge- 
ment, due  to  the  accumulation  of  fluid  mixed  with  flakes  of  caseous  material.  The 
interior  is  lined  with  pale,  flabby  granulation-tissue  containing  giant  cells,  but  few 
bacilli.  Sometimes,  especially  in  the  case  of  the  sub-gluteal  bursa,  these  cavities 
attain  a  very  large  size,  and  spread  for  considerable  distances  among  surrounding 
structures  before  they  break  ;  and  then  they  are  ])rone  to  leave  behind  them  chronic 
sinuses  covered  by  flaps  of  purplish  skin.  Usually  they  retpiire  the  free  applica- 
tion of  the  cautery  or  of  Volkmann's  spoon  before  they  get  well. 

Syphilitic  disease  chiefly  occurs  round  the  knee  and  over  the  tuberosity  of  the 
ischium,  owing  in  all  probability  to  the  great  liability  of  these  parts  of  the  body 
to  injury.  The  gummatous  deposit  breaks  down,  leaving  round,  punched-out 
oi:)enings  with  overhanging  edges.  In  gout  the  bursa  that  forms  over  the  metatarso- 
phalangeal joint  of  the  great  toe  is  the  one  that  suffers  most  frequently,  but  occa- 
sionally deposits  of  urate  of  soda  are  found  in  the  interior  of  those  in  other  parts 
of  the  body. 

{c)  Suppuration. — The  onset  of  suppuration  in  a  bursa  is  usually  marked  either 
by  a  rigor  or  by  a  sudden  rise  of  temperature  with  severe  throbbing  pain.  The 
swelling  rapidly  increases  in  size  ;  the  skin  becomes  l)oggy  and  cedematous  ;  and 
if  free  exit  is  not  given  at  once  the  walls  of  the  bursa  give  way,  the  pus  si)reads  far 
and  wide  in  the  softened  and  hviicra^mic  connective  tissue  around,  and  diffuse 
inflannnation  of  the  cellular  tissue   follows.      In  part  this  is  due  to  the  difficulty 


BURS.-^.  321 

the  pus  has  in  escaping  through  the  dense  layer  of  tissue  that  has  been  formed  over 
the  cavity  by  constant  friction  ;  in  part  to  the  fact  that,  after  all,  a  bursa,  even 
when  it  is  surrounded  by  a  wall  of  its  own,  is  only  a  space  in  the  cellular  tissue, 
and  is  in  free  communication  with  all  the  interstices  around.  Usually  the  neigh- 
boring lymphatic  glands  are  involved  as  well,  and  sometimes,  especially  in  the  case 
of  the  bursce  over  the  olecranon  and  the  patella,  the  mischief  s|jreads  into  the 
bones,  and  even  by  direct  extension  into  the  synovial  cavity  of  the  joints. 

Treatment. — Acute  inflammation  must  be  treated  by  rest,  cold,  and  pressure. 
[Hot  antiscplic  fomentations  are  serviceal)le  in  these  cases.]  In  most  cases  it  is 
advisable  to  place  the  limb  upon  a  splint,  and  when  the  lower  one  is  concerned  to 
confine  the  patient  to  bed.  If  this  does  not  succeed  and  the  swelling  does  not 
subside,  it  should  be  punctured  and  the  fluid  let  out  to  prevent  suppuration. 

Simple  distention,  if  the  wall  is  thin,  may  be  treated  very  successfully  by 
tapping  with  a  trocar  and  cannula,  and  applying  pressure  afterward;  or,  if  the 
case  has  not  lasted  long,  and  the  part  is  conveniently  situated,  pressure  alone  may 
be  tried  first.  Counter-irritation  (the  free  application  of  l)listering  fluid)  some- 
times effects  a  cure.  The  injection  of  iodine  is  strongly  recommended  by  some ; 
but  the  limb  must  be  placed  upon  a  splint,  and  careful  watch  kept  that  the  reaction 
does  not  go  too  far.  In  such  cases  the  walls  are  probably  well-defined,  but  if  the 
iodine  should  escape  into  the  cellular  tissue,  it  is  not  unlikely  to  cause  a  consider- 
able degree  of  inflammation. 

When  the  wall  is  much  thickened,  measures  of  this  kind  are  of  very  little  use. 
It  is  better,  if  the  bursa  is  unsightly  or  causes  any  inconvenience,  to  excise  it 
altogether  ;  and  this  is  certainly  adv;isable  when  foreign  bodies  are  present,  unless 
they  can  be  thoroughly  cleared  out  by  free  incision. 

Deep-seated  bursse  are  so  frequently  in  communication  with  neighboring 
joints,  especially  when  they  become  enlarged,  that  very  great  care  is  required  in 
dealing  with  them.  The  most  treacherous  of  all,  perhaps,  is  that  which  appears 
sometimes  along  the  inner  border  of  the  popliteal  space.  When  the  knee  is 
extended  it  forms  a  firm,  elastic  swelling,  owing  to  the  tension  of  the  semi-mem- 
branosus  and  the  inner  head  of  the  gastrocnemius  between  which  it  lies.  In  flexion, 
on  the  other  hand,  it  is  so  soft  and  flaccid  that  it  can  scarcely  be  felt  ;  but  neither 
in  one  condition  nor  the  other  is  it  possible  to  prove  or  disprove  whether  it  has  a 
communication  with  the  joint.  Fortunately,  in  these  deep-seated  bursae  the  more 
serious  consequences,  such  as  the  formation  of  loose  bodies  and  suppuration,  are 
of  rare  occurrence  ;  but  even  chronic  distention  causes  a  very  unpleasant  sense  of 
weakness  and  greatly  impairs  the  utility  of  the  limb.  Sometimes,  moreover,  as 
they  grow  larger  they  approach  nearer  the  surface  (the  pressure  in  their  interior 
increases  in  proportion  to  their  size),  and  then,  like  the  synovial  diverticula  they 
so  much  resemble  in  structure,  they  may  either  point  beneath  the  skin  and  be 
opened  by  mistake,  or  may  actually  cause  it  to  rupture  and  give  way.  In  cases 
such  as  these  aspiration  and  pressure  should  be  tried  first  ;  but  if  these  fail,  and 
the  cyst  is  accessible,  it  is  better  to  cut  down  upon  it,  excise  it,  and  stitch 
the  neck  up  with  catgut,  than  to  resort  to  measures  calculated  to  excite 
inflammation. 

In  the  case  of  suppuration,  free  incision  as  soon  as  possible  is  the  only  course. 
Very  often  more  than  one  is  necessary,  and  not  unfrequently,  especially  in  the  case 
of  the  knee,  they  must  be  made  some  little  distance  from  the  actual  bursa,  down 
by  the  side  of  the  limb,  so  as  to  tap  the  cavity  at  its  lowest  point.  Recovery  in 
such  cases  is  always  exceedingly  slow.  Sloughs  of  fibrous  tissue  often  have  to 
separate  ;  the  skin  is  extensively  undermined  ;  the  part,  even  in  the  case  of  the 
knee  joint,  is  very  difficult  to  keep  at  rest ;  matter  will  collect  in  outlying 
pockets,  which  have  to  be  drained  ;  and  even  when  recovery  is  apparently  ensured, 
not  unfrequently  as  soon  as  the  joint  is  used,  some  of  the  old  cicatrices  break 
down  again.  If  the  suppuration  has  extended  to  other  structures — if,  for  example, 
the  bone  beneath  is  exposed  and  carious — repeated  operations  may  be  required 
before  it  is  sound  enough  to  stand  friction  and  pressure. 


322     DISEASES  AND  INJURES    OF  SPECIAL    STRUCTURES. 


CHAPTER  VI. 

INJURIES  A.\D  DISEASES  OF  BOXES  AXD  JOINTS. 

SECTION   I.— MALFORMATION  AND  DHFORMITIHS  OF  THH  LIMBS. 

Disproportionate  Growth. 

Overgrowth,  involving  either  a  limb  or  one  part  of  it  only,  is  not  uncommon. 
The  condition  is  present  at  birth,  but  naturally  becomes  more  noticeable  as  age 
advances.  One  foot  may  be  many  times  larger  than  the  other,  or  one  or  two  toes 
only  ;  one  or  two  fingers  in  each  hand  may  grow  until  they  are  three  or  four  times 
the  natural  size,  and  occasionally  this  is  almost  symmetrical. 

On  the  other  hand,  there  may  be  congenital  absence  of  the  whole  or  part  of 
one  of  the  bones  ;  the  radius,  for  example,  may  be  wanting,  or  the  tibia  or  fibula, 
causing  very  severe  distortion  of  the  foot  or  hand  as  the  case  may  be,  and  associated 
occasionally  with  defect  of  the  corresponding  digits  ;  or  one  end  may  be  developed 

and  not  the  other.  Deformities  of 
this  nature  are,  as  might  be  expected, 
gften  associated  with  other  defects, 
mental  as  well  as  bodil\',  but  they 
occur  as  well  in  people  who  are  in  all 
other  respects  well  formed  and  well 
developed. 

Supernumerary  fingers  and  toes 
are  occasionally  met  with,  particu- 
larly in  connection  with  the  thumb. 
If  they  are  merely  attached  by  a  pedi- 
cle of  skin,  it  maybe  divided  at  once  ;  but  in  all  other  cases  a  careful  examination 
should  be  made  first,  as  not  unfrecpiently  the  synovial  membrane  of  the  joint  that 
belongs  to  the  supernumerary  finger  communicates  with  that  of  the  normal  one 
(Fig.  87). 

CoNGENiT-AL  Dislocations. 

This  name  has  been  given  to  a  peculiar  deformity,  which  is  of  common  occur- 
rence at  the  hip  joint,  and  is  occasionally  met  with  elsewhere.  Instances  of  it  have 
been  recorded  in  connection  with  the  shoulder,  elbow,  wrist,  fingers,  knee,  patella, 
ankle,  toes,  and  even  the  lower  jaw  ;  l)ut  in  many  of  these  other  more  grave  defects 
were  present  as  well.  Like  similar  deformities  which  do  not  involve  joints,  it  may 
exist  in  many  grades  ;  it  is  rarely  noticed  at  birth,  and  it  becomes  more  and  more 
marked  so  long  as  the  period  of  growth  lasts.  [''  It  is  probable  that  congenital 
displacements  may  occur  in  all  the  articulations  of  the  skeleton  ;  in  most  of 
them  their  existence  has  been  established  by  dissections." — Frank  Hastings 
Hamilton.] 

The  chief  interest  is  in  connection  with  congenital  dislocation  of  the  hip  joint. 
The  limbs  at  birth  appear  well  developed  and  in  most  cases  there  is  no  suspicion 
that  anything  is  wrong  until  the  child  is  a  twelvemonth  old  ;  possibly  there  is 
slightly  greater  difficulty  in  abduction  than  usual,  but  not  sufficient  to  attract  the 
nurse's  attention.  Walking,  however,  is  unaccountably  delayed,  and  even  when 
the  child  begins  to  move  about,  its  action  is  exceedingly  awkward  and  insecure. 
On  examination  it  is  found  that  there  is  an  unusual  prominence  in  the  gluteal 
region,  that  extension  and  abduction  are  unduly  limited,  and  that  the  head  of  the 
femur  can  be  made  to  slii<  up  and  down  upon  the  dorsum  ilii. 


Fig.  87. — Supernumerary  Thumb. 


CONGENITAL   DISLOCATIONS.  323 

When  the  child  at  length  does  walk,  the  deformity,  provided  the  affection  is 
bilateral,  is  exceedingly  characteristic.  The  normal  rounded  shape  of  the  gluteal 
region  is  lost,  the  trochanters  are  pushed  up  far  beyond  their  proper  level,  and 
form  a  great  i)rojection  over  the  ilium  ;  the  basis  of  support  for  the  pelvis  is 
shifted  backward,  the  front  part  of  the  body  projects,  the  shoulders  are  thrown 
back,  and  in  other  words  there  is  extreme  lordosis  with  an  unusually  jjrotuberant 
abdomen.  In  many  instances  this  is  associated  with  consideral)le  inversion  of  the 
limb  and  flat-foot. 

If  one  side  only  is  affected  the  deformity  is  even  more  conspicuous,  owing  to 
the  difference  in  length  of  the  legs,  and  consequent  tilting  of  the  pelvis  and  lateral 
curvature  of  the  spine.  When  the  child  is  lying  on  its  back  the  malformation  is 
much  less  distinct,  and  at  first  at  least  the  head  of  the  femur  can  be  drawn  down 
nearly  to  its  natural  situation  (Figs.  88  and  89). 

Formerly  this  was  attributed  to  traumatic  dislocation  occurring  at  birth,  and 


Congenital  Dislocations  of  Hip. 
Fig.  88.— Double.  Fic.  89.— Single. 


it  was  pointed  out  in  support  of  this  view  that  it  was  much  more  common  in  breech 
presentations  than  in  others  ;  and  that  the  extreme  shallowness  of  the  acetabulum 
would  undoubtedly  favor  it.  Without,  however,  denying  the  possibility  of  such  an 
occurrence  (in  one  or  two  cases  a  distinct  slip  has  been  felt  at  the  time),  there  can 
be  no  doubt  that  this  is  not  the  ordinary  cause.  It  is  very  doubtful  whether  it  is 
really  more  common  in  these  presentations ;  in  the  majority  of  cases  the  birth  is 
described  as  having  been  particularly  easy  ;  the  affection  is  often  bilateral,  it  may 
be  hereditary,  and  it  is  seven  or  eight  times  more  frequent  in  female  children  than 
in  male. 

Opportunities  of  examining  the  interior  of  the  joint  are  not  common,  and  in 
all  the  cases  hitherto  the  patients  have  either  been  adults  or  at  least  have  walked 
for  some  time,  so  that  secondary  changes  had  developed.  There  is,  however,  a 
fair  amount  of  agreement  among  them  ;  the  iliac  portion  of  the  acetabulum  is  want- 
ing, either  altogether  or  in  part;  the  cavity  itself  is  very  small  and  triangular  in 
shape ;  it  may  be  lined  to  some  extent  with  cartilage,  but  it  is  much  too  shallow  to 


3-M     DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 

accommodate  the  head  of  the  bone.  The  ligamentum  teres  is  usually  present  (its 
occasional  disappearance  is  probably  secondary)  ;  the  capsule  is  strongly  developed 
and  contains  the  head  of,  the  bone,  although,  of  course,  it  is  immensely  stretched. 
The  upper  extremity  of  the  femur  is  rather  smaller  than  natural,  somewhat  flat- 
tened, and  rests  in  an  imperfect  socket  upon  the  dorsum.  I'he  lower  part  of  the 
innominate  bone  is  narrow  and  elongated,  the  ischial  tuberosity  everted,  and  its 
ramus  twisted,  and  the  glutei  muscles  (esi)ecially  the  maximus),  are  usually  con- 
siderably wasted. 

It  is  po.ssible  that  this  may  be  caused  by  extreme  distention  of  the  synovial  sac 
in  utcro  ;  there  is  no  doubt  that,  even  when  the  head  of  the  femur  fits  much  more 
securely  in  its  cup  than  it  does  at  that  period  of  life,  dislocation  within  the  cai^sule 
can  be  produced  in  this  way,  the  fluid  penetrating  between  the  articular  surfaces 
until  it  separates  them  from  each  other  ;  and  it  is  also  true  that  reparative  processes 
are  carried  to  a  much  greater  extent  of  perfection  in  intra-uterine  life  than  after- 
ward :  but  certainly  for  the  majority  there  is  no  more  evidence  in  favor  of  this 
view  than  there  is  in  favor  of  traumatic  dislocation.  Sometimes  it  is  associated 
with  what  has  been  called  genu  recurvatum — hyper-extension  of  the  knee,  caused 
by  fixed  malposition  ///  utcro  ;  but  there  is  no  ])roof  that  this  is  present  in  ordinary 
cases. 

In  comparison  with  this,  congenital  dislocation  of  other  joints  is  exceedingly 
rare,  that  of  the  humerus  being  perhaps  the  most  common. 

The  diagnosis  rarely  presents  any  difficulty.  After  acute  epiphysitis  in  infants 
the  limb  sometimes  assumes  the  same  position  and  direction,  owing  to  the  head  of 
the  bone  having  been  destroyed  ;  but  the  history  and  the  cicatrices  are  sufficient 
evidence. 

Treatment. — It  rarely  happens  that  this  deformity  is  detected  until  some 
considerable  time  after  birth,  so  that  even  if  it  were  due  to  traumatic  dislocation 
during  parturition  any  attempt  at  reduction  would  be  futile.  In  the  vast  majority 
of  cases  little  or  nothing  can  be  done  for  it.  Continued  extension,  however,  kept 
up  for  a  twelvemonth  or  even  longer,  has  been  followed  by  improvement  more  or 
less  permanent.  In  other  cases,  pelvic  bands  and  supports  of  various  kinds  have 
been  worn  to  transfer  some  of  the  weight  directly  on  to  the  trochanters  either  by 
vertical  or  circular  pressure,  but  such  accurate  and  at  the  same  time  constantly 
varying  adjustment  is  required  that  it  is  very  doubtful  if  any  real  benefit  is  conferred. 
In  the  worst  cases  (and  they  differ  very  much  in  severity)  Ogston  recommends 
the  formation  of  a  new  cavity  in  the  proper  situation,  and  dovetailing  the  femur 
into  it. 

If  it  is  unilateral  a  high  boot  must,  of  course,  be  worn,  to  obviate  twisting  of 
the  pelvis  and  lateral  curvature  of  the  spine. 


Club  Hand. 

A  distorted  and  deformed  condition  of  the  hand  is  occasionally  met  with  at 
birth,  consequent  on  defective  development  of  one  of  the  bones  of  the  forearm. 
Very  rarely  it  is  due  to  mu.scular  rigidity  or  contraction  of  the  palmar  fascia.  In 
a  few  cases  a  certain  amount  of  benefit  is  obtained  by  tenotomy  and  the  use  of 
splints;  but  in  the  majority  it  is  beyond  remedy. 


WKBnKD  Fin(;f.rs  and  Toes. 

In  this  malformation  the  double  fold  of  skin  which  should  be  limited  to  the 
angle  between  the  digits  is  prolonged  downward  along  the  sides  until  in  some  cases 
it  reaches  the  whole  length  (Fig.  90).  Very  often  it  is  symmetrical,  and  some- 
times, in  the  worst  cases,  all  the  fingers  are  united. 

Division  is  apparently  a  simple  matter,  but  unless  proper  precautions  are  taken 


CONGENITAL   TA  L I  PES. 


325 


reunion  from  the  angle  onward  is  almost  sure  to  occur.      It  has  been  recommended 
to  make  a  hole  through  the  web  as  far  back  as    possible  and  insert  a  metal  ring,  in 
order  that  thorough  cicatrization 
may   take  place   first,  and   tlien      r>- 
the  rest  can  be  divided  without 
fear,    but    if    there    is  sufficient 
thickness  of  tissue  a  plastic  opera- 
tion is  preferable. 

In  one  foshion  (that  of  Di- 
dot)  an  incision  is  made  along  the 
dorsal  surface  of  one  finger  and 
the  palmar  of  the  other,  and  the 
flaps  of  skin  so  marked  out  are 
reflected  toward  each  other  until 
they  meet  in  the  middle.  The 
division  is  then  completed,  and 
the  flaps  carefully  wrapped  round 
and  sutured  in  position,  the  dorsal  one,  for  example,  reaching  round  to  the  palmar 
surface  of  the  same  finger  and  vice  versa.  This,  however,  is  rarely  practicable 
unless  there  is  a  good  thickness  of  tissue  available,  and  the  longitudinal  cicatrix 
running  down  the  middle  of  the  palmar  surface  of  one  finger  is  not  unlikely  to 
lead  to  a  very  obstinate  variety  of  contraction. 

In  Agnew's  method  a  dorsal  flap,  triangular  in  shape,  is  cut  from  the  upper 
surface  of  the  web.  The  apex  corresponds  to  the  free  margin,  the  base  to  the 
interval  between  the  proximal  ends  of  the  first  phalanges.  This  is  reflected  back- 
ward on  to  the  dorsum  of  the  hand,  the  rest  of  the  web  divided  as  far  back  as 
necessary,  and  then  it  is  folded  over,  in  between  the  fingers,  so  as  to  fit  into  the 
gap.  The  edges,  both  of  the  reflected  flap  and  of  the  wounds  down  the  sides  of 
the  fingers,  must  be  sutured  accurately  so  as  to  ensure  primary  union. 


Fig.  go 


-Weblied  Fingers. 


Congenital  Talipes. 

There  are  three  primary  varieties  of  this  deformity. 

1.  Talipes  Equino-varus. — The  heel  is  raised,  the  inner  edge  is  drawn  upward, 
and  the  sole  is  twisted  inward  so  that  the  patient  stands  upon  the  outer  side  of  the 
foot,  or  in  extreme  cases  upon  the  dorsum  and  the  outer  ankle  (Fig.  91). 

2.  Talipes  Calcaneus. — The  toes  are  raised  and  the  heel  depressed,  so  that 
this  part  only  of  the  foot  is  brought  into  contact  with  the  ground. 

3.  Talipes  Valgus. — This  is  the  opposite  to  varus,  the  foot  being  so  twisted 
that  the  outer  side  is  raised  and  the  patient  walks  upon  the  inner  ankle.  Occa- 
sionally it  is  associated  with  equinus  or  calcaneus  (equino-valgus  or  calcaneo- 
valgus),  but  it  is  very  much  more  rare  than  the  others  (Fig.  92). 

Congenital  absence  of  the  tibia  or  the  fibula  gives  rise  to  a  form  of  talipes, 
which  must  not  be  confused  with  the  preceding,  in  which  the  bones  are  present. 

Causes. — Congenital  talipes  in  the  vast  majority  of  instances  is  merely  an 
arrest  of  development  with  persistence  of  growth,  similar  to  cleft  palate  and 
other  malformations.  The  parts  retain  the  relative  position  that  is  natural  to 
them  at  different  periods  of  foetal  life,  slight  modifications  following  as  the  size 
of  each  increases. 

The  cause  of  the  arrest  is  unknown.  In  exceptional  instances  it  may  be  due 
to  pressure,  as  suggested  by  Parker  and  Shattock,  the  foot  being  confined  in  some 
irregular  position,  so  that  the  natural  evolution  of  the  limb  cannot  take  place, 
just  as  genu  recurvatum  can  be  produced  in  the  foetus  by  persistent  extension 
of  the  knee  ;  but  in  the  majority  no  evidence  of  such  confinement  exists,  the 
parts  are  as  well  grown  (in  point  of  size)  and  the  skin  as  natural  as  in  ordinary 
feet. 

Like    other    malformations,   it    is   not    un frequently  hereditary,  and    often 


326     DISEASES  AND   INJURIES   OE  SPECIAL   STRUCTURES. 

descends  in  the  father's  line.  In  a  certain  proportion  of  cases  it  is  associated  with 
spina  bifida  and  other  defects,  and  on  this  the  argument  has  been  based  that, 
because  they  occur  together,  one  is  the  cause  of  the  other.  The  muscles  and 
nerves  going  to  the  part  have  lx;en  examined  many  times,  but  in  nearly  every 
instance  their  structure  has  been  perfectly  normal,  and  with  the  above-mentioned 
exceptions,  the  same  maybe  said  of  the  spinal  cord. 

Pathology. — In  talipes  equino-varus  the  foot  retains  the  position  it  assumes 
about  the  sixth  week,  when  the  hip  and  knee  are  flexed  and  the  feet  meet  over  the 
lower  pjart  of  the  abdomen  and  cross  each  other.  In  talipes  calcaneus  the 
deformity  is  much  later,  dating  from  the  time  when  the  feet  are  bent  upward  with 
the  dorsum  resting  against  the  front  of  the  leg,  and  the  normal  unfolding  of  the 
part  is  not  interfered  with.  The  earlier  the  date  at  which  the  arrest  takes  place, 
the  worse  the  deformity. 

The  chief  change  is  in  the  astragalus,  and  particularly  in  the  obliquity  of  its 
neck,  which  retains  the  direction  that  is  normal  in  anthropoid  apes.  This  is 
measured  ^Parker  and  Shattock)  by  means  of  two  threads  stretched  over  the  bone 
when  placed  upon  a  horizontal  surface.  One  passes  from  before  backward  over 
the  middle  of  the  trochlea,  at  right  angles  to  its  transverse  diameter ;  the  other 
along  the  outer  edge  of  the  neck.  The  angle  that  the  two  make  with  each  other 
in  front  is  the  measure  of  the  deviation.  In  adult  specimens  the  mean  was  found 
to  be  12°  ;  in  the  foetus  at  full  time  35°  ;  in  varus  49°  ;  and  in  a  young  orang  45** 
(it  is  less  in  the  adult).     In  other  words,  although  the  difference  in  the  various 


Fig   91. — Congenital  Varus.     Three  Grades  of  Severity. 


Fig  92. — Congenital  Valgus. 


specimens  was  considerable,  these  observers  found  a  regular  gradation  from  the 
earlier  periods  of  life  to  the  later,  and  showed  that  the  deformity  in  talipes  varus 
was  the  worst,  in  talipes  calcaneus  much  less.  The  position  of  the  internal  mal- 
leolar facet,  which  runs  nearly  as  far  forward  as  that  for  the  scaphoid  in  the  foetus 
at  full  term  and  the  anthropoid  apes,  may  also  be  taken  as  an  indication  of  the 
obliquity  ;  in  the  former  it  recedes,  in  the  latter  it  persists,  though  not  in  quite 
such  a  marked  degree. 

Defective  development  of  the  lower  limbs  is  exceedingly  common  in  children 
at  birth.  The  hips  and  knees  in  many  infants  cannot  be  straightened  out  for 
months ;  and  the  feet,  although  they  can  readily  be  brought  into  the  proper  line, 
and  by  degrees  come  to  it  of  themselves,  in  the  vast  majority  assume  naturally  the 
position  of  varus.  In  others  there  is  a  certain  degree  of  calcaneus,  which,  how- 
ever, unless  it  is  associated  with  other  troubles,  nearly  always  disappears  sponta- 
neously. With  regard  to  this  latter  deformity,  as  it  does  not  appear,  like  talipes 
varus,  to  have  a  persisting  representative  among  the  lower  animals,  it  may  possibly 
be  due  to  the  accidental  retention  of  the  foot  in  one  position  ;  and  perhaps  this 
may  account  for  the  fact  that  it  rarely  requires  much  treatment.  If  this  really  is 
the  case  there  is  a  very  distinct  difference  in  origin  between  the  two.  the  one  being 
due  to  retention  of  a  normal  developmental  condition,  the  other  to  what  maybe 
considered  an  accidental  one,  acquired  late  in  the  evolution  of  the  race. 

The  amount  of  distortion  in  the  common  forms  varies  very  considerably,  and 
is  immensely  exaggerated  if  the  child  is  allowed  to  bear  its  weight  upon  the  foot 
in  the  deformed  position.     The  tuberosity  of  the  os  calcis  is  drawn  upward  until 


CONGENITAL   TALIPES. 


327 


its  direction  is  almost  vertical  ;  and  at  the  same  time  it  is  rotated  on  its  longitu- 
dinal axis  until  the  greater  process  rests  upon  the  ground.  The  astragalus  is  tilted 
forward,  almost  out  from  its  socket,  and  its  neck  twisted  even  more.  The 
scaphoid  is  drawn  up  to  its  inner  side,  leaving  the  front  articulation  and  forming 
another  for  itself  between  the  astragalus  and  the  internal  malleolus,  while  the 
cuboid  is  so  twisted  round  that  its  dorsal  surface  may  even  rest  upon  the  ground. 
The  outer  border  of  the  foot  becomes  convex  downward  from  the  heel  to  the  toes, 
the  inner  border  is  much  shortened.  The  head  of  the  astragalus  is  divided  into 
two  parts,  an  outer  subcutaneous  and  an  inner,  almost  at  right  angles  with  it,  for 
the  scaphoid  ;  and  the  external  malleolus  is  pushed  far  back,  beyond  the  level  of 
the  internal. 

The  inferior  calcaneo-scaphoid,  and  the  anterior  and  middle  parts  of  the 
internal  lateral  ligament  of  the  ankle  joint  are  very  much  shortened  ;  the  bands 
on  the  outer  side,  on  the  other  hand,  are  stretched  ;  and  the  tendons  of  the  anterior 
and  posterior  tibial  muscles  are  brought  close  together. 

In  the  worst  cases,  those  which  have  been  neglected  or  have  relapsed,  the 
whole  foot  is  shortened  and  stunted,  the  weight  is  borne  upon  the  cuboid,  the 
external  malleolus,  and  the  outer  side  of  the  anterior  end  of  the  os  calcis  ;  an 
enormous  bursa  or  callosity  is  developed,  covering  the  whole  surface  ;  and  the 
metatarsal  bones  are  so  squeezed  together  that  the  transverse  arch  of  the  foot  is 
narrowed,  and  a  deep  longitudinal  furrow  formed  in  the  sole. 

Analogous  changes,  but,  as  a  rule,  much  less  marked,  are  present  in  talipes 
calcaneus  and  in  the  rare  form  of  congenital  valgus. 

Treatment. — Slight  cases  are  treated  by  manipulation.      If  the  foot  comes 
easily  into  the  proper  position,  and  the  muscles  are  well  nourished,  it  will  assume 
the  normal  position  in  course  of  time  with  very  little  assistance.    The  joints  should 
be  thoroughly  worked  and  rubbed  every 
night  and  morning,  taking  care  that  the 
foot  is  in  plantar  flexion  w^hen  eversion 
is  being  practiced  ;  and  all  that  is  needed 
is    perseverance   [during  these  measures, 
in  the  interval  between  the  movements  a 
fan-shaped  adhesive  plaster  is  applied  to 
retain  the  foot  in  position,  as  suggested 
by  Mr.  R.  Barwell.] 

In  every  case  it  is  essential  to  make 
sure  that  the  varus  is  real.  In  many  in- 
stances of  apparent  equino-varus,  one- 
half  of  the  deformity  disappears  as  soon 
as  the  gastrocnemius  is  thoroughly  re- 
laxed ;  the  traction  of  the  tendo-Achillis 
has  caused  equinus,  and  the  natural  ten- 
dency to  inversion,  when  there  is  nothing 
to  prevent  it,  has  led  to  the  semblance  of 
varus.  If  both  are  present,  the  equinus 
should  be  left  to  the  last. 

A  combination  of  these  two  plans  is  very  successful ;  a  strip  of  metal  being 
placed  next  the  flannel,  running  up  the  side  of  the  leg  and  under  the  sole  of  the 
foot,  with  a  few  turns  of  plaster  bandage  over  it.  Just  before  the  plaster  sets  the 
foot  is  twisted  outward  a  little  and  left.  Careful  watch  must,  of  course,  be  kept 
upon  the  circulation  in  the  toes. 

When  manipulation  does  not  succeed,  and  yet  there  is  no  degree  of  rigidity, 
the  foot  may  be  twisted  into  the  proper  position  by  the  hand,  and  fixed  by  means 
of  a  splint  or  plaster  bandage,  until  the  bones  have  grown  into  the  normal  shape. 
A  flannel  bandage  is  applied  first,  from  the  foot  to  above  the  knee.  An  outside 
metal  splint  (either  of  tin  or  zinc)  is  then  fixed  along  the  limb  and  the  foot  drawn 
out  to  it  (still  in  the  equinus  position)  ;   or  a  plaster  bandage  placed  over  it,  and 


Fig.  9J — Barwell's  Adhesive  Straps,  with  "Rubber 
Muscle."     {After  Sayre.) 


32S     DISEASES  AND  INJURIES    OE  SPECIAL   STRiCTURES. 

the  limb  held  as  near  the  normal  as  possible,  without  using  too  much  force,  until 
it  is  firmly  set.  A  splint  must  be  removed  and  reapjdied  at  least  every  second 
day,  the  skin  being  thoroughly  well  rubbed  and  sponged  with  spirit  and  water 
each  time,  so  that  there  may  be  no  redness ;  a  plaster  bandage  may  be  left  for  a 
week,  but  it  is  not  advisable  to  leave  it  longer.  As  soon  as  the  varus  is  thoroughly 
corrected  (or,  better  still,  a  little  over-corrected,  for  it  is  sure  to  relapse  somewhat) 
the  etiuinus  may  be  attended  to  ;  the  object  of  leaving  it  is  to  give  a  better  ]jur- 
chase  for  the  bandage,  and  to  allow  the  anterior  part  of  the  tarsus  and  the  os  calcis 
to  move  freely  upon  the  astragalus.  Nearly  the  whole  of  the  inversion  and  ever- 
sion  of  the  foot  takes  place  at  the  calcaneo-astragaloid  articulation,  very  little  at 
the  mid-tarsal,  at  least  on  the  outer  side. 

In  a  large  proportion  of  cases  this  treatment,  if  persevered  in,  .succeeds 
admirably  ;  but  in  the  worst,  in  which  the  sole  of  the  foot  is  inverted  and  deeply 
furrowed,  and  the  muscles  and  tendons  stand  out  rigidly,  something  further  is 
required. 

\^Briscmcnt  Eorce. — This  consists  in  forcibly  breaking  all  the  resisting  struct- 
ures, either  by  the  hand  or  by  some  one  of  the  traction  apparatus.  The  patient,  being 
fully  anaesthetized,  is  placed  on  a  table  and  the  foot  upon  a  triangular,  cloth-covered 


Fic.  94. — Morton's  Club-foot  Stretcher. 
{After  Brad/ord.) 


Fig.  9;. — Bradford's  Club  foot  Stretcher. 


wood-block.  The  operator  gra.sps  the  foot,  and  by  main  force  pres.ses  it  against 
the  block  until  all  resistance  ceases.  Then  the  deformity  should  be  over-corrected, 
on  account  of  the  constant  tendency  to  recontraction.  The  foot  is  then  firmly 
held  in  its  corrected  position  and  bandaged.  Over  this  a  plaster-of- Paris  bandage 
is  applied  and  allowed  to  remain  for  a  period  of  ten  to  twenty  days,  according  to 
the  severity  of  the  case.  Morton's  club-foot  stretcher  may  be  used  instead  of  the 
hand  in  obstinate  cases. 

A  certain  number  of  clul>-foot  cases  may  be  well  cured  by  brisement  force, 
but  so  many  relapses  occur  that  tenotomy  is  certain  to  continue  to  be  employed 
in  the  largest  proportion  of  cases.] 

The  plantar  fascia,  the  anterior  and  posterior  tibial  tendons,  and  sometimes 
the  tendon  of  the  flexor  longus  digitorum  may  require  division  ;  but  the  only  rule 
is  to  divide  all  soft  tissues  that  stand  out  tensely  and  prevent  rectification. 

Tenotomy. — Tendons  and  ligaments  should  be  divided  subcutaneously.  A 
small  puncture  is  made  in  the  skin  with  a  tenotome  opposite  the  i)roposed  seat  of 
section  (which,  other  things  being  equal,  is  the  spot  at  which  the  tendon  is  thin- 
nest and  stands  out  most  prominently),  and  either  the  same  instrument  or  a  simi- 
lar one  with  a  blunt  point  is  passed  with  its  blade  on  the  flat  behind  the  tendon 


CONGENITAL   TALIPES.  329 

(as  a  rule),  while  the  assistant  holds  tlie  linib  in  such  a  way  as  to  relax  the  struc- 
tures to  be  divided.  As  soon  as  it  has  i)assed  a  sufficient  de])th,  the  blade  is  rotated 
through  a  (luarter  of  a  circle  and  the  cutting  edge  Ijrought  against  the  tough, 
fibrous  tissue,  the  assistant  meanwhile  changing  the  position.  Hexing  or  extentling 
as  the  case  may  be,  so  as  to  make  everything  tense.  Then,  with  a  gentle  back- 
ward and  forward  movement,  the  fibres  are  cut  through  in  succe.ssive  layers,  giving 
a  kind  of  crisp  sensation  to  the  hand,  until  the  resistance  gives  way.  The  .separa- 
tion should  be  distinctly  felt,  but  there  should  be  no  jerk,  for  fear  of  sending  the 
knife  through  the  skin.  As  a  precaution,  the  finger  of  the  other  hand  should  be 
pressed  upon  the  surface  in  order  that  the  presence  of  the  blade  may  be  detected 
as  the  skin  is  approached. 

In  other  ca.ses,  if  it  is  close  to  the  insertion  of  the  tendon,  the  knife  is  passed 
tetween  it  and  the  skin  and  the  division  practiced  in  the  opposite  direction. 
Recently  the  plan  of  open  section  has  been  advocated,  on  the  ground  that  it  is 
more  thorough  and  complete,  without  being  more  dangerous;  but  it  is  question- 
able whether  the  .supposed  advantage  this  possesses  is  sufficient  compensation  for 
the  time  the  wound  takes  in  healing,  even  if  there  is  no  more  risk. 

Wounds  inflicted  with  a  tenotomy  knife  are  dusted  over  with  a  little  iodoform 
and  covered  with  a  piece  of  lint  or  cotton-wool  and  a  bandage.  As  a  rule,  their 
site  can  hardly  be  detected  on  the  fourth  day,  and  suppuration  is  unknown.  The 
tendon  unites,  like  all  other  tissues,  by  the  organization  of  vascular  granulation 
tissue,  springing  chiefly  from  the  sheath  and  the  tissues  around  ;  itself  contains  so 
few  blood-ve.s,sels  that,  like  compact  bone,  it  takes  at  first  but  little  .share  in  the 
proceeding  ;  after  a  time  it,  too,  becomes  more  vascular,  and  then  the  tissue  that 
lies  between  the  ends  slowly  shapes  itself  into  the  fashion  of  the  structures  it 
joins,  and  the  tendon  and  its  sheath  are  thoroughly  restored.  It  is  a  matter  of 
very  great  importance,  so  far  as  the  immediate  treatment  of  talipes  is  concerned, 
that  this  process  of  repair  is  practically  independent  of  the  distance  between  the 
ends,  so  long  as  it  is  not  extreme. 

The  central  and  inner  parts  of  the  plantar  fascia  often  require  division,  some- 
times in  more  places  than  one ;  it  is  best  accoriiplished  by  slipping  the  tenotome 
between  the  skin  and  the  fascia  and  cutting  toward  the  deeper  structures.  The 
tendinous  part  of  the  abductor  hallucis  may  be  cut  at  the  same  time  by  introduc- 
ing the  tenotome  just  in  front  of  the  inner  tuberosity  of  the  os  calcis  and  cutting 
down  to  the  bone. 

The  posterior  tibial,  the  one  that  usually  comes  next,  lies  almost  in  the  mid- 
point (from  front  to  back)  of  the  leg,  just  above  the  internal  malleolus.  Here  it 
can  be  easily  divided  by  making  a  puncture  with  a  sharp-pointed  tenotome  right 
down  to  the  tibia,  withdrawing  it,  and  passing  a  blunt-pointed  one  along  its  track 
(with  its  blade  parallel  to  the  leg)  until  the  posterior  border  of  the  bone  is  felt. 
Then  the  tenotome  is  turned  round,  and  the  tendon  that  lies  next  to  the  bone, 
immediately  behind  it,  divided,  w^hile  the  assistant  forcibly  everts  the  foot.  If  the 
incision  is  carried  a  little  too  far,  the  tendon  of  the  flexor  longus  digitorum  is 
divided  as  well ;  and,  if  further  still,  the  posterior  tibial  artery.  The  hemorrhage 
may,  however,  always  be  stopped  by  means  of  a  pad  and  a  bandage. 

In  Syme's  operation  the  tendon  of  the  posterior  tibial  is  divided  just  behind 
its  insertion  into  the  scaphoid,  below  and  in  front  of  the  internal  malleolus,  against 
the  bone  ;  and  if,  as  in  many  cases  of  club-foot,  the  anterior  and  middle  bands  of  the 
internal  lateral  ligament  requires  section  as  well,  preference  should  be  given  to  this. 

The  anterior  tibial  presents  much  less  difficulty,  as  it  can  always  be  felt,  in 
cases  of  club-foot,  standing  out  distinctly.  The  points  usually  selected  are  either 
immediately  above  its  insertion,  cutting  down  on  to  the  bone,  or  higher  up  where 
it  is  prominent  on  the  inner  side  of  the  front  of  the  ankle-joint. 

The  tendo-Achillis  (unless  the  case  is  equinus  without  varus,  or  with  only  the 
appearance  of  it)  should  be  left  until  the  foot  is  in  a  perfectly  unfolded  condition, 
in  a  right  line  with  the  leg.  As  soon  as  this  is  accomplished,  it  may  be  divided 
and  the  foot  brought  up. 


330     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

The  usual  i)oint  is  opposite  the  narrowest  i)art  of  the  tendon,  not  more  than 
an  inch  al)ove  its  insertion,  in  an  infant.  The  foot  is  hehl  by  an  assistant  (the 
patient  \y\\v^  on  the  face)  in  a  position  of  moderate  i)lantar  flexion  ;  a  puncture  is 
made  with  a  sharp  tenotome  on  one  side  or  the  other,  according  to  convenience, 
and  the  blade  of  the  instrument  (i)arallel  to  the  limb)  pushed  on  until  it  can  be 
felt  under  the  skin,  upon  the  opposite  side.  It  is  then  turned  round,  the  foot  bent 
up  toward  the  front  of  the  leg  to  make  the  tendon  tense;  a  finger  of  the  left  hand 
placed  on  the  skin  over  it;  and  the  fibres  gently  divided,  rather  by  the  pressure 
of  the  l)lade  than  anything  else.  Care  must  be  taken  that  there  is  no  jerk  at  the 
end. 

Division  of  the  Ligaments. — Recently,  Parker,  Sayre,  and  others  have  strongly 
advocated  division  of  all  resisting  l)ands  [and  the  plantar  fascicX-],  especially  the 
shortened  and  rigid  ligaments  on  the  inner  side  of  the  foot.  A  curved  tenotome 
with  a  short  cutting  edge  is  entered  just  in  front  of  the  anterior  l)order  of  the  inter- 
nal malleolus,  passed  carefully,  flatwise,  between  the  ligaments  and  the  skin,  and 
then,  by  a  gentle,  sawing  action,  made  to  divide  everything  down  to  the  bone. 
The  foot  must  be  rotated  out  by  an  assistant,  so  as  to  separate  the  malleolus  as  far  as 
possible  from  the  sustentaculum  tali  and  the  scaphoid.  The  same  instrument  is  then 
gently  pushed  forward,  close  to  the  bone,  on  the  plantar  aspect,  so  as  to  divide  the 


Fig.  96. — Tin  Splint  for  Slight  Cases  in  Infants. 


Fig.  97. — Little's  Shoe  for  Slight  Cases  of  Yams. 


calcaneo-scaphoid  ligament  and  the  tendon  of  the  posterior  tibial.  The  long 
and  short  jjlantar  bands  are  cut  through  from  the  outer  side.  A  straight  tenotome 
is  passed  in,  opposite  the  calcaneo-cuboid  articulation  (almost,  sometimes,  on  the 
sole  of  the  foot),  and  carefully  pushed  inward,  close  to  the  bone,  dividing  the 
ligament  as  it  goes. 

After  Tenotomy. — Until  recently,  it  was  always  recommended  that  when  the 
punctures  were  dressed,  the  foot  should  be  carefully  enveloped  with  a  flannel  band- 
age, and  secured  to  a  light  splint  made  of  flexible  metal  in  the  faulty  position. 
It  was  feared  that  inflammation  might  set  in,  or  that  the  ends  of  the  tendons  might 
be  so  far  separated  that  union  would  not  take  place  between  them.  In  five  or  six 
days,  when  the  little  wounds  were  sound,  the  splint  was  removed  and  an  extend- 
ing apparatus  applied,  in  order  to  stretch  by  slow  degrees  the  lymph  poured  out 
between  the  cut  ends.  Parker,  however,  has  clearly  shown  that  there  is  absolutely 
no  foundation  for  this;  that  the  displaced  position  may  be  rectified  at  once  with 
perfect  safety,  and  that  the  long  and  tedious  plan  of  treatment  previously  fol- 
lowed may  be  effectively  supplanted  by  a  much  more  rapid  one.  Thomas  employs 
a  foot-wreiich,  the  prongs  of  which  are  covered  with  rubber,  for  the  purpose  of 
reducing  deformity  as  rapidly  as  possible. 

If  this  method  of  rapid  reduction  is  adopted,  all  the  tendons  and  ligaments 
that   resist  and   stand   out  when  the  foot  is  brought  into  the  right  position   are 


CONGENITAL  TALIPES. 


Zl^ 


divided  ;  the  punctures  sealed  with  iodoform  and  a  carefully  picked  layer  of  cotton- 
wool ;  a  llannel  bandage  applied  from  the  toes  upward  ;  and  then,  while  the  assist- 
ant holds  the  foot  in  as  gootl  a  position  as  possible,  a  jjlaster  Ijandage  placed  over 
the  whole.  This  is  left  for  a  week  ;  at  the  end  of  that  time  it  is  taken  off,  the 
skin  thoroughly  rubbed,  and  a  fresh  casing  put  on,  pressure  l)eing  used,  as  before, 
to  twist  the  foot  outward  into  the  normal  line.  The  advantages  of  this  plan  over 
the  old  one  are  obvious  at  the  first  glance.  It  may  be  commenced  at  once,  within 
a  few  days  of  birth,  at  a  time  when  any  appliance,  such  as  Scarpa's  shoe,  or  a 
metal  splint,  is  practically  out  of  the  question  ;  it  avoids  the  evil  effects  of  local 
pressure  ui)on  the  skin,  which  only  too  often,  when  the  older  plan  was  followed, 
rendered  it  necessary  to  interrupt  the  treatment  for  days  or  weeks  together  ;  it  is 
carried  out  during  the  i^eriod  when  developmental  changes  are  most  active  ;  the 
longer  the  case  is  left,  the  more  difficult  the  deformity  is  to  rectify,  and  it  effects 
a  greater  degree  of  improvement  in  weeks  than  the  former  plan  did  in  months. 
As  a  rule,  unless  the  case  is  very  severe,  the  foot  is  practically  unfolded  by  the 
end  of  the  fourth  or  fifth  week. 

Opeti  Incision. — Phelps  adopts  the  same  method,  but  divides  everything  in 
an  open  wound.  An  incision,  an  inch  or  two  in  length,  according  to  the  age  of 
the  patient,  is  made  downward  from  just  in  front  of  the  tip  of  the  internal  mal- 
leolus, and  everything,  tendons,  fascia,  ligaments,  nerves,  and,  if  they  are  in  the 
way,  vessels,  divided  down  to  the  bone.  Esmarch's  bandage  is  used  and  the  limb 
raised  afterward,  the  wound  being  covered  with  protective  and  enveloped  in  ab- 
sorbent dressings.      In  old  cases,  the  neck  of  the  astragalus  is  divided  too. 

As  soon  as  the  deformity  is  thoroughly  corrected,  the  splints  are  left  oft"  dur- 
ing the  daytime,  and  the  feet  exercised  at  least  twice  a  day,  the  skin  well  rubbed, 
the  muscles  kneaded,  and  all  the  joints  worked  ;  but  some  appliance  is  required  at 
night  until  the  tendency  to  relapse  has  disappeared — until,  that  is  to  say,  the  shape 
of  the  bones  is  definitely  changed.  For  infants,  a  light,  tin  splint  is  sufficient ; 
it  consists  of  a  trough  for  the  leg,  a  foot-piece  at  right  angles  with  it  and  a  little 
everted  ;  a  soft  leather  strap  to  keep  the  ankle  down,  and  two  webbing  ones  to 
maintain  the  position  of  the  leg  and  foot  respectively  (Fig.  96).  For  older  children 
the  same  appliance  made  of  stouter  metal,  thin 
sheet-iron,  for  example,  may  be  employed,  or 
Little's  (Fig.  97)  or  Scarpe's  shoe.  The  latter 
is  formed  of  a  leather  slipper  with  a  leg-iron,  and 
a  well-padded,  leather  strap  to  fit  round  the  calf. 
Opposite  the  ankle  is  a  cog  and  ratchet  arrange- 
ment in  order  to  alter  the  angle  as  required,  and 
attached  to  the  outer  side  of  the  sole-plate  is  a 
metal  spring,  by  which  a  certain  degree  of  ever- 
sion  can  be  secured.  The  foot  is  fixed  in  position 
first,  the  heel  being  held  down  by  a  strap  passing 
over  the  front  of  the  ankle,  the  calf-piece  buckled, 
and  then  the  sole-plate  brought  to  the  required 
angle  with  a  key  (Fig.  98). 

In  older  children,  especially  in  those  cases 
which  have  either  never  been  treated  at  all,  or, 
what  is  nearly  equally  bad,  have  been  allowed  to 
relapse,  a  properly  made  boot  with  an  outside 
iron  and  a  calf-piece  must  be  w^orn  for  a  very  con- 
siderable time  after  reduction,  often  for  years,  or  the  deformity  is  almost  certain 
to  return.  If  there  is  any  inward  rotation  at  the  knee,  the  irons  must  be  carried 
up  the  limb  and  fixed  to  a  pelvic  girdle  (with  a  proper  arrangement  of  joints)  to 
prevent  relapse  effectually. 

Tarsectomy. — An  almost  hopeless  form  of  club-foot  is  occasionally  met  with 
in  children  and  young  adults.  Tenotomy  has  been  performed  time  after  time 
without  any  permanent  benefit ;  the  bones  are  hopelessly  distorted  and  peculiarly 


Fig. 


-Little's  Modification  of  Scarpa's 
Shoe  for  Talipes. 


332     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 

hard,  the  ligaments  shortened,  the  muscles  wasted,  and  the  limb  comparatively 
useless.  For  such  as  these  there  is  no  alternative  l»ut  amputation,  giving  them  a 
stump  to  wrilk  on  (which  is  better  than  walking  on  the  dorsum  of  the  foot);  or 
tarsectomy,  removal  of  a  portion  of  the  tarsus,  so  that  the  sole  may  be  brought 
down  to  the  ground.  Various  forms  of  this  operation  have  been  devised,  but  the 
two  that  best  answer  the  conditions  are  excision  of  the  astragalus  and  the  removal 
of  a  wedge-shaped  portion  of  bone  (taken  chiefly  from  the  cuboid  and  those  on 
either  side  of  it)  from  the  outer  border  of  the  foot. 

Excision  of  the  astragalus  is  performed  through  a  longitudinal  incision  on 
the  outer  side  of  the  foot,  between  the  tendons  of  the  extensor  longus  digitorum 
and  the  peroneus  tertius.  The  articulation  between  the  scaphoid  and  astragalus  is 
exposed,  and  the  dorsal  astragalo-scaphoid  ligament  (which  may  be  much  thickened) 
freely  divided.  The  anterior  end  of  the  foot  is  then  twisted  so  as  to  separate  the 
astragalus  from  the  surrounding  bones,  the  anterior  fasciculus  of  the  external 
lateral  ligament  of  the  ankle  joint  cut  through,  and  a  stout,  sharply-curved  hook 
with  a  cutting  edge  on  its  concave  surface  passed  between  the  os  calcis  and  astra- 
galus until  it  reaches  the  posterior  extremity  of  the  interosseous  band.  This  must 
be  cut  through  by  steady  traction,  and  then  the  astragalus  is  so  nearly  free  that  it 
may  almost  be  tilted  out  of  its  socket  by  forced  plantar  flexion.  The  wound  is 
treated  in  the  ordinary  manner,  the  foot  being  secured  at  once  at  right  angles  to 
the  leg,  with  the  sole  in  the  proper  position. 

Excision  of  a  wedge-shaped  portion  from  the  outer  border  of  the  foot  is  pre- 
ferable if  the  vanis  is  the  more  prominent.  An  incision,  convex  downward,  is 
made  along  the  outer  border  of  the  foot  from  the  middle  of  the  metatarsal  bone  of 
the  little  toe  to  the  os  calcis;  the  soft  parts,  tendons,  arteries,  etc.,  are  carefully 
lifted  off  from  the  dorsal  surface,  and  the  peronei  if  possible  pulled  to  one  side. 
Then  a  wedge-shaped  mass  of  bone,  corresponding  in  size  and  shape  to  the  de- 
formity that  is  present,  is  removed  with  a  chisel  or  with  Adams'  saw.  The  base  of 
the  wedge  faces  the  upper  and  outer  border  of  the  foot  ;  the  apex  points  inward, 
while  the  sides  slant  down  toward  each  other,  so  that  the  under  (plantar)  surface  is 
much  smaller  than  the  upper.  In  actual  practice  the  part  removed  is  rarely  so 
geometrical  ;  roughly  it  corresponds  to  the  cuboid  with  a  varying  amount  of  the 
neighboring  bones  ;  the  essential  point  is  that  it  should  be  of  sufficient  size  to  enable 
the  foot  to  become  straight  and  lie  flat.  Afterward  the  wound  is  thoroughly 
cleansed,  drained  if  thought  advisable,  covered  with  an  absorbent  antiseptic  dress- 
ing, and  fixed  with  a  plaster  bandage.  How  long  it  should  l)e  left  depends  upon 
the  patient's  temperature  and  whether  a  drainage-tube  has  been  used  or  not. 

Fitzgerald,  in  old  cases,  divides  all  the  tendons,  including  the  tendo-Achillis 
and  deep  ligaments,  down  to  the  astragalo-scaphoid  articulation.  He  then  makes 
an  incision  on  the  outer  side  of  the  foot,  from  above  downward,  behind  the  cal- 
caneo-cuboid  articulation,  passes  a  chisel  in  front  of  the  ankle  joint,  down  to  the 
neck  of  the  astragalus,  divides  this,  the  os  calcis,  and  the  scaphoid,  and  forcibly 
moulds  and  wrenches  the  foot  into  shape.  A  splint  with  a  foot-piece  is  used  to 
retain  it  in  position  afterward. 

These  ojierations  undoubtedly  enable  the  foot  to  be  brought  into  a  better  posi- 
tion, and  are  infinitely  preferable  either  to  amputation  or  to  progression  upon  the 
dorsum  with  the  great  toe  projecting  upward,  a  condition  not  uncommon  among 
relapsed  cases;  but  the  necessity  for  them  would  not  arise  if  they  were  properly 
attended  to  in  infancy. 

Acquired  Talipes. 

Club-foot,  apparently  resembling  the  congenital  variety,  but  in  reality  differ- 
ing from  it  in  many  essential  particulars,  may  be  caused  by  infantile  paralysis, 
spasmodic  muscular  contraction,  fibroid  degeneration  of  muscles  consequent  on 
inflammation  or  injury,  and  cicatrices  following  burns;  or,  again,  it  may  be  sec- 
ondary, as  when  talipes  equinus  develops  in  hip  disease  owing  to  the  shortening  of 
the  limb.     Of  these  the  most  important  and  the  most  common  is  the  first. 


ACQUIRED  TALIPES. 


ii:!> 


I .    Talipes  due  to  Infantile  Paralysis. 

In  congenital  club-foot  the  essential  lesion  is  an  arrest  of  development  ;  the 
bones,  ligaments,  fascine,  and  muscles  all  take  part  in  it.  In  talipes  due  to  infantile 
paralysis  the  muscles  alone  are  in  fault  at  first,  the  bones  are  well  developed,  the 
fasciae  and  the  ligaments  are  not  tense,  the  sole  cause  is  the  loss  of  power  of 
one  or  more  muscles  or  groups  of  muscles.  Secondary  changes,  however,  take 
place  in  this  (unless  means  are  taken  to  j^revent  them)  just  as  they  do  in  the  con- 
genital form.  The  opposing  groui)s  of  muscles,  having  lost  their  antagonists,  grad- 
ually become  shortened  and  rigid  ;  the  bones  from  constant  jn-essure  become  altered 
in  shape,  and  even  sometimes  the  ligaments  contract  (possil)ly  owing  to  local  in- 
flammation, for  as  a  rule  they  remain  quite  lax  in  other  joints).  The  result  is  that, 
although  the  diagnosis  between  the  two  varieties  is  exceedingly  easy,  so  long  as  the 
case  is  recent  (in  the  one  the  foot  can  be  placed  at  once  in  its  natural  position,  in 
the  other  it  cannot),  it  may  become  difficult  in  the  later  stages,  unless  there  is  a 
history  of  the  deformity  having  been  present  at  birth.  Other  symptoms  of  infantile 
paralysis  render  it,  of  course,  practically  definite;  if  the  limb  is  cold  and  wasted, 


Fig.  99. — Talipes  Equinus. 


liable  to  chilblains,  and  smaller  than  the  other  in  all  its  dimensions,  the  question 
may  be  regarded  as  settled  ;  but  the  presence  of  one  complaint  cannot  logically  be 
regarded  as  conclusive  proof  of  the  absence  of  another. 

Varieties. — These  are  the  same  as  in  the  congenital  form,  but  there  are  certain 
points  of  difference.  Talipes  equinus,  for  example,  often  occurs  by  itself ;  indeed, 
it  is  the  most  frequent  of  all,  though  mixed  and  irregular  forms  are  not  uncommon. 
Every  grade  is  met  with,  from  paralysis  of  all  the  muscles  of  the  limb,  with  extreme 
distortion,  to  a  loss  of  power  that  is  scarcely  perceptible  and  confined  perhaps  to  a 
few  fibres  of  a  single  muscle.  As  a  rule  it  comes  on  about  the  second  year,  but  it 
may  not  occur  until  much  later  ;  on  the  other  hand,  in  cases  of  rickets,  it  may  be 
present  before  the  child  begins  to  walk,  so  that  the  defect  is  often  believed  by  the 
parents  to  have  been  present  at  birth  (Fig.  99). 

Talipes  ecpiinus  results  from  paralysis  of  the  extensors  on  the  front  of  the  leg. 
If  all  are  involved  equally  the  foot  remains  straight  ;  if  the  tibialis  anticus  retains 
any  power  the  inner  side  is  raised  and  the  sole  looks  inward. 

In  the  worst  form  of  infantile  paralysis,  when  the  loss  of  power  is  complete, 
the  whole  foot  drops  forward,  the  heel  becomes  almost  vertical,  and  the  astragalus 


334    £>ISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


rolls  forward  from  under  the  tibia  until  the  dorsum  drags  along  the  ground.  The 
whole  extremity  is  atrophied  and  cold,  the  bones  fail  to  grow,  the  skin  is  consUmtly 
liable  to  chilblains,  and  chronic  ulcers  make  their  apiJcarance  every  winter.  If  the 
gastrocnemius  escapes  the  heel  is  dragged  uj)  and  after  a  time  becomes  fixed,  with 
usually  a  certain  degree  of  varus,  owing  to  the  natural  tendency  of  the  foot  to  as- 
sume that  position  when  at  rest.  Nearly  always,  however,  when  the  mischief  is  so 
extensive  as  to  involve  all  the  muscles  on  the  front,  the  gastrocnemius  and  the  deep 
flexors  suffer  too,  not,  perhaps,  so  severely,  and  the  paralysis  being  general,  fixed 
displacement  does  not  follow. 

In  those  not  ([uite  so  bad  when  the  loss  of  power  in  the  anterior  muscles  is 
only  partial,  the  chief  displacement  usually  occurs  at  the  mid-tarsal  joint,  the  ankle 
itself  being  less  affected.  The  scaphoid  and  cuboid  are  drawn  downward  and 
backward,  and  the  head  of  the  astragalus  is  left  projecting  on  the  dorsum  almost 
uncovered.  After  a  time  this  becomes  permanent,  the  ligaments  and  fascia  on  the 
plantar  surface  shortening  and  growing  rigid.  In  some  instances  the  sole  of  the 
foot  is  so  much  contracted  that  the  anterior  half  is  almost  if  not  (piite  at  right 
angles  with  the  posterior,  the  heel  is  raised  completely  off  the  ground,  and  the 
weight  borne  on  the  ends  of  the  metatarsal  bones.     In  others,  probably  when  the 

interossei  and  the  short  flexors  of  the  great  and 
little  toes  are  involved,  this  is  associated  with  a 
peculiar  claw-like  condition  of  the  foot,  the 
proximal  phalanx  being  over-extended,  the  dis- 
tal ones  flexed. 

In  the  milder  forms  when  the  paralysis  is 
temporary  only  (as  after  diphtheria)  the  distor- 
tion is  very  slight  ;  the  heel  is  merely  a  little 
raised,  and  the  sole  of  the  foot  a  little  shortened 
{talipes  arcuatus)  ;  but  if  it  continues  long 
enough  for  contraction  of  the  fascia  to  take 
place  (talipes  plan  fan's)  it  may  prove  the  source 
of  great  inconvenience;  the  gait  is  awkward, 
there  is  great  pain  on  standing,  corns  form  be- 
neath the  metatarsals,  reflex  muscular  spasm  is 
not  uncommon,  and  active  exercise  is  very  difli- 
cult.  The  diagnosis  can  be  made  at  once  by 
comparing  the  impression  left  after  standing 
with  that  of  the  opposite  foot ;  the  arch  is 
shorter,  very  much  less  of  the  sole  comes  into 
contact  with  the  ground,  and  the  outer  part  of 
the  tread  in  particular  is  narrowed.  In  long- 
standing cases  the  contracted  bands  can  be  felt 
standing  out  on  the  inner  side  of  the  sole. 

Analogous  deformities  are  caused  by  paral- 
ysis of  other  groups.  Talipes  calcaneus  is  due  to  loss  of  power  over  the  muscles  of 
the  calf  (Fig.  loo)  ;  valgus  is  said  to  occur  when  the  tibials  are  affected,  and  com- 
pound forms  if  more  than  one  group  is  weakened.  Very  often  these  are  rendered 
still  more  complicated  by  secondary  displacements  caused  by  attempts  at  progres- 
sion. Thus  inversion  and  rotation  may  occur  to  such  an  extent  in  talipes  equinus 
that  a  condition  closely  similar  to  true  varus  is  produced,  the  foot  being  displaced 
laterally  to  compensate  for  the  want  of  flexion.  In  other  instances  valgus  follows, 
but  as  a  rule  these  additional  deformities  can  be  recognized  as  such  by  examining 
the  foot  when  lifted  from  the  ground  ;  as  soon  as  the  weight  of  the  body  is  taken 
off  it  drops  of  itself  into  the  straight  line. 

Treatment. — This  is  entirely  different  from  that  of  congenital  talipes,  and 
depends  upon  the  grade  of  paralysis  and  the  extent  to  which  deformity  has  taken 
place  already.  [In  all  cases,  however,  it  is  e.ssential  that  the  foot  be  kept  in  posi- 
tion continuously,  by  an  appropriate  appliance.] 


Fig.  loo. — T.-ilipes  Calcaneus. 


ACQUIRED  TALIPES. 


335 


In  the  slighter  cases,  in  whicli  the  power  over  one  or  more  groups  of  muscles 
is  imi)aired  without  being  lost,  an  attempt  must  he  made  to  improve  the  nutrition 
of  the  part  antl  compensate  for  what  is  lost  by  educating  and  developing  all  that  is 
left.  Warm  clothing,  douching  twice  a  day  with  cold  water,  salt  baths,  friction, 
massage,  jnnching,  galvanism,  passive  motion,  manijnilation,  suitably-devised  gym- 
nastics, everything,  in  short,  is  advisable  that  can  in  any  way  improve  the  circula- 
tion through  the  part  or  strengthen  the  residue  of  the  muscles.  If  this  can  be 
done  deformity  can  be  prevented. 

If,  however,  the  whole  of  one  muscle  is  destroyed  its  action  must  be  sup- 
planted by  a  mechanical  contrivance.  The  simplest  is  a  rubber  accumulator  as 
suggested  by  Barwell.  A  thin  piece  of  sheet  lead  or  jwroplastic  felt  is  fastened  to 
the  limb,  on  the  anterior  surface  of  the  leg,  for  example,  in  varus  ;  a  .soft  piece  of 
leather  is  adjusted  round  the  foot  (held  in  position,  if  it  has  a  tendency  to  slip, 
with  some  emplastrum  plumbi  or  emplastrum  ferri)  ;  a  tai)e  is  fastened  on  to  this 
so  that  it  shall  descend  on  the  inner  side  of  the  foot,  pass  under  the  sole,  and 
ascend  again  on  the  outer  side  ;  and  this  is  connected  to  the  splint  with  a  rubber 
band  of  suitable  strength.  For  equinus  it  is  even  simpler,  as  the  whole  apparatus 
can  be  fixed  to  a  boot  with  side  supports  maintaining  a  calf  band  immediately 
below  the  knee.  Each  case  naturally  requires  a  separate  plan  ;  but  if  the  defect 
is  a  simple  one,  and  permanent  shortening  has  not  yet  occurred,  some  contrivance 
of  this  kind  can  often  be  devised  to  enable  the  patient  to  get  about  with  comfort 
and  maintain  the  condition  of  the  other  mus- 
cles and  of  the  rest  of  the  limb  unimpaired 
(Fig.  loi). 

[Prof.  Lewis  A.  Sayre  has  made  a  useful 
modification  of  this  shoe  by  substituting  a  ball- 
and-socket  joint  for  the  hinge  joint  shown  in 
the  cut.] 

In  the  worst  cases,  in  which  it  is  not  so 
much  one  muscle  or  even  one  group  that  is 
affected,  but  every  one,  and  in  which  the  cir- 
culation is  defective,  the  bones  small  and  light, 
the  skin  cold,  even  in  midsummer,  and  the 
joints  almost  like  flails,  the  same  plan  may  be 
tried,  and  sometimes,  even  in  the  most  hope- 
less cases,  an  immense  amount  of  improvement 
is  effected  by  ceaseless,  untiring  perseverance  ; 
but  more  often  it  means  that  the  limb  is  almost 
useless,  except  as  a  support  in  the  narrowest 
sense  of  the  term,  and  that  some  contrivance 
must  be  devised  to  enable  it  to  act  as  such. 
The  particular  variety  and  the  height  along  the 
limb  to  which  it  must  be  carried  naturally  vary 
with  each  case.  A  boot  with  outside  and  in- 
side supports  and  a  calf  band  may  be  sufficient 
in  the  slighter  ones  ;  but  in  the  majority  it  is 
necessary  to  carry  the  apparatus  at  least  up  to 
the  thigh,  and  not  unfrequently  up  to  the  pel- 
vis, with  joints  suitably  arranged,  and  stops  so 
that  the  limb  can  be  bent  underneath  while 
sitting  down.  The  weight,  of  course,  is  con- 
siderable ;  the  nutrition  of  the  limb,  used  merely  as  the  central  pillar  of  a 
mechanical  support,  does  not  improve  ;  and  as  the  patient  grows  older  the  tend- 
ency to  the  formation  of  chronic  ulcers  not  unfrequently  become  so  marked  that 
amputation  is  preferred.     The  flaps,  as  a  rule,  heal  well,  but  slowly. 

If  the  patient  is  not  seen  until  deformity  has  already  appeared,  steps  must  be 
taken  to  rectify  it  by  tenotomy  and  mechanical  extending  appliances.     Thus,  in 


Fig.  ioi. — Barwell's  Shoe. 


336    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  simplest  form  of  talipes  eciuiiuis,  where  the  arch  of  the  foot  is  exaggerated,  the 
tread  narrowed,  and  standing  painful,  relief  may  be  obtained  almost  at  once  by 
dividing  the  contracted  bands  in  the  plantar  fascia.  In  all  cases,  however,  of 
paralytic  talipes  it  is  advisable  to  exercise  great  discretion  in  the  manner  of  ten- 
otomy, or  the  already  weakened  limb  may  become  still  worse. 

[The  rule  is  that  when  the  foot  can  be  restored  to  position  by  the  hand  easily, 
the  patient  being  under  an  anaesthetic,  operative  niea.sures  are  useless,  for  there  is 
no  actual  contracture  of  the  .soft  structures.] 

2.    Talipes  due  to  Muscular  Rigidity. 

What  is  known  as  "  spastic  rigidity"  of  the  muscles  of  the  lower  limb  (and 
occasionally  of  the  whole  body)  is  sometimes  present  at  or  shortly  after  birth,  con- 
nected, in  all  i)robability,  either  with  defective  development  of  the  nerve-centres, 
or  with  injury  sustained  during  parturition  ;  but  the  deformities  to  which  it  gives 
rise  are  rarely  limited  to  the  feet ;  and  even  when  they  are,  they  present  but  a 
remote  resemblance  to  ordinary  talipes. 

Tonic  shortening  of  the  gastrocnemius  (the  so-called  right-angled  contraction 
of  thetendo-Achillis)  is  not  infrecpient  as  a  consequence  of  prolonged  confinement 
with  the  foot  pointing  forward,  whether  it  is  due  to  a  badly  set  fracture  or  to  the 
pressure  of  the  bedclothes  in  the  course  of  some  exhausting  illness,  such  as  typhoid 
fever.  It  can  be  recognized  at  once  by  pressing  the  knee  well  back  while  the  leg 
is  extended  ;  and  though  it  does  not  appear  serious,  it  causes  a  very  considerable 
degree  of  lameness  in  walking,  and  not  infrequently  ends  in  grave  deformity.  The 
movement  that  cannot  take  place  at  one  joint  must  take  place  at  another;  and  the 
arch  of  the  foot  gradually  gives  way  until  a  condition  clo.sely  resembling  ordinary 
flat-foot  is  produced  ;  the  head  of  the  astragalus  and  the  scaphoid  sink  together, 
and  in  some  extreme  cases  the  inner  border  of  the  foot  becomes  convex.  Some- 
times, on  the  other  hand,  especially  in  those  instances  in  which  no  attempt  at 
walking  is  made,  the  foot  is  twisted  into  a  shape  resembling  varus,  the  natural 
position  it  assumes  when  at  rest  ;  but  it  rarely  happens  that  this  is  permanent  unless 
there  is  at  the  same  time  paralysis  of  the  extensors. 

In  every  case  of  fracture  the  foot  should  be  carefully  kept  at  a  right  angle 
throughout ;  if  the  toes  are  allowed  to  point,  serious  disablement  may  be  produced 
before  it  is  noticed  ;  and  attention  should  be  paid  to  this  in  cases  of  exhausting  ill- 
ness;  the  bedclothes  should  not  be  allowed  constantly  to  weigh  the  feet  down.  If 
it  is  present  already  it  can  usually  be  cured  by  massage,  passive  motion,  and  the 
use  of  an  extending  rubber  band  ;  but  occasionally  tenotomy  is  required. 

Flat-Foot. 

The  antero-])Osterior  arch  of  the  foot  is  maintained  partly  by  ligaments,  partly 
by  muscles  ;  the  former  are  the  inferior  and  external  calcaneo-scaphoid  and  the 
anterior  fa.sciculus  of  the  internal  lateral  of  the  ankle  joint  ;  the  latter,  the  tibialis 
anticus,  the  flexors  of  the  toes,  and  especially  the  peroneus  longus,  which  i)asses 
like  a  strap  across  it  and  prevents  the  anterior  pillar  slipping  forward  when  the 
weight  of  the  body  rests  upon  it. 

Cause. — Neither  ligaments  nor  muscles  are  capable  of  maintaining  the  arch 
of  the  foot  by  themselves  ;  the  combination  is  essential.  Some  of  the  worst  cases 
of  flat-foot  follow  Pott's  fracture  when  the  internal  lateral  ligament  of  the  ankle 
joint  is  torn,  while,  on  the  other  hand,  it  is  often  the  result  of  loss  of  power  in  some 
of  the  muscles  ;  the  rest  become  tired  out,  and  the  ligaments  which  are  not  calcu- 
lated to  stand  a  persistent  strain  yield  and  give  way  under  the  weight. 

Independently  of  accidents,  it  may  occur  in  infancy,  at  puberty,  or  in  adult 
life.  At  birth  the  arch  has  hardly  any  existence  ;  it  only  becomes  perfect,  like 
the  curves  of  the  spine,  when  the  muscular  system  becomes  active,  and  if  from 
rickets  or  any  other  cause  in  early  childhood  the  time  at  which  this  takes  place  is 


FLAT-FOOT. 


337 


much  delayed,  the  development  of  the  arch  is  seriously  impaired.  It  is  probable 
that  in  this  matter  rickets  is  of  unusual  importance  ;  although  the  change  is  not  so 
obvious  there  can  l)e  little  doubt  that  tlie  osseous  nuclei  in  the  tarsus  are  affected  in 
the  same  way  as  those  elsewhere,  and  that  the  shape  of  the  bones,  esijecially  when 
the  rickety  period  is  prolonged,  may  be  permanently  altered,  rendering  subsetpient 
development  imperfect.  It  is  not  uncommon  to  find  every  single  member  of  a 
family  tlat-footed  from  early  childhood. 

The  form  of  fiat-foot  that  occurs  at  puberty  is  still  more  common,  and  is 
nearly  always  associated  with  genu  valgum  and  lateral  curvature  of  the  spine.  The 
cau.ses  of  the  three  deformities  are  the  same,  and  naturally  they  usually  occur 
together.  The  strength  of  the  bones  and  ligaments  is  dependent  upon  the  perfec- 
tion of  muscular  development ;  at  puberty,  if  growth  is  rapid,  the  weight  of  the 
body  becomes  too  great  for  its  strength,  the  muscles  give  way,  the  strain  falls  upon 
the  ligaments,  which  are  already  weak  and  lax,  and  deformity  follows,  either  in 
the  feet,  the  knees,  or  the  spine,  or  in  all  three  together.  At  first  the  bones  are 
unaffected,  but  in  a  very  little  while  they  become  altered  in  shape,  and  then,  short 
of  operation,  the  condition  is  permanent.  When  the  food  is  poor,  the  hours  of 
labor  long,  and  the  patient  kept  standing  without  a  rest  the  whole  time,  deformity 
is  exceedingly  rapid. 

In  adults,  fiat-foot  rarely  occurs  except  as  a  result  of  accident  (Pott's  frac- 
ture), of  rheumatism  (gonorrhoeal  or  not),  or  of  some  illness  that  seriously  affects 
the  strength  of  the  muscles,  such  as  diphtheria  or  typhoid  fever.  I  have  known  it 
result  from  a  violent  blow  on  the  uj^per  part  of  the  fibula  injuring  the  peronei, 
either  directly  or  through  their  nerve  supply. 

Symptoms. — The  alteration  in  shape  is  characteristic.  The  astragalus 
slowly  sinks  forward,  slipping,  as  it  were,  off  the  sustentaculum,  which  sinks  with 
it ;  the  scaphoid  is  displaced,  or  even  partially  dislocated,  the  axis  of  the  os  calcis  is 
no  longer  directed  upward,  the  inner  side  of  the  foot  is  lengthened,  and  when  the 
patient  rests  his  weight  upon  it  the  whole  of  it  touches  the  ground.  In  the  worst 
cases  the  outer  edge  is  a  little  raised  and  everted,  and  the  peronei  tendons  stand 
out  like  rigid  cords. 

In  the  rheumatic  and  gonorrhoial  forms  the  pain  is  intense ;  in  the  ordinary 
one  that  occurs  at  puberty,  the  foot  is  perfectly  easy  of  a  morning  ;  the  muscles  are 
rested  then  and  can  do  their  work.  By-and-by,  however,  they  become  tired,  the 
strain  falls  upon  the  ligaments,  and  the  pain  as  they  stretch  grows  more  and  more 
severe.  It  ceases  at  once  if  the  foot  is  raised  from  the  ground.  Sometimes  in 
these  cases,  when  the  strain  is  kept  up  continuously,  there  is  a  considerable  degree 
of  inflammation,  and  the  astragalus  and  scaphoid  may  even  become  ankylosed. 
More  often  the  arch  sinks  completely  down,  and  then  the  pain  subsides  ;  the 
weight  is  borne  by  the  bones  directly,  and  there  is  no  more  stretching. 

In  many  instances  the  foot  is  perfectly  flat,  even  when  there  is  no  weight 
resting  upon  it  ;  in  doubtful  cases  it  is  advisable  to  let  the  patient  stand  for  a 
moment,  with  his  feet  just  wetted,  upon  a  sheet  of  colored  blotting  paper ;  the  sur- 
face that  comes  into  contact  with  the  ground  w-hen  his  weight  bears  upon  the  arch 
can  be  seen  at  a  glance. 

Treatment. — In  the  early  stages  of  the  deformity,  while  the  arch  still  per- 
sists, much  may  be  done  by  means  of  massage,  cold  sponging,  and  tiptoe  exercises. 
The  nutrition  of  the  muscles  improves,  and  if  long  standing  and  fatigue  are 
avoided,  the  cure  is  often  permanent.  The  heel  of  the  boot  should  in  all  cases  be 
deeper  upon  the  inner  side  than  the  outer,  as  recommended  by  Thomas,  of  Liver- 
pool. 

If  the  arch  is  already  lowered,  and  the  patient's  occupation  cannot  be  changed, 
cure  is  practically  hopeless  ;  the  cause  continues  and  the  effect  will  grow^  worse. 
Relief,  however,  may  be  obtained  by  wearing  properly  contrived  supports.  In 
the  slighter  cases,  a  valgus  pad  made  of  rubber,  or,  if  this  is  too  hard,  of  leather 
stuffed  with  horse  hair,  may  be  fixed  inside  the  boot.  The  heel  should  be  broad 
and   low,  the  waist   fairly  rigid,  and  ample  space  allowed  in  front.     The  pressure 


338     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 


must,  it   is  true,  act   to  a  certain  extent   injuriously  upon   the  tissues  in  the  con- 
cavity, but  it  is  a  choice  between  two  evils. 

In  worse  cases,  when  the  foot  remains  flat, 
even  though  no  weight  is  resting  ujjon  it,  this  is 
not  enough  ;  however  well  made  the  boot,  the  foot 
is  sure  to  rotate  in  it,  and  the  only  way  to  make  it 
secure  is  by  means  of  an  outside  iron.  The  lower 
end  of  this  is  let  into  the  heel  ;  opposite  the  ankle 
it  is  jointed,  and  above  it  is  fastened  by  a  band 
round  the  calf.  A  triangular  piece  of  leather  is 
sewn  inside  the  boot,  on  its  outer  Ijorder,  so  that 
it  passes  under  the  sole  of  the  foot,  beneath  the 
astragalo-scaphoid  articulation,  up  the  inner  side, 
through  a  slit  in  the  uppers,  and  is  buckled  to  the 
iron.  Or  a  rubber  band  is  used  in  the  same  way, 
after  Walsham's  plan  (Fig.  102).  For  a  time  at 
least  this  gives  relief ;  and  if  tiptoe  exercise  is 
diligently  practiced,  after  some  months  there  may 
be  distinct  improvement. 

When  the  i)ain  is  very  great,  and  the  peronei 
tendons  are  tense,  this  cannot  be  carried  out  at 
first.  The  foot  must  be  rested  and  raised,  until 
the  tenderness  has  subsided  ;  then  the  patient  is 
placed  under  an  anaesthetic,  all  the  joints  worked 
and  wrenched  to  their  full  extent,  and  the  foot 
brought  into  the  best  possible  position  by  forced  inversion,  combined  with  direct 
pressure  upon  the  scaphoid.  This  position  is  maintained  for  a  week  or  ten  days 
by  means  of  a  plaster  bandage,  and  then  the  process  is  repeated  until  something 
like  an  arch  is  restored.  The  peronei  tendons  should  not  be  divided  if  it  can 
possibly  be  avoided. 

In  some  of  those  that  are  worse  still  tarsectomy  and  other  similar  operations 
are  recommended.  The  head  of  the  astragalus  has  been  exci.sed  (Stokes)  and  the 
foot  forcibly  adducted.  The  astragalo-scaphoid  articulation  has  been  opened 
freely,  sufficient  bone  removed  to  enable  the  arch  to  be  restored,  and  the  two 
bones  drilled  and  fixed  with  a  couple  of  ivory  pegs  passed  through  them  (Ogston)  ; 
and  the  scaphoid  has  been  excised  by  others.  It  is  possible  that  in  some  cases  in 
which  there  is  persistent  pain  these  operations  may  be  of  some  use  ;  they  un- 
doubtedly restore  the  shape  of  the  arch,  although  it  is  probable  that  bony  anky- 
losis always  occurs  (in  Ogston 's  this  is  partly  the  object)  ;  but  seeing  that  they  can 
only  be  recommended  for  extreme  cases,  and  that  these  have  for  the  most  part 
already  passed  the  painful  stage,  the  number  for  which  they  are  advisable  is  very 
small.  When  the  arch  has  once  become  flat,  so  that  the  inner  border  of  the  foot 
rests  upon  the  ground,  the  gait  is  very  ungainly,  it  is  true,  but  the  inconvenience 
is  rarely  sufficient  to  recommend  an  operation  which  practically  must  lay  the 
patient  up  for  many  months.  [And  even  after  the  operation  the  shoe  will,  never- 
theless, have  to  be  worn  for  a  long  period,  so  that  the  operation  is  obviously  of 
extremely  doubtful  utility.] 


Fig.  102. — Walsham's  Shoe. 


Deformities  of  the  Toes. 
Hammer-  Toe. 
This  name  has  been  given  to  a  peculiar  deformity  which  affects  the  second 
toe  in  ])articular,  but  .sometimes  all.  The  first  phalanx  is  retracted  at  the  meta- 
tarso-phalangeal  articulation,  the  second  is  flexed  at  right  angles  to  the  first,  and 
the  third  bent  so  that  its  true  extremity  is  directed  downward.  In  the  earlier 
stages  of  the  disease  the  parts  can  l)e  placed  in  the  normal  position  without  diffi- 
culty, but  after  a  little  while  the  ligaments  contract  and  the  displacement  is  per- 


DEFORMITIES  OF  THE  TOES.  339 

niancnt,  tlie  first  i)halangeal  joint  Itecoming  rigid,  as  a  rule,  before  the  metatarso- 
phalangeal one. 

The  cause  of  this  deformity  is  unknown  in  most  cases.  It  is  not  unfre- 
quently  congenital  and  even  hereditary  ;  usually  it  is  symmetrical  and  often  con- 
fined to  the  second  toe.  It  may  be  associated  with  the  slighter  forms  of  talipes 
ecjuinus  (talipes  arcuatus  and  plantaris)  and  caused  l)y  contraction  of  the  ])lantar 
fascia  ;  or  the  rest  of  the  foot  may  be  absolutely  normal.  That  it  can  be  produced 
by  wasting  of  the  interossei  there  is  no  doubt,  as  it  is  not  unfrequently  seen  in 
cases  of  progressive  muscular  atrophy  ;  these  muscles  flex  the  nietatarso-])halangeal 
articulation  and  extend  the  other  two,  and  when  they  alone  are  paralyzed,  the 
various  segments  naturally  assume  the  opposite  position.  In  the  vast  majority  of 
instances,  however,  no  evidence  of  paralysis  is  present.  The  lower  part  of  the 
lateral  ligaments  of  the  first  jjhalangeal  joint  is  always  much  shortened  and  con- 
tracted, and  it  has  been  suggested  that  the  deformity  is  due  to  chronic  inflamma- 
tion beginning  in  this  articulation  ;  but  it  is  equally  possible  that  the  change  is  a 
secondary  one,  caused  by  permanent  fixation  in  an  unnatural  position.  The 
changes  in  the  other  structures  of  the  joint,  no  doubt,  are  secondary.  Whether  it 
can  be  caused  by  ill-fitting  boots  is  equally  uncertain  ;  it  is  probable  they  aggravate 
the  deformity,  but  as  it  is  occasionally  present  at  birth  (though  it  more  frequently 
develops  at  puberty),  and  as  it  is  not  more  common  in  one  class  of  life  than 
another,  hospital  patients  suffering  as  frequently  as  those  in  a  better  station,  the 
influence  they  possess  is  doubtful. 

Treatment. — In  the  slighter  cases,  in  which  contraction  has  not  yet  taken 
place,  relief  may  be  obtained  by  wearing  suitable  boots,  sufficiently  broad  in  front, 
with  low  heels,  and  by  massage  and  friction.  If  this  does  not  succeed,  an  attempt 
may  be  made  to  keep  the  toes  extended  by  means  of  a  metal  sole-plate,  worn  at 
night,  and  as  long  during  the  day  as  practicable.  The  portion  that  comes  under 
the  toes  is  provided  with  slits  through  which  little  elastic  and  leather  bands  are 
passed,  so  as  to  draw  the  toes  down  ;  or  the  plate  may  be  double,  one  part  above 
the  foot  and  the  other  below,  wnth  little  screws  and  pads,  so  that  direct  pressure 
can  be  exerted  upon  the  joints  from  above. 

In  most  cases,  however,  the  time  for  such  simple  remedies  as  this  is  already 
past.  The  contraction  of  the  ligaments  and  fascia  is  too  rigid  to  admit  of  gradual 
extension,  and  the  toes  are  distorted  and  deformed  with  callosities.  The  choice 
then  lies  between  division  of  the  lateral  ligaments,  excision  of  the  proximal  end 
of  the  offending  phalanx,  and  amputation.  Of  these  the  second  is  the  only  one 
that  holds  out  a  definite  prospect  of  relief  without  risk  of  relapse  and  without  the 
mutilation  involved  in  amputation.  Subcutaneous  section  of  the  lateral  ligaments, 
however,  is  such  a  simple  proceeding  and  lays  the  patient  up  for  such  a  short  time 
that  it  may  reasonably  be  tried  first. 

Deformities  of  the  Great  Toe. 

(a)  Hallux  Flexiis. — This  deformity,  described  by  Davis-Colley,  closely 
resembles  hammer-toe  in  many  respects.  It  occurs  under  the  same  conditions  ;  it 
is  apparently  not,  like  hallux  rigidus,  dependent  upon  flat-foot,  and  it  usually 
develops  at  puberty  ;  but  the  metatarso-phalangeal  joint  is  flexed  instead  of  being 
over-extended,  and  the  toe  is  wholly  bent  downward,  so  that  the  patient  is  com- 
pelled to  walk  upon  the  outer  side  of  the  foot.  The  suggestion  that  the  difference 
is  to  be  accounted  for  by  the  different  development  of  the  great  toe,  the  metatarso- 
phalangeal joint  corresponding  to  the  interphalangeal  of  the  others,  is  attractive, 
iDut  probably  not  correct,  as  true  hammer-toe  is  sometimes  met  with. 

(J))  Hallux  Rigidus. — This  name  has  been  given  to  a  peculiar  stiff  and  painful 
condition  of  the  metatarso-phalangeal  articulation.  Considerable  doubt  exists  as  to 
whether  it  is  not  identical  with  the  former  (although  the  toe  is  kept  in  a  straight 
line  with  the  foot)  ;  it  differs,  however,  in  being  nearly  always  associated  with  flat- 
foot,  and  probably  dependent  upon  it,  inflammation  of  the  joint  being  caused  by 


340     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 


repeated  slight  injury  from  ill-fitting  boots.    A  similar  condition  is  sometimes  pro- 
duced by  osteoarthritis. 

It  is  usually  met  with  at  puberty  and  in  boys  who  have  to  stand  for  many  hours 
together.  In  the  early  stages  there  is  often  a  certain  amount  of  inflammation,  but 
it  is  rarely  very  marked  or  prolonged.  Nearly  always  the  toe  is  cold,  stiff,  and 
rigidly  extended,  sometimes  cjuite  straight,  sometimes  with  a  certain  degree  of 
valgus.  The  least  attempt  at  flexion  causes  severe  pain,  and  in  all  but  the  slightest 
cases  there  is  distinct  enlargement  with  lipping  and  hypertrojjhy  of  the  articular 
ends.  The  nature  of  the  deformity  can  often  be  detected  at  once  by  noticing  the 
condition  of  the  boot ;  the  arch  is  flat ;  there  is  a  projection  in  front  where  the 
toe  presses  against  it,  and  there  are  no  wrinkles  in  the  leather,  .showing  that  the 
joint  is  never  used. 

The  treatment  of  this  affection,  like  that  of  hallux  flexus  and  hallux  valgus, 
is  very  unsatisfactory.  If  seen  in  time,  it  may  be  cured  by  restoration  of  the  arch 
of  the  foot,  but  nearly  always  extensive  changes  have  made  their  appearance  in  the 
articular  surfaces  before  the  patient  is  aware  of  the  extent  of  the  mischief.  The 
question  then  turns  upon  the  amount  of  pain  ;  if  it  is  only  slight  a  well-made,  roomy 
boot,  with  a  valgus-pad,  may  answer;  but  if  it  is  more  severe,  particularly  if  it 
prevents  the  patient  taking  a  fair  amount  of  exercise,  the  best  plan  of  treatment 

is  to  remove  a  sufficient  portion  from 
the  proximal  end  of  the  first  phalanx. 
The  same  thing  must  be  done  for  hal- 
lux flexus. 

{c)  Hallux  Valgus. — The  deform- 
ity affects  the  same  joint,  but  the  toe 
is  bent  outward,  either  over  or  under 
the  others,  until  it  may  be  at  right 
angles  to  its  normal  direction.  This, 
there  is  no  doubt,  is  always  due  to  ill- 
fitting  boots.  The  articular  changes 
in  the  early  stages  are  the  same  as  in 
hallux  rigidus  and  in  other  forms  of 
chronic  traumatic  arthritis;  but  after 
a  time  gouty  or  rheumatic  inflamma- 
tion usually  follows,  and  urate  of  soda 
is  deposited,  or  immense  lips  of  bone 
are  formed  and  the  surface  becomes 
hard  and  polished  from  friction. 
Hallux  valgus  derives  much  of  its  importance  from  its  association  with  bunion, 
a  bursa  developed  over  the  inner  side  of  the  joint  from  the  constant  pressure  and 
friction  of  the  boot.  This  may  be  found  in  all  stages  of  inflammation  ;  when  it 
is  recent  there  is  merely  a  thin-walled  sac,  filled  with  clear  fluid  ;  after  repeated 
attacks  it  becomes  thick  and  fibrous,  until,  with  the  corn  that  lies  upon  it,  it  forms 
an  almost  solid  swelling  ;  or  else  it  suppurates,  and  then  it  becomes  serious,  from 
the  fact  that  it  nearly  always  communicates  with  the  joint.  In  most  cases,  how- 
ever, by  this  time  the  cartilages  have  disappeared  and  there  is  nothing  left  but  two 
hard,  bony  surfaces,  held  together  by  a  tough,  fibrous  capsule. 

The  treatment  in  the  earlier  stages  is  very  simple;  the  boot  must  be 
made  the  shape  of  the  foot — straight,  that  is  to  say,  upon  the  inner  side  ;  and 
at  night,  and  whenever  it  is  convenient,  a  sole-plate  must  be  worn  with  a  spring 
upon  its  inner  border  to  draw  the  toe  into  line  again.  If  matters  have  gone  too 
far  for  this,  all  that  can  be  done  is  to  prevent  further  injury.  Should  sup- 
puration occur  in  connection  with  the  joint,  a  free  opening  must  be  made 
upon  the  inner  side,  and  a  sufficient  portion  of  the  ba.se  of  the  first  phalanx 
removed  to  bring  the  toe  into  the  right  line  again.  The  metatarsal  itself  is 
better  left  untouched,  but  a  fair  amount  of  bone  must  be  taken  away  or  osseous 
ankylosis  will  ensue.     Osteotomy  of  the  neck  of  the  first  metatarsal  is  recommended 


Fig.  103. — Lever  for  Relief  of  Hallux  Valgus. 


GENU  VALGUM.  341 

for  simple  hallux  valj;us,  l)ringiiig  the  toe  into  line  at  once,  and  as  it  can  be  done 
almost  subcutaneoiisly  is  not  a  serious  operation  ;  but  it  rarely  happens  that  patients 
consitler  the  deformity  alone  a  sufficient  reason,  as  it  seldom  causes  much  discom- 
fort until  a  bunion  is  develoj^ed. 

Gknu  Valgum. 

Knock-knee,  like  the  other  deformities  due  to  want  of  strength,  may  occur 
either  in  childhood  or  at  puberty.  In  the  former  case  it  is  always  associated  with 
rickets  ;  in  the  latter  it  is  usually  met  with  in  conjunction  with  flat-foot  and  lateral 
curvature  of  the  spine.  Owing  to  the  width  of  the  pelvis  the  natural  direction  of 
the  femur  is  from  above  obliquely  downward  and  inward,  and  this  determines 
the  direction  of  the  deformity  ;  the  disproportion  l)etween  the  weight  to  be  carried 
and  the  strength  of  the  muscles  (upon  which  the  perfection  of  the  ligaments  and 
bones  depends)  regulates  the  amount;  and  when  it  once  has  commenced  it  natur- 
ally advances  at  a  much  more  rapid  rate. 

The  nature  of  the  deformity  is  obvious  at  once,  but  the  extent  requires  careful 
measurement.  The  lower  margin  of  the  internal  condyle  is  prolonged  downward 
far  below  the  level  of  the  external ;  but  it  does  not  project  in  the  least  backward. 
Consecpiently  the  legs  are  perfectly  parallel  when  the  knees  are  bent,  and  diverge 
only  when  they  are  extended.  The  essential  change  is  an  overgrowth  of  the  inner 
border  of  the  diaphysis,  although  the  internal  condyle  may  be  itself  somewhat 
elongated. 

That  it  is  solely  due  to  obliquity  of  pressure  and  consecutive  alteration  in  the 
shape  of  the  bone  is  shown  by  the  similar  distortion  that  occurs  when  one  thigh 
has  been  amputated  in  a  child  and  no  artificial  limb  has  been  worn.  From  con- 
stantly bringing  the  remaining  leg  under  the  centre  of  gravity  of  the  body,  so  that 
the  crutches  may  be  swung  forward,  it  assumes  a  condition  of  extreme  genu 
valgum,  the  inner  condyle  being  prolonged  downward  and  not  backward  in  pre- 
cisely the  same  manner.  The  two  worst  cases  I  have  ever  seen  were  caused  by  this  ; 
the  method  of  production  is  identical  with  that  of  the  ordinary  form  which 
develops  at  puberty  ;   the  cause  is  somewhat  different. 

Treatment. — This  depends  upon  the  degree  of  deformity  and  the  length  of 
time  it  has  lasted.  In  any  case  a  certain  amount  of  rest  is  the  first  consideration  ; 
the  cause,  as  in  lateral  curvature,  is  excessive  work  ;  the  strength  is  not  equal  to  the 
weight,  and  so  long  as  the  weight  is  allowed  to  press  upon  the  knees  and  drive  them 
inward  the  deformity  must  grow  worse. 

(^a)  In  children  in  whom  there  is  other  evidence  of  rickets  the  prognosis  is 
good  unless  the  hardening  stage  has  set  in,  and  buttresses  of  compact  tis.sue  have 
been  dei:)Osi ted  in  the  concavities  of  all  the  bones  ;  if  this  has  occurred  the  condi- 
tion is  permanent,  short  of  operation.  Cod-liver  oil,  iron,  good  food,  meat,  eggs, 
and  milk  are  es.sential.  In  the  slighter  cases  it  is  impossible  to  confine  the  child  to 
bed,  but  it  should  never  be  allowed  to  tire  itself;  the  nutrition  of  the  legs  and  of 
the  muscles  in  particular  must  be  maintained  by  rubbing  with  oil  night  and  morn- 
ing, bathing  with  salt  water,  friction,  massage,  warmth,  and  galvanism.  If  this  is 
thoroughly  carried  out  the  limbs  gradually  become  straight  of  themselves. 

If  the  condition  is  more  serious — that  is  to  .say,  if  there  is  a  definite  interval 
of  some  inches  between  the  malleoli  when  the  knees  are  extended — the  same  plan 
must  be  pursued  ;  the  child  must  be  kept  in  bed  and  splints  applied  every  day,  to 
draw  the  knees  slightly  outward.  Too  much  pressure  should  not  be  used  ;  the 
skin  is  exceedingly  delicate  and  sores  are  easily  formed  ;  but,  on  the  other  hand, 
unless  the  parts  are  well  fixed,  children  can  always  twist  their  legs  round  until  by 
slightly  flexing  the  knees  they  escape  pressure  altogether.  Where  trouble  is  no 
object  the  splints  should  be  removed  night  and  morning,  an  inside  one  being  worn 
at  night,  an  outside  one  in  the  daytime  ;  and  every  time  they  are  changed  the 
skin  should  be  thoroughly  rubbed,  the  muscles  kneaded,' and  the  part  manipulated 
into  the  right  direction  with  as  much  force  as  is  consistent  with  avoiding  pain. 


342    DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 

An  extraordinary  degree  of  improvement  can  be  effected  in  this  way  in  a  very 
short  space  of  time,  'rhe  muscles  gain  size  and  strength  ;  the  tone  of  the  limb 
improves;  the  legs  grow  straighter  and  the  inequality  between  the  condyles  dis- 
appears. 1  have  more  than  once  seen  a  leg  become  perfectly  straight  while  a  child 
was  lying  in  bed  recovering  from  an  osteotomy  performed  upon  the  other  one.  It 
is,  however,  of  little  or  no  good  after  sclerosis  has  set  in. 

(/')  The  form  of  knock-knee  that  develops  at  puberty  must  be  treated  on  the 
same  principles.  It  is  nearly  always  met  with  in  those  whose  occupations  compel 
them,  just  at  the  time  they  are  growing  most,  to  stand  many  hours  a  day  ;  and  it 
is  nearly  always  associated  with  flat  feet.  Of  course,  if  the  occupation  is  con- 
tinued very  little  can  be  done  ;  the  deformity  will  grow  worse  until  a  kind  of  equi- 
librium is  reached  ;  but  if  this  can  be  changed,  and  the  tendency  to  flat-foot 
checked  either  by  a  valgus-pad  or  by  Thomas's  obliquely-cut  heel,  the  limbs  can 
generally  be  brought  into  the  right  line. 

In  worse  cases,  in  which  the  period  of  growth  is  ended,  or  in  which  the 
deformity  when  the  knees  are  extended  is  considerable,  osteotomy  affords  the  better 
promise.  At  this  age  it  is  not  possible  to  effect  any  considerable  change  in  the 
shape  of  the  bones,  as  it  is  in  children  and  especially  in  rickety  children.  If  pres- 
sure is  persisted  in,  the  fibrous  structures  on  the  outer  side  of  the  joint,  the  exter- 
nal lateral  ligaments,  and  the  ilio-tibial  band  are  very  likely  to  yield,  and  allow  the 
external  condyle  to  separate  itself  from  the  tibia,  so  that  when  the  splints  are 
removed  and  the  patient  is  allowed  to  stand  upright,  he  is  merely  propped  upon 
the  internal  condyle  in  a  most  insecure  manner. 

Rickets. 

In  rickets  many  deformities  of  bones  are  met  with  besides  genu  valgum.  The 
femur  is  often  bowed  outward  and  forward  ;  the  tibia  is  bent,  especially  at  its 
lower  extremity  where,  it  is  weakest,  until  the  convexity  of  the  curve  seems  to  hang 
over  the  ankle  ;  and  in  other  cases  again  the  femur  and  tibia  together  are  curved 
outward,  so  that  exactly  the  opposite  condition  to  genu  valgum  is  produced — bow- 
leg, or  genu  extrorsum.  The  particular  kind  of  deformity  is  regulated  partly  by 
the  natural  curve  of  the  bones,  partly  by  the  attitude  and  habits  of  the  child, 
whether  it  is  old  enough  to  run  about,  or  sits  tailor-wise  upon  the  ground.  In 
some  rare  instances  genu  valgum  on  one  side  is  associated  with  the  o])posite  deflec- 
tion upon  the  other,  but  this  is  more  usually  a  product  of  later  life,  caused  by 
accidental  deformity. 

The  treatment  is  the  same  as  that  for  genu  valgum.  If  the  bones  are  still  soft 
and  the  weight  is  taken  off  them,  and  if  the  strength  of  the  child  and  the  condi- 
tion of  its  muscles  can  be  sufficiently  improved,  the  deformity  disappears  of  itself. 
Splints  are  of  no  use  in  the  majority  of  cases  ;  the  antero-posterior  curvature  of  the 
tibia,  for  example,  does  not  admit  of  pressure  being  applied  ;  and  it  is  cjuestionable 
whether  the  fashion  of  fastening  them  on  so  that  they  project  below  the  feet  and 
prevent  walking  does  not  do  more  harm  than  good  ;  for  not  unfrequently  the  child 
learns  to  shuffle  about  with  its  limbs  in  a  worse  position  than  they  were  before. 

If  the  rickety  stage  is  passed,  and  deformity  is  left,  it  can  only  be  rectified  by 
osteotomy. 

Osteotomy. — Section  of  a  bone  for  reduction  of  deformity,  or  osteotomy, 
is  performed  either  with  a  chisel  or  a  saw.  The  former,  as  a  rule,  is  preferable, 
not  so  much  because  of  the  dust  caused  by  the  teeth,  as  because  of  the  almost 
unavoidable  laceration  of  the  soft  parts ;  and  MacEwen's  chisels,  made  of  solid 
metal  throughout  and  graduated,  are  the  best.  If  a  saw  is  used,  no  instrument 
has  superseded  that  devised  by  Adams  for  subcutaneous  section  of  the  neck  of  the 
femur. 

The  operation  is  subcutaneous  so  far  as  it  is  possible  to  make  it.  The  limb  is 
thoroughly  cleansed  and  embedded  firmly  on  a  sand-bag  covered  over  with  a  rub- 
ber sheet.     A  small   incision,  parallel   to  the   most  important  structures,  is  made 


RICKETS.  343 

down  to  the  bone  at  the  spot  at  which  it  is  intended  to  divide  it,  and  the  chisel  or 
saw  passed  down  by  the  side  of  it  before  it  is  withdrawn.  If  a  chisel  is  used,  care 
must  be  taken  always  to  work  away  from  important  structures  ;  with  a  little  prac- 
tice, the  different  sensation  as  it  passes  from  compact  to  cancellous  bone  or  vice 
versa  can  be  appreciated  at  once  ;  but  there  is  no  object  in  running  any  risk. 
MacEwen  recommends  that  the  surgeon  should  always  cut  toward  instead  of  from 
himself,  and  that,  if  the  structure  to  be  divided  is  very  wide,  and  the  chisel  deeply 
buried,  a  narrower  one  should  be  substituted  for  it  as  soon  as  the  first  incision  is 
made  ;  it  is  impossible  to  form  a  correct  impression  if  the  instrument  is  fixed,  like 
a  wedge,  by  the  sides  of  the  cut.  The  chisel  must  be  held  in  a  firm  grasp,  and 
should  be  loosened  in  its  bed  from  time  to  time  as  required  by  an  upward  and 
downward  movement,  not  a  transverse  one,  for  fear  of  splintering. 

The  general  rule  is  to  divide  the  compact  tissue  opposite  the  point  of  entrance 
of  the  chisel  first  ;  then  (if  it  is  working  from  the  side)  that  on  the  upper  and 
under  surface  of  the  bone  ;  and  finally  the  soft  central  portion,  leaving  in  this  way 
the  part  on  the  furthest  side  uncut.  If  the  bone  is  very  wide  the  last  part  may  be 
effected  with  a  narrower  chisel,  which  wall  produce  something  of  the  effect  of  a 
wedge-shaped  wound.  As  soon  as  the  division  is  considered  sufficiently  complete, 
the  chisel  is  withdrawn  from  the  bone  with  an  upward  and  downward  movement, 
gradually  loosening  it,  a  sponge  placed  over  the  wound,  and  the  remaining  part 
of  the  compact  shell  fractured.  Some  iodoform  is  then  dusted  over  the  sur- 
face ;  a  catgut  suture  inserted  if  necessary  ;  then  an  absorbent  dressing,  and  a 
suitable  splint,  taking  care  to  move  the  limb  as  little  as  possible  while  it  is  being 
applied. 

Operations  for  Genu  Valgum. — Many  operations  have  been  devised  for 
the  correction  of  this  deformity  ;  but  except  in  special  cases,  MacEwen's  is  the  one 
that  is  usually  practiced.  It  consists  in  subcutaneous  section  of  the  lower  end  of 
the  femur,  immediately  above  the  condyles,  with  a  special  chisel. 

The  cutaneous  incision  commences  at  the  junction  of  a  line  drawn  transversely 
a  finger's  breadth  above  the  external  condyle  with  a  longitudinal  one  half-an-inch 
in  front  of  the  tendon  of  the  adductor  magnus.  The  scalpel  is  carried  down  to 
the  bone  and  the  incision  prolonged  sufiliciently  to  admit  the  osteotome.  This 
(beginning  with  the  largest)  is  introduced  by  the  side  of  the  scalpel  before  it  is 
withdrawn,  and  then  turned  round  through  a  right  angle.  The  posterior  internal 
border  is  the  part  first  divided,  the  chisel  pointing  forward  and  outward  ;  then 
the  internal  border ;  and  after  that  toward  the.  outer  posterior  angle,  working 
always  from  the  artery.  After  the  compact  layer  is  cut  through  it  is  advisable 
to  change  the  osteotome  for  one  with  a  narrower  blade,  especially  in  the  case  of 
an  adult.  Then  the  residue  of  the  bone  is  fractured,  the  limb  brought  into  a 
straight  line,  and  a  suitable  splint  applied.  In  children,  the  most  convenient 
apparatus  is  one  of  the  ornamental  flower-pot  holders  made  of  diagonal  bars ;  it 
can  be  placed  in  position  at  once  ;  and  it  is  sufficiently  flexible  to  fit  accurately 
over  the  dressing.  If  the  little  wound  is  sealed  with  iodoform-collodion  and 
covered  with  wood-wool,  there  is  no  need  to  disturb' it  until  the  fracture  is  sound. 

In  Ogston's  operation  the  internal  condyle  of  the  femur  is  detached  and 
pushed  further  up  the  shaft.  It  may  be  performed  either  with  a  chisel  or  a  saw. 
A  long-bladed  tenotomy  knife  is  introduced  two  or  three  inches  above  the  internal 
condyle  and  pushed  through  the  tissues  until  it  can  be  felt  in  the  inter-condyloid 
space ;  the  soft  structures  are  then  divided  down  to  the  bone,  Adams'  saw  passed 
by  its  side,  and  the  tenotome  withdrawn.  The  internal  condyle  is  sawni  about 
three-quarters  through  from  above  downward,  and  the  fracture  completed  by 
forcibly  straightening  the  limb.  The  same  precautions  and  the  same  after-treat- 
ment are  required  as  before. 

Reeves,  who  uses  round-edged  chisels  without  angles,  modifies  this  by 
dividing  the  bone  only  and  leaving  the  cartilage  to  be  ruptured. 

Redresseme7it  (forcible  straightening)  was  practiced  largely  at  one  time, 
but  though  the  limb  can   often  be  brought  into  a  straight  line,  it  is  impossible  to 


344    DISEASES  AND  IXJURIES  OE  SPECIAL  STRUCTURES. 

say  what  yields  ;  it  may  l)e  tlie  epiphysial  line,  or  the  lower  end  of  the  shaft,  or  the 
ligaments. 

Whatever  forni  of  operation  is  used,  the  limb  requires  support  for  many 
months.  It  must  not  be  forgotten  that,  though  the  deformity  is  cured,  the  causes 
that  gave  rise  to  it  are  probably  there  still,  and  that,  unless  precautions  are  taken, 
it  will  infallibly  return. 

Rickety  deformities  of  bones  are  treated  on  the  same  ])rinciples.  Subcuta- 
neous fracture  (either  manual  or  with  an  osteoclast)  succeeds  sometimes,  the  bone 
breaking  (or  if  it  is  still  soft,  bending)  at  the  weakest  spot,  and  enabling  the  limb 


31 


Fig.  104. — The  Osteoclast  of  Rizzoli. 


to  be  brought  straight  at  once.  In  most  cases,  however,  osteotomy  is  preferred, 
either  simple  linear  division,  or,  if  the  deformity  is  very  great,  cuneiform — that  is 
to  say,  the  excision  of  a  wedge. 

[Osteoclasis. — This  consists  in  fracturing  the  bone  with  the  osteoclast 
invented  by  Rizzoli,  and  in  special  cases  it  is  preferable  to  osteotomy;  the 
difference  in  the  respective  wounds  being  that  between  a  simple  fracture  and  an 
open  (compound)  one,  except  that  in  osteotomy  there  is  a  clean-cut  incision 
instead  of  an  irregular  or  serrated  break.  Repair  is  apparently  more  speedy  after 
osteoclasis.] 


FRACTURES.  345 


SHCTION  II.— INJUKIHS  OF  BONHS. 

1  RACTURES. 

A  fracture  is  a  sudden  interruption  in  the  continuity  of  a  bone,  produced  by 
violence.  For  convenience  of  description,  this  definition  is  allowed  to  include 
other  injuries  similar  in  character,  such  as  separation  of  the  costal  cartilages  from 
the  ribs,  and  in  young  subjects  separation  of  epiphyses. 

Fractures  are  divided  into  two  classes,  simple  z\\(\.  coinpimnd."^-  In  the  former 
the  skin  is  unbroken,  the  fragments  are  never  exposed  to  the  air,  there  is  no  ri.sk  of 
absori)tion,  and  the  injury  is  repaired  like  a  wound  that  lieals  by  the  first  intention  ; 
in  the  latter,  the  broken  ends  are  laid  bare  at  some  time  or  other,  away  is  opened 
up  for  the  absorption  of  foreign  substances,  and  there  is  (so  long  as  the  wound  is 
open)  the  constant  danger  of  cellulitis,  necrosis,  phlebitis,  pyaemia,  and  other 
infectious  diseases. 

A  fracture  may  be  compound  at  the  time  of  the  accident,  or  may  become  so 
at  a  later  period  from  sloughing  of  the  skin  and  soft  tissues  over  the  broken  ends. 
When  it  is  compound  from  the  first,  either  the  wound  and  the 
fracture  are  produced   together  by   the  same   force — a  cart-  __ 

wheel,  for  example,  pa.ssing  over  a  limb  and  tearing  the  skin      f 
from  off  the  bone  as  it  crushes  it;  or  the  pointed  end  of  one      | 
of  the  fragments  is  driven  from  underneath  through  the  skin,      \ 
owing  to  involuntary  muscular  contraction  at  the  time  of  the 
accident,  or  want  of  care  in  handling  the  part  afterward.      In  \    tlti'l; 

the  former  case  {compound  by  direct  violence'),  the  injury  to  the  |  ^vfy, 

soft  parts  is  generally  extensive  ;   they  are  bruised  and  cru.shed  |  i^b 

for  a  considerable  distance  on  either  side;   in  the  latter  {com-  \ 

pound  by  indirect  violence^  there  is  only  a  puncture,  the  wound*         1    ^ 
may  close  at  once,  and  the  fracture  become,  to  all  intents  and         r, 
purposes,  a  simple  one.  *J 

The  danger  is  less  when  the  fracture  becomes  compound         % 
secondarily  from  sloughing  or  other  causes.     Absorption  from  I 

the  surface  is  not  so  easy  ;  the  gaping  channels  that  are  present  fv^'iViij 

in  a  recent  wound  are  sealed  by  the  lymph  already  thrown  \\  v^M 

out,  and   the  current  sets  rather  from  the  deeper  parts  out-  tJ^*'\ 

ward,  so  that,   provided  the  sloughing  is  local  and  limited, 
the  risk  of  septic  poisoning  is  not  so  immediate. 

Fractures,  simple  or  compound,  are  said  to  be  complicated  '.,%^ 

when   the  viscera  or  other   important  structures  near  are  in-  <:v^« 

volved ;  when,  for  instance,  the  ribs  are  driven  into  the  lungs 
or  liver,  or  when  a  large  artery  is  punctured  or  torn  across.  — - 

Fractures  are  complete,  if  the  bone  is  broken  entirely f,g.  105— Transverse  Sub- 
through  ;  incomplete,  if  the  injury  falls  short  of  this  in  any  way;    Periosteal  Fracture  of  Fe- 

,  .  J  J  J      mur,   wuh    Beginning    of 

and  sub  periosteal,   if,  as  often  happens  in  children,  the  tough    Callus.    From  an  infant, 
periosteum  remains  untorn  (Fig.  105). 

The  cancellous  tissue  of  a  bone,  for  example,  may  be  crushed  and  compressed, 
or  a  splinter  may  be  chipped  off  from  the  side  ;  or  the  compact  tissue  may  be 
fissured  in  one  or  more  directions,  without  any  fragment  being  actually  detached. 
A  peculiar  form  is  common  in  children,  affecting  the  long  bones,  especially  the 
clavicle.     The  osseous  tissue  in  them  is  so  soft  and  elastic  that  it  can  bend,  in  some 

[*  The  term,  "  compound,"  so  long  applied  to  these  fractures,  is  a  meaningless  one  ;  the  German 
term,  open  fracture,  is  much  more  expressive.] 
23 


346     DISEASES  AND   INJURIES   OF  SPECIAL    SIR UC TURKS. 

cases  almost  to  a  right  angle,  without  breaking,  and  regain  its  shape  coni|)letely  as 
soon  as  the  pressure  is  removed.  (Generally,  however,  before  this  point  is  reac  hed, 
longitudinal  fissures  make  their  ai)pearance  in  the  bones,  and  then,  if  the  force 
continues,  the  periosteum  and  the  compact  tissue  at  the  apex  of  the  curve  begin 
to  tear,  until  the  fracture  extends  perhaps  half  across.  These  are  called  ^rr^«- 
stick  fractures,  as  the  bone  is  not  actually  broken  in  two  ;  they  do  not  regain  their 
shape  when  the  force  is  spent,  and  often,  owing  to  the  jagged  nature  of  the  end 
and  the  way  they  fit  against  each  other,  there  is  considerable  difficulty  in  straighten- 
ing them  again  (Fig.   io6). 

A  fracture  is  single  when  the  bone  is  broken  f^ 

in  only  one  place,  multiple  when  it  gives  way  in  ^M'i:'^\ 

more  than  one,  and  cotnminuted  when  there  is  a  ' 

number  of  small  fragments  at  one  spot.      It  may 


■\y»'>. 


Fig.  io6  — Greenstick  Fracture  of  Radius,  Showing  the  Longi- 
tudinal Splintering.  In  this  case  it  ran  down  to  the  epiphysis, 
which  has  been  separated  by  maceration. 


Fig.  107. — Comminuted  Fracture  of  Clavicle.  Fk..  1       — I —liaped  Fracture  of  Lower 

Knd  of  Humerus. 

vary  in  direction  aS  well  as  in  extent,  and  be  transverse,  oblique,  or  longitudinal. 
Sometimes,  as  in  the  patella,  it  is  stellate ;  sometimes  serrated,  like  the  teeth  of  a 
saw;  or  it  may  run  round  a  long  bone  in  the  form  of  a  spiral.  It  is  T-shaped 
when  there  is  a  transverse  fracture  immediately  above  a  joint  and  the  smaller  of 
the  fragments  is  split  vertically  into  two  (Fig.  io8)  ;  punctured,  when  there  is  a 
Avound  in  the  substance  of  the  bones;  o.x\(\  perforated,  when  it  goes  right  through. 
Finally,  if  one  fragment  is  driven  into  the  substance  of  the  other — if,  for  example, 
the  compact  wall  of  the  shaft  is  driven  into  the  soft,  cancellous  tissue  of  one  of 
the  articular  ends,  so  that  the  two  are  locked  together,  it  is  said  to  be  impacted. 

Influence  of  Age. — Fractures  are  met  w^ith  in  all  periods  of  life,  but  with  very 
different  degrees  of  frequency  at  different  ages. 

Intra-uterine  fractures  are  not  uncommon,  lliey  may  be  caused  by  muscu- 
lar contraction  of  the  walls;  but  in  most  cases  they  can  be  traced  directly  to  a 
severe  fall  or  a  violent  blow  upon  the  abdomen  during  pregnancy.  The  long 
bones,  especially  those  of  the  leg,  suffer  most  frecjuently,  the  skull  from  its  pro- 
tected position  and  its  elasticity  generally  escaping  ;  sometimes  they  are  compound 
and  a  scar  is  found  upon  the  skin  corresjjonding  to  the  point  at  which  it  was  per- 
forated by  the  bone.  The  degree  of  union  depends  upon  the  time  ;  as  a  rule,  it 
is  fairly  firm,  though  the  position  may  be  faulty.  Multiple  fractures  (and  in  some 
instances  an  enormous  number  has  been  recorded)  rarely  occur,  except  in  the  case 
of  intra-uterine  disease,  possibly  hereditary  syphilis. 

It  is  noteworthy  that  in  quite  half  the  cases  in  which  the  leg  is  found  at 
birth  to  be  bent  at  an  angle,  as  if  it  had  1  een  broken,  and  even  when  there  is  the 
appearance  of  a  cicatrix  at  the  point,  the  fibula  and  the  toes  on  the  outer  side  of 
the  foot  are  deficient.  Talipes  is  often  present  at  the  same  time  ;  the  limb  is  im- 
jierfectly  grown,  and  frequently  remains  more  or  le.ss  stunted  throughout  life. 


FRACTURES.  347 

In  inhincv,  the  clavicle  and  the  fenmr  are  the  bones  that  suffer  most  fre- 
(juentlv,  and  the  fractures  arc  often  greenstick  or  sub-i)eriosteal.  Separation  of 
the  eiMphyses  is  common  in  chiltlhood,  but  may  be  met  with  up  to  one  or  two  and 
twenty  years  of  age.  In  adult  life,  much  depends  uj)on  the  sex  and  occupation. 
The  bones  are  harder  and  more  dense  than  they  are  at  earlier  periods.  Fissured 
fractures  occur  more  easily,  and,  as  a  consequence,  the  joints  are  more  often  in- 
volved. Old  age  is  specially  characterized  by  two  varieties,  fracture  of  the  neck 
of  the  femur  and  (particularly  in  women)  feicture  of  the  lower  end  of  the  radius 
from  falls  upon  the  hantl. 

Causes. 

The  causes  of  fractures  are  predisposing  and  immediate.  The  former  include 
all  those  conditions  which  render  the  bone  more  fragile  ;  the  latter,  the  actual 
breaking  force.  If  this  is  unusually  slight,  so  that  the  bone  gives  way  without 
(apparently)  sufficient  reason,  the  fracture  is  said  to  be  spontaneous. 

I.   Predisposing  Causes 

These  may  involve  the  whole  length  of  a  bone  (and  even  the  whole  skeleton) 
or  may  be  local,  affecting  the  structure  and  impairing  the  strength  at  one  part 
only. 

(a)  General. — Simple  atrophy  is  the  most  common.  When  a  limb  is  kept  at 
rest  for  any  length  of  time-frigidly  confined  in  splints,  for  example,  owing  to 
disease  of  some  neighbouring  joint — the  bones  gradually  waste  away,  the  cancellous 
tissue  becomes  more  and  more  open,  the  medullary  canal  enlarges,  and  the  com- 
pact layer  is  absorbed  from  the  interior,  until,  in  extreme  cases,  a  thin  shell  of 
solid  substance  is  all  that  is  left.  It  is  in  a  certain  measure  owing  to  this,  that  if 
a  bone  once  broken  gives  way  a  second  time  before  repair  is  complete,  it  nearly 
always  yields — not  at,  but  close  to,  the  seat  of  the  original  injury.  Atrophy  is  also 
said  sometimes  to  follow  injury  to  the  nutrient  artery. 

///  old  age  the  bones  are  affected  in  a  similar  way,  and  in  addition  the  propor- 
tion of  lime-salts  to  the  organic  basis  appears  to  increase,  so  that  they  become  more 
brittle.  This  cannot,  however,  be  called  pathological  unless  the  change  reaches 
an  extreme  degree,  so  that  an  unusually  slight  amount  of  violence  is  sufficient  to 
make  them  give  way. 

Infantile  paralysis,  owing  to  the  feeble  nutrition  of  the  limb,  leads  to  the  same 
result.  The  bones  never  attain  their  full  development ;  they  remain  slender  and 
feeble  ;  the  surface  is  smooth,  without  any  muscular  ridges  to  act  as  supports,  and 
they  are  deficient  in  weight  and  strength. 

Fractures  are  very  prone  to  occur  in  certain  affections  of  t/ie  nervous  system. 
The  nutrition  of  the  bone  suffers  whether  the  limbs  are  kept  at  rest  or  not ;  there 
is  no  tendency  to  inflammation,  but  two-thirds  of  the  inorganic  material  (especially 
the  phosphate  of  lime)  may  disappear  ;  the  cortex  becomes  exceedingly  thin,  and 
the  medulla  replaced  by  fat,  until  in  some  cases  the  bony  substance  is  so  soft  that 
it  can  be  cut  with  a  knife.  This  has  been  noticed  particularly  in  locomotor  ataxy, 
affecting  chiefly  the  lower  limbs,  and  appearing  even  before  the  incoordination  ; 
in  general  paralysis,  where  the  ribs  seem  to  suffer  most,  and  also  in  some  cases  of 
dilatation  of  the  central  canal  of  the  spinal  cord.  It  is  singular  that  if  the  bones 
do  give  way  under  these  conditions,  union  often  takes  place  easily  and  with  an 
exceptionally  large  amount  of  callus. 

Rickets  is  another  common  cause.  The  intermediate  layer  of  cartilage  becomes 
abnormally  thick  ;  instead  of  there  being  merely  a  line  of  soft  tissue  ready  to  be 
replaced  by  bone,  it  may  form  a  broad  band  of  gelatinous  material,  in  some  cases 
nearly  as  thick  as  the  cartilage  of  the  epiphysis  itself.  The  deeper  layer  of  the 
periosteum  is  affected  in  the  same  way  ;  and,  as  the  process  of  absorption  from  the 
interior  continues  with  unabated  vigor,  the  strength  of  the  bone  at  last  becomes 
impaired  to  such  an  extent  that  it  is  unable  to  bear  any  strain.    Owing  to  the  thin- 


348    DISEASES  AND  INJURES  OE  SPECIAL  STRUCTURES. 

ness  of  the  compact  tissue  in  comparison  with  the  thick  layer  of  soft  material  on 
the  outside,  subjieriosteal  and  jjartial  or  greenstick  fractures  are  very  common, 
especially  at  those  places  where  the  bones  are  naturally  curved.  So  long  as  the 
rickets  is  actively  progressing,  the  amount  of  callus  is  only  small  ;  afterward,  it  is 
thrown  out  in  great  excess,  particularly  on  the  concave  side. 

In  osteomalacia  the  l)ones,  if  they  are  ex])Osed  to  any  force,  do  not  break  so 
much  as  double  upon  themselves  and  bend.  The  compact  tissue  is  softened  and 
disappears  ;  the  Haversian  spaces  and  the  medullary  canal  grow  larger  and  larger, 
until  at  length  in  the  more  severe  forms,  all  that  is  left  is  a  cylinder  of  osseous 
tissue,  as  thin  as  paper,  fdled  with  a  kind  of  reddish-brown  pulp,  and  unable  to 
resist  a  strain  of  any  kind. 

In  certain  people  the  bones  are  peculiarly  liable  to  break,  without  its  being 
possible  to  assign  a  reason  for  it.  Their  health  is  to  all  appearance  perfectly  good, 
and  the  fractures  unite  without  difficulty.  This  condition,  which  sometimes  affects 
several  members  in  one  family,  and  which  may  be  hereditary,  for  want  of  a  better 
name  is  known  as  Eragilitas  ossii/m. 

(/>)  Local. — These  are  for  the  most  part  connected  either  with  inflammation, 
or  with  the  presence  of  some  new  growth  of  or  in  the  neighborhood  of  the 
bone. 

Inflammation,  if  the  process  of  repair  does  not  keep  pace  with  that  of  destruc- 
tion, of  necessity  renders  the  bone  more  likely  to  give  way.  In  acute  suppurative 
osteomyelitis,  for  example,  total  necrosis  and  separation  of  a  portion  of  the  shaft 
may  take  place  before  a  sheath  of  new  bone  can  form  ;  or,  after  this  has  been 
thrown  out  by  the  periosteum,  it  may  be  so  weak  as  to  bend  or  break  almost  of 
itself  as  soon  as  tlie  sequestrum  is  removed.  The  same  accident  sometimes  com- 
plicates inflammation  and  suppuration  in  the  medullary  canal,  even  when  there  is 
no  secpiestrum  of  appreciable  size  ;  and  it  has  been  known  to  occur  from  rarefying 
ostitis  gradually  eating  away  the  interior  of  the  shaft  without  any  corresponding 
deposit  being  formed  on  the  exterior.  Caries  involves  the  shafts  of  bones  so  rarely 
that  in  this  respect  it  is  of  little  importance,  except  in  the  case  of  the  ribs  and  the 
odontoid  process. 

Separation  of  an  epiphysis,  due  to  softening  of  the  cartilage,  is  sometimes 
discovered  unexpectedly  in  the  course  of  acute  periostitis  and  osteomyelitis.  It  is 
most  often  met  with  at  the  upper  end  of  the  tibia,  and  union  may  have  taken  place 
in  a  faulty  position  before  it  is  noticed. 

The  most  common  local  cause  is  the  presence  of  some  new  i^nnotli,  such  as 
sarcoma  or  carcinoma.  Sometimes  the  fracture  is  preceded  by  swelling  or  by  con- 
stant pain,  but  it  is  not  unusual  for  there  to  be  no  .suspicion  of  anything  wrong 
until  one  of  the  bones  unaccountably  gives  way. 

Central  sarcomata  are  the  most  important.  They  grow  from  the  interior,  very 
often  at  the  ei)iphysial  ends,  and  replace  the  bone  until  there  is  nothing  left  but  a 
soft,  vascular  mass,  which  may  retain  the  shai)e  of  the  part,  or  cause  it  to  expand 
into  a  thin-walled  cyst.  Periosteal  ones,  as  a  rule,  do  not  interfere  to  a  sufficient 
extent  with  the  structure  of  the  bone.  Secondary  deposits  of  carcinoma,  especially 
after  scirrhus  of  the  breast,  may  lead  to  the  same  result.  Apart  from  the  local 
growth  there  is  no  evidence  that  either  the  cancerous  or  the  sarcomatous  cachexia 
has  any  special  influence  on  the  stability  of  the  skeleton. 

Enchondromata,  cysts,  and  echinococci  occasionally  weaken  the  bone  in 
which  they  grow,  so  that  it  gives  way  unexpectedly  ;  and  sometimes  the  same  result 
follows  from  absorption  due  to  the  pressure  of  external  tumors,  such  as  an 
aneurysm. 

Syphilis  occasionally  acts  as  a  predisposing  cause  by  the  local  changes  it 
induces — caries,  or  much  more  often  gummatous  infiltration  of  the  periosteum  or 
bone.  .Sr//77y;  hardly  seems  to  have  any  influence,  except  perhaps  in  the  case  of 
the  costal  cartilages.  It  is  stated  that  when  it  is  very  severe  these  are  liable  to  be 
detached,  owing  to  changes  which  take  place  at  the  ends  of  the  ribs,  and  which 
are  often  associated  with  hemorrhagic  periostitis. 


I^RACTLRES.  349 

Changes  of  a  similar  character  occur  at  the  ends  of  tlie  long  bones  (particularly 
the  lower  epii)hysis  of  the  humerus)  in  young  infants,  as  a  result  of  hereditary 
syi)hilis,  and  more  rarely  scurvy,  so  that  the  growing  ends  are  liable  to  be  separated 
by  very  slight  degrees  of  violence.  Some  of  these  may  be  genuine  examples  of 
detached  epiphyses  ;  in  others  it  is  probable  the  line  of  separation  runs  through 
the  softened  and  infiltrated  layer  of  bone  bordering  the  end  of  the  shaft. 

2 .    Jmmciliatc   Causes. 

These  are  eitlier  external  violence,  or  muscular  contraction,  or  in  some  in- 
stances a  combination  of  the  two. 

((/)  External  Violence. — This  may  be  direct  or  indirect.  In  fractures  by  direct 
violence  the  bone  is  broken  at  the  .seat  of  the  injury,  as  when  a  limb  is  run  over  and 
crushed  by  a  heavy  wheel ;  the  fracture  is  often  comminuted  and  the  soft  parts 
seriously  injured  from  the  way  in  which  they  are  ground  between  the  offending 
object  and  the  bone.  In  the  other  variety  the  fracture  occurs  at  some  other,  per- 
haps far-distant,  point,  where  the  strength  of  the  bone  or  chain  of  bones  is  least, 
and  the  soft  tissues  may  escape  almost  entirely.  In  falls,  for  example,  upon  the 
outstretched  hand,  the  shock  is  transmitted  through  the  arm  to  the  clavicle,  and 
this  gives  way  at  its  .veakest  point.  The  two  ends  are  driven  together  and  the  bone 
is  bent  more  and  more  until  the  limit  is  reached. 

Fractures  at  the  base  of  the  skull  and  fractures  by  what  is  known  as  contrecoup 
(where  the  bone  is  broken  exactly  opposite  the  point  on  which  the  violence  falls) 
are  caused  in  the  same  way.  The  skull,  which  is  exceedingly  elastic,  is  compressed 
in  one  of  its  diameters,  the  vertical,  if  the  force  falls  on  the  vault,  and  proportion- 
ately lengthened  in  the  others ;  and  the  bone  breaks  where  it  is  weakest  and  most 
brittle,  generally  at  the  base.  In  other  instances,  however,  as  in  falls  upon  the 
feet,  the  fracture  occurs  from  the  impact  of  the  base  of  the  skull  upon  the  vertebral 
column,  as  when  the  head  of  a  hammer  is  driven  home  upon  the  handle  by  smartly 
striking  the  latter  on  the  ground. 

{b)  Muscular  Contraction. — If  it  were  not  for  the  patella,  which  very  fre- 
quently gives  way  from  this  cause  alone,  fractures  due  solely  to  muscular  contrac- 
tion would  be  regarded  as  uncommon.  Sometimes,  however,  bony  prominences, 
such  as  the  acromion,  or  the  tubercle  of  the  tibia,  are  torn  off  by  violent  muscular 
action,  and  occasionally  the  long  bones  themselves  snap  quite  suddenly.  Many 
instances  are  recorded  in  which  this  has  happened  to  the  humerus,  clavicle,  and 
femur,  but  in  the  ca.se  of  other  bones  it  is  exceedingly  rare.  In  most  the  fracture 
seems  to  have  been  due  to  the  sudden  arrest  of  rapid  action,  as  in  striking  out  at 
an  object  without  hitting  it,  and,  therefore,  to  have  been  caused,  in  part  at  least, 
by  the  weight  and  momentum  of  the  arm. 


Repair. 

Fractures  are  repaired,  like  other  injuries,  by  the  effusion  and  organization  of 
lymph.  It  is  not  clear  how  far  this  is  derived  from  the  blood-vessels,  and  how 
far  it  is  the  product  of  the  tissues  around.  It  is  certain  that  the  medulla  and  the 
deeper  la3^ers  of  the  periosteum  possess  the  power  of  causing  the  development  or 
new  bone  when  transplanted  into  other  parts;  but,  according  to  McF^wen,  the 
superficial  ones  are  quite  inert. 

I.    Union  in  Simple  Fractures. 

Early  Changes. — There  is  nothing  peculiar  about  these ;  the  injured  parts 
swell  up  at  once,  owing  to  the  extravasation,  which  is  always  extensive  ;  the  blood 
pours  out  from  the  torn  vessels,  and  spreads  in  the  central  cavity,  and  in  the  loose 
cellular  tissue  around,  until  it  is  checked  by  the  tension  it  creates.  After  a  time 
it  coagulates,  and  the  ends  of  the  vessels  become  sealed  ;  the  fibrin  and  corpuscles 


350    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

form  a  loose,  ilark-colored  mass,  which  fills  up  all  the  interstices;  the  serum  is 
carried  away  by  the  lymphatics  (the  neighboring  glands  are  often  swollen  at  this 
stage),  or,  if  it  is  excessive  in  amount,  escapes  through  the  skin  and  raises  up  the 
epidermis  in  great  blebs. 

While  this  is  going  on,  the  vessels  around  the  injured  area  begin  to  dilate, 
those  in  the  soft  parts  first,  in  the  compact  bone  last,  and  lymph  pours  out  through 
their  walls  ;  the  skin,  if  the  fracture  is  near  the  surface,  grows  warm  and  red  ;  the 
blood  circulates  more  rapidly  ;  all  the  tissues  around  become  softer  and  more 
open  ;  the  fat  is  absorbed,  and  the  medulla  resumes  its  embryonic  character. 

Almost  from  the  first  day  the  coagulated  blood  begins  to  lose  its  color.  The 
red  corpuscles  break  down  ;  the  hemoglobin  soaks  into  and  stains  all  the  tissues 
near,  and  the  stroma  and  fibrin  disappear  little  by  little  before  the  advancing 
lymph.  Probably  the  white  corpuscles  share  the  same  fate,  though,  as  in  other 
cases  of  extravasation,  .some  few  on  the  outside  may  remain.  Meanwhile  the 
lymph  grows  in  from  all  sides,  spreading  further  and  further,  until  it  finds  its  way 
between  the  fragments  into  the  medullary  canal,  and  joins  with  that  which  is 
developed  there. 

At  this  stage,  up  to  the  seventh  or  tenth  day,  the  bone  itself  is  almost  un- 
changed ;  only  the  surface  near  the  seat  of  injury  is  slightly  more  porous  ;  the 
periosteum  is  swollen  and  thickened,  its  fibres  are  softened  and  separated  from 
each  other  by  masses  of  lymph,  so  that  its  deeper  layers  are  almost  gelatinous, 
and  it  strips  off  more  readily  from  the  bone  beneath.  Between  the  fragments, 
and  lying  in  the  central  space,  is  the  debris  of  the  old  extravasation  ;  and  round 
the  whole  is  an  ill-defined,  soft  mass  of  vascular  granulation-tissue,  mixed  with  old 
blood-clot,  and  inseparably  fused  with  the  torn  shreds  of  the  muscles  and  other 
structures  near. 

The  amoutit  of  lymph  thrown  out  is  regulated  mainly  by  the  extent  and 
duration  of  the  injury.  In  children,  it  is  true,  owing  to  the  activity  with  which 
all  tissue-changes  are  carried  on,  the  quantity  is  relatively  greater  than  at  other 
periods  of  life ;  but  it  rarely  happens,  even  in  old  age,  that  it  is>insufficient  for 
the  purpose.  On  the  other  hand,  the  wider  the  extent  of  the  injury,  the  more  the 
soft  parts  around  the  broken  ends  are  crushed  and  bruised,  so  long  as  they  are  not 
actually  destroyed,  and  the  oftener  the  injury  is  repeated,  the  greater  the  amount 
produced.  Where  a  bone  is  simply  broken,  with  no  displacement  or  extensive 
laceration  of  the  periosteum,  and  where  the  parts  are  kept  at  ])erfect  rest  (as,  for 
example,  in  fissures  of  the  cranium),  the  lymph  merely  unites  the  broken  surfaces, 
fills  up  some  of  the  medullary  space,  and  causes  a  little  thickening  of  the  perios- 
teum. On  the  other  hand,  in  children  ;  in  animals;  where  there  is  a  thick  layer 
of  soft  tissue  on  the  bone  (and  if  it  is  on  one  side,  as  in  the  case  of  the  tibia,  on 
that  side  only)  ;  where  the  fragments  are  allowed  to  move  one  on  the  other,  as  in 
the  ribs  ;  and  where  there  is  a  number  of  splinters  wounding  all  the  jjarts  around, — 
a  huge  mass  may  be  formed,  welding  everything  together,  and  filling  up  the  medul- 
lary canal  so  completely  that  it  is  divided  into  two. 

Callus. — This  effused  lymph  becomes  ossified,  and  is  known  as  callus.  At 
first  it  is  soft  and  porous,  very  irregular  in  shape,  and  perforated  in  every  direc- 
tion by  a  number  of  vessels  running  from  all  sides  toward  the  centre;  later,  it 
shrinks  and  becomes  more  dense,  the  outer  layers  remain  fibrous,  and  fuse  with 
the  periosteum  at  either  end  ;  the  rest  is  slowly  absorbed,  until  there  is  only  suffi- 
cient left  to  restore  the  strength  of  the  fractured  bone.  That  part  of  it  which 
surrounds  the  broken  ends  and  fills  up  the  medullary  canal  was  formerly  called 
provisional ;  it  is  formed  earlier,  and  mechanically  acts  as  a  kind  of  splint ;  that 
which  directly  unites  the  broken  ends  is  dcfinitiz^e  (Dupuytren)  ;  it  is  not  developed 
until  the  other  has  already  a.ssumed  the  form  of  spongy  bone,  and  after  this  has 
disappeared  it  forms  the  permanent  bond  of  union. 

The  former  comes  from  the  periosteum  and  surrounding  tissues,  and,  perhaps, 
to  some  extent,  from  the  medulla,  the  latter  from  the  bone  itself;  but  there  is  tio 
real  distinction  between  them.     The  difference  in  the  time  of  their  appearance  is 


FRACTURES.  351 

clue  to  the  relative  ease  with  which  the  changes  after  injury  take  place  in  soft, 
cellular  tissue,  and  dense,  unyielding  bone  ;  and  the  difference  in  the  direction  of 
their  vessels  depends  solely  on  the  position  of  the  old  ones  from  which  the  new 
ones  spring  ;  they  are  mainly  transverse  in  the  outside  callus,  because  they  con- 
verge from  all  points  on  the  exterior  toward  the  fractured  spot ;  and  they  are 
longitudinal  in  the  intermediate  part  when  this  is  once  developed,  because  the  old 
ones  lie  above  and  below. 

Provisional  callus  is  not  thrown  out,  as  its  name  implies,  to  act  as  a  tem])orary 
support,  until  the  definitive  can  appear  and  take  its  place.  It  is  the  real  bond  of 
union  between  the  broken  ends,  an  attempt  to  restore  the  strength  of  the  part  with 
as  little  delay  as  possible.  If  a  splinter  is  detached  from  the  side  of  a  bone,  and 
the  periosteum  replaced,  the  hollow  is  very  soon  filled  with  spongy  callus,  in  great 
excess  because  its  strength  is  so  much  less  than  that  of  the  solid  part  that  has  been 
lost.  The  bone  is  weakened  and  an  attempt  is  made  to  restore  its  strength  as  soon 
as  possible  ;  cancellous  tissue  can  be  formed  almost  at  once,  while  compact  cannot, 
but  a  greater  quantity  is  required.  By  degrees,  when  the  vessels  in  the  old  bone 
have  had  time  to  dilate,  and  buds  of  lymph  can  grow  out  from  the  Haversian 
canals,  some  of  the  newly-formed  cancellous  bone  becomes  compact  and  modeled 
on  the  old  lines,  and  then  the  excess  is  removed  by  absorption  and  the  original 
shape  restored. 

The  same  thing  occurs  in  a  transverse  fracture.  Soft  callus  is  thrown  out 
round  the  ends,  because  this  can  be  done  at  once  ;  and  the  bulk  is  greater  to  make 
up  for  its  feebler  strength.  Later,  when  there  has  been  time  for  the  central  ring  to 
become  compact,  the  outside  part,  having  no  further  purpose,  is  removed,  and  the 
original  shape  regained. 

The  ossification  of  callus  may  be  preceded  by  the  formation  of  cartilage  or  not, 
but  in  any  case  it  follows  strictly  the  physiological  type  of  normal  growth. 

The  first  deposit  of  lime  makes  its  appearance  on  the  tenth  to  the  fourteenth 
day,  in  the  layer  of  the  periosteum  that  lies  nearest  to  the  old  bone.  Almost  from 
the  first,  the  cells  that  occupy  this  part  are  larger  than  the  rest ;  many  of  them  are 
stellate,  with  one  or  more  nuclei,  and  all  have  a  large  amount  of  granular  proto- 
plasm. The  lime  is  deposited  around  these,  so  that  if  the  periosteum  is  stripped 
up  from  the  old  bone,  this  is  not  only  porous,  but  rough,  from  a  covering  of  little 
spines  and  points.  Far  away  from  the  fracture,  at  the  boundary  of  the  unaltered 
periosteum,  the  callus  is  converted  directly  into  bone,  even  in  animals.  The 
intercellular  substance  at  a  distance  from  the  vessels  becomes  darker  ;  granular 
patches  make  their  appearance  in  it,  and  grow  larger  and  larger  until  they  join 
together  ;  and  a  network  of  trabeculse,  enclosing  spaces  of  the  most  irregular  shape, 
is  built  up  by  degrees.  In  these  lie  the  vessels,  with  the  cells  arranged  in  con- 
centric masses  around.  Gradually  more  and  more  bone  is  deposited,  layer  after 
layer  of  cells  becomes  infiltrated  with  inorganic  material,  always  closing  in  toward 
the  centre,  until  at  length  the  spaces  become  narrowed  down  into  Haversian  canals, 
lined  with  lamellae  of  soft  but  true  bone. 

In  dogs  and  rabbits  a  very  large  proportion  of  the  callus,  internal  as  well  as 
external,  is  converted  into  cartilage.  In  infants,  too,  this  takes  place  to  a  very 
considerable  extent,  but  in  adults  only  islets  of  it  are  formed  here  and  there, 
close  to  the  broken  ends,  rarely  or  never  between  them  or  in  the  medullary  canal. 
A  great  deal  of  it,  however,  is  not  true  hyaline  cartilage  ;  near  the  perio.steum 
it  shades  off  gradually  into  fibrous  tissue,  and  in  other  parts  the  ground  substance 
differs  from  the  matrix  of  true  cartilage  in  the  way  it  stains  with  carmine.  In 
places,  too,  it  becomes  converted  directly,  into  bone,  the  cells  becoming  smaller 
and  stellate,  and  lime  being  deposited  in  the  substance  between  them.  Only 
here  and  there  are  there  true  capsules,  which,  as  in  normal  cartilaginous  ossifica- 
tion, become  replaced  by  vascular  buds  of  small  cells,  growing  in  from  the 
surrounding  parts. 

Absorption  begins  long  before  the  process  of  o.ssification  is  complete,  work- 
ing in  both  directions,  from  the  interior  of  the  medulla  and  the  exterior  of  the 


jj- 


DTSEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 


■J 


Fig. 


callus,  toward  the  shaft.     (]iant-cells  are  abundant,  esj^ecially  in   the  medullary 

part,    but   they  may   also  be   found    here   and    there,    under  the  newly-finished 

periosteum,  and  in    the  superficial   layers  of  the  callus, 

eating  it  away  irregularly  until,  by  slow  degrees,  it  is 

reduced  to  its  i)ermanent  dimensions. 

T/ie  Pennanftit  Form  of  the  Bone. — 'I'he  lines 
upon  which  a  l;one  is  built,  as  shown  by  its  shape  and 
by  the  direction  of  its  traljecuKne,  are  governed  by  the 
strains  it  has  to  meet.  After  a  fracture,  if  the  ends  are 
so  accurately  adjusted  that  the  axis  is  not  altered,  the 
original  shape  and  construction  are  restored,  becau.se 
the  strains  the  bone  has  to  bear  after  the  accident  are 
identical  with  those  it  received  before.  But  if  it  is  not 
well  set,  so  that  its  two  ends  overlap  or  form  an  angle 
with  each  other,  the  forces  may  still  be  the  same,  but 
they  no  longer  act  in  the  same  way.  The  shape 
becomes  modified,  even  that  of  the  old  bone,  and  the 
lines  are  altered  to  those  which  under  the  circum.stances 
are  best  adapted  to  the  Avork  ;  and  it  often  happens 
that  they  are  very  different  from  the  original  one  (Fig. 
109). 

If  the  ends  are  in  api)Osition,  but  form  an  angle 
with  each  other,  the  medullary  canal  may  be  re-estab- 
lished, but  it  will  not  lie  in  the  centre.  The  compact 
tissue  on  the  convexity  is  thinned  ;  that  in  the  concavity 
becomes  thicker.  If  thev  overlap,  the  central  cavity  is 
''?:^.;:l^l'it:i^^:^:^^.  never  restored,  each  end  remaining  sealed.  The  ad- 
of  the  meduiiarj-  canal  and  the  jacent  surfaces  of  boue  either  fuse  together  or  are  held 

immense  increase  in  density  and  1  ■       ^       1         11  /-\  r^  ^\  \  1 

strength  of  the  bone  along  the  sccure  by  periosteal  callus.     Often  they  become  cancel- 

iine  of  direct  pressure.  lous,  bccausc  the  transverse  section  of  the  whole  is  so 

much  larger  that   porous  bone  is  strong  enough  for  the 

work  ;  and  the  trabeculae,  both   in  the  old  and  the  new  bone,  become  arranged 

in  curves,  as  regular  and  as  even  as  those  in  the  neck  of  the  femur. 

Intra-articidar  Fractures. — Repair  is  frecjuently  imperfect  when  the  line  of 
fracture  lies  inside  the  synovial  cavity  of  a  joint ;  either  bony  union  does  not  take 
place,  or  perfect  freedom  of  movement  is  not  regained.  The  extrava.sation  is  the 
first  obstacle.  Sometimes  the  blood  collects  in  the  interior,  and,  as  in  transverse 
fractures  .of  the  patella,  forces  the  two  fragments  so  far  apart  that  no  bridge  of 
callus  can  be  formed  between  them  ;  or  it  coagulates  and  lies  for  weeks  between 
the  broken  surfaces,  so  that  it  is  impossible  to  bring  them  together.  In  other  cases 
it  lines  the  interior  of  the  cavity  like  a  false  membrane,  and  interferes  with  its 
secretion  ;  or  it  makes  the  capsule  stiff  and  unyielding,  and  it  may  even,  as  Hunter 
first  suggested,  remain  detached  and  form  the  nucleus  of  a  foreign  body. 

Then  the  amount  of  callus  thrown  out  is  frequently  deficient.  None  is  formed 
by  that  part  of  the  bone  which  is  covered  with  cartilage,  and  very  little,  as  a  rule, 
by  the  periosteum  inside  the  joint.  In  some  bones,  according  to  Bidder,  there  is 
no  osteogenic  substance  here  at  all,  the  fibrous  layer  merely  being  continued  from 
the  shaft  to  the  cartilage  of  the  epiphysis.  The  only  part  that  takes  any  active 
share  is  the  broken  surface,  and,  unless  the  ends  are  held  absolutely  in  contact  by 
impaction  or  other  means,  this  is  not  sufficient,  and  either  union  is  fibrous  or 
it  fails  altogether,  and  the  surfaces  become  dense  and  hard  from  long-continued 
friction. 

This  is  certain  to  happen  if  one  fragment  is  very  small,  or  if,  as  in  intracap- 
sular fractures  of  the  neck  of  the  femur,  it  is  cut  off  from  its  blood-supply.  The 
chief  nutrient  vessels  of  the  head  of  the  bone  enter  the  under  surface  of  the  neck  ; 
the  branch  running  with  the  round  ligament,  even  if  it  does  reach  so  far,  is  not 
large  enough  to  be  of  much  service,  and  consequently,  though  it  does  not  undergo 


FRACTURES.  353 

necrosis,  the  vitality  of  the  fragment  is  so  feeble  that,  unless  there  is  imjiaction, 
union  never  takes  place. 

Fractures  Tlirou}:;h  Cartilage. — In  the  case  of  the  costal  cartilages  the  broken 
ends  are  generally  held  together  by  a  ring  of  fibrous  tissue,  formed  from  the  peri- 
chondrium and  the  cellular  tissue  outside  it.  Sometimes  this  is  converted  into 
bone  and  the  cartilages  themselves  are  calcified.  In  young  subjects  it  seems 
probable  that  the  cartilage  corpuscles  at  a  little  distance  from  the  seat  of  injury 
take  some  share  in  the  process  ;  those  immediately  bordering  on  it  break  down  and 
disappear. 

When  the  articular  cartilage  of  a  joint  is  split,  as  in  T-sIiaped  fractures,  the 
cleft  is  filled  in  after  a  time  by  fibrous  tissue;  and  the  same  thing  hapjjens,  only 
very  slowly,  when  a  portion  is  completely  detached,  the  fragment  itself  remaining 
as  a  foreign  body. 

2 .    Union  in  Compound  Fractures. 

In  compound  fractures  the  process  of  repair  depends  upon  the  beha\ior  of  the 
wound.  If  this  heals  by  the  first  intention,  or  if  it  is  sealed  successfully,  the 
tissue-changes  are  essentially  the  same  as  those  described  already.  A  certain 
amount  of  blood  is  extravasated,  some  of  the  tissues  are  disorganized  and  require 
to  be  repaired  or  replaced,  but  unless  the  crushing  is  so  severe  that  the  part  sloughs 
en  masse,  the  debris  is  carried  away  little  by  little  ;  granulation  tissue  grows  into 
the  space  that  is  left,  and  fills  it,  and  there  is  only  a  slight  degree  of  hypergemia 
and  swelling,  corresponding  to  the  increase  in  the  activity  of  the  circulation. 

If,  on  the  other  hand,  the  breach  of  surface  is  not  closed  in  at  once,  union 
takes  place  more  slowly,  and  is  attended  by  suppuration  of  a  more  extensive  char- 
acter. In  the  slighter  cases,  in  which  the  soft  parts  are  not  much  bruised,  or  the 
bone  si)lintered,  and  in  which  there  is  free  exit  for  all  discharges,  the  wound  soon 
begins  to  fill.  The  vessels  dilate,  lymph  pours  out  into  the  periosteum  and  the 
loose  tissues  around,  until  they  are  so  swollen  that  it  is  not  easy  to  distinguish  one 
from  another  ;  the  fibrin  coagulates  on  the  surface,  the  serum  drains  away,  and  as 
the  new  vessels  are  formed  the  broken  ends  of  the  bone  become  surrounded  and 
enclosed  by  a  mass  of  vascular  granulation-tissue  which  grows  until  the  cavity  is 
obliterated.  At  first  the  surface  of  the  bone,  if  the  periosteum  is  stripped  off, 
shows  but  little  change  ;  in  a  few  days  a  number  of  minute  red  dots  appear  upon  it ; 
then  each  of  these  enlarges  into  a  little  bud  of  vascular  granulation-tissue,  spring- 
ing from  the  side  openings  of  the  Haversian  canals,  and  at  length  it  becomes  as 
porous  as  the  cancellous  part,  and  is  covered  over  with  a  layer  of  vascular  lymph, 
continuous  with  that  formed  from  the  structures  around. 

The  granulation  tissue  is  converted  directly  into  bone,  without  passing  through 
any  intermediate  stage,  and  without  the  formation  of  cartilage.  The  lime  salts 
make  their  appearance  first,  as  in  simple  fractures,  between  the  cells  on  the  surface 
of  the  old  bone  at  the  boundary  of  the  injury.  From  this  they  advance  by 
degrees  toward  the  injured  part,  until  each  of  the  fragments  is  surrounded  by  a 
ring  of  soft,  spongy  callus.  These  gradually  increase  in  size,  approach  nearer  and 
nearer  until  they  join  across,  and  unite  at  length  with  that  which  is  developed  from 
the  medulla.  The  shape  at  first  is  very  irregular  and  the  amount  excessive,  while 
openings  persist  here  and  there  in  the  newly-formed  sheath  for  the  discharge  of 
pus ;  but  if  there  are  no  sequestra  these  soon  close  in  and  the  whole  becomes  firm 
and  dense. 

In  many  cases,  however,  the  result  is  not  so  fortunate.  Sometimes  it  is  due  to 
the  severity  of  the  original  injury  ;  even  in  simple  fractures  it  occasionally  happens 
that  the  parts  are  so  crushed  and  bruised  that  they  slough ;  much  more  often  it  is 
the  result  of  some  fresh  additional  cause.  The  wound  itself  is  of  a  peculiarly 
unfavorable  character,  nearly  always  deep  and  irregular  in  shape,  divided  by  the 
layers  of  fascia  into  many  strata,  the  openings  of  which  do  not  correspond  ;  the 
external  orifice  is  often  small,  while  the  external  cavity  is  always  a  great  deal  larger 
than  it  appears  to  be,  and  it  is  filled  with  a  material  exceedingly  prone  to  decom- 


354     DISEASES  AND  INJURIES   OF  SPECIAL    STRUCTURES. 

position.  If  this  occurs  before  the  barrier  of  lymph  is  thrown  out,  the  products 
poison  all  the  tissues  near,  inflammation  of  the  most  intense  description  follows, 
and  unless  checked  in  time  spreads  up  and  down  the  limb  until  it  is  thoroughly  dis- 
organized, or  life  itself  is  lost.  The  i>eriosteum  and  medulla  quickly  become 
involved  ;  in  the  neighborhood  of  the  wound  itself,  where  the  process  is  most 
intense,  they  may  be  completely  destroyed.  Sjjlinters  jjerish  at  once,  and  are 
thrown  off  ;  the  ends  of  the  bone,  deprived  of  their  blood-supply,  undergo  necrosis, 
and  enormous  masses  of  callus  are  thrown  out  round  them  by  the  more  distant 
parts  which  suffer  less. 

If  this  happens,  when  nothing  worse  results,  months  often  pass  before  union 
is  complete.  A  line  of  demarcation  must  form  round  the  necrosed  fragments  ; 
granulations  must  be  thrown  out  by  the  living  compact  bone  before  the  sequestra 
can  be  moved  ;  and  often,  long  before  this  takes  place,  callus  has  grown  round 
them  and  locked  them  in,  so  that  an  operation  is  necessary  to  release  them.  I 
have  known  them  work  their  way  out  more  than  fifty  years  after  the  original 
injury.  Firm  union  is  often  established  months  before  the  wounds  have  closed,  and 
sinuses  leading  down  to  the  interior  of  the  bone  sometimes  persist  for  the  rest 
of  life. 

I.MPERFECT    ReP.\IR. 

The  amount  of  callus  thrown  out  may  be  excessive.  This  is  more  likely  to 
happen  after  compound  fractures,  or  when  there  is  a  large  number  of  splinters  and 
the  tissues  around  are  much  irritated.  As  a  rule,  it  is  not  of  material  consequence  ; 
the  outline  of  the  limb  is  altered,  and  the  action  of  the  muscles  slightly  impaired  ; 
but  the  inconvenience  is  not  great,  and  the  excess  is  soon  removed  by  absorption. 
.Sometimes,  however,  a  nerve  is  compressed,  and  paralysis  or  wasting  sets  in  ;  or  a 
joint  is  locked  and  useless,  owing  to  outgrowths  of  bone  around  it ;  or  two  parallel 
bones,  such  as  the  radius  and  ulna,  are  joined  together  so  that  pronation  and  supi- 
nation are  lost.  When  this  occurs,  more  active  measures  are  required,  and  it  is 
generally  necessary  to  cut  down  upon  the  offending  portion  and  excise  it.  These 
cases  of  overgrowth  must  be  clearly  distinguished  from  callus  tumors  fenchondro- 
mata  and  osteomata  chiefly),  of  which  a  very  few  have  been  recorded,  occurring, 
for  the  most  part,  at  a  much  later  period. 

Occasionally,  the  callus  becomes  soft  again,  and  is  absorbed  to  a  great  extent, 
so  that  the  deformity  reappears.  This  may  be  due  entirely  to  local  causes — necro- 
sis, for  example,  taking  place,  at  the  seat  of  injury  ;  or  it  may  happen  during 
an  attack  of  erysipelas,  and  in  the  course  of  acute  specific  fevers.  In  one  or  two 
extraordinary  instances  the  absorption  has  not  been  limited  to  the  callus,  but  has 
extended  to  the  fractured  bone  itself.  As  a  rule,  only  recent  fractures,  in  which 
consolidation  has  hardly  taken  place  yet,  are  afTfected. 

It  is  more  common  for  the  amount  to  be  deficient  from  the  first,  or  for  the 
process  of  ossification  to  fail.  Bony  union,  then,  is  either  delayed,  or  else  never 
takes  place  at  all ;  no  distinct  line  can  be  drawn  between  them  ;  the  causes  that 
occasion  the  one  will,  if  they  act  with  sufficient  persistence  and  vigor,  equally  give 
rise  to  the  other. 

I.  Delayed  union,  as  might  have  been  expected,  is  met  with  much  more  fre- 
quently than  complete  failure.  In  simple  fractures  of  the  leg  it  is  not  uncommon 
to  find  at  the  end  of  four  or  five  weeks  that  the  fragments  are  apparently  unal- 
tered, as  easily  moved  as  they  were  at  first.  Sometimes  a  definite  cause  can  be 
found  ;  but  more  often  there  is  nothing  of  the  kind.  Generally  in  these  cases 
there  has  been  very  little  displacement,  with  little  injury  to  the  surrounding  parts, 
and  consequently  the  amount  of  provisional  callus  is  exceedingly  small.  Or  the 
fragments  may  appear  to  be  united,  there  may  be  no  pain  or  undue  mobility  when 
the  limb  is  tested  ;  but  a  few  days  after  the  patient  is  allowed  to  get  up  the  union 
begins  to  bend,  and  it  is  clear  that  the  callus  is  not  sufficiently  firm.  In  the  vast 
majority  of  instances  this  gets  well  of  itself ;  the  limb  is  straightened  ;  a  fixed 
apparatus,  rather  stronger  than  usual,  is  applied ;   and  the  patient  is  allowed  to 


FRACTURES. 


355 


get  about  on  crutches,  with  a  strict  injiinctioii  not  to  let  tiic  injureti  limh  touch 
the  grountl  under  any  circumstances  ;  but  every  now  and  then  the  reverse  takes 
place,  the  caUus  becomes  absorbed,  from  too  erly  movement,  the  union  becomes 
weaker  and  weaker,  and  a  false  joint  results. 

2.  Non-union. — When  there  is  no  bony  i.nion  at  all,  the  ends  may  remain 
separate  and  distinct,  without  so  much  as  a  band  between  them  ;  or  they  may 
be  connected  together  by  fibrous  tissue  of  various  degrees  of  strength  ;  or  they 
may  lie  in  apposition,  held  by  a  capsule  of  connective  tissue,  so  that  a  more  or 
less  perfect  joint  is  formed. 

[Interposition  of  muscles  between  the  fragments  may  sometimes  cause  non- 
union.] 

{ii)  Absolute  non-union  is  rarel)'  met  with  except  in  intracapsular  fracture  of 
the  neck  of  the  femur,  and  in  some  cases  of  fractured  ])atella.  It  is  nearly  always 
due  to  wide  separation  of  the  fragments.     I'he  medullary  spaces  become  closed  ; 


Fig.  lie. — Ununiled 
Fracture  of  Ulna. 


Fig.  Ill . — Ununited  Fracture  of  Tibia 

with  Consecutive  Bending  and 

Strengthening  of  Fibula. 


Fig.  112. — False  Joint  in  Tibia  from 
a  Fracture,  Probably  at  Birth. 


the  ends  become  rounded  and  wasted  ;  the  surfaces,  if  they  are  in  contact  with 
other  hard  structures,  become  dense  and  polished  ;  and  the  callus  that  is  thrown 
out  after  the  fracture  is  absorbed  again. 

(J))  Fibrous  or  imperfect  miion  is  much  more  common.  Sometimes  it  is 
exceedingly  firm  ;  the  ends  of  the  bones  are  well  nourished  ;  the  broken  surfaces 
face  each  other  ;  the  fibres  that  pass  across  are  short  and  strong,  with,  perhaps, 
islets  of  cartilage  and  even  of  bone  scattered  among  them,  so  that  it  is  difficult  to 
be  certain  that  perfect  union  has  not  taken  place.  Sometimes,  on  the  other  hand 
the  fibres  are  long  and  weak,  formed  rather  by  a  condensation  of  the  connective 
tissue  around  the  ends  than  from  a  layer  of  callus  directly  connecting  them  ;  and 
the  bones  are  thin  and  conical,  with  their  ends  much  wasted.  Every  grade,  in 
short,  maybe  found,  between  union  that  is  nearly  as  strong  as  bone  and  absolute 
failure. 

(/)    False  joints    (pseudarthroses)  strictly  so    called,  are  rarely  met    w'ith. 


356     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCIURES. 

They  appear  to  be  formed  out  of  false  union  in  simple  fractures  by  constant 
movement  for  months  together.  In  some  cases  they  are  almost  perfect  ;  the  ends 
are  moulded  so  that  they  fit  each  other  accurately  ;  they  are  surrounded  and  held 
together  by  a  tough  ligamentous  cai)sule  ;  this  is  lined  with  a  layer  of  flattened 
connective-tissue  corpuscles  like  an  endothelium,  and  is  filled  with  a  fluid  which, 
as  in  the  case  of  adventitious  bursa;,  closely  resembles  synovia.  Sometimes  islets 
of  cartilage,  hyaline  or  fibrous,  may  be  found  \\\>o\\  the  apposed  surfaces,  probably 
the  remains  of  the  callus  that  was  thrown  out  shortly  after  the  fracture.  More 
often  the  surface  is  dense  and  polished,  as  in  joints  affected  with  arthritis  defor- 
mans ;  and  lips,  fringes,  and  even  loose  bodies  are  occasionally  found  around  the 
margin.  False  joints  of  this  descri])tion  are  most  frequently  met  with  in  the 
humerus  and  femur,  possibly  owing  to  the  peculiarly  dense  character  of  the 
compact  tissue. 

They  have  been  known  to  occur  in  children,  especially  in  the  leg,  and  to 
lead  to  impairment  in  the  growth  of  the  limb.  When  they  occur  in  adults,  the 
bones  and  muscles  are  often  well  nourished,  much  better  than  they  are  in  cases 
of  fibrous  union. 

Causes. — The  causes  of  delayed  union  and  false  joints  may  be  general  or 
local ;   but  the  latter  are  by  far  the  more  important. 


Fig.  113  — Position  Assumed  by  the  Limb  in  this  Case  before  it  was  Amputated. 

1.  General  Causes. — Very  few  can  be  regarded  as  more  than  occasional  ; 
union  is  sometimes  delayed  ;  but  more  often  than  not  it  takes  place  as  quickly 
as  in  health.  Fevers,  Bright's  disease,  diabetes,  scurvy,  starvation,  advanced 
syphilis  or  carcinoma,  pregnancy,  lactation,  any  severe  cache.Kia,  in  short,  may 
check  the  progress  of  repair,  but  though  undoubted  instances  are  recorded,  it  is 
rare  to  find  that  any  one  of  these  is  sufficient  by  itself.  Sometimes  the  urine 
has  been  found  to  be  alkaline  and  loaded  with  phosphates,  and  it  has  been 
thought  that  this  was  the  reason,  and  in  a  very  few  cases  it  has  seemed  as  if  the 
fault  lay  with  the  nervous  system.  Old  age  is  certainly  not  a  cause  ;  fractures 
unite  as  well  in  peo[)le  over  seventy  as  in  younger  ones,  with  the  exception  of 
intra-capsular  fracture  of  the  neck  of  the  femur,  the  reasons  for  which  are  probably 
entirely  local.      Complete  failure  may  nearly  always  be  traced  to  local  causes. 

2.  Local  Causes. — Some  of  these,  like  the  general  ones  already  mentioned, 
merely  delay  union  ;  others  prevent  it  altogether  ;  but  with  a  few  exceptions  it 
cannot  be  said  even  of  these  that  they  are  invariaiile  ;  and  in  a  large  proportion 
of  cases  it  is  impossible  to  give  a  definite  reason  why  union  fails. 

{a^  Separation  of  the  Broken  Surfaces. — This  is  the  most  imjiortant  ;  if  the 
space  between  the  fragments  is  filled  up  with  other  structures,  whether  muscle, 
tendon,  joint-capsule,  or  blood-clot,  so  that  they  cannot  be  brought  together, 
failure  is  almost  certain.     It  does  not  matter  how  the  separation  is  produced  ; 


FRACTURES.  357 

the  ends  may  be  driven  into  the  substance  of  other  structures  near  ;  or  drawn 
apart  by  the  action  of  muscles ;  or  made  to  overlap  so  that  the  periosteal  surfaces 
only  are  in  contact ;  unless  they  are  i)roperly  adjusted  the  result  is  almost  certain. 
Non-union  is  more  frequent  in  compound  fractures  than  simple  ones,  owing  to 
the  amount  of  bone  that  is  sometimes  lost  by  resecting  the  ends,  or  from  necrosis. 

(/-')  Afovcfitcnf. — In  other  instances  the  method  is  in  fault ;  either  the  frag- 
ments are  not  properly  secured,  and  the  neighboring  joints  not  fixed  as  they  should 
be,  or  movement  is  allowed  too  foon,  and  the  callus  is  absorbed  again.  This 
happens  in  a  variety  of  ways:  the  bandages  may  become  loose  from  shrinking  of 
the  limb  ;  the  patient  may  be  delirious  ;  surrounding  circumstances  may  be  unfavor- 
able, or  a  neighboring  joint  may  become  stiff,  so  that  when  the  limb  is  used  an 
undue  strain  falls  upon  the  seat  of  fracture.  One  of  the  favorite  sites  is  the  middle 
of  the  shaft  of  the  humerus,  and  it  is  certainly  not  uncommon  to  find  in  the.se 
cases  that  the  elbow  is  stiff ;  but  I  am  disposed  to  think  that  more  importance 
should  be  attached  to  the  peculiarly  dense  character  of  the  bone  at  this  spot,  and 
to  the  possibility  of  slips  of  the  neighboring  muscles  getting  in  the  way.  In  the 
case  of  sailors,  among  whom  cases  of  ununited  fracture  are  unusually  frecpient,  full 
allowance  must  be  made  for  defective  hygienic  conditions,  although,  admittedly, 
fractures  of  the  ribs  rarely  fail  to  unite  in  them. 

[The  e.xperience  of  the  editor  in  many  years'  service  in  the  Marine  Hospitals 
of  the  United  States  does  not  sustain  this  view  as  to  the  frequency  of  non-union 
in  fractures  among  sailors,  although  he  cannot  recall  a  single  instance  of  non-union 
of  the  ribs,  as  having  fallen  under  his  observation.  The  cases  of  non-union 
among  sailors  that  he  has  seen  were  of  the  long  bones,  and  were  due  to  either  lack 
of  proper  attention  on  shipboard  before  arriving  in  hospital,  or  to  constitutional 
syphilis.  In  the  latter,  there  was  no  effusion  of  callus,  nor  could  exudation  be 
excited  by  ordinary  means  of  treatment.] 

(<:)  Malmitritio?i. — The  prolonged  application  of  cold,  ligature  of  the  main 
artery,  tight  bandaging  so  as  to  interfere  with  the  circulation,  thrombosis  of  the 
veins,  leading  to  oedema,  and  rupture  of  the  nutrient  vessels,  are  all  cited  as  occa- 
sional causes  ;  and  no  doubt  they  are  not  without  some  influence,  although  it  is 
difficult  to  believe  they  are  sufficient  of  themselves.  It  has  not  been  proved  that 
the  nerves  exert  any  direct  effect. 

{d)  Disease  of  the  done  itself  is  an  occasional  cause.  Necrosis  has  been 
already  mentioned  as  especially  frequent  in  compound  fractures  ;  but  tertiary  syph- 
ilitic nodes,  mollities  ossium,  atrophy,  hydatid  cysts,  sarcomata,  and  chronic 
abscesses  sometimes  lead  to  the  same  result. 

Diagnosis. — This  rests  mainly  upon  the  degree  of  mobility  that  is  present. 
In  cases  of  delayed  union  it  is  usually  slight,  though  the  amount  of  deformity  may  be 
considerable,  and  it  is  always  painful ;  in  fibrous  union  or  false  joint,  on  the  other 
hand,  it  is  free  and  nearly  painless.  The  probability  of  the  latter  increases  greatly 
with  the  length  of  time  since  the  accident ;  but  union  of  a  fractured  femur  has 
been  known  to  take  place  without  operation  after  as  long  an  interval  as  twenty- 
two  months. 

Treatment. — Like  the  causes,  this  is  general  as  well  as  local ;  but  while  the 
former  may  prove  serviceable  in  mere  delay,  it  is  entirely  without  effect  in  genuine 
cases  of  false  joint. 

I.  Constitutional. — This  naturally  varies  with  the  requirements  of  each  case. 
Nourishing  food  and  fresh  air  are  essential  in  all  ;  tonics  are  often  needed  to  im- 
prove digestion  ;  a  fair  amount  of  stimulants  is  advisable,  especially  in  those  who 
are  accustomed  to  them  ;  and  iron,  cod-liver  oil,  and  other  remedies  may  be  given 
to  improve  the  general  health  \  but  there  is  no  proof  that  the  administration  of 
lime  or  of  phosphorus  in  any  shape  has  any  effect  upon  the  deposition  or  the  ossi- 
fication of  callus.  In  cases  of  syphilis,  mercury  and  iodide  of  potash  must  be  given 
according  to  the  general  rules  ;  and  mercury  has  been  given  experimentally  with 
success  where  no  history  could  be  obtained  ;  but,  apart  from  the  presence  of  gum- 
mata  upon  the  bones,  it  very  rarely  happens  that  union  is  in  any  way  delayed  by  this 
disorder.     Vegetables  and  lime-juice  are  equally  important  if  there  is  any  suspicion 


358    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

of  scurvy;  and  a  woman  who  is  suckling  should  be  directed  to  wean  her  infant; 
but,  beyond  general  considerations  of  this  character,  nothing  can  be  done.  There 
is  no  evidence  that  any  drug  has  the  least  direct  influence  on  the  rapidity  with 
which  union  takes  place. 

2.  Local. — Readjustment. — The  first  thing,  if  the  ordinary  time  has  elai)sed 
and  the  fragments  are  still  movable,  is  to  reset  them,  bring  them  into  apjjosition 
with  each  other,  and  secure  them  in  some  form  of  splint  (a  fixed  one  generally)  that 
will  ensure  absolute  immobility,  and  at  the  same  time  enable  the  patient  to  get 
into  the  open  air.  This  alone  is  sufficient  in  a  large  j^roportion  of  cases,  especially 
those  in  which  the  chief  cause  is  want  of  rest.  Only  it  is  necessary  to  make  cer- 
tain once  for  all  that  the  fragments  are  really  in  apposition,  and  that  nothing  has 
slipped  in  between.  Should  this  have  happened,  union  is  almost  certain  to  fail ; 
and  unless  the  ends  can  in  some  way  be  disengaged  and  brought  together,  it  is 
scarcely  worth  while  wasting  time  in  trying  measures  that  must  be  ineffectual. 

Coitiiter-irritatioTi. — This  may  be  combined  in  some  instances  with  the  use 
of  counter-irritants — tincture  of  iodine,  for  example,  painted  once  every  night,  or 
light  blisters.  These  no  doubt  do  increase  the  amount  of  blood  flowing  through 
the  parts  beneath  ;  the  exact  form  of  a  blister  painted  on  the  thorax  may  be  traced 
sometimes  upon  the  costal  pleura ;  and  where  a  bone  is  near  the  surface,  as  in  the 
case  of  the  leg,  the  periosteum  would  almost  certainly  be  stimulated  to  increased 
action  ;  but  at  the  best  they  can  only  be  of  very  limited  application. 

Mechanical  Stimulation. — If  this  procedure  fails,  an  attempt  may  be  made  to 
excite  a  certain  degree  of  inflammation  by  friction  or  percussion,  and  then  to  ob- 
tain union  by  securing  the  fracture  in  a  plaster  case.  One  method  is  to  rub  the 
ends  of  the  bones  together  every  day,  until  a  certain  amount  of  heat  and  swelling 
is  produced  around  the  seat  of  fracture.  Another  aims  at  the  same  effect  by  ham- 
mering them  with  a  mallet,  the  skin  being  protected  from  injury  by  a  piece  of  felt. 
A  third,  which  is  sometimes  successful,  not  only  in  delayed  union,  but  even  in  case 
of  false  joint  of  long  standing,  consists  in  encasing  the  limb  in  an  apparatus  so  con- 
trived that  the  patient  may  get  about,  while  the  fragments  are  held  rigidly  fixed 
and  in  contact  with  each  other.  This  is  especially  useful  in  fractures  of  the  lower 
limb,  where  there  is  already  a  fair  amount  of  union,  and  where  the  direction  is  not 
too  oblique.  The  appliance,  which  must  be  worn  night  and  day,  naturally  must 
be  fairly  strong,  and  must  fit  with  the  greatest  accuracy.  The  best  are  made  of 
leather,  with  lateral  iron  supports,  jointed  in  the  proper  situations,  and  let  into  the 
boot  beneath.  The  health  of  the  ])atient  improves;  the  nutrition  of  the  limb 
becomes  more  .satisfactory  ;  and  the  constant  friction  of  the  ends  of  the  bones 
stimulates  them  to  such  an  extent  that  in  many  instances  the  fracture  unites  and 
becomes  firm  without  anything  further  being  required. 

Puncture  and  Injectioii. — When  it  is  no  longer  a  question  merely  of  delay,  the 
same  kind  of  treatment  may  be  adopted,  but  in  a  more  vigorous  manner.  If  the 
bone  lies  near  the  surface,  it  sometimes  answers  to  drive  a  number  of  stout  needles 
directly  through  the  skin  into  the  space  between  the  fragments,  and  leave  them 
there  for  a  week  or  ten  days.  In  other  cases  the  injection  of  various  kinds  of  fluid, 
tincture  of  iodine,  carbolic  acid,  and  alcohol  has  been  tried.  Or  the  negative  pole 
of  a  galvanic  battery  has  been  attached  to  a  needle  inserted  between  the  fragments, 
and  a  current  as  strong  as  the  patient  could  bear  without  an  anfesthetic  passed 
through  it ;  or  the  ends  have  been  scarified  with  a  tenotome,  or  perforated  with  a 
drill,  with  the  view  of  exciting  sufficient  inflammation  about  the  part  to  fix  the 
fragments  in  the  exudation.  None  of  these,  however,  can  be  advocated  very 
strongly ;  acupuncture  and  drilling  the  ends  are  perhaps  the  most  .satisfactory,  but 
they  are  not  so  devoid  of  danger  as  they  seem  to  be,  especially  as  the  large  blood- 
vessels are  often  adherent  to  the  fragments,  and  their  action  is  by  no  means 
certain.      Setons  should  certainly  not  l)e  used. 

Pegging. — Of  all  the  methods  that  act  in  this  way,  the  one  that  has  enjoyed 
the  greatest  amount  of  success  is  that  first  practiced  by  Dieffenbach.  According 
to  his  directions,  a  small  incision  is  made  through  the  soft  parts  down  to  the  bone, 


FRACTURES.  359 

on  the  side  that  is  most  accessible,  and  both  fragments  are  drilled  completely 
through  ;  then  an  ivory  peg  is  driven  into  each  with  a  wooden  hammer,  until  its 
end  can  be  felt  projecting  on  the  other  side,  and  the  fracture  secured  in  a  plaster 
casing.  The  pegs  may  be  left  in  for  ten  days  or  a  fortnight,  according  to  the 
amount  of  reaction  they  cause. 

It  is  generally  found  when  the  pegs  are  removed  that  the  surface  is  deeply 
eroded  (after  the  fashion  of  Howship's  lacunae)  by  the  cells  in  the  medulla  ;  and  it 
is  much  simpler  to  break  them  off  short,  and  leave  them  in  the  substance  of  the 
bone,  to  be  absorbed  there  ;  they  do  not  of  themselves  excite  suppuration,  the  skin 
wound  can  be  closed  at  once,  and  there  is  much  less  chance  of  inflammatory  com- 
plications setting  in.  In  very  oblique  fractures,  where  the  ends  of  the  bones  over- 
lap, an  additional  amount  of  security  maybe  obtained  by  driving  the  pegs  through 
both,  so  as  to  pin  them  together  ;  and  steel  screws  may  be  used  in  the  same  way, 
the  handles  being  detached  after  they  are  fixed,  so  that  the  whole  can  be  covered 
up  in  one  dressing  ■  but  if  measures  of  this  kind  are  adopted,  it  is  more  satisfactory 
to  expose  the  ends  of  the  bone  thoroughly,  resect  them  if  necessary,  and  adjust 
them  accurately.  The  operation  is  scarcely,  if  at  all,  more  severe  and  the  result  is 
decidedly  more  certain. 

Resection  and  Wiring. — In  a  large  number  of  cases  this  is  the  only  plan  that 
offers  a  reasonable  prospect  of  success.  Where  there  is  a  false  joint  of  long  stand- 
ing, or  great  displacement  of  the  ends,  or  when  some  foreign  substance  has  become 
entangled  in  the  fracture  so  that  the  bone  cannot  be  released,  nothing  else  can  be 
of  any  avail.  The  immediate-neighborhood  of  a  joint  is  no  objection  ;  if  the  tissues 
themselves  are  healthy,  and  if  there  is  no  great  amount  of  inflammatory  exudation 
around  the  part  already,  there  is  no  reason  why  suppuration  should  occur.  A  cer- 
tain amount  of  stiff'ness  may  result,  it  is  true,  either  from  the  formation  of  adhesions 
or  from  excess  of  callus,  but  it  is  rarely  of  any  extent,  and,  of  course,  such  an 
operation  as  this  is  not  done  unless  the  usefulness  of  the  limb  is  seriously  impaired. 

The  operation  itself,  especially  in  the  case  of  a  deeply-seated  bone,  is  by  no 
means  easy.  The  limb  is  rendered  bloodless  ;  the  parts  thoroughly  exposed  by  a 
longitudinal  incision,  if  possible,  through  one  of  the  inter-muscular  septa,  so  as  to 
avoid  injury  to  other  structures,  all  intervening  tissue  removed,  taking  especial  care 
to  preserve  every  fragment  of  periosteum,  and  the  ends  either  sawn  off" or  thoroughly 
freshened.  It  is  of  little  or  no  use  unless  they  are  made  to  fit  each  other  accurately, 
over  a  surface  of  some  extent,  and  are  firmly  held  together.  They  may  be  secured 
in  various  ways  according  to  their  shape;  sometimes,  when  they  are  both  oblique, 
they  may  be  pegged  through  with  wire  or  ivory  needles  ;  in  other  cases  they  may 
be  dovetailed  or  wedged  into  each  other  ;  in  one  example  the  lower  end  of  the 
fibula  was  driven  into  the  medullary  canal  of  the  upper  end  of  the  tibia  with  a  very 
good  result ;  or  if  the  central  canal  of  both  fragments  is  exposed,  an  ivory  peg  may 
be  fixed,  first  in  the  one  and  then  in  the  other,  so  as  to  hold  them  in  the  same 
straight  line  ;  but  the  ordinary  method  is  to  drill  them  both,  and  suture  them  to- 
gether, either  with  silver  wire  (the  ends  of  which  can  be  hammered  down)  or  kan- 
garoo tendon.  Especial  care  must  be  taken  to  provide  sufficient  drainage  ;  owing 
to  the  amount  of  manipulation  to  which  the  parts  must  be  subjected  in  an  operation 
of  this  kind  the  oozing  is  in  general  very  extensive. 

Even  this  is  not  always  successful.  A  great  deal  depends  upon  the  condition  of 
the  bones  ;  if  they  are  much  wasted,  and  if  the  ends  are  sharp  and  pointed,  failure 
is  not  at  all  unlikely.  Sometimes,  when  a  first  attempt  under  strict  antiseptic  pre- 
cautions does  not  succeed,  a  second  without  is  more  satisfactory,  and  union  has 
taken  place  after  an  attack  of  erysipelas.  Perhaps  the  best  thing,  if  the  opera- 
tion fails,  is  to  put  the  limb  up  in  some  apparatus  that  will  allow  it  to  be  used  to 
a  certain  extent,  in  the  hope  that,  though  this  may  not  improve  the  chance  of 
union,  the  bones  will  be  better  nourished,  and  then  another  attempt  may  be  made 
later  on. 

Transpla7itatioii. — Nussbaum,  in  two  instances  in  which  there  was  a  great 
deficiency  in  the  ulna,  separated  a  portion  of  bone  from  one  of  the  ends,  leaving 


36o     DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

it  attached  by  periosteum,  ami  reflected  it,  so  that  it  filled  up  the  interval.  If 
this  is  attempted,  the  circulation  through  the  bone  must  first  of  all  be  stimulated 
by  inserting  needles  into  it,  and  great  care  must  be  taken  to  prepare  the  bed  for 
the  new  fragment. 

Grafting. — MacEwen  has  carried  the  process  further  still,  and  by  dint  of  re- 
peatedly grafting  in  fragments  of  bone  obtained  by  osteotomy,  succeeded,  in  a 
child,  three  years  old,  in  causing  the  reproduction  of  nearly  the  whole  of  the 
shaft  of  the  humerus.  Fragments  of  bone  and  periosteum  obtained  from  animals 
have  also  been  used,  and  with  success;  in  one  instance,  a  gap  of  two  and  three- 
quarters  inches  in  the  clavicle  was  gradually  filled  up  by  grafts  of  bone  from  dogs, 
three  successive  series  being  used;  and,  in  another  (.\IcCjill),  thirteen  fragments 
of  bone  from  the  femur  of  a  rabbit  were  transplanted  into  a  gap  in  the  radius, 
with  a  perfect  result.  It  is  possible,  of  course,  that  this  may  be  due  merely  to 
the  irritating  effect  of  a  foreign  body  ;  but  it  is  difficult  to  believe  that  the  nature 
of  the  foreign  body  is  of  no  importance. 

Sy.mptoms  and  Diagnosis. 

A  fractured  limb  must  be  made  secure  at  once,  to  avoid  further  injury.  Full 
and  detailed  examination  is  better  postponed  until  the  splints  and  other  appli- 
ances are  ready,  that  the  fracture  may  be  set,  without  being  handled  a  second 
time.  The  extent  to  which  it  is  advisable  to  carry  the  investigation  and  the 
question  of  an  anaesthetic,  vary  in  each  case,  and  must  be  left  to  the  discretion 
of  the  surgeon.  In  some  instances,  such  as  fracture  of  the  neck  of  the  femur  in 
an  old  person,  manipulation  should  never  be  attempted  ;  on  the  other  hand,  in 
an  injury  to  the  lower  extremity  of  the  humerus,  it  is  absolutely  essential  to  find 
out  the  e.xact  position  and  direction,  if  serious  deformity  is  not  to  result. 

The  possibility  that  neighboring  structures,  especially  arteries  and  joints,  are 
injured  too,  should  never  be  forgotten,  and  a  careful  examination  into  their  con- 
dition should  be  made  in  every  case  ;  they  may  easily  be  wounded  by  splinters 
and  in  other  ways,  and,  if  overlooked,  may  lead  to  very  grave  complications. 

Method. — No  pains  should  be  spared  to  obtain  a  clear  account  of  the  acci- 
dent, whether  the  injury  was  the  result  of  direct  or  indirect  violence,  or  if  it  was 
due  to  muscular  action — sometimes  a  sound  is  heard  at  the  moment  that  the  bone 
gives  way — then  what  happened  afterward,  whether  the  limb  was  used  again,  or 
if  all  power  over  it  was  gone,  and  where  the  pain  was  most  acute.  In  many  cases 
a  shrewd  suspicion  may  be  formed  from  this  alone,  not  merely  as  to  the  part  of 
the  body  which  has  been  hurt,  but  even  as  to  the  kind  of  injury  sustained. 

Then,  before  it  is  touched  further  than  is  required  for  the  removal  of  the 
clothes  (which  should  be  cut  wherever  necessary),  it  must  be  inspected  with  the 
greatest  care,  and  compared,  point  for  point,  with  the  corresponding  part  of  the 
opposite  side.  Often,  the  position  is  characteristic  of  some  special  kind  of  injury  ; 
sometimes  the  outline  is  greatly  changed,  natural  hollows  perhaps  are  obliterated, 
or  bony  prominences  have  disappeared,  or  measurement  even  by  the  eye  reveals 
an  amount  of  shortening  or  displacement  that  can  be  accounted  for  in  no  other 
way. 

Xot  till  this  is  finished  may  the  part  be  handled,  and  then  as  lightly  as  pos- 
sible, beginning  at  some  distance  from  the  supposed  seat  of  injury,  and  tracing 
down  with  the  finger  the  prominent  ridges  or  crests  of  bone.  One  spot  may  be 
more  tender  than  the  rest  ;  nearly  always  there  is  swelling  either  from  the  extrava- 
sation of  blood,  or  from  displacement  of  the  broken  ends  ;  sometimes,  there  is  dis- 
coloration, or  the  skin  is  abraded  and  even  torn.  All  this  must  be  noted  before 
any  attempt  is  made  to  move  the  part,  either  for  the  purpose  of  eliciting  crepitus, 
or  of  ascertaining  the  presence  of  abnormal  mobility.  This,  if  it  cannot  be 
avoided  altogether,  must  be  postponed  to  the  last.  It  must  never  be  forgotten 
that,  in  all  cases,  a  great  deal  (in  fractures  by  indirect  violence  nearly  the  whole) 
of  the  injury  sustained  by  the  soft  parts  is  due  to  the  movement  of  the  broken  ends. 


FRACTURES.  361 

Symptoms. — -'rhe  three  distinetive  signs  of  fracture  are  an  alteration  in  the 
shape  of  the  i)art  due  to  the  displacement  of  the  broken  ends,  undue  mobility,  and 
the  rough,  grating  sensation,  or  crepitus,  felt  when  one  broken  surface  is  rubbed 
against  another.  The  presence  of  any  one  of  them  is  enough  ;  when  they  are  all 
three  wanting,  as  in  fissures  of  the  cranium,  the  existence  of  a  fracture  is  only  a 
matter  of  inference. 

1.  Drfonnity. — ( )f  these  three  displacement  is  the  most  valuable,  as  it  requires 
little  manipulation,  and  is  the  one  most  often  present.  Sometimes  it  is  so  con- 
siderable, that  it  is  visible  to  the  eye  at  once;  more  often  it  can  be  felt  beneath 
the  skin,  but,  in  most  instances,  it  is  only  possible  to  make  certain  by  means  of 
measurement.  In  the  limbs,  comparison  with  the  opposite  side  of  the  body  is  an 
absolute  rule.  In  some  cases,  a  fairly  accurate  estimate  may  be  made  with  the 
hands  alone,  grasping,  for  example,  the  anterior  superior  spines  of  the  ilium,  in  a 
case  of  injury  to  the  upper  extremity  of  the  femur,  and  measuring  with  the  fingers 
the  relative  position  of  the  trochanters  on  each  side.  In  general,  as  the  displace- 
ment is  so  often  longitudinal,  it. is  done  much  better  with  a  measuring-tape  or  a 
sliding  graduated  rod.  The  points  selected  on  the  two  sides  should  be  well  marked, 
and  must  absolutely  correspond  ;  the  position  of  the  limbs  must  be  identically  the 
same,  and,  as  asymmetry  is  not  at  all  uncommon,  it  is  often  advisable  to  measure 
not  only  the  length  of  the  whole  limb,  but  that  of  the  individual  segments.  This 
is  particularly  necessary  in  the  lower  extremity  ;  whether  from  previous  injury  or 
disease,  or  from  some  difference  in  the  rate  of  growth,  it  is  not  at  all  uncommon 
to  find  one  of  the  lower  limbs  considerably  longer  than  the  other. 

The  direction  of  the  displacement  depends  chiefly  on  the  character  of  the 
part  that  is  injured.  It  may  be  angular,  as  in  a  greenstick  fracture ;  transverse, 
or  lateral,  when  a  flat  bone  is  concerned ;  circular,  as  in  fractures  of  the  lower 
extremity,  with  eversion  of  the  foot ;  or  longitudinal,  the  ends  either  being  drawn 
apart  as  in  transverse  fractures  of  the  patella,  or  approximated  so  that  they  lie 
side  by  side  and  override  each  other.  In  some  cases,  when,  for  example,  one  is 
so  driven  into  the  substance  of  the  other  that  it  becomes  impacted  there,  deformity 
is  the  only  one  of  the  three  cardinal  symptoms  present ;  occasionally,  it  is  absent, 
as  in  fissures  of  the  cranium,  or  when  only  one  of  a  pair  of  bones  is  broken. 

In  impacted  fractures,  the  displacement  is  entirely  the  result  of  the  original 
force  ;  in  other  cases,  it  depends  to  a  great  extent  on  causes  which  continue  to 
act  after  the  bone  is  broken,  so  that  it  grows  worse  and  worse  the  longer  the 
fracture  is  left  to  itself.  The  most  serious  is  the  contraction  of  the  muscles,  not 
merely  the  tonic  shortening  which  results  naturally  as  soon  as  they  are  released 
from  their  state  of  tension,  but  violent  and  continued  spasmodic  contraction,  due 
no  doubt  to  the  irritation  caused  by  the  broken  ends.  This  is  responsible  almost 
altogether  for  the  separation  when  a  bony  projection  is  wrenched  off,  and  for  the 
shortening  which  is  nearly  invariable  in  fractures  of  the  long  bones  of  the  limbs, 
and,  therefore,  in  cases  of  paralysis,  displacement  is  always  slight.  In  other  in- 
juries, the  weight  of  the  limb  and,  what  is  a  great  deal  worse,  subsequent  attempts 
at  moving  the  part,  either  by  the  patient  himself  or  by  others,  often  add  seriously 
to  it.  Indeed,  it  is  in  great  measure  owing  to  these  two  last-mentioned  causes 
that  so  many  fractures  by  indirect  violence  become  compound. 

2.  Abnormal  Mobility. — Abnormal  mobility,  when  it  is  present,  is  conclu- 
sive, but,  if  the  degree  is  slight,  or  if  the  fracture  is  in  the  neighborhood  of  a 
joint,  it  is  very  hard  to  appreciate,  and,  if  there  is  impaction,  it  is  wanting 
altogether.  It  is  most  plain  in  transverse  fractures  of  the  shaft  of  long  bones, 
where  there  is  only  one ;  in  injuries  of  short  bones,  or  where  one  fragment  is  so 
small  or  so  deeply  placed  that  it  cannot  be  fixed,  it  is  of  little  or  no  assistance, 
and,  though  it  is  nearly  always  present  when  one  of  a  pair  of  bones  has  given 
way,  special  manipulation  is  generally  required  to  show  it.  If,  for  example,  the 
radius  is  in  question,  the  thumb  of  one  hand  must  be  placed  upon  the  head  of 
the  bone,  while  the  other  alternately  pronates  and  supinates  the  forearm ;  if  the 
lower  end  of  the  fibula,  a  finger  must  be  pressed  firmly  on   the  suspected  spot, 

24 


362     DISEASES  AND  INJURIES   OE  SPECIAL   STRUCTURES. 

while  the  upper  part  of  the  two  bones  are  squeezed  together,  or  the  foot  is  forcibly 
inverted  and  everted. 

Manipulation  of  this  kind  must  be  carried  out  with  the  greatest  gentleness, 
not  merelv  because  it  is  so  painful  (this  may  be  prevented  by  an  ana;sthetic),  but 
because  it  inflicts  such  injury  on  surrounding  structures.  For  this  reason,  in 
some  fractures,  of  the  spine,  for  example,  any  attempt  should  be  absolutely  pro- 
hibited. 

3.  Crepitus. — Crepitus,  the  peculiar  sensation,  partly  felt,  partly  heard,  when 
one  broken  surface  is  made  to  rub  upon  another,  is  still  more  limited  in  its  appli- 
cation, for  in  order  to  produce  it  the  fragments  must  not  only  be  freely  movable, 
but  in  actual  contact,  or  at  least  so  close  that  they  can  be  made  to  touch.  If 
they  are  fixed  or  widely  separated,  or  if  a  piece  of  fascia  or  muscle,  or  even  blood- 
clot,  has  slipped  between,  it  fails  completely,  and  when  an  epiphysis  is  detached, 
especially  in  very  young  children,  it  is  so  soft  and  faint  that  it  can  scarcely  be 
recognized.  Other  sounds,  too,  resemble  it  more  or  less  closely  ;  if  a  synovial 
sheath  or  bursa  is  inflamed,  or  if  there  is  a  collection  of  e.xtravasated  blood  be- 
neath a  layer  of  dense  fascia,  such  as  is  not  uncommon  in  the  region  of  the 
shoulder,  direct  pressure  may  cause  a  sensation  that  is  almost  identical ;  but,  as  a 
rule,  it  only  does  so  once,  and  the  sensation  cannot  be  repeated  at  the  same  spot 
till  some  little  time  has  elapsed.  Single  clicks,  too,  something  similar  in  charac- 
ter, may  often  be  felt  near  joints  that  have  been  injured  when  they  are  moved  in 
certain  directions;  and  sometimes,  as  in  the  elbows  of  children,  in  whom  the 
bony  prominences  are  naturally  low,  and  often  still  further  concealed  by  swelling, 
they  may  be  so  clear  as  to  cause  a  momentary  doubt. 

In  rheumatoid  arthritis,  when  the  cartilage  has  disappeared  from  the  articular 
surfaces,  and  the  polished  bones  are  rubbed  upon  each  other  in  every  movement 
of  the  joint,  the  sound  is  almost  identical,  but  the  feeling  is  much  smoother,  and 
the  surfaces  do  not  grate  on  each  other  in  the  same  way. 

The  sudden  sound  that  is  sometimes  heard  at  the  moment  of  the  accident, 
not  only  by  the  patient,  but  even  by  those  standing  near,  is  rarely  of  any  assistance 
in  diagnosis,  as  it  only  occurs  when  a  long  bone  is  broken,  in  circumstances  that 
nearly  always  cause  much  displacement. 

Fain. — In  addition  to  these,  there  are  other  symptoms  which  are  not  confined 
to  fractures,  and  which,  therefore,  can  only  be  regarded  as  proof  when  there  is 
other  evidence  in  support  of  them.  Intense  pain  at  the  seat  of  injury,  for  ex- 
ample, is  nearly  invariable,  but  to  be  of  any  use  in  diagnosis  it  must  be  constant 
and  limited  to  one  particular  spot.  If,  for  example,  pressure  on  one  part  of  a  rib 
always  causes  pain  at  another,  or  if  after  the  foot  has  been  twisted  an  exceed- 
ingly painful  spot  is  found  on  the  fibula,  an  inch  or  two  above  the  ankle  joint, 
fracture  more  or  less  complete  is  almost  certain  ;  there  is  nothing  else  that  can 
explain  localized  tenderness  so  far  from  the  seat  of  injury. 

Ecchymosis. — Extensive  ecchymosis  again  is  a  common  occurrence  in  cases 
of  fracture,  but  is  of  little  use  in  diagnosis,  unless  it  has  the  support  of  other 
signs.  Hemorrhage  from  the  ear,  for  example,  is  generally  present  in  fractures 
through  the  middle  fossa  of  the  skull,  but  it  is  only  conclusive  when  it  is  sudden 
and  profuse ;  and  staining  of  the  skin  is  not  in  any  way  peculiar,  unless  it  is 
accompanied  by  localized  tenderness  and  it  is  certain  that  the  part  itself  was  not 
directly  hurt. 

Helplcsstiess. — Inability  to  make  use  of  the  part  is  very  general,  but  by  no 
means  invariable.  It  depends,  of  course,  upon  the  size  and  importance  of  the 
injured  bone  and  the  extent  to  which  it  is  hurt.  If  the  ends  are  impacted,  or  the 
periosteum  is  not  torn,  or  if  only  one  bone  of  a  pair  is  broken,  the  limb  may  still 
be  used  to  a  certain  extent,  though  not  without  pain.  In  some  ca.ses  of  fracture  of 
the  clavicle,  it  is  quite  possible  to  raise  the  arm  above  the  head,  and  persons  with 
impacted  fracture  of  the  neck  of  the  femur  have  been  known  to  walk  about  for 
days.  When,  on  the  other  hand,  the  bony  support  for  the  leverage  of  the  muscles 
is  lost,  this  is  absolutely  impossible.     Unhappily,  this  symptom  is  not  confined  to 


FRA  CTURES.  363 

fractures,  ])ut  is  present  in  other  injuries,  too,  particularly  in  those  which  present 
the  closest  resemblance  to  them. 

Diagnosis. —  The  diagnosis  of  fracture  has  to  be  made  from  separation  of 
epiphyses,  dislocations,  and  contusions.  Injuries  in  the  neighborhood  of  joints, 
therefore,  present  the  greatest  difficulty,  and  if  the  examination  is  delayed  until 
swelling  has  set  in,  or  if  the  joint  has  been  previously  the  seat  of  disease,  particu- 
larly of  rheumatoid  arthritis,  it  may  be  necessary  to  wait  for  some  days  and  to 
watch  the  progress  of  the  case  before  a  definite  opinion  can  be  given.  In  such  a 
case  the  injury  must  always  be  treated  as  if  it  was  certain  that  the  bone  was  really 
broken. 

The  separation  of  an  epiphysis  is  distinguished  by  the  locality,  by  the  age  at 
which  it  occurs,  and  by  the  peculiar  soft  character  of  the  crepitus,  when  it  is  pres- 
ent :  in  infants  it  may  be  absent  altogether,  as  the  line  of  detachment  in  them 
lies  in  the  substance  of  the  cartilage.  The  amount  of  displacement  is  rarely  very 
great,  as  the  periosteum  belonging  to  the  shaft  is  closely  attached  to  the  epiphysis, 
and  is  so  tough  that  it  is  seldom  torn  completely  in  two  ;  but  sometimes,  when 
the  end  of  the  shaft  is  near  the  skin,  its  smooth  and  rounded  shape  can  be  dis- 
tinguished from  the  sharp  outline  of  a  fracture.  The  diagnosis  is  important,  be- 
cause in  a  certain  number  of  cases  this  accident  is  followed  by  an  arrest  of 
growth,  and  it  is  advisable  that  the  possibility  of  such  an  occurrence  should  be 
pointed  out  at  the  time,  ^^"hen  there  is  only  one  bone,  as  in  the  arm,  there  is 
merely  a  certain  degree  of  shortening,  and  if  the  upper  end  is  in  question,  some 
restriction  in  over-hand  movements ;  but  when  the  lower  end  of  the  radius  fails 
to  grow,  the  styloid  process  of  the  ulna  projects  further  and  further  until  the  use 
of  the  hand  is  seriously  interfered  with  and  the  appearance  is  very  unsightly. 

Dislocations  rarely  present  any  difficulty  if  the  injury  is  seen  shortly  after 
the  accident,  before  swelling  has  set  in  and  the  bony  prominences  are  obscured. 
If  displacement  is  once  rectified,  there  is  no  tendency  for  it  to  return  ;  true  crep- 
itus is  Avanting,  though  sometimes  there  is  a  very  fair  imitation,  and  there  is  no 
abnormal  mobility.  The  position  of  the  limb  is  fixed,  and  can  only  be  altered  by 
the  exercise  of  a  certain  degree  of  force.  It  must  not  be  forgotten,  however,  that 
fractures  sometimes  occur  with  dislocations,  and  that,  particularly  in  the  case  of 
the  elbow,  fractures  into  joints  may  be  accompanied  by  a  degree  of  displacement 
that  produces  a  very  close  resemblance. 

Severe  contusions,  in  which  there  is  complete  loss  of  power  over  the  limb  or 
a  considerable  extravasation  of  blood,  in  many  cases  cannot  be  distinguished  from 
impacted  fractures,  and  should  be  treated  as  such.  It  is  impossible  to  prove  that 
the  crushing  force  has  been  expended  entirely  on  the  soft  parts,  and  has  not 
reached  the  bone,  without  handling  the  part  to  an  extent  which,  in  such  injuries, 
is  certainly  not  advisable. 

Course  and  General  Complications. 

Shock. — All  fractures  of  any  consequence  are  attended  by  shock  and  followed 
by  a  certain  degree  of  fever.  The  former  of  these  is  dependent,  not  only  on  the 
fracture  itself,  but  on  the  extent  of  the  injury  the  soft  parts  have  sustained,  the 
way  in  which  the  accident  happened,  and  the  condition,  mental  as  well  as  bodily, 
of  the  patient  at  the  time.  I  have  known  a  man  whose  great  toe  was  run  over  by 
a  railway  engine,  so  collapsed  that  twenty-four  hours  passed  before  the  reaction 
was  sufficiently  good  to  justify  an  operation. 

Retention. — Retention  of  urine  for  a  day  or  two  is  present  in  a  large  number 
of  cases,  especially  when  the  fracture  involves  the  pelvis  or  the  femur,  and  when 
the  patient  is  confined  to  bed. 

Fever. — In  simple  fractures,  and  in  compound  ones  in  which  the  wound  heals 
by  the  first  intention,  the  fever  rarely  reaches  any  height.  It  is  traumatic  fever 
in  the  strictest  sense  of  the  term.  The  same  evening  there  is,  generally  speak- 
ing, a  fall  of  temperature  due  to  the  shock  ;  the  next  day  it  is  slightly  raised,  and 


364    DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

it  reaches  its  maximum,  100°  or  101°  K.,  by  the  evening  of  the  second  day.  To 
some  extent  it  is  due  to  the  pain  and  tension  ui)on  the  sensory  nerves  of  the  part, 
and,  as  a  rule,  it  is  projjortionate  to  the  amount  of  extravasation  ;  but  the  main 
cause  is  the  gradual  absorption  into  the  circulation  of  the  blood  ferment  set  free 
by  the  injured  tissues,  and  the  broken-down  clot  which  fills  the  wound. 

If,  on  the  other  hand,  the  fracture  is  compound  and  the  wound  does  not  heal 
by  the  first  intention,  or  if,  as  very  rarely  happens,  the  limb  is  so  injured  that, 
though  the  skin  is  unbroken,  it  becomes  gangrenous,  no  rule  can  be  laid  down 
either  as  to  the  kind  or  the  degree  of  the  fever.  It  depends  entirely  on  the  com- 
plications that  set  in  and  the  extent  and  severity  of  the  inflammation  by  which 
they  are  accompanied. 

Fat  Embolism. — Fat  embolism  occurs  probably  in  every  fracture.  It  comes, 
no  doubt,  mainly  from  the  medulla,  but  as  the  amount  found  in  the  lungs  is  some- 
times too  great  to  be  accounted  for  in  this  way,  it  may  be  derived  to  a  certain 
extent  from  the  subcutaneous  tissue  as  well.  Large  veins  are  torn  across,  their 
ends  are  held  open,  the  pressure  in  their  interior  is  exceedingly  low,  that  in  the 
space  around  from  various  causes  much  higher,  and  as  a  consequence  the  contents 
of  the  broken  fat-cells  and  the  extravasated  blood  are  taken  up  and  carried  away 
by  the  current.  It  commences  almost  at  once.  I  found  abundant  evidence  of 
its  presence  in  the  lungs  of  a  man  whose  death  was  almost  instantaneous  from  a 
broken  neck  ;  and  it  continues  for  some  weeks,  the  drops  of  fat  circulating  in  the 
vessels  becoming  broken  up  as  they  pass  through  the  capillaries,  and  reuniting 
again  in  the  larger  trunks  until  they  are  finally  excreted  by  the  kidneys. 

The  clinical  significance  of  this  complication  has  been  very  variously  esti- 
mated. There  can  be  no  doubt  that  in  the  vast  majority  of  instances  it  gives  rise 
to  no  symptoms  at  all,  and  animals,  at  least,  are  not  materially  affected  when  four 
times  the  quantity  of  fat  contained  in  a  femur  is  suddenly  injected  into  one  of  the 
larger  veins.  When  the  amount  is  greater  than  this,  there  is  a  conspicuous  lower- 
ing of  temperature,  difficult)' of  respiration,  and  evidence  of  heart-failure.  The 
same  symptoms  have  occasionally  been  observed  after  simple  fractures  in  man,  and 
may,  with  a  fair  amount  of  probability,  be  assigned  to  this.  Collapse  is  always 
prominent,  not  immediate,  as  if  it  were  due  to  shock,  but  coming  on  after  an 
interval  of  some  hours  ;  the  pulse  is  small  and  quick,  respiration  hurried  and  shal- 
low, the  temperature  falls  rapidly,  the  face  becomes  pale,  there  is  a  feeling  of  great 
weakness,  the  senses  gradually  become  more  and  more  dull  until  death  ensues,  per- 
haps preceded  by  convulsive  attacks.  In  the  case  of  compound  fractures  it  is, 
generally  speaking,  impossible  to  decide  how  much  is  due  merely  to  the  mechanical 
influence  of  fat  embolism,  and  how  much  to  acute  septic  intoxication,  which  is 
frequently  present  in  the  same  kind  of  case.* 

It  is  a  very  old  observation  that  sometimes  after  fractures  an  oily  scum  forms 
upon  the  surface  of  the  urine  after  it  has  been  allowed  to  stand,  and  it  seems 
probable,  when  this  happens,  that  it  is  due  to  the  particles  of  fat  which  are  excreted 
by  the  kidneys  in  a  state  of  molecular  subdivision.  It  is  not  common,  however, 
for  the  amount  to  be  sufficient  to  produce  this  effect.  Oily  and  albuminous  casts 
have  also  been  described,  but  their  presence  is  certainly  unusual. 

The  further  course  of  a  simple  fracture  is,  as  a  rule,  quite  uneventful.  The 
swelling  of  the  limb  gradually  subsides  and  becomes  localized  to  the  immediate 
seat  of  injury,  where,  owing  to  the  callus  that  is  thrown  out  around  the  broken 
ends,  it  may  persist  for  months.  The  extravasated  blood  is  slowly  absorbed,  the 
discoloration  sometimes  showing  itself  in  far  distant  parts  of  the  limb.  Occa- 
sionally blebs  filled  with  serum,  more  or  less  deeply  stained,  make  their  appearance 
by  the  side  of  pads  where  there  is  little  or  no  pressure.  These  should  be  pricked, 
their  contents  absorbed  with  wool  or  blotting  paper,  and  carefully  dried,  or,  par- 
ticularly if  there  is  much  oedema,  they  may  prove  the  starting  point  for  some 
inflammatory  process. 


*  See  Paper  by  author  in  British  Medical  Journal  iox  July,  1881. 


FRA  CTURES.  365 

Thrombosis. — 'riiroinl)osis  of  the  veins  is  not  unconmujn  after  fracture.  It 
involves  most  frecjuently  the  deep  veins  of  the  leg,  especially  in  oUl  people  and  in 
those  whose  circulation  is  not  very  vigorous,  starting  either  from  the  seat  of  injury 
or  from  some  ])art  where  a  vein  is  compressed  or  irritated  by  the  edge  of  a  band- 
age. The  limb  becomes  (jcdematous,  even  before  it  is  allowed  to  hang  down  ;  it 
pits  with  pressure  (but  only  if  this  is  firm  and  long  continued),  and  it  feels  cold, 
heavy,  and  helpless.  When  once  this  is  developed,  it  is  exceedingly  obstinate  ;  it 
may  interfere  with  the  union  of  the  fracture,  and  it  has  been  known  to  spread 
until  even  the  vena  cava  became  involved.  If  a  fragment  is  detached,  the  con- 
sequences are  exceedingly  grave  ;  so  long  as  it  is  small,  it  merely  causes  a  transient 
attack  of  dyspncea,  due  to  the  blocking  of  a  branch  of  the  pulmonary  artery  ; 
but  when  it  is  large,  either  the  trunk  of  the  vessel  itself  is  suddenly  occluded,  or 
the  embolus  is  coiled  up  in  the  cavity  of  the  right  ventricle.  In  either  case 
death  is  immediate.  When  this  occurs,  there  has  generally  l^een  something  to 
detach  a  portion  of  the  clot,  some  sudden  movement,  either  of  the  patient  or  the 
limb  ;  and,  consequently,  it  is  most  likely  to  happen  when  the  fracture  is  nearly 
consolidated  and  the  patient  is  beginning  to  move  about. 

[These  cases  require  active  stimulation  as  soon  as  the  condition  is  recognized.] 

Constipation  is  a  very  general  complaint.  It  may  be  due  to  a  slight  extent, 
perhaps,  to  the  fever,  but  mainly  it  is  the  result  of  the  confinement  to  bed  and  the 
sluggish  circulation  through  the  liver.  Sometimes  it  ends  in  an  attack  of  gout  or 
jaundice. 

Congestian  of  tlic  lungs  a-nd  hypostatic  pneumonia  are  often  brought  on  in  the 
same  way,  especially  in  old  people,  many  of  whom  never  really  lie  down  at  all.  If 
they  meet  with  any  accident  their  circulation,  already  feeble,  is  so  affected  by  the 
shock  that  passive  congestion  and  oedema  set  in  and  rapidly  prove  fatal. 

Bed-sofes,  too,  are  very  prone  to  occur  from  the  same  cause,  especially  if  the 
patient  is  not  kept  scrupulously  clean.  Over  the  sacrum  is  the  most  common  situa- 
tion, but  they  may  form  anywhere  over  bony  prominences  if  care  is  not  taken  in 
fitting  the  splints.  The  back  of  the  heel,  for  example,  is  a  very  favorite  locality 
in  fractures  of  the  leg,  and  a  sore  is  sure  to  form  unless  proper  precautions  are 
taken.  One  great  advantage  of  fixed  apparatus  is  that  by  enabling  the  patient  to 
sit  up  and  change  his  position  from  time  to  time  all  these  troubles  due  to  rigid 
confinement  are  very  greatly  mitigated. 

Special  Complications. 

The  local  complications  that  occur  in  connection  with  fractures  are  immediate 
or  remote.  The  former  depend  upon  the  injury  inflicted  on  surrounding  structures 
at  the  time  of  the  accident,  the  latter  result  from  the  changes  that  take  place  sub- 
sequently during  the  progress  of  the  case.  Cases  of  injury  to  important  viscera 
must  be  treated  by  themselves. 

Laceration. — Laceration  of  the  soft  tissues  and  extravasation  of  blood  are  so 
general  that  they  can  scarcely  be  called  complications,  unless  exceptionally  severe. 
In  simple  fractures  the  skin  is  sometimes  stripped  up  from  the  fascia  beneath,  and 
floats,  as  it  were,  upon  the  surface  of  a  hematoma ;  but  unless  some  large  vessel 
has  given  way,  this  is  readily  checked  by  compression  or  position,  and  soon  dis- 
appears of  itself.  Suppuration  rarel}"  occurs.  In  compound  fractures  the  danger 
is  greater,  for  if  inflammation  once  breaks  out,  it  is  only  too  likely  to  spread  along 
the  track  so  well  prepared  for  it ;  and  in  severe  cases,  where  there  is  much  lacera- 
tion, and  the  extravasation  extends  along  the  limb,  it  is  often  a  wise  precaution  to 
enlarge  the  opening,  and  even  make  fresh  incisions  for  the  purpose  of  washing  out 
the  extravasated  blood  and  securing  effectual  drainage. 

Rupture  of  Arteries. — When  the  main  artery  of  a  limb  is  concerned,  the  ques- 
tion is  much  more  serious.  It  ma}-  be  compressed  by  one  of  the  fragments  ;  the 
sharp  edge  of  the  lower  end  of  the  femur,  for  example,  may  be  pressed  against  the 
popliteal ;  or  it  may  be  punctured  by  a  splinter,  or  crushed  so  that  the  two  inner 


366    DISEASES  AND  I XJ CRIES  OF  SPECIAL  STRUCTURES. 

coats  give  way  and  curl  up  in  the  interior  of  the  vessel ;  or  it  may  be  torn  com- 
l^letely  in  tvvo.  Sometimes,  therefore,  it  is  blocked  (though  it  may  give  way  later), 
and  sometimes  it  continues  to  bleed  until  it  is  stopped  by  the  tension  of  the  tissues 
around  or  by  the  failure  of  the  heart. 

If  there  is  a  wound,  the  nature  of  the  complication  is  generally  evident  at 
once,  though  when  the  external  opening  is  very  small  and  tortuous  the  stream  may 
be  continuous  instead  of  coming  in  jets.  In  simple  fractures  the  symptoms  depend 
upon  the  size  of  the  artery  and  the  nature  of  the  injury.  If  one  of  the  main 
trunks  is  torn  across,  a  tense,  elastic  swelling  forms  with  great  rapiditv,  there  is  the 
most  excruciating  pain,  the  pulse  below  is  comi)letely  lost,  and  the  limb  becomes 
cold,  cedematous,  and  numbed.  If,  on  the  other  hand,  there  is  only  a  puncture, 
so  that  the  continuity  of  the  vessel  is  not  interrupted,  this  takes  place  more  slowly  ; 
a  certain  amount  of  indistinct  pulsation  may  be  felt  for  a  time,  and  sometimes,  at 
least,  a  low  murmur  may  be  distinguished,  synchronous  with  the  pulse. 

{a)  In  Compound  Fractures. — In  the  case  of  a  compound  fracture,  if  the 
vessel  is  of  any  size  or  importance,  the  choice  of  treatment  is  very  limited  ;  either 
the  wounded  artery  must  be  found  and  tied  above  and  below,  or  the  limb  must  be 
amputated.  Which  of  these  alternatives  is  adopted  in  any  particular  case  depends 
upon  the  patient,  on  the  particular  artery  that  is  wounded,  and  on  the  extent  of 
the  injury  inflicted  on  the  other  structures  around.  Obviously,  a  much  greater 
risk  may  be  run  with  a  child  than  with  an  adult,  though  children  bear  hemorrhage 
badly ;  there  is  much  more  hope  when  the  upper  limb  is  in  question  ;  and  the 
prognosis  is  much  better  when  the  fracture  has  been  caused  by  indirect  violence 
than  when  the  soft  parts  are  cnished,  the  collateral  circulation  destroyed,  and  the 
neighboring  joints  torn  open. 

The  hemorrhage  must  first  be  checked  by  a  tourniquet,  or  other  means  suited 
to  the  part,  the  wound  enlarged,  all  clots  turned  out  and  a  thorough  search  made. 
Sometimes  this  is  successful,  but  finding  a  torn  vessel  under  conditions  such  as  these 
is  always  a  matter  of  the  greatest  difficulty.  Ligature  of  the  vessel  higher  up  can- 
not be  recommended  ;  if  the  collateral  circulation  is  good,  the  bleeding  continues ; 
if  it  is  not.  gangrene  sets  in. 

(J))  In  Simple  Fractures. — In  simple  fractures  the  question  turns  upon  the 
collateral  circulation  and  the  limitation  of  the  extravasation.  If  the  swelling  is 
tense  and  diffuse,  so  that  the  limb  below  is  cold  and  pulseless,  amputation  must  be 
performed  at  once  before  gangrene  sets  in.  The  only  exception  is  where  the  sur- 
rounding structures  are  but  little  injured,  and  the  interruption  to  the  circulation 
is  due  more  to  the  tension  than  to  the  destruction  of  the  collateral  vessels.  Occa- 
sionally this  happens  to  the  popliteal;  an  attempt  may  then  be  made,  provided 
everything  else  is  favorable,  to  find  and  tie  the  injured  artery,  but  it  must  be  recol- 
lected that  this  makes  the  fracture  a  compound  one.  and  that  very  often  it  extends 
into  the  knee  joint. 

If,  on  the  other  hand,  the  circulation  is  not  completely  interrupted,  if  the 
limb  still  retains  some  warmth  and  sensation,  there  is  some  hope  either  that  a  trau- 
matic aneurysm  will  form,  or  that,  better  still,  the  wound  in  the  artery  may  close, 
and  the  blood  riuietly  become  absorbed  without  further  trouble.  I  have  known 
this  happen  even  when  it  was  practically  certain,  from  the  extent  of  the  extravasa- 
tion, that  the  brachial  artery  had  been  torn  across.  The  limb  should  be  raised, 
kept  quiet,  jjlaced  in  as  comfortable  a  position  as  possible,  and  wrapped  in  cotton- 
wool to  maintain  the  temperature.  No  firm  bandages  or  splints  may  be  applied, 
merely  something  to  protect  the  part  against  incautious  movement ;  the  l>est  hope 
lies  in  perfect  rest  and  gentle  compression. 

In  the  case  of  the  anterior  tibial  the  symptoms  sometimes  disapjjear  of  them- 
selves ;  more  often  the  swelling  continues  to  pulsate  without  extending  very  rapidly, 
and  a  wall,  more  or  less  perfect,  is  gradually  formed  around  the  hematoma  until  it 
becomes  a  traumatic  aneurysm.  This  may  be  cured  at  any  time  by  any  of  the 
ordinary  methods ;  compression  maybe  tried  first;  if  this  fails  the  artery  may  be 
tied  above,  or  the  sac  may  be  laid  open  and  both  ends  of  the  vessel  secured.   Care- 


FRACTURES.  367 

fill  examination  for  pulsation  should  be  made  in  every  case  of  localized  swelling 
that  makes  its  api)earance  after  a  fracture  ;  very  often  there  is  a  certain  amount  of 
redness  and  inllammation  round  a  traumatic  aneurysm,  and  many  of  them  have 
been  laid  open  in  mistake  for  abscesses,  especially  as  they  are  sometimes  met  with 
at  some  distance  from  the  seat  of  injury. 

When  the  posterior  tibial  is  wounded,  it  is  rare  for  the  swelling  either  to  sub- 
side or  become  localized.  If  the  limb  continues  warm,  digital  compression  of  the 
femoral  may  be  tried  ;  at  least  it  places  the  patient  in  no  greater  danger,  for  if 
gangrene  supervenes  amputation  can  always  be  performed  at  the  seat  of  injury  ; 
and  ligature  in  Scarpa's  triangle  has  proved  successful  in  a  few  instances.  If,  how- 
ever, the  swelling  is  rapid,  and  there  is  evidence  of  venous  congestion  ;  or  if  the 
part  is  plainly  becoming  colder,  an  attempt  may  be  made  to  tie  the  vessel,  but  in 
all  probability  the  limb  will  have  to  be  amputated.  When  the  popliteal  is  in  ques- 
tion, owing  to  the  space  round  the  vessel,  the  swelling,  as  I  have  mentioned 
already,  is  always  diffuse. 

Rupture  of  Veins. — Rupture  or  puncture  of  a  large  vein  is  a  very  unusual  and 
a  very  grave  complication.  The  poj^liteal  is  occasionally  torn  or  compressed  at 
the  same  time  as  the  artery,  and  the  subclavian  is  sometimes,  but  very  rarely,  injured 
in  fractures  of  the  clavicle  ;  in  other  cases  the  vein  usually  escapes,  unless  the  limb 
is  utterly  disorganized.  The  symptoms,  with  the  exception  of  the  pulsation,  are 
almost  the  same  as  those  of  ruptured  artery,  and  gangrene  is  even  more  likely  to 
occur.  If  the  limb  is  growing  cold,  the  only  course  is  to  lay  the  swelling  open, 
turn  out  all  the  extravasated  blood,  and  try  to  secure  the  two  ends  as  soon  as  pos- 
sible, and  failing  this,  amputate. 

Seco/idary  Hemorrhage. — Secondary  hemorrhage  may  occur  after  compound 
fractures,  just  as  it  may  after  any  other  injury,  and  from  the  same  causes.  In  addi- 
tion, however,  there  is  always  the  danger  of  simple  as  well  as  compound  ones, 
that  a  loose  splinter  may  be  driven  into  an  artery  or  vein  by  some  incautious 
movement,  or  that  the  wall  of  the  artery  may  ulcerate  through  from  pressure.  I 
have  known  this  occur  in  the  case  of  the  popliteal  a  twelvemonth  after  the  original 
accident ;  the  lower  end  of  the  upper  fragment  was  displaced  backward,  so  that  it 
came  into  contact  with  the  vessel  and  gradually  wore  a  hole  through  its  coats,  long 
after  recovery  was  thought  to  be  complete. 

Injury  to  A^erves. — Large  nerve-trunks  are  so  strong  that  they  are  seldom 
torn,  but  they  often  suffer  in  other  ways.  They  may  be  contused  or  wounded  by 
splinters ;  sometimes  they  are  caught  between  the  bones  so  as  even  to  prevent 
union,  or  they  slip  into  a  cleft  in  one  of  the  fragments,  or^what  is  much  more  fre- 
quent, they  are  enclosed  in  the  callus  that  is  thrown  out  after  the  injury,  and 
slowly  but  surely  constricted  until  their  physiological  continuity  is  destroyed. 
More  than  half  the  cases  on  record  refer  to  the  musculo-spiral  nerve  :  but,  con- 
sidering the  rarity  of  fractures  of  the  upper  end  of  the  fibula,  the  peroneal  seems 
to  suffer  almost  as  often.  The  symptoms  presented  by  this  complication  vary 
according  to  whether  the  nerve  is  irritated  or  only  compressed.  Tetanus,  spas- 
modic contraction,  hyperaesthesia,  and  intense  neuralgia  are  occasioned  by  the 
former  ;  loss  of  power,  wasting,  diminution  of  sensibility,  and  constant  pain  until 
the  nerve  has  undergone  degeneration,  are  met  with  in  the  latter.  If  the  com- 
pression is  only  transient,  the  prognosis  is,  generally  speaking,  good,  though  in  a 
few  instances  the  loss  of  power  has  been  permanent ;  if  it  is  continuous,  as  when 
the  nerve  is  compressed  by  callus,  atrophy  sets  in,  the  fibres  disappear,  and  only  a 
cord  is  left. 

Release  of  the  nerve  by  chiseling  through  the  callus  or  sawing  off  part  of  the 
bone  has  proved  successful  even  in  advanced  cases ;  and  in  some  instances,  resec- 
tion of  a  portion  that  could  not  be  set  free  has  been  performed  with  the  same 
result.  The  prognosis  depends  upon  the  extent  to  which  degeneration  has 
occurred  ;  if  the  electric  excitability  of  the  parts  below  is  not  completely  lost, 
early  recovery  may  be  expected,  though  it  may  not  be  perfect  for  some  consider- 
able time. 


368    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Injury  to  Joints. — Extension  of  the  fracture  into  a  neighlx^ring  joint  is  always 
a  t,'rave  complication,  even  when  the  skin  is  unbroken.  The  synovial  cavity  is 
filled  with  blood  ;  it  is  often  difficult  to  restore  the  fragments  to  their  ]jroper 
position,  and  still  more  to  keep  them  there  ;  and  for  fear  of  the  joint  becoming 
stiff,  passive  motion  has  to  be  commenced  at  a  very  early  period,  long  before  the 
union  is  sound  enough  for  use.  Moreover,  later  in  life,  a  joint  that  has  been 
injured  in  this  way  is  very  liable  to  be  attacked  by  an  obstinate  form  of  osteo- 
arthritis. When  the  fracture  is  compound,  the  danger  is  greater  still.  'l"he  cavity 
that  is  oiiened  up  is  often  of  very  great  size  and  very  irregular  in  shaj^e  ;  and  it  is 
lined  with  a  membrane  exceedingly  i)rone  to  absorb  any  poisonous  material  that  is 
present.  Under  these  circumstances,  it  is  .scarcely  sur])rising  that  the  danger  of 
accute  suppurative  arthritis  is  so  great. 

Dislocation  is  occasionally,  but  very  rarely,  associated  with  fracture,  the  bone 
being  forced  from  its  socket,  and  then  broken  by  the  continuance  of  the  same 
force.  No  pains  should  be  spared  to  effect  reduction.  The  patient  must  be 
placed  under  an  anaesthetic,  the  limbs  secured  by  means  of  splints,  and  the  dis- 
placed part  of  the  bone,  if  possible,  pushed  back.  If  this  does  not  succeed,  either 
the  joint  must  be  laid  open  and  the  head  of  the  bone  dislodged  and  restored  to 
its  position,  or  the  fracture  must  be  set  and  another  attempt  made  later  when  the 
bone  is  firmly  united. 

Inflammation. — Inflammation  in  the  course  of  a  simple  fracture  is  quite  ex- 
ceptional. Sometimes,  when  the  extravasation  is  very  extensive,  the  htematoma 
slowly  suppurates,  as  it  does  occasionally  in  contusions ;  or  inflammation  starts 
from  the  blebs  that  form  on  the  surface  of  the  skin  ;  and  sometimes  a  slow,  chronic 
form  of  ostitis  sets  in  afterward,  akin,  perhaps,  to  the  arthritis  that  follows 
contusions  about  joints  ;  but  this  does  not  occur  unless  some  additional  cau.se  is 
at  work. 

In  compound  fractures,  on  the  other  hand,  if  the  wound  does  not  heal  at 
once,  it  often  proves  a  most  serious  complication.  Erysipelas,  cellulitis  spreading 
through  the  deeper  planes  of  areolar  tissue,  as  well  as  the  superficial  ones,  diffuse 
suppuration,  acute  periostitis,  osteo-myelitis,  septicaemia,  pyaemia,  hectic,  every 
form  of  wound  disease,  in  short,  may  break  out  in  the  course  of  treatment,  and 
either  delay  recovery  indefinitely  by  the  sloughing  and  necro.sis  it  causes,  or  itself 
prove  fatal. 

Sioitg/iing. — Sloughing  of  the  skin  and  cellular  tissue  may  be  caused  by  the 
violence  to  which  the  part  is  subjected  at  the  moment  of  the  accident;  or  may 
occur,  as  already  mentioned,  from  the  pressure  of  badly-made  splints  on  bony 
prominences.  In  the  former  case  the  fracture  is  almost  certain  to  become  com- 
pound if  it  was  not  so  already ;  in  the  latter  the  slough  often  bears  no  relation  to 
the  seat  of  injury,  and,  so  long  as  it  is  limited,  may  be  treated  as  an  ordinary  bed- 
sore. All  pressure  must  be  removed,  so  far  as  is  consistent  with  safety  ;  the  posi- 
tion of  the  limb  must  be  adjusted  so  that  the  circulation  is  unimpeded,  and  putre- 
faction prevented.  If  the  cause  is  removed  and  no  fresh  irritant  allowed  to 
appear,  the  sore  that  is  left  soon  granulates  up. 

Gangrene. — Traumatic  gangrene  may  be  local  or  spreading.  In  the  former 
case  it  may  arise  from  the  actual  crushing,  even  when  the  fracture  is  a  simple  one, 
or  from  thrombosis,  rupture  of  the  main  vessels,  or  tight  bandaging  ;  but  whatever 
the  reason,  if  an  attem])t  has  l)een  made  to  save  the  limb,  and  it  is  j)lainly  becom- 
ing colder,  amputation  should  be  ])erformed  at  once.  The  most  difficult  cases  are 
those  which  hang  in  the  balance  for  a  day  or  two,  sometimes  warmer,  sometimes 
colder,  before  it  is  possible  to  be  certain. 

Spreading  traumatic  gangrene  may  result  solel)'  from  the  defective  nutrition 
of  the  tissues — the  vitality  of  the  i)art  is  so  low  from  renal  disea.se,  diabetes,  cold, 
exposure,  or  other  causes,  that  the  structures  perish  even  if  they  are  only  bruised — 
or  much  more  frequently  from  the  action  of  irritants  that  make  their  appearance 
subsequently  in  the  wound.  Septic  decomposition,  high  tension  and  suppuration 
acting  together  cause    the  most  fearfiil   form.     Putrefaction   takes  place  in  the 


FRACTURES.  369 

wound  ;  the  ])oisons  producetl  arc  driven  l)y  the  tension  into  the  celhilar  inter- 
spaces, destroying  everything  they  touch,  and  the  microorganisms  of  suppuration 
comi)lete  the  destruction.  Hospital  gangrene,  wliich  was  the  worst  form  ever 
known,  was  simply  the  product  of  these  agents  acting  under  ]>eculiarly  favorable 
conditions. 

Solid  CEiiema. — Solid  (edema,  due  to  lymphatic  and  venous  obstruction,  is 
often  present  after  fractures,  especially  comjjound  ones,  in  which  there  has  been 
inflammation  or  sloughing  of  the  cellular  tissues.  The  nutrition  of  the  whole 
limb  sufters  ;  it  remains  cold  and  hard  ;  the  skin  is  tightly  bound  down  to  the 
parts  beneath  ;  ulcers  are  liable  to  form,  and  though  they  may  be  cured  by  atten- 
tion to  position  and  rest  in  bed,  they  invariably  break  out  again  as  soon  as  the 
limb  is  used.  In  one  case  I  removed  a  leg,  at  the  patient's  request,  seven  years 
after  a  severe  compound  fracture,  in  which  resection  had  been  performed  ;  the 
ulcer,  which  was  exceedingly  ])ainful,  had  broken  out  nine  times,  and  he  had 
spent  more  than  four  years  of  the  seven  in  bed. 

Muscular  Atrophy. — Muscular  atrophy  is  present  in  most  cases  of  fracture. 
If  it  is  merely  the  result  of  inactivity,  recovery  is,  generally  speaking,  rapid  and 
easy  ;  but  sometimes,  when  the  limb  has  been  severely  crushed,  or  when  there 
has  been  much  inflammation,  the  fibres  are  so  matted  together,  and  the  tendons 
so  crippled  by  adhesions,  that  the  process  is  very  tedious.  In  other  cases  there 
are  special  reasons  for  it ;  the  lower  part  of  the  vastus  internus,  for  example, 
never  quite  regains  its  size  after  fracture  of  the  patella.  According  to  Volkmann, 
paralysis  and  contracture  are  sometimes  caused  by  the  prolonged  constriction  of 
the  blood-vessels ;  the  muscles  become  stiff  and  hard  ;  all  control  over  them  is 
lost ;  and  movement  becomes  intensely  painful.  It  is  said  that  this  is  due  to  the 
breaking  up  of  the  contractile  substance  in  consequence  of  the  deficient  supply  of 
blood.  In  other  cases  again,  shortening,  sometimes  of  a  very  obstinate  descrip- 
tion, is  brought  on  through  malposition  during  treatment. 

Ankylosis. — Stiffness  of  the  joints  is  very  common  even  when  they  ha\e 
escaped  direct  injury.  Bonnet  and  others  have  described  very  extensive  alterations 
as  taking  place  in  them  merely  from  prolonged  rest,  the  cartilage  disappearing, 
and  the  opposing  surfaces  becoming  united  by  dense,  fibrous  tissue.  Such  changes, 
however,  occurring  independently  of  inflammation,  are  very  rare.  As  a  rule,  the 
joint  becomes  stiff  because  passive  motion  is  not  resorted  to  sufficiently  early ;  the 
capsule  becomes  rigid  ;  the  amount  of  synovia  is  deficient ;  the  soft  tissues  around 
grow  hard  and  thick ;  and  the  folds  and  fringes  become  adherent  to  each  other, 
and  no  longer  accommodate  themselves  to  the  changes  in  pressure  as  the  bones 
are  moved.  The  ti.ssues,  in  short,  are  so  badly  nourished  that  they  are  unable  to 
do  their  share  of  work. 

Residual  abscesses  occasionally  make  their  appearance  in  compound  fractures 
many  years  after  the  original  accident,  and  sometimes  minute  sequestra  are  found 
inside  them;  in  some  cases,  perhaps,  they  are  small  fragments  that  have  been 
locked  in  during  the  process  of  repair.  Atrophy  of  the  bone  has  also  been  known 
to  follow  without  apparent  reason,  and  cases  of  malignant  disease  starting  from  the 
seat  of  injury  are  not  so  uncommon  as  might  be  exjjccted. 

Treatment  (Immediate). 

In  every  case  of  fracture  the  first  thing  is  to  prevent  further  injury.  The 
limb  must  be  placed  in  a  suitable  position  ;  the  clothes  removed,  always  beginning 
with  the  sound  side,  and  where  it  is  necessary,  slitting  up  the  seams  ;  and  the 
injured  part  thoroughly  exposed.  A  small  wound  is  better  sealed  at  once  ;  dried 
blood-clot  is  an  excellent  protection  ;  if  it  is  large,  means  must  be  taken  to  check 
the  hemorrhage  before  anything  else.  Then  the  limb  must  be  secured  so  that  the 
patient  may  be  moved  with  the  least  amount  of  risk. 

In  fractures  of  the  ujjper  extremity  there  is  no  difficulty ;  the  arm  can  be 
bound  to  the  side  of  the  body  with  one  handkerchiet"  and  the  hand  and  wrist 


370     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 

supported  with  another  tied  round  the  neck  to  form  a  sling.  In  the  case  of  the 
leg  and  thigh,  however,  some  form  of  splint  must  be  extemporized.  It  may  be 
made  out  of  almost  anything  :  laths  or  wood,  bundles  of  straw,  rolls  of  newsi)ai)er, 
umbrellas,  or  whatever  else  is  to  be  had  at  the  moment ;  the  only  requirement  is 
that  it  should  be  sufficiently  long  and  rigid  to  keep  the  limb  steady  in  the  most 
comfortable  position.  A  broken  leg  should  be  laid  on  its  outer  side  with  the  knee 
and  hip  flexed  ;  the  thigh  may  either  be  placed  in  the  same  position,  or  the  two 
limbs  may  be  tied  together  and  secured  to  a  splint  made  out  of  a  broomstick  with 
some  cloths  round  it,  long  enough  to  reach  from  the  armpit  to  below  the  knee. 
Only  in  the  case  of  the  spine  and  pelvis  nothing  of  the  kind  should  be  attempted  ; 
the  patient  is  merely  to  be  placed  perfectly  straight  in  the  recuml)ent  position  until 
he  can  be  lifted  on  to  a  stretcher. 

To  raise  an  adult  with  a  broken  leg  comfortably,  at  least  three  persons  are 
necessary  :  one  to  take  charge  of  the  limb,  the  others  one  on  each  side,  facing 
each  other,  with  their  hands  well  beneath  the  hips  and  shoulders ;  the  .stretcher 
should  be  placed  at  the  patient's  head,  as  it  is  more  easy  to  lift  him  over  the  end. 
Bearers  should  be  cautioned  against  keeping  step,  and  if  the  lower  extremity 
is  broken,  care  must  be  taken  that  the  shoulders  are  not  raised  higher  than  the 
feet. 

A  fracture  bed  should  be  narrow,  so  that  the  patient  may  be  reached  from 
either  side,  firm  and  elastic  without  being  soft,  and  if  the  spine  or  the  upper  part 
of  the  leg  is  involved,  so  arranged  that  nothing  is  disturbed' when  the  bowels  act. 
Woven  wire  mattresses  with  a  hair  one  on  the  top  are  the  best ;  sinking  at  the  hip 
may  be  prevented  by  a  board  underneath  extending  from  side  to  side.  In  injuries 
of  the  spine,  and  in  any  case  in  an  old  person,  water-cushions  under  the  pelvis 
are  essential.  Very  many  contrivances  have  been  devised  for  the  use  of  the  bed- 
pan :  one  of  the  best  is  a  circular  opening  in  the  mattress  protected  round  the 
edges  with  oiled  silk,  immediately  under  the  nates  ;  this  is  filled  up  from  beneath 
with  a  cushion  which,  when  occasion  requires,  can  be  lowered  by  means  of  a  screw 
attached  to  the  side  of  the  bed  and  replaced  by  the  pan.  Two  sheets,  of  course,  must 
be  used,  folded  double,  one  beneath  the  shoulders,  the  other  at  the  lower  end  of 
the  bed,  the  folded  margins  meeting  over  the  opening.  In  other  cases  a  conical 
wedge  of  the  mattress  may  be  made  to  slide  in  and  out  from  the  side.  Or  the 
opposite  plan  may  be  adopted  :  a  very  stout  piece  of  canvas,  perforated  in  the 
centre,  is  laid  over  the  mattress  and  fastened  all  round  to  a  strong  wooden  frame,  a 
little  smaller  than  the  bed  itself.  When  it  is  not  in  use,  this  rests  upon  the 
framework  of  the  bed  ;  but  it  is  so  contrived  that  when  the  pan  is  required  it 
can  be  raised  with  screws  or  pulleys  six  inches  or  so  from  the  mattress  with  the 
patient  lying  on  it. 

The  same  precautions  must  be  taken  in  lifting  the  patient  on  to  the  bed  ;  then 
the  clothes  must  be  removed,  the  skin  thoroughly  washed  and  dried,  all  temporary 
appliances  taken  away,  and  the  limb  either  secured  with  sand-bags  or  laid  upon  a 
pillow  lengthwise  and  tied  up  in  it. 

Treatment  (Permanent). 

Fractures  should  in  all  cases  be  set  as  soon  as  possible ;  the  only  exception  is 
when  the  swelling  and  tension  are  already  so  extreme  as  to  threaten  gangrene.  If 
there  is  the  least  danger  of  .such  a  complication,  it  is  better  to  avoid  manipulation, 
and  merely  to  raise  the  limb  and  place  it  in  a  comfortable  position,  secured  by 
sand-bags  or  tied  up  in  a  pillow.  In  other  circumstances  there  is  nothing  to  be 
gained  by  waiting,  or  by  the  application  of  cooling  lotions  ;  the  difficulty  increases 
every  hour  ;  the  swelling  becomes  greater  and  greater  ;  the  muscles,  which  at  first 
are  relaxed,  grow  more  and  more  rigid  ;  and  there  is  always  the  risk  that  by  some 
incautious  movement  the  injury  may  be  made  a  great  deal  worse. 


FRACTURES.  371 

I .   Rciiiiction  of  tJic  Fraciiirc. 

The  first  thing  is  to  disengage  the  fragments  and  restore  them  to  their  proper 
position.  If  they  are  impacted,  and  it  is  considered  advisable  to  separate  them,  a 
certain  amount  of  force  must  be  used,  and  where  a  bone  is  only  partly  broken,  as  in 
greenstick  fractures,  it  is  generally  impossible  to  restore  the  shape  without  consider- 
able pressure,  sometimes  even  making  the  fracture  complete;  but  in  all  ordinary 
cases,  where  the  displacement  is  due  either  to  the  weight  of  the  part  or  to  muscular 
contraction,  the  less  force  that  is  used  the  better.  Gravity  must  be  counterbalanced 
by  arranging  the  patient  so  that  it  a.ssists  in  the  reduction  of  the  deformity,  instead 
of  being  a  source  of  difficulty,  and  the  muscles  must  in  some  way  or  other  be 
induced  to  relax. 

{a)  Aniesthctics. — In  many  cases  an  anaesthetic  is  essential.  The  rigidity  dis- 
appears at  once,  the  limb  can  be  thoroughly  examined  without  causing  pain,  and  if 
the  bone  is  set  immediately,  before  consciousness  is  restored,  while  the  muscles  are 
still  at  rest,  the  spasmodic  contraction  does  not  return.  The  only  objection  is  that, 
particularly  in  men  who  are  accustomed  to  a  large  amount  of  stimulants,  and  whose 
struggles  are  sometimes  very  violent,  the  injured  limb  may  be  seriously  hurt  unless 
it  is  very  firmly  held.  Where  gas  and  ether  are  used  the  risk  is  not  nearly  so 
great. 

{F)  Jenotomy. — Tenotomy  may  be  employed  when  one  muscle  in  particular  is 
in  fault.  The  tendo-Achillis,  for  example,  may  be  divided  when  there  is  obstinate 
spasm  of  the  gastrocnemius,  or  when  the  lower  end  of  the  femur  is  detached  from 
the  shaft  and  rotated  backward,  so  that  it  is  in  danger  of  pressing  upon  the  popli- 
teal artery  or  vein,  but  it  is  seldom  required  in  other  cases. 

{/)  Positio7i. — It  is  of  the  utmost  importance  to  place  the  limb  in  a  position 
that  will  secure  the  maximum  degree  of  muscular  relaxation.  In  Pott's  fracture, 
for  instance,  the  knee  is  flexed  to  prevent  displacement  of  the  foot  by  the  gastroc- 
nemius ;  and  when  the  femur  is  broken  immediately  below  the  trochanter,  the 
whole  limb  is  placed  upon  an  inclined  plane  if  the  upper  fragment  is  raised  to  any 
degree  by  the  ilio-psoas.  The  opposite  muscles  are  stretched,  it  is  true,  but  in 
most  of  the  cases  their  action  upon  the  fragments  is  insignificant  in  comparison, 
and  unless  they  are  irritated  by  the  broken  ends  and  made  to  contract,  they  gener- 
ally yield  without  trouble. 

{d^  Extension. — When  the  deformity  cannot  be  reduced  in  this  way,  exten- 
sion and  counter-extension  must  be  employed,  either  for  the  time  only,  until  the 
limb  is  secured  by  a  splint,  or  during  the  whole  period  of  treatment.  In  tem- 
porary extension  one  part  (generally  speaking  that  nearer  the  trunk)  is  held  by  an 
assistant,  the  other  is  grasped  by  the  surgeon,  and  steady  traction  made  in  the 
axis  of  the  limb  until  the  fragments  are  unlocked  and  the  length  and  shape  restored. 
Often  it  is  necessary  to  sway  the  part  gently  from  side  to  side,  or  to  rotate  it  a 
little  so  as  to  disengage  the  ends,  and  sometimes  it  is  better  for  the  extension  to  be 
made  by  the  a.ssistant,  while  the  surgeon  manipulates  the  part  himself;  in  any  case 
the  pull  must  be  absolutely  steady  and  continuous,  without  violent  movement  or 
jerking  of  any  kind.  When  a  sufficiently  good  hold  can  be  obtained,  the  grasp 
should  be  made  on  the  ends  of  the  fractured  bone,  and  the  interposition  of  a  joint 
avoided  ;  the  soft  parts  are  not  so  liable  to  be  injured,  but  the  rule  is  not  absolute. 
In  fractures  of  the  femur,  for  example,  extension  must  be  made  from  the  leg  and 
counter-extension  fromthe  pelvis  ;  and  when  the  leg  is  broken  it  is  very  much 
better  to  use  a  slight  degree  of  extension  with  the  knee  flexed  (so  as  to  relax  the 
muscles  of  the  calf)  than  to  pull  it  into  position  by  main  force. 

The  amount  of  force  used  and  the  extent  to  which  manipulation  is  carried 
must  be  left  to  the  discretion  of  the  surgeon.  In  some  cases  the  fragments  are  too 
firmly  impacted  to  be  separated  ;  in  others  a  splinter  is  so  far  displaced  from  its 
normal  situation  that  it  cannot  be  restored  ;  or  again,  the  sharp-pointed  ends  have 
been  pushed  so  far  into  the  soft  parts  by  the  contraction  of  the  muscles,  that  it  is 
impossible  to  disengage  them  and  bring  them  into  apposition.     So  long  as  the 


372     DISEASES  AND   INJURIES    OF  SPECIAL    STRUCTURES. 

fracture  is  a  simple  one,  it  is  better  to  leave  these  alone,  in  spite  of  the  prospect  of 
deformity,  and  the  possibility  in  the  last  mentioned  case  of  failure  of  union,  than 
to  run  the  risk  of  inflicting  even  greater  injury  on  the  patient.  If  the  fracture  is 
already  compound,  the  question,  of  course,  is  entirely  different. 

Continuous  extension  is  recpiired  for  those  cases  in  which  the  displacement  is 
maintained  by  muscular  contraction,  as  in  fractures  of  the  thigh.  If  the  femur  is 
broken  obliquely,  especially  in  an  adult,  it  is  only  possible  to  restore  the  limb 
to  its  normal  length  by  placing  the  ])atient  under  an  anaesthetic,  or  tiring  the 
muscles  out.  Extension  for  a  time  only  is  of  little  or  no  u.se,  but,  if  it  is  kept  up 
steadily  and  continuou.sly,  even  though  the  force  is  only  slight,  the  contraction 
gradually  gives  way,  and  the  liml)  regains,  or  nearly  regains,  its  normal  length. 

2.  F/r7'cn/io/i  of  Return  of  Displacement. 

As  soon  as  the  deformity  is  rectified  and  broken  ends  adjusted,  the  part  mast 
be  secured  against  displacement  a  second  time.  The  same  forces  are  still  acting  ; 
however  quiet  the  patient  may  lie,  it  is  impossible  to  avoid  involuntary  movements, 
the  influence  of  gravity  is  always  at  work,  tending  to  disjjlace  one  fragment  from 
another,  and,  even  when  there  is  no  spasmodic  contraction,  the  muscles  cannot 
help  growing  shorter  and  shorter  when  the  rigid  framework  is  once  broken. 

The  means  used  to  prevent  this  depend  chiefly  upon  the  degree  and  nature  of 
the  deformity.  In  fractures  of  the  bones  of  the  face,  for  example  (the  lower  jaw 
excepted),  the  tendency  to  displacement  is  so  slight  that,  if  the  fragments  can  be 
restored  to  their  proi)er  situation,  little  more  than  protection  is  required  ;  and 
where  one  bone  in  a  series  has  given  way,  a  rib,  for  instance,  or  one  of  the  meta- 
carpals, a  bandage  is,  generally  speaking,  sufficient.  lOven  if  there  is  only  a  pair, 
as  in  the  leg,  the  uninjured  one  nearly  always  prevents  any  serious  degree  of  dis- 
placement. On  the  other  hand,  in  fracture  of  the  bones  of  the  extremities,  where 
the  muscles  are  very  powerful,  and  the  deformity  often  exceedingly  difficult  to 
rectify,  it  is  rarely  possible  to  keep  the  broken  ends  in  apposition  without  the  aid 
of  bandages  and  splints. 

Bandages. — Roller  and  triangular  bandages  are  the  ones  in  common  use, 
though  many  other  varieties  are  employed  in  s])ecial  ca.ses.  The  former  answer 
best  where  firm  and  continued  pressure  is  required,  and  are  made  of  unbleached 
calico  torn  in  strips,  from  four  to  six  yards  long,  and  two  to  four  inches  wide,  or 
of  flannel,  domette,  or  other  loosely  woven  material,  according  to  the  nature  of  the 
case  and  the  amount  of  yielding  desired.  The  latter  are  most  easily  made  from  a 
square  yard  of  calico  cut  in  two  diagonally,  and  are  chiefly  of  use  for  retaining 
dressings  in  position  and  as  slings  for  the  support  of  the  arm  or  hand. 

Splints. — Splints  may  be  made  of  almost  anything,  but  invariably  the  simpler 
they  are,  the  better.  Their  object  is  to  keep  the  broken  ends  in  thorough  appo- 
sition and  at  i)erfect  rest;  they  must,  therefore,  fit  the  limb  accurately;  they 
must  be  well  padded,  so  that  the  pressure  is  uniform,  and  does  not  fall  too  heavily 
on  the  bony  prominences  or  the  injured  part ;  they  must,  as  far  as  possible,  fix  the 
neighboring  joints  ;  they  must  be  arranged  so  that,  at  any  rate  at  first,  the  seat 
of  fracture  can  be  easily  examined,  and  they  must  not  interfere  with  the  circula- 
tion. Bandages,  or  webbing  straps  and  buckles,  are  used  to  secure  them  round 
the  limb.  No  constricting  band  should  ever  be  applied  directly  to  the  limb 
beneath.  The  circulation  is  already  impeded  by  the  swelling  and  extravasation  ;  the 
veins  are  compressed  more  than  the  arteries,  owing  to  the  thinness  of  their  walls  ; 
blood  continues  to  pour  into  the  i)art,  without  being  able  to  return,  and,  if  there 
is  an  unyielding  bandage  round  the  limb,  strangulation  and  gangrene  are  very 
likely  to  follow.  For  the  same  reason,  when  a  single,  flat  splint  is  used,  however 
well  it  is  padded,  it  should  never  be  secured  to  a  fractured  limb  with  strapping. 
Below  the  seat  of  injury,  there  is  not  the  same  ol)jection.  When  the  humerus  is 
broken,  for  example,  a  bandage  may  be  applied  with  advantage  to  the  hand  and 
forearm,  to  jtrevent  the  passive  oedema  and  swelling  that  are  caused  by  the  obstruc- 


FRACTURES.  373 

tion  ;  but  even  then  it  is  advisable  to  leave  the  tips  of  the  fingers  exposed,  so  that 
there  may  be  no  doubt  as  to  the  condition  of  the  circulation. 

Ordinary  pads  are  much  too  hard,  especially  when  made  with  tow  ;  they  ought 
to  be  sufficiently  soft  to  press  evenly  on  all  the  surface  of  a  limb,  and  not  harshly 
on  any  part.      Absorbent  cotton-wool,  folded  in  sheets,  answers  best. 

Movable  Splints. — The  simplest  splints  are  made  from  soft,  light  wood,  gen- 
erally deal,  as  it  can  be  worked  easily.  If  they  are  flat,  they  should  be  a  little 
wider  than  the  limb,  to  take  off  the  pressure,  but  it  is  more  comfortable  to  have 
them  hollowed  out,  especially  opposite  bony  projections,  and  beveled  at  the  edges. 
Others  are  of  metal,  sometimes  perforated  on  account  of  the  weight.  They  may 
be  trough-shaped,  rigid,  and  provided  with  hinges  to  allow  a  limited  range  of 
movement,  or  made  of  some  flexible  material,  such  as  zinc,  or  woven  wire,  so  as 
to  fit  into  all  the  curves  of  the  part.  Where  strength  is  not  of  imijortance,  as  in 
the  upper  limb,  and  in  the  case  of  children,  lighter  materials  are  used,  pasteboard, 
gutta-percha,  or,  what  is  much  better,  as  it  is  porous  and  weighs  less,  felt  steeped 
in  resin,  so  that  it  becomes  hard  when  cool.  The  two  last  are  especially  useful,  as 
by  warming  they  can  be  readily  moulded  to  fit  any  part,  and  felt  splints  can  be 
obtained  in  sizes,  roughly  shaped  already,  so  that  a  very  slight  degree  of  modeling 
is  required. 

Immovable  Splinfs. — Other  kinds  are  made  by  surrounding  the  limb  with  a 
woven  material,  such  as  muslin,  calico,  or  flannel,  and  saturating  this  with  sub- 
stances which  set,  or  become  hard  when  they  dry.  Starch-paste  was  one  of  the 
first  employed.  The  limb  is  enclosed  in  a  thick  layer  of  cotton-wool,  over  this 
are  placed  longitudinal  strips  of  torn  pasteboard  soaked  in  starch,  so  close 
together  that  only  a  small  space  is  left  between,  and  these  are  bound  together  with 
layer  after  layer  of  bandages  saturated  with  the  paste,  as  many  as  may  be  required. 
Sometimes,  strips  of  tin  are  inserted  opposite  the  joints  to  give  additional  rigidity. 
Then,  the  limb  is  fixed  on  a  splint  until  the  starch  is  dry.  In  this  way  a  firm  and 
even  casing  is  obtained,  but  the  process  of  hardening  is  very  tedious,  even  when 
the  temperature  is  maintained  ;  the  outer  layers  dry  first,  and  prevent  evaporation 
from  those  beneath,  so  that,  where  special  thickness  is  required,  it  may  be  some 
days  before  the  splint  is  thoroughly  firm. 

Plaster-of- Paris  is  free  from  this  objection.  The  ordinary  bandages  are  made 
of  a  coarse,  crinoline  muslin,  and  may  be  kept  in  a  tin  case  ready  for  use.  The 
powder  is  rubbed  into  their  meshes  while  they  are  being  rolled,  and  they  only  re- 
quire to  be  placed  upright  in  water  for  a  minute  or  two,  until  the  bubbles  of  air 
have  escaped.  A  flannel  bandage  is  put  on  first ;  cotton-wool  does  not  answer  so 
well,  as  it  is  very  difficult  to  keep  it  sufficiently  smooth  ;  and  then  the  prepared 
bandages  are  rolled  round  the  limb,  without  employing  any  pressure  or  making 
any  reverses.  Generally  speaking,  two  layers  are  enough,  some  loose  powder 
being  rubbed  in  between  them,  and  a  little  more,  with  plenty  of  water,  over  the 
surface  of  the  last.  Strips  of  tin  may  be  employed,  as  wath  starch,  and,  especially 
for  children,  the  splint  may  be  made  waterproof  with  paraffin.  The  setting  of  the 
plaster  can  be  delayed  by  adding  mucilage  or  borax  to  the  water,  and  accelerated 
to  some  extent  by  alum  ;  but,  if  there  is  any  doubt  as  to  the  freshness  of  the 
powder,  it  should  be  rebaked. 

For  many  purposes,  plaster  splints  can  be  made  more  conveniently  with  absor- 
bent cotton-wool,  as  recommended  by  Gamgee.  The  limb  must  be  first  invested 
with  a  sheet  of  wool,  and  then  strips  of  the  same  material,  cut  to  shape,  are  dipped 
in  plaster  and  water,  the  consistence  of  cream  (made  by  sprinkling  the  powder 
into  a  basin  of  water,  stirring  all  the  while),  and  fastened  round  with  absorbent 
bandages.  As  soon  as  it  is  set,  these  are  cut,  and  the  shells  lined  with  the  first 
layer  fall  apart  from  the  limb. 

Gum  and  chalk — powdered  chalk  rubbed  dowai  with  mucilage,  until  it  is  the 
consistence  of  thick  gruel — answers  better  in  some  cases.  It  does  not  dry  so 
quickly,  it  is  true,  but  it  is  lighter,  firmer,  less  apt  to  crack  and  crumble  at  the 
edges,  and  is  more  elastic.     A  flannel  bandage  is  applied  first,  then  an  ordinary 


374    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

calico  one,  into  which  the  mixture  is  well  rubbed  ;  a  second  is  placed  over  this 
the  whole  is  given  a  final  coating,  and  it  is  then  left  to  dry. 

Silicate  of  soda,  of  the  consistence  of  syrup,  is  applied  in  the  same  way.  but 
it  is  better  to  roll  the  bandages  in  the  solution,  and  keep  them  in  it  until  required. 
It  dries  rather  more  quickly. 

Tripolith  differs  very  little  in  its  uses  from  ordinary  plaster.  It  has  the  ad- 
vantage of  being  rather  lighter,  and  of  not  softening  to  the  same  e.xtent  if  moist- 
ened after  it  has  once  set.  It  is  said,  too,  to  set  more  rai^idly ;  but  this  depends 
a  great  deal  upon  the  amount  of  water  with  which  it  is  mixed. 

t*araffin  is  rarely  employed.  The  most  convenient  method  is  to  steep  long 
strips  of  cotton-wool  in  the  melted  fluid,  in  the  same  way  as  with  plaster  cream, 
and,  when  sufficiently  cool,  to  mould  them  to  the  limb.  They  must  then  be  fixed 
with  a  bandage  and  allowed  to  harden.  A  very  exact  cast  of  the  part  may  be 
taken  in  this  way,  but  it  is  not  so  rigid  as  plaster,  or  gum  and  chalk,  and,  unless 
the  jjaraffin  is  one  that  only  melts  at  a  high  temperature,  it  is  liable  to  become  soft 
from  the  heat  of  the  body. 

Care  must  be  taken  to  keep  the  limb  well  raised  while  these  splints  are  drying, 
as  most  of  them  contract  a  little  during  the  process,  and  the  extremities  must 
always  be  left  exposed,  in  order  to  judge  the  condition  of  the  circulation.  If 
the  fingers  or  toes  look  blue,  or  become  cold  and  numbed,  or  if  the  blood  does 
not  return  immediately  when  driven  from  the  matrix  of  a  nail  by  a  little  pressure, 
the  splint  must  be  slit  and  removed  at  once.  In  recent  injuries  watchfulness  is  even 
more  imperative;  swelling  sometimes  .sets  in  very  rapidly,  and,  if  the  constric- 
tion is  not  relieved,  the  circulation  may  be  stopped  altogether,  and  strangulation 
and  gangrene  be  caused  in  a  few  hours. 

After  they  have  been  on  some  time  the  opposite  result  generally  happens,  and 
the  splints  become  too  loose  from  absorption  of  the  extravasation  and  wasting  of 
the  muscles. 

[This,  indeed,  is  one  of  the  most  serious  objections  to  the  immediate  applica- 
tion of  immovable  splints,  for  it  is  obvious  that  as  the  swelling  subsides,  the 
splint,  at  first  accurately  fitting,  becomes  loose,  and  free  motion  between  the 
fragments  is  alloived,  with  sometimes  very  bad  results.] 

Movable  V.  Ivwiovable. — There  is  no  doubt  that  splints  made  in  this  way  are 
admirably  suited  to  fractures  that  have  already  united  in  part ;  but  the  question  is 
whether  it  is  wi.se  to  ajjply  them  while  the  injury  is  recent,  before  the  swelling  has 
subsided  and  the  danger  of  inflammation  is  past.  When  well  made  they  fit  to  per- 
fection ;  they  do  not  require  to  be  readjusted  as  often  as  other  splints ;  movement 
or  displacement  is  hardly  possible ;  the  uniform  pressure  checks  muscular  .spasm 
and  lessens  the  tendency  to  swelling  and  oedema ;  the  patient  is  able  to  get  about 
earlier  than  he  otherwise  would  ;  and  the  risk  of  bed-sores  and  pneumonia  is 
avoided.  In  short,  they  answer  every  requisite  of  a  splint  but  one  ;  they  do  not 
allow  the  seat  of  injury  to  be  inspected  ;  the  whole  limb  is  surrounded  so  that  if 
anything  were  to  happen  gangrene  might  occur  before  it  was  found  out,  especially 
as  in  such  cases  pain  is  sometimes  conspicuously  absent.  This  danger  is  lessened 
by  using  a  thick  layer  of  cotton-wool  instead  of  a  flannel  bandage,  so  that  the 
pressure  is  uniform  and  elastic  ;  but  it  can  be  prevented  entirely  by  making  the 
splint  in  such  a  way  that  it  can  be  loosened  or  removed  at  a  moment's  notice.  It 
may  be  either  cut  down  one  side  and  fastened  with  a  lace  or  bandage,  or,  better, 
made  in  two  halves. 

Modified  in  this  way,  a  fixed  apparatus  may  be  adopted  in  many  cases  from 
the  first  ;  only,  of  course,  care  must  be  used  in  the  selection  and  they  must  be  well 
watched.  The  advantages  are  immense ;  reduction  is  immediate  ;  there  is  no 
spasmodic  contraction  ;  the  extrava.sation  is  kept  within  bounds  ;  blebs  cannot  form, 
and  a  check  is  placed  upon  the  inflammatory  swelling.  But  the  pads  must  fit 
accurately  and  be  thick  enough  ;  the  pressure  must  be  soft  and  perfectly  uniform  ; 
and  the  case  must  be  made  in  at  least  two  pieces,  so  that  it  can  be  removed  easily 
and  at  once  if  there  is  of  congestion  or  any  needfear  for  any  readjustment. 


FRACTURES.  375 

In  fractures  of  the  femur  it  does  not  answer,  except  in  the  transverse  ones  of 
infants  and  children.  Longitudinal  displacement  is  too  easy,  and  the  bony  points 
are  not  sufficiently  marked.  These  must  be  left  three  or  four  weeks,  until  there  is 
a  certain  amount  of  consolidation  and  the  tendency  to  shortening  is  lessened.  In 
the  leg,  it  is  more  suitable  so  far  as  the  limb  is  concerned  ;  the  foot  and  the  knee 
can  be  easily  secured,  while  the  hip  cannot ;  the  bone  is  not  so  thickly  covered, 
and  the  muscular  contraction  is  more  easily  controlled  ;  but  the  question  does  not 
rest  on  this  altogether.  The  condition  of  the  skin,  and  the  extent  to  which  the 
soft  parts  are  injured,  are  more  important.  If  the  fracture  is  comminuted,  and 
some  time  has  passed  since  the  accident,  so  that  already  there  is  a  great  deal  of  ex- 
travasation ;  if  a  big  vessel  has  given  way  ;  if  the  skin  and  the  subjacent  tissues  are 
badly  bruised,  and  it  is  doubtful  if  they  can  live  ;  or  if  there  is  any  danger  of  the 
fracture  becoming  compound, — it  is  better  to  take  the  leg  entirely  out  of  the 
patient's  control  by  means  of  a  swing  and  the  ordinary  back  and  side  splints. 
With  such  an  injury,  confinement  to  bed  for  several  weeks  is  absolutely  necessary, 
whatever  appliance  the  patient  wears.  It  is  not  necessary  to  sacrifice  the  benefits 
of  uniform  compression  over  the  whole  surface ;  the  blebs,  which  often  form  the 
starting-point  for  inflammation,  and  are  never  found  under  splints,  but  always  at 
their  edges,  can  be  prevented  equally  well  by  using  a  sufficient  amount  of  absor- 
bent cotton-wool  in  addition  to  and  between  the  splints  ;  but  these  must  be 
arranged  so  that  it  is  possible  to  examine  the  injured  part  as  often  as  may  be 
wished,  without  disturbing  one  of  them  or  relaxing  the  grasp  on  the  limb. 

In  other  cases,  when,  for  example,  the  bone  is  broken  transversely  and  there 
is  not  much  displacement,  when  only  one  of  a  pair  has  given  way,  and  when 
the  structures  around  are  but  little  hurt,  this  plan  should  be  adopted  from  the 
first. 

Treatment  of  Fractures  that  are  Compound  by  Indirect  Violence. 

The  treatment  of  open  fractures  is  guided  by  the  nature  and  extent  of 
the  injury  inflicted  on  the  surrounding  structures.  When  the  skin  is  merely  punc- 
tured from  beneath  by  the  sharp  end  of  a  broken  bone,  no  plan  is  more  successful 
than  that  advocated  by  Astley  Cooper.  If  the  opening  is  already  closed  by  a  clot, 
every  effort  must  be  made  to  preserve  it ;  but  if  blood  is  still  oozing  out  or  if 
the  wound  is  unavoidably  reopened  by  the  manipulation  necessary  to  reduce  the 
fracture  the  skin  around  is  to  be  thoroughly  cleansed  with  antiseptics  (corrosive 
sublimate  i  in  500,  or  carbolic  acid  i  in  20),  the  edges  carefully  adjusted,  iodoform 
powder  dusted  in,  and  then  a  soft  absorbent  pad  of  wood-w^ool  or  prepared  moss 
laid  over  it.  Sometimes,  especially  in  the  leg,  the  bone  is  still  protruding,  tightly 
grasped  by  the  skin  ;  and  occasionally  there  is  some  little  difficulty  in  reducing  it, 
even  when  the  patient  is  under  an  anaesthetic.  The  opening  may  then  be  slightly 
enlarged  and  a  further  attempt  made  ;  if  this  is  unsuccessful,  particularly  if  it  is  a 
long,  pointed  spine  that  is  likely  to  give  trouble  afterward,  or  if  the  periosteum  has 
been  stripped  back  from  it,  it  is  better  to  cut  it  off  at  once  with  bone  forceps. 
The  w^ound  should  then  be  thoroughly  washed  out  and  treated  in  the  same  way. 
Even  if  there  is  comminution,  or  if  the  fracture  extends  into  a  neighboring  joint, 
this  plan  in  actual  practice  gives  results  that  have  not  been  surpassed. 

In  all  compound  fractures,  except  in  the  case  of  the  smallest  bones,  the  patient 
should  be  confined  to  bed  until  it  can  be  seen  what  course  events  are  likely  to  take. 
If  the  wound  is  only  a  puncture,  a  fixed  apparatus  may  be  applied  at  once ;  but 
the  splint  must  be  arranged  so  that  the  dressing  can  be  easily  removed.  Either  a 
window  must  be  cut,  or,  what  is  better,  an  opening  left  while  the  splint  is  being 
applied  ;  and  to  prevent  the  tissues  becoming  oedematous  and  projecting  outward 
through  this,  a  small  but  firm  pad  should  be  fitted  into  it.  If  the  temperature 
rises,  the  dressing  must  be  removed  at  once. 

In  all  other  cases  interrupted  splints  are  used,  the  pads  being  covered  with 
oiled  silk,  and  so  arranged  as  to  interfere  with  drainage  as  little  as  possible.     Fixed 


376    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

apparatus  should  be  reserved  until  the  bones  are  beginninj,^  to  unite  and  any  wound 
that  is  i)resent  has  healed. 

TrEATMKNT    of    FRACrURES     I  HAT    ARE    COMPOL'ND    HY     DlRECT    \'l()LEXCE. 

In  fractures  by  direct  violence  where  the  soft  parts  are  crushed,  the  bone  per- 
haps comminuted,  and  the  skin  torn  and  lacerated,  the  question  is  different. 

The  first  thing  to  decide  is  whether  the  injury  is  consistent  with  life.  In 
many  cases,  such  as  railway  accidents  in  which  both  thighs  have  been  crushed,  the 
shock  is  so  great  that  the  patient  never  rallies,  and  any  attempt  at  operating  merely 
precipitates  the  end  ;  or  other  injuries  of  an  even  more  serious  description  are 
inflicted  at  the  same  time.  In  such  as  these,  all  that  can  be  done  is  to  prevent 
hemorrhage  (even  capillary  oozing  is  serious)  and  check  the  tendency  to  putrefac- 
tion, which  is  particularly  jjrone  to  occur  in  the  region  of  the  bone.  Arteries 
rarely  bleed  under  these  conditions,  but  if  they  do,  or  the. veins,  they  should  be 
tied  or  clamped  ;  then  the  wound  must  be  thoroughly  washed  out  with  a  solution 
of  corrosive  sublimate  as  hot  as  can  be  borne,  and  wrapped  in  an  absorbent  dress- 
ing. Loose  clots  may  be  allowed  to  float  away ;  others  should  be  left  untouched. 
Hemorrhage  from  the  bone,  which  is  often  very  persistent,  must  be  stopped  by 
elevation  or  pressure. 

Meanwhile,  every  effort  must  be  made  to  tide  the  patient  over  the  shock  ;  the 
blankets  must  be  warmed,  hot  bottles  placed  all  round  the  body,  the  limbs  ban- 
daged, and  stimulants,  brandy  and  ammonia,  administered  freely,  or  even  injected 
under  the  skin.  If  reaction  definitely  sets  in,  and  the  temperature  begins  to  rise, 
it  becomes  a  question  whether  amputation  should  be  performed  at  once,  or  an 
attempt  made  to  save  the  limb. 

I.  Aviputaiion. 

{a)  The  Patient. — The  age  and  constitution  of  the  patient  are  the  first  things 
to  be  considered.  In  children  much  more  may  be  attempted  than  in  adults  ;  their 
tissues  heal  more  readily,  and  they  have  no  anxieties  ;  but  in  sound  old  age  the 
power  of  recovery  is  often  surprisingly  good.  The  condition  of  the  viscera,  par- 
ticularly of  the  kidneys,  is  of  greater  importance.  Sloughing  and  diffuse  inflam- 
mation are  almost  sure  to  occur,  if  the  urine  is  albuminous  or  the  specific  gravity 
persistently  low.  The  vitality  of  the  tissues,  if  they  are  crushed  or  bruised,  is  too 
feeble  to  resist,  and  the  only  chance  of  life  lies  in  the  complete  removal  of  all  the 
damaged  part.  Even  when  no  change  in  the  secreting  power  of  the  kidnevs  can 
be  directly  proved,  it  is  distinctly  unfavorable  if  the  aspect  of  the  patient  is  such 
as  to  suggest  over-indulgence  either  in  food  or  drink. 

ij))  The  Injury. — The  locality  of  the  injury  and  the  complications  that  are 
present,  as  a  rule,  are  final. 

The  Upper  Extremity. — In  the  hand  and  forearm  the  jjart  must  be  almost  disor- 
ganized to  justify  amputation.  The  wrist  joint  may  be  opened,  the  carpal  bones 
crushed,  and  the  hand  cut  to  pieces,  without  such  an  extreme  measure  being  neces- 
sary, if  only  a  single  movable  finger  is  likely  to  be  left.  I  have  known  such  injuries 
as  this  treated  with  corrosive  sublimate  baths  for  an  hour  each  day  recover  without 
a  single  febrile  symptom.  If,  however,  the  large  nerve-trunks  are  injured  beyond 
repair,  or  if  the  skin  is  torn  off  round  the  whole  circumference  for  even  a  short 
distance,  the  limb  never  recovers  so  as  to  be  of  any  use.  In  the  former  case  it 
remains  cold  and  helpless,  often  ulcerated  or  the  seat  of  severe  pain  ;  in  the  latter, 
it  swells  up  to  such  a  size  from  solid  cedema  and  becomes  so  hard  and  stift'  that  it 
is  merely  a  useless  log. 

The  extent  of  the  injury  to  the  soft  parts  is  equally  decisive  in  the  case  of  the 
arm  or  elbow.  The  artery  may  be  wounded,  the  joint  laid  open,  and  the  ends  of 
the  bone  badly  comminuted,  and  yet  the  vessel  may  be  tied,  the  fragments  of 
bone  removed,  and  an  informal  kind  of  excision  performed  w^ith  an  excellent 
result,  so  far  as  utility  is  concerned,  if  only  the  surrounding  structures  are  not  too 


FRACTURES.  zii 

badly  bruised.  Unhajipily,  such  accidents  generally  occur  from  direct  violence, 
and  then  the  skin  is  stripped  up,  the  muscles  are  torn  and  bruised,  and  everything 
is  crushed  to  such  an  extent  that  no  alternative  is  possible. 

The  Lower  Extremity. — Amputation  is  more  fre(]uently  required  in  compound 
fractures  of  the  lower  limb.  The  circulation  is  not  .so  active  as  it  is  in  the  ujjper, 
repair  is  not  carried  on  with  the  .same  degree  of  energy,  there  is  a  greater  risk  of 
gangrene  and  of  diffuse  inflammation,  the  joints  are  larger  and  more  complex,  and 
the  need  for  stability  is  much  greater. 

In  the  ca.se  of  the  foot,  for  example,  everything  must  be  sacrificed  to  gain  a 
firm  support.  In  the  hand  it  is  a  rule  never  to  remove  anything  that  can  by  any 
possibility  recover  ;  a  fragment  of  a  thumb  is  infinitely  more  useful  than  an  artifi- 
cial one  ;  in  the  foot  free  removal  is  often  the  better  i)lan.  Yet  even  here  much 
may  be  done  sometimes  by  judicious  conservatism.  In  a  case  under  my  care,  in 
which  the  contents  of  a  gun  had  passed  completely  through  the  foot,  so  that  an 
opening  was  left  into  which  three  fingers  could  have  been  placed,  recovery  was  so 
perfect  that  the  patient  could  walk  three  or  four  miles  without  inconvenience  six 
months  after  the  accident.  The  bases  of  the  first  two  metatarsal  bones  with  the 
corresponding  portions  of  the  internal  and  middle  cuneiform  were  blown  com- 
pletely away  ;  but  the  external  plantar  artery  in  all  probability  remained  intact  and 
the  tread  of  the  sole  was  uninjured. 

When  there  is  a  compound  fracture  of  the  leg,  the  question  is  generally 
decided  by  the  condition  of  the  soft  parts,  especially  the  skin  and  the  blood- 
vessels. The  ankle  joint  maybe  opened  and  the  bones  comminuted,  but  so  long 
as  the  circulation  is  good,  and  the  skin  is  not  destroyed,  a  very  useful  limb  may 
be  obtained  by  resetting  the  broken  ends  and  removing  splinters  that  are  loosened 
too  much  to  live.  Similar  injuries  in  the  case  of  the  knee  joint  are  much  more 
serious  ;  compound  fractures  of  the  patella  only  may  be  treated  in  this  way  with  a 
fair  prospect  of  success,  even  though  the  cavity  of  the  joint  is  widely  opened  ;  but 
when  the  lower  end  of  the  femur  or  the  upper  end  of  the  tibia  is  badly  com- 
minuted, the  injury  is,  generally  speaking,  too  severe.  Even  here,  however, 
primary  resection  has  been  performed  with  success  in  the  case  of  gunshot 
wounds. 

Compound  fractures  of  the  femur  are  still  more  serious.  If  they  are  caused 
by  direct  violence  the  injury  is  almost  hopeless  so  far  as  the  limb  is  concerned. 
Very  often  it  is  much  worse  than  at  first  sight  it  appears  to  be  ;  the  muscles  are 
torn  and  crushed  so  that  they  protrude  from  their  sheaths  ;  the  deep  planes  of  areolar 
tissue  are  laid  open,  and  the  skin  stripped  up  from  the  fascia  beneath  and  bruised 
beyond  recovery  for  a  distance  above  the  seat  of  injury  almost  equal  to  the 
diameter  of  the  part. 

When  the  injury  involves  the  upper  part  of  the  thigh  or  the  hip  joint,  the 
shock  is  nearly  always  fatal ;  and  even  if  the  patient  rallies  it  is  very  questionable 
whether  primary  amputation  in  the  upper  third  or  disarticulation  should  be  per- 
formed. It  is  true  that  there  are  a  few  successful  cases  on  record  ;  but  certainly  in 
gunshot  wounds,  if  the  head  of  the  bone  is  shattered,  better  results  are  obtained 
by  removing  the  fragments,  securing  perfect  drainage,  and  amputating  later,  when 
the  period  of  acute  suppuration  is  past.  Probably  in  the  majority  of  those  in- 
stances in  which  the  patient  does  rally  sufficiently,  the  best  chance  lies  in  merely 
removing  the  part  that  is  injured  (for  which  Paquelin's  cautery  is  of  excellent 
service),  leaving  the  wound  open,  and  by  means  of  antiseptics  and  drainage, 
limiting  the  amount  of  septic  ab.sorption  as  much  as  possible.  Even  in  other 
parts  of  the  body  this  plan  may  sometimes  be  followed  with  advantage  ;  it  is 
true  there  is  usually  a  large  amount  of  suppuration,  but  the  shock  is  not  nearly 
so  great  as  when  a  formal  amputation  is  performed,  and  owing  to  the  nature  of 
the  wound  the  amount  of  septic  absorption  is  much  less  than  might  be  expected. 


37S    DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 

•    2.   Preservation. 

If  it  is  determinetl  to  try  and  save  the  part  the  fracture  must  be  reduced  and 
the  same  general  princij^les  of  treatment  followed,  interrupted  splints  and  jiads 
covered  with  oiled  silk  being  used.  The  presence  of  a  wound,  however,  and  of 
more  or  less  serious  injury  to  the  other  structures  in  the  limb — muscles,  arteries, 
cellular  tissue,  etc. — necessitates  something  more. 

Hemorrhage  must  be  checked  at  once.  The  limb  must  be  raised,  all  con- 
striction removed,  the  main  artery,  if  necessary,  placed  under  control,  all  loose 
clots  washed  away,  and  any  bleeding  i)oint  secured,  (leneral  oozing  is  checked  by 
washing  out  the  wound  with  an  anti.septic  solution  (tincture  of  iodine  or  corro- 
sive sul)limate)  as  hot  as  can  be  borne,  and  ajjplying  gentle  pressure  afterward. 

Splinters  that  are  quite  loose  and  detached  should  be  removed,  and  if  the  ends 
of  the  bone  cannot  be  readjusted,  especially  if  they  are  stripped  of  their  perios- 
teum, they  may  be  resected.  Large  fragments  that  are  firmly  adherent  should  be 
left.  An  exception  may  be  made  in  the  case  of  gunshot  wounds  caused  by  pro- 
jectiles of  high  velocity  ;  in  these  it  has  recently  been  shown  that,  if  a  commence- 
ment is  once  made,  it  is  very  difficult  to  stop  ;  removing  one  fragment  seems  to 
loosen  all  the  rest,  so  that  if  the  drainage  is  good  it  is  better  to  leave  them  until  a 
certain  amount  of  consolidation  has  taken  place.  If  much  is  removed  care  must 
be  taken  to  bring  the  broken  ends  well  together,  or  union  may  fail. 

The  looiind  must  be  thoroughly  cleansed,  so  that  no  poisonous  material  can 
form,  and  thoroughly  drained,  so  that  if  it  does  it  may  escape  externally,  and  not 
be  absorbed.  The  principles  on  which  this  is  to  be  done  are  easily  laid  down  ; 
the  details  vary  naturally  with  each  case. 

The  skin  for  some  distance  around  must  be  cleansed  with  turpentine  and  a 
strong  solution  (i  in  500)  of  corrosive  sublimate.  All  dirt  must  be  picked  out; 
if  it  is  so  much  ground  in  it  that  it  is  impossible,  the  tissue  should  be  cut  away, 
unless  it  is  skin.  The  dirt  is  always  on  the  outside  of  this,  and  it  can  be  rendered 
inert  without  destroying  the  whole  thickness  and  endangering  cicatrization. 

If  the  wound  is  foul,  or  such  that  it  cannot  be  sealed  at  once,  it  must  be 
cleared  of  all  foreign  matter  and  blood-clot,  and  washed  out  with  an  antisei)tic, 
using  a  rubber  drainage-tulie  or  a  catheter  to  conduct  the  fluid  into  all  the  recesses. 
At  the  same  time,  care  must  be  taken  to  make  the  opening  sufficiently  free,  and  if 
necessary  to  make  others,  so  that  the  fluid  is  not  retained  and  absorbed.  Immedi- 
ately after  an  injury  of  this  kind,  when  the  planes  of  fascia  are  torn  across  at 
different  levels,  and  all  the  lymphatic  spaces  are  gaping  widely,  a  poisonous  amount 
can  easily  get  into  the  circulation,  and  either  cause  local  sloughing  or  lead  to 
constitutional  symptoms. 

Tincture  of  iodine  (i  in  80),  carbolic  acid  (i  in  40),  or  corrosive  sublimate 
(i  in  Tooo)  are  the  most  used  :  the  last  is  the  most  effectual,  but  at  the  same  time 
the  most  dangerous  if  retained.  If  there  is  any  capillary  oozing  they  should  be 
injected  at  a  temperature  of  120°  to  140°  F.,  so  as  to  leave  the  wound  thoroughly 
dry ;  it  is  of  great  importance  to  reduce  the  amount  of  discharge  as  much  as 
possible,  and  keep  the  cavity  free  from  any  putrescible  matter.  With  this  object 
Gamgee  recommended  ecjual  i)arts  of  spirit  and  water,  or  a  saturated  solution  of 
borax  with  about  one-eighth  of  its  l)ulk  of  glycerine,  in  preference  to  the  watery 
solution  of  any  antisejitic. 

After  this  iodoform  may  be  dusted  lightly  over  the  surface.  It  is  true  that 
grave  doubt  has  been  thrown  on  its  merits  as  a  germicide,  and  that  in  some  in- 
stances, when  too  much  has  been  used  or  the  patient  has  been  i)eculiarly  susce])tible, 
serious  symptoms  have  followed  its  employment,  but  there  can  be  no  question  that 
in  some  way  it  possesses  the  power  of  limiting  the  amount  of  exudation  and  dis- 
couraging decomposition. 

As  soon  as  everything  is  .satisfactory,  the  deeper  parts  must  be  brought  into 
the  best  apposition  jiossible,  buried  sutures  of  catgut  being  used,  if  necessary,  both 
in  the  bones  themselves  and  in   the  dense  sheets  of  fascia.     If  the  wound  were  a 


FRACTURES.  379 

simple  incised  one  this  would  be  enough,  l)ut  it  is  always  irregular  in  shape;  the 
tissues  are  badly  bruised  and  crushed,  not  cut,  and  the  necessary  cleansing  and 
the  antiseptics  injure  them  still  more.  As  a  result,  a  large  amount  of  fluid  is  sure 
to  collect ;  absori)tion,  even  when  aided  by  pressure,  cannot  keep  pace  with 
exudation,  and  unless  free  exit  is  i)rovided  tension  and  inflammation  must  follow. 
If  there  is  a  dependent  opening,  })erfectly  straight  and  wide,  it  may  be  left,  with 
an  absorbent  dressing  properly  arranged  (that  is  to  say,  a  piece  of  protective 
first,  as  large  as  the  wound),  and  all  the  fluid  will  be  sucked  out ;  but  such  a  con- 
dition is  rare  in  a  compound  fracture.  Almost  always  the  internal  wound  is  very 
large,  and  tlie  external  very  small,  and  at  the  top,  or  at  least  very  rarely  at  the 
bottom. 

Under  these  circumstances  counter-openings  must  l)e  made  wherever  there  is 
the  least  indication  (and  advantage  may  be  taken  of  these  to  get  rid  of  as  much 
of  the  extrava.sated  blood  as  possible),  drainage-tubes  of  sufficient  size  must  be 
inserted,  and  the  edges  of  the  skin  wound  must  be  left  widely  open,  sutures  only 
being  used  to  retain  torn  flaps  in  position. 

All  the  points  at  which  fluid  can  exude  should  be  covered  with  waterproof  or 
protective  to  prevent  the  dressing  sticking  to  the  surface  and  becoming  clogged. 
The  more  absorbent  the  material  used  to  envelop  the  part  the  better.  Wood-wool 
and  prepared  moss  are  some  of  the  best ;  Lister's  gauze,  owing,  in  a  measure,  to 
the  resinous  substance  with  which  it  is  impregnated,  takes  up  too  little,  and 
absorbent  cotton-wool  by  itself  is  apt  to  cake  if  there  is  much  discharge.  Decom- 
position of  the  exudation  can  hardly  take  place  in  the  dressings,  owing  to  its  con- 
centration, and  it  mayj^e  rendered  impossible  by  having  the  material  prepared 
with  some  non-volatile  antiseptic. 

If  this  has  been  successful  the  dressing  may  be  left  untouched  for  two  or 
three  weeks.  Drainage-tubes,  however,  cannot  remain  so  long ;  as  a  rule,  they 
must  be  removed  by  the  third  day,  as  they  are  very  liable  to  become  plugged 
with  coagula  and  rendered  useless.  After  this  the  longer  the  second  dressing  is 
postponed  the  better.  Every  time  the  fracture  is  touched  it  gives  pain,  causes 
irritation,  and  delays  repair.  The  wound,  if  the  treatment  is  carried  out  thor- 
oughly, and  the  patient's  tissues  are  fairly  sound,  fills  up  from  the  bottom,  and 
when  at  length  it  is  exposed,  it  is  either  already  skinned  over,  or  else  is  level  with 
the  surrounding  surface,  perfectly  smooth,  pale,  and,  perhaps,  just  moistened  by  a 
trace  of  pus. 

Inflammation,  the  result  of  continued  irritation  (whether  by  tension,  want  of 
rest,  foreign  substance,  or  decomposition),  has  been  successfully  prevented. 

In  many  cases,  especially  where  the  foot  and  hand  are  concerned,  or  where  a 
joint  is  involved,  or  where  from  any  other  cause  the  prospect  of  limiting  the 
amount  of  exudation  is  doubtful,  the  whole  part  may  be  immersed  in  a  bath. 
Sometimes,  when  a  hand  is  crushed,  it  is  impossible  to  tell  what  will  live  and  what 
will  not ;  more  than  is  necessary  may  be  cut  away,  or,  on  the  other  hand,  some 
part  that  is  already  dead  and  beginning  to  slough  may  be  left.  Such  cases  may 
be  placed  in  a  warm  bath  of  corrosive  sublimate  and  left  with  perfect  safety, 
always  provided  the  whole  cavity  of  the  wound  is  laid  open.  If  this  is  not  done, 
putrefaction  may  still  go  on  in  the  interior.  I  have  known  this  happen  in  a  com- 
pound dislocation  of  the  wrist ;  a  large  cavity  filled  with  extravasated  blood  was 
overlooked  under  the  deep  palmar  fascia,  and  putrefaction  and  suppuration  con- 
tinued unchecked,  although  the  hand  was  kept  in  a  continuous  bath  ;  the  fluid 
never  penetrated  into  it. 

If  the  bath  is  continuous,  one  part  in  ten  thousand  is  sufficient ;  if  it  is  only 
used  for  an  hour  or  two  in  the  course  of  the  day,  it  should  be  at  least  one  in  a 
thousand  ;  and  a  few  drops  of  hydrochloric  acid  or  ammonium  chloride  should  be 
added.  Careful  watch  must,  of  course,  be  kept  upon  the  patient's  teeth,  and  if 
there  is  any  diarrhrea,  the  corrosive  sublimate  should  be  stopped  at  once  and 
boracic  acid  substituted  ;  but  though  I  have  treated  many  cases  in  this  way,  I  have 
never  known  any  serious  consequence  of  this  kind  result.     The  limb  should  be 


3So    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

fastened  lightly  on  a  splint,  the  wound  left  widely  open,  and,  if  necessary,  coun- 
ter-openings freely  made.  There  is  no  decomposition  ;  the  dead  tissues  absorb 
and  retain  so  much  of  the  antiseptic  that  they  do  not  become  putrid  ;  the  sloughs 
are,  it  is  true,  somewhat  slow  in  sejjarating,  but  when  granulations  have  once 
formed,  recovery  is  rapid,  and  the  only  tissue  lost  is  that  which  has  been  killed 
by  injury  ;   none  is  destroyed  by  inflanuiiation. 

Sometimes,  however,  in  spite  of  all  precauti(jns,  or  because  they  are  adopted 
too  late,  the  temperature  begins  to  rise,  the  patient  becomes  feverish  and  restless; 
redness  shows  itself  round  the  wound,  and  the  limb  becomes  hot,  swollen,  and  tense. 
Inflammation  has  set  in. 

The  treatment  of  this  depends  upon  the  cause.  If  it  is  really  due  to  a  broken- 
down  constitution  ;  if,  as  sometimes  happens,  even  with  simple  fractures,  the  tissues 
are  so  badly  nourished  in  consequence  of  diabetes,  renal  disease,  chronic  alcohol- 
ism, cold,  exposure,  and  other  causes  acting  together,  that  the  least  injury  makes 
them  slough,  the  prognosis  is  exceedingly  grave  ;  operation  is  hopeless  ;  the  dress- 
ing must  be  taken  off,  the  limb  raised  and  kept  at  an  even  temperature,  all  con- 
striction removed,  decomposition  prevented  as  far  as  possible,  and  the  jjatient's 
strength  husbanded  in  every  way,  in  the  hope  that  the  sloughing  may  cease  and  a 
line  of  demarcation  form.  Too  often  it  becomes  a  case  of  spreading  traumatic 
gangrene  ;  the  temperature  falls,  the  face  becomes  dusky,  and  the  patient  sinks 
into  a  semi-comatose  condition,  which  proves  fatal  in  the  course  of  forty-eight 
hours. 

If,  on  the  other  hand,  the  inflammation  is  the  result  of  local  causes,  there  is 
some  hope  of  being  able  to  save  the  limb. 

Free  exit  must  be  provided  for  all  discharges,  the  wound  must  be  thoroughly 
washed  out  again,  incisions  made  wherever  the  skin  is  tense  and  cedematous, 
especially  on  the  inner  side,  and  where  the  tissues  are  saturated  with  extravasated 
blood,  and  large  drainage-tubes  inserted,  as  the  secretion  is  sure  to  be  profuse. 
It  is  no  use  waiting  for  the  boggy  sensation  of  impending  suppuration.  If  the 
inflammation  is  acute,  the  continuous  application  of  cold,  though  it  is  not  so 
comfortable  at  first,  is  better  than  warmth.  An  ice-bag  should  be  laid  along  the 
course  of  the  main  artery,  and  a  number  of  drip  pots  containing  spirit  and  lead 
lotion  arranged  over  the  injured  part,  so  that  there  may  be  constant  evaporation 
from  the  surface.  Any  degree  of  cold  that  is  desired  may  be  obtained  in  this 
way  ;  the  vessels  become  so  constricted  and  the  amount  of  blood  flowing  through 
the  limb  so  reduced  that  the  exudation  comes  to  an  end  and  the  inflammation 
cannot  spread.  Care,  indeed,  must  be  taken  not  to  carry  the  proceeding  too  far  ; 
I  have  known  a  limb  cooled  down  to  such  a  degree  that  there  was  some  fear  of 
gangrene. 

Meanwhile,  the  constitutional  treatment  requires  no  less  attention.  It  very 
rarely  happens  that  the  patients  in  whom  this  comj^lication  occurs  arc  such  as  would 
stand  depletion  or  blood-letting.  Much  more  freciuently  they  are  utterly  broken- 
down  in  health,  often  on  the  verge  of  delirium,  and  quite  incapable  of  taking  the 
requisite  amount  of  nourishment.  Stimulants  generally  have  to  be  administered 
freely — brandy  in  ordinary  cases,  bottled  stout  if  there  is  any  sign  of  delirium 
tremens  ;  pain  and  sleeplessness  must  be  controlled  by  sedatives ;  opium  is  by  far 
the  most  useful,  but  great  care  must  be  taken  in  its  administration,  as  many  of 
these  patients  are  already  the  subjects  of  advanced  renal  disease  ;  the  bowels  must 
be  kei)t  open,  and  quinine  given  freely,  if  the  temperature  is  high  or  if  rigors  set 
in.  ICverything  depends  upon  maintaining  the  patient's  strength  until  further 
absorption  of  the  poison  can  be  checked  by  energetic  local  treatment. 

Secondary  Amputation. — If  it  can  possibly  be  avoided,  amputation  should  not 
be  performed  at  this  stage.  If  the  attempt  to  save  the  limb  has  failed,  and  the 
time  before  the  inflammation  commenced  has  been  lost,  it  is  best,  if  it  can  be  done, 
to  wait  until  the  fall  of  the  temperature  in  the  morning  shows  that  the  tissues  are 
getting  the  better  of  the  contest,  and  are  forming  a  line  of  demarcation.  Then 
the  operation  is  very  successful,  and  it  often  happens  that   a  patient  who  appears 


I 


FRACTURE  OF  BONES  OF  THE   FACE.  38 1 

to  be  dying  from  exhaustion  and  fever  sleeps  well  the  following  night,  and  re- 
covers from  that  moment.  Sometimes,  however,  it  must  l)e  done  at  once  ;  it 
gives  the  only  chance  of  saving  a  life  threatened  l)y  absorption  from  an  inflamed 
and  partly  gangrenous  limb.  The  condition  may  appear  to  be  desperate,  but  the 
free  removal  of  the  whole  source  of  the  poison  is  the  only  thing  left,  and  occa- 
sionally, even  when  the  flaj^s  are  sodden  and  oedematous,  and  the  pulse  too  tpiick 
to  be  counted,  it  meets  with  surprising  success. 

Compound  Fractures  into  Joint.s. 

The  treatment  must  be  carried  out  on  exactly  the  same  plan,  only  it  must  be 
remembered  that  now,  no  matter  how  small  the  wound  of  the  skin  may  be,  its  real 
extent  corresponds  to  the  size  of  the  synovial  membrane.  If  there  is  only  a  punc- 
ture (such  as  is  sometimes  i)roduced  by  a  splinter  of  bone),  and  the  opening  does 
not  appear  direct,  or  if  it  is  merely  a  clean  incision,  an  attempt  may  be  made  to 
close  the  wound,  as  already  described,  and  prevent  inflammation  by  cold,  eleva- 
tion, rest,  and  every  other  means  that  may  be  available ;  but  careful  watch  must 
be  kept  upon  the  condition  of  the  joint  and  the  temperature  of  the  patient,  so 
that  suppuration  may  not  set  in  unawares.  If  it  does,  the  only  hope  lies  in  free 
incision  and  thorough  drainage.  In  all  other  cases,  especially  where  the  force  is 
direct,  and  the  skin  perhaps  torn  or  ground  in  with  dirt,  it  is  better  to  enlarge  the 
wound  at  once,  wash  out  the  joint  thoroughly  with  corrosive  sublimate  solution 
(or  immerse  the  part  bodily  in  a  bath),  and  make  counter-openings  for  drainage 
wherever  there  is  a  chance  of  any  pocket  forming.  The  question  as  to  the  ad- 
visability of  excision  or  amputation  must  be  determined  in  each  case,  partly  by 
the  constitution  of  the  patient,  partly  by  the  amount  of  injury  ;  if  the  bone  is 
extensively  comminuted,  but  the  skin  fairly  sound,  and  the  circulation  not  seriously 
interfered  with,  primary  excision  may  be  attended  with  the  greatest  success,  even 
in  the  largest  joints  ;  under  other  circumstances  (except  in  the  case  of  the  hip) 
amputation  affords  the  only  chance. 

Other  complications  that  occur  in  the  course  of  treatment  of  fractures  must 
be  dealt  with  by  themselves.  Injuries  to  important  viscera,  such  as  the  lungs, 
require  special  consideration  ;  cellulitis,  erysipelas,  pyaemia,  and  other  forms  of 
diffuse  inflammation  are  described  elsewhere.  Abscesses  may  have  to  be  opened 
and  sequestra  removed  years  after  the  original  accident ;  passive  motion  and  the 
breaking  down  of  adhesions  are  often  required  before  it  is  possible  to  make  use  of 
the  joints  or  tendons  ;  ma.ssage  and  galvanism  may  be  needed  to  restore  strength 
to  the  muscles  ;  friction  and  bandaging  may  be  necessary  to  relieve  the  obstinate 
oedema  that  sometimes  follows,  and  to  prevent  ulceration  ;  and  even  amputation 
may  be  required  after  all ;  either  the  limb  is  useless  and  the  seat  of  constant  pain, 
or  there  is  such  an  amount  of  suppuration  that  the  patient  is  in  danger  of  sinking 
from  hectic  and  exhaustion. 


FRACTURE  OF  THE  BOXES  OF  THE  FACE. 

The  Nasal  Bones. 

The  nasal  bones  often  suffer  from  direct  violence  :  the  fracture  may  be  com- 
pound, either  externally,  internally,  or  both,  or  it  may  be  comminuted,  and  the 
injury  may  be  limited  to  the  bones  themselves,  or  the  septum  may  be  bent  or 
crushed  in,  or  the  other  bones  that  surround  the  nasal  cavities  may  be  involved  as 
well.  I  have  known  the  greater  part  of  the  cribriform  plate  of  the  ethmoid  com- 
minuted and  removed  in  splinters  through  an  opening  in  the  nose,  so  that  the 
dura  mater  was  plainly  visible. 

Hemorrhage  is  always  profuse  ;  emphysema  is  occasionally  present  from  the 
escape  of  air  into  the  tissues,  and  deformity  and  swelling  are  generally  very  con- 
siderable.    No  pains  should  be  spared   to   effect  reduction  as  early  as  possible. 


382    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Manipulation  is  exceed inj^lv  paiiiful,  so  that,  if  the  displacement  is  at  all  extensive, 
it  is  advisable  to  give  an  anivsthetic.  The  bleeding,  which  is  sure  to  be  profuse, 
must  be  checked  afterward  by  injecting  ice-cold  water,  or  by  the  application  of 
an  ice-bag.  Elevation  from  within  with  a  steel  director,  or  a  jjair  of  dressing- 
forceps,  may  be  tried  first,  but  they  are  not  of  much  service  in  really  bad  cases. 
In  some  instances  it  is  necessary  to  gras[)  the  fragments  with  smooth-bladed  forceps, 
bent  so  as  not  to  pinch  the  soft  tissues  near  the  nostril,  and  twist  them  into  posi- 
tion. Later  on  a  great  deal  may  be  done  to  correct  any  deformity  that  is  left  by 
means  of  pressure.  A  spring  truss  may  be  used,  especially  at  night,  outside  the 
face,  or,  as  Krichsen  suggests,  india-rubber  bags  may  be  introduced  into  the  nostril 
and  inflated.  Suppuration  is  not  uncommon,  but  it  is  rarely  .serious;  ozjena  and 
necrosis,  however,  occasionally  occur,  and  when  the  fracture  extends  on  to  the 
face,  so  as  to  involve  the  nasal  process  of  the  superior  maxilla,  stricture  of  the 
lachrymal  duct  generally  follows. 

Fracture  of  the  Superior  Maxilla. 

The  anterior  wall  of  the  antrum  may  be  driven  in  by  a  blow  with  the  fist,  or 
from  a  cricket-ball,  loosening  the  teeth  and  leaving  a  serious  degree  of  disfigure- 
ment. Hemorrhage  is  always  profuse,  and  surgical  emphysema  may  occur,  but 
rarely  to  any  extent.  Or  the  whole  bone  may  l)e  driven  in  and  crushed,  and  the 
injury  may  extend  to  the  other  bones  of  the  face,  and  even  to  the  base  of  the 
skull.  The  deformity  in  these  cases  is  very  often  extreme,  and  in  many  of  them 
very  little  can  be  done  to  reduce  it.  The  prognosis  must  always  be  guarded,  as  it 
is  not  uncommon  for  serious  injuries  of  this  character  to  be  associated  with  con- 
cussion of  the  brain  and  fracture  of  the  bones  of  the  skull. 

Fracture  of  the  Malar  Bone. 

The  zygoma  is  occasionally  broken  by  direct  violence,  and  it  has  given  way 
from  within.  Unless  it  is  driven  so  far  inward  as  to  interfere  with  the  action  of 
the  temporal  muscle  or  the  lower  jaw,  treatment  is  scarcely  necessary. 

Fracture  of  the  Lower  Jaw. 

These  may  be  the  result  of  direct  or  indirect  violence.  Blows  with  the  fist 
and  kicks  are  the  most  common  cause,  but  occasionally  they  are  due  to  lateral 
compression.  Fracture  near  the  condyles  is  produced  either  by  a  fall  upon  the 
chin,  or  by  a  blow  on  the  side  of  the  face  ;  in  the  former  case  there  may  be  at  the 
same  time  injury  to  the  external  auditory  meatus,  or  to  the  base  of  the  skull ;  in 
the  latter  it  is  usually  associated  with  a  fi.ssure  through  the  opposite  ramus. 

Seat  of  hijury. — The  most  fre(|uent  seat  of  injury  is  immediately  in  front  of 
the  mental  foramen  close  to  the  canine  tooth,  owing  to  the  way  in  which  the  bone 
is  hollowed  out  to  form  the  socket  for  its  fang;  but  suppuration  may  take  i)laceat 
or  near  the  symphysis,  and  the  angle,  the  neck  of  the  condyle,  and  even  the  coro- 
noid  process  have  been  known  to  give  way  occasionally.  Multiple  and  commi- 
nuted fractures  are  common,  and  with  few  exceptions  they  are  compound  into  the 
mouth.     Teeth  are  often  loo.sened  and  sometimes  detached  completely. 

Symptoms. — Displaccmnit. — The  nature  and  degree  of  the  displacement 
depend  upon  the  seat  of  injury,  the  ol)li<iuity  of  the  fracture,  the  nature  of  the 
force,  and  the  action  of  the  muscles.  When  it  occurs  at  the  angle,  and  the  dense 
tendinous  insertion  of  the  masseter  is  not  torn,  it  is  generally  very  slight ;  when  the 
neck  is  broken  the  condyle  is  pulled  almost  out  of  its  socket  by  the  external  ptery- 
goid, and  the  rest  of  the  jaw  is  forced  to  one  side  by  the  action  of  the  other  mus- 
cles. In  the  ordinary  form,  when  there  is  but  a  single  fracture  through  the  hori- 
zontal ramus,  the  longer  of  the  two  j^ortions  drops  to  a  certain  extent,  partly  from 
its  weight,  p-artly  from  the  action  of  the  muscles  attached  to  the  hyoid  bone  ;  the 


FRACTURE  OF  IWNES  OF  TIIF   FACE.  383 

shorter  may  lie  to  its  inner  or  outer  side,  according  to  the  ol)H(juity  of  the  fracture, 
but  it  is  rarely  displaced  far  enough  to  completely  override  the  other,  if  the  median 
l)ortion  is  detached,  it  is  drawn  downward  and  backward  from  between  the  others, 
so  that  these  overlap  it  and  ap))roach  each  other  in  front.  When  the  bone  is  com- 
minutetl  the  displacement  may  be  greater  still,  and  detached  fragments  and  loos- 
ened teeth  may  have  to  be  removed  before  the  deformity  can  be  rectified. 

Undue  mobility  and  crepitus  are  nearly  always  present  ;  impaction  very  rarely 
occurs  ;  pain  is  severe,  and  is  much  increased  by  speaking  or  by  attempts  at  mastica- 
tion ;  the  patient  inileed  often  supi)orts  his  jaw  with  one  hand  so  as  to  steady  it  to 
a  certain  extent  ;  and  blood  escapes  freely  into  the  mouth,  not  only  from  the 
bone  but  from  the  torn  vascular  gum,  and  drib])les  away  with  the  saliva.  Inflam- 
mation, leading  to  subma.xillary  suppuration  and  even  necrosis,  is  very  common, 
and  the  amount  of  callus  thrown  out  rarely  fails.  In  many  cases  the  inferior  den- 
tal artery  must  be  injured,  but  it  is  very  unusual  for  it  to  bleed  seriously  ;  and  though 
the  accompanying  nerve  must  be  torn  or  stretched  in  fractures  behind  the  mental 
foramen,  anaesthesia  is  rarely  noticed.  It  is  quite  })o.ssible  that  it  is  usually  over- 
looked until  the  injury  is  repaired.  Many  of  the  teeth  may  be  loosened,  and  occa- 
sionally some  of  them  are  completely  detached  ;  these,  if  they  do  not  interfere  with 
the  adjustment  of  the  fracture,  should  be  replaced  and  carefully  protected  from 
pressure  ;  if,  however,  they  are  in  the  line  of  the  fracture  itself,  they  generally  have 
to  be  removed  at  a  later  period. 

Treatment. — External  Appliances. — When  there  is  only  a  single  fracture 
and  the  teeth  are  fairly  sound,  the  simplest  apparatus  is  sufficient.  One  webbing 
strap  is  placed  beneath  the  jaw,  carried  upward  on  either  side  over  the  temporal 
region,  and  fastened  a  little  in  front  of  the  vertex  ;  and  a  second  is  passed  horizon- 
tally round  the  forehead  and  below  the  occipital  protuberance.  Where  they  cross, 
a  slit  should  be  cut  in  the  horizontal  one  to  allow  the  other  to  pass  through,  or  they 
should  be  sewn  together,  and  for  additional  security  they  may  be  connected  by  a 
tape  over  the  sagittal  suture.  Buckles,  protected  underneath  with  little  wash- 
leather  pads,  should  be  used  to  secure  them.  In  ordinary  cases  there  is  no  ten- 
dency to  displacement  forward  ;  but  if,  owing  to  the  convexity  of  the  lower  margin 
of  the  jaw,  the  vertical  band  is  inclined  to  slip  too  far  back,  it  may  be  secured  in 
position  by  a  tape  stitched  to  it  and  pas.sed  in  front  of  the  chin.  In  comparison 
with  this  a  four-tailed  bandage  is  untidy  and  always  liable  to  become  loose. 

If,  owing  to  the  obliquity  of  the  fracture,  there  is  any  tendency  for  the  shorter 
of  the  two  fragments  to  be  displaced  inward,  lateral  compression  must  be  avoided. 
A  cap  may  be  made  from  gutta-percha  cut 
into  the  shape  figured,  moulded  round  the  __ 

chin  and  lined  with  wash-leather  ;  but  it  is,        /^  ,..    '         -t 

generally  speaking,  sufificient  to  stiffen  the       (  "  '  | 

portion  of  the  strap  that  lies  beneath  the ■->     "~~ 

jaw  by  fastening  to  it  a  strip  of  pasteboard, 

poroplastic  felt,  or  tin  covered   over  with  ,-'"'-., 

wash-leather.     As  it  is  intended  to  prevent  '~'^"  '^"^ — "^ 

rather  than  to  exert  pressure,  it  should  be  a        f.g.  ..4.-Gutta-percha  Spiint  for  Lower  ja^v. 
little  wider  than  the  part  of  the  jaw  to  which 

it  is  fitted,  and  the  ends  should  be  bent  up  on  either  side.  Gutta-percha  is  cum- 
bersome, uncomfortable  from  retaining  perspiration,  and  encourages  suppuration, 
especially  if  the  tissues  are  bruised  (Fig.  114). 

Interdental  Splints. — Interdental  splints  are  occasionally  required  when  the 
teeth  are  absolutely  perfect,  in  order  that  the  patient  may  be  fed  ;  the  space  that 
exists  behind  the  last  molar  is  rarely  sufficient  for  the  purpose,  and  its  position  is 
exceedingly  inconvenient.  In  many  cases  they  may  be  used  with  great  advantage 
to  retain  the  fragments  in  position. 

The  simplest,  but  one  that  is  very  efficient,  is  made  of  gutta-percha  moulded 
directly  on  to  the  teeth.     Two  wedge-shaped  pieces  are  used,  one  for  each  side, 


3S4     n/SEASES  AND   JXJi'RlES   OE  SPECIAL   STRUCTURES. 

and  one  of  them  must  t)e  long  enough  to  reach  from  the  last  molar  to  Ix^vond  the 
fracture.  The  giitta-iKTcha  is  merely  softened,  introduced  into  the  mouth,  and  the 
teeth  of  both  jaws  pressed  down  into  it,  while  the  outer  and  inner  surfaces  are 
smoothed  down  and  moulded  as  much  as  possible  by  the  aid  of  the  fingers.  A 
certain  amount  of  shaping  is  required  afterward  ;  redundant  portions  have  to  be 
cut  away,  and  angles  rounded  off  to  avoid  pressure,  but  an  excellent  splint,  hold- 
ing each  fragment  firmly  on  to  the  upper  jaw,  is  obtained  in  this  way,  and  abun- 
dant room  left  either  at  the  front  or  on  one  of  the  sides  for  feeding  purposes. 

The  quieter  the  part  can  be  kept,  the  cpiicker  union  takes  place  ;  talking  must 
be  prevented  as  far  as  possible,  no  attempt  at  mastication  may  be  allowed  until  the 
fragments  are  fairly  well  united,  that  is  to  say,  after  four  or  five  weeks.  All  food 
must  be  either  fluid  or  semi-fluid,  as  even  movements  of  the  tongue  are  injurious  ; 
and,  to  avoid  the  accumulation  of  decomposing  particles,  the  mouth  must  be 
washed  out  frequently  with  a  weak  carbolic  or  other  antiseptic  solution,  and  the 
teeth  cleansed  at  least  once  a  day  with  some  soft  linen. 

In  a  large  number  of  cases,  however,  owing  either  to  the  obliquity  of  the 
broken  surface  or  the  comminution  of  the  fragments,  a  more  complicated  apparatus 
is  required.  If  the  teeth  are  fairly  good  and  numerous,  Hammond's  wire  splint 
or  an  interdental  plate  of  vulcanite  is  the  most  satisfactory.  In  either  case  it  is 
essential  to  take  a  wax  mould  of  the  alveolar  arch,  and  from  this  form  a  plaster 
cast.  The  easiest  way  is  to  take  each  fragment  separately,  and  combine  the  casts 
together,  so  as  to  get  a  fair  representation  of  the  arch  before  the  accident ;  but 
sometimes  a  mould  must  be  taken  of  the  whole  at  once,  and  the  cast  sawn  in  two 
and  readjusted  afterward.     Whichever  plan  is  adopted,  the  splint  must  be  formed 

upon  the  cast,  and  must  be  made  to  fit  it 
in  every  detail.  Hammond's  consists  of 
a  stout  piece  of  wire  bent  into  the  shape 
of  a  horseshoe.  The  ends  are  soldered 
together,  and  it  is  twisted  and  turned  un- 
til it  fits  perfectly  into  every  irregularity 
of  the  teeth,  both  on  the  outside  and  the 
inside  of  the  arch.  When  this  framework 
is  allowed  to  settle  down  well  upon  the 
necks  of  the  teeth,  and  is  secured  here 
and  there  at  convenient  distances,  with 
finer  wires  passing   from  one  bar  of  the 

Fig.  113. — Wire  Splint  for  Fracture  of  Lower  Jaw.  i-     ^     ^        ^l  ^u  i_    ,.  ^u        ^      ..l 

•'  splint    to  the   other  between    the  teeth, 

movement  is  scarcely  possible  (Fig.  115). 

Vulcanite  splints  are  made  to  fit  upon  the  crowns  so  that  the  teeth  sink  into 
deep  sockets  and  interlacing  wires  are  not  required  ;  they  are  equally  secure,  but 
the  rubber  from  which  they  are  made  requires  special  skill  during  the  process  of 
manufacture,  and  they  are  more  cumbersome.  Moreover,  they  cannot  so  well  be 
trusted  without  a  retaining  band  outside  the  face,  and  particles  of  food  are  more 
likely  to  collect  beneath  them  and  become  offensive  from  decomposition.  The 
same  objection  holds  good  with  regard  to  metal  plates,  which  have  been  employed 
in  a  few  instances  with  considerable  success. 

Wiring. — It  must  be  admitted  that  in  some  obstinate  cases  there  is  a  great 
temptation  to  try  and  secure  the  fragments  by  fastening  the  teeth  together  with 
wire  or  silk,  but  it  rarely  succeeds.  The  process  is  not  nearly  so  simple  as  it 
appears  to  be ;  it  is  very  difficult  to  get  the  wire  sufficiently  tight,  and  even  when 
it  is  it  has  very  little  real  hold  upon  the  fragments.  But  the  most  serious  objec- 
tion is  that  it  tends  to  irritate  the  gums  and  to  loosen  and  even  cut  into  the 
substance  of  the  teeth.  The  plan  advocated  by  Thomas  is  the  least  objectionable. 
A  hole  is  drilled  through  the  alveolar  margin  of  the  jaw  on  one  side  of  the 
fracture  and  the  ends  of  a  loop  of  wire  passed  through  this  in  opposite 
directions,  so  that  it  embraces  a  tooth   belonging  to  the  other  fragment.     The 


FRACTURE  OF  THE  CLAVICLE. 


385 


^r 


Fic.  116  — fracture  of  Lower  Jaw  Wired,  after  Thomas's  Plan. 


ends  are   not  fastened  toj^ether,  but  merely  coiled   up  on  a   twister  so  that  they 
can  he  tightened  as  required  (Fig.  116). 

When,  however,  measures  of 
this  kind  are  necessary  it  seems 
better  at  once  to  drill  and  wire 
the  fragments  themselves.  I  have 
adoptctl  this  plan  on  several  occa- 
sions in  which  the  median  part 
carrying  the  incisor  teeth  was  com- 
l)letely  separated  from  the  rest. 
There  is  no  difficulty  about  the 
operation,  especially  with  the 
American  dentist  drill ;  the  wires 
can  be  passed  through  and  either 
twisted  as  Thomas  suggests  or  tied 
and  clamped  with  shot ;  and  I 
should  not  hesitate  to  adopt  it 
when,  from  obliquity  of  the  frag- 
ments or  other  causes,  it  was 
difficult  to  retain  the  ends  in  position  by  ordinary  measures. 

Combined  Inte7'nal  and  External  Splints. — Many  attempts  have  been  made  to 
fix  the  broken  portions  between  an  interdental  plate  made  of  ivory,  metal,  or 
vulcanite,  and  a  splint  below  the  jaw.  Lonsdale's  clamp  is  made  upon  this  plan, 
with  or  without  side-pieces  to  fit  along  the  cheeks,  the  two  splints  being  connected 
together  by  means  of  a  screw  outside  the  mouth.  In  other  cases  stout  metal  bars 
are  fastened  to  the  interdental  plate  and  then  curved  round  the  lips  at  the  angles 
of  the  mouth  and  fastened  to  the  under  piece.  But  though  these  may  be  of 
.service  in  exceptional  instances,  chiefly  when  the  fracture  is  near  the  symphysis, 
it  rarely  happens  that  the  tissues  beneath  the  jaw  remain  in  a  condition  fit  to 
stand  much  pressure  during  the  critical  period  of  the  treatment.  Nearly  always 
they  are  too  tender  and  too  much  swollen,  and  they  very  soon  become  inflamed. 
Moreover,  all  these  appliances  have  the  serious  disadvantage  of  projecting  outside  the 
mouth, so  that  they  are  very  liable  to  accidental  displacement, especially  during  sleep. 

When  the  fracture  is  situated  far  back  the  difficulty  of  retaining  accurate 
adjustment  is  greater  still,  and  many  of  these  cases  tax  the  ingenuity  of  the  sur- 
geon to  the  utmost.  It  has  even  been  necessary  to  drill  and  wire  together 
opposite  teeth  in  the  upper  and  lower  jaws.  Fortunately,  however,  these  cases 
are  not  often  met  with,  and  it  is  not  uncommon  for  fractures  which  at  first  look 
perfectly  hopeless,  so  far  as  adjustment  is  concerned,  to  improve  gradually  as  the 
callus  grows  firmer,  until  the  position  is,  comparatively  speaking,  good. 

Complete  failure  of  union  is  very  rare,  but  it  has  been  known  to  occur  from 
necrosis  and  from  accidental  displacement  of  teeth.  If  a  false  joint  is  formed 
and  from  its  position  the  jaw  is  disabled,  the  ends  must  be  exposed,  thoroughly 
re-freshed,  and  wired  together.  Complications  during  treatment  are  of  common 
occurrence.  The  health  of  the  patient  sometimes  suffers  considerably,  especially 
when  there  is  much  discharge  into  the  mouth.  Abscesses  form  beneath  the  jaw 
and  have  to  be  opened  and  drained.  Fragments  of  bone  necrose  and  must  be 
removed,  and  the  same  thing  often  happens  to  the  teeth  when  they  have  been 
loosened  at  the  time  of  the  accident.  One  or  two  cases  of  permanent  paralysis 
of  the  inferior  dental  nerve  have  been  recorded. 


FRACTURE  OF  THE  CL.WICLE. 

Cause. — These  are  the  commonest  of  all  fractures,  and  more  than  half  take 
place  in  children  under  six  years  old.  Occasionally  they  are  due  to  direct  violence, 
and  then  any  part  of  the  bone  gives  way,  and  the  fracture  may  be  transverse, 
oblique,  comminuted,  or  even  compound.     Much  more  often  the  force  is  indirect 


386     DISEASES  AND  INJURES   OF  SPECIAL   STRUCTURES. 

(from  a  fall  out  of  bed,  for  example),  and  the  line  of  separation  either  runs 
through  the  middle  of  the  bone,  as  in  children,  or  just  external  to  it,  where  the 
two  curves  meet,  as  in  adults.  In  a  few  instances  the  clavicle  has  been  broken, 
even  in  men  who  to  all  appearar.ce  were  jjerfectly  healthy,  by  the  sudden  arrest 
of  the  momentum  of  the  arm  ;  and  sometimes  it  has  given  way  genuinely  from 
muscular  contraction,  probably  of  the  pectoralis  major  and  deltoid. 

The  scapula  and  the  upper  extremity  are  held  off  from  the  thorax  by  the 
clavicle,  as  by  an  outrigger,  so  that  the  arm  may  have  a  wider  range  of  movement 
and  the  muscles  better  leverage  ;  but,  as  a  result,  the  whole  force  of  any  shock 
that  falls  upon  the  point  of  the  shoulder  or  upon  the  outstretched  arm  is  borne 
by  this  bone  alone  ;  if  it  is  soft,  it  bends  ;  if  firm  and  hard,  as  in  adults,  it  breaks 
at  the  point  of  least  resistance  midway  between  the  two  fixed  points.  Were  it 
not  for  the  peculiarity  of  its  shape  and  its  great  elasticity,  fractures  would  be  even 
more  common  than  they  are. 

Fractures  in  other  parts  of  the  bone  are  rare,  unless  they  are  caused  by  blows 
or  other  direct  violence  ;  but  they  may  take  jjlace  either  at  the  sternal  end,  in 
the  region  of  the  coraco-clavicular  ligaments,  or  outside  them,  and  I  have  seen 
one  case  in  which,  so  far  as  could  be  ascertained  at  the  time,  the  epiphysis  had 
been  detached.  In  infants  many  of  the  cases  are  merely  partial  or  greenstick 
fractures  ;  in  adults  they  are  usually  complete  and  oblicjue  from  above  downward 
and  inward.  Comijlications  are  very  rare,  but  occasionally  the  skin  gives  way, 
generally  from  sloughing  over  a  projecting  fragment  of  bone  ;  and  a  few  cxses  are 
on  record  in  which  the  subclavian  vein  or  artery,  the  brachial  plexus,  the  pleura, 
and  even  the  first  rib  have  been  injured  at  the  same  time. 

Displacement. — In  greenstick  fractures  there  is  merely  an  elevation  about  the 
middle  of  the  bone,  projecting  upward  and  backward.  In  complete  ones  the 
displacement  is  in  the  same  direction,  but  more  extensive.  The  inner  fragment 
held  by  the  rhomboid  ligament  and  the  costo-coracoid  membrane  on  the  one  side, 
and  the  sterno-mastoid  muscle  on  the  other,  is  rarely  much  affected,  but  sometimes 
the  outer  end  is  raised  so  that  it  projects  beneath  the  skin.  This  may  be  due  to 
the  pressure  of  the  outer  fragment  on  its  under  surface  ;  the  rhomboid  ligament 
varies,  however,  very  much  in  strength,  and  I  have  known  it  replaced  by  an 
arthrodial  joint  with  a  small  .separate  synovial  membrane.  The  outer  fragment, 
on  the  other  hand,  is  drawn  inward  by  the  action  of  the  muscles  passing  from  the 
thorax  to  the  arm,  so  that  there  is  a  distinct  amount  of  shortening,  one  fragment 
slipping  beneath  the  other;  it  is  rotated  forward  at  its  outer  end  by  the  serratus 
magnus  and  the  pectorals  until  it  forms  an  angle  with  the  true  axis  of  the  bone, 
and  it  is  depressed  to  some  extent  by  the  weight  of  the  arm. 

Of  these  three,  the  shortening  is  the  most  serious  and  the  most  difficult  to 
rectify.     Depression  is  often  more  apparent  than  real.     Owing  to  the  shape  of  the 

thorax,  the  shoulder  in  the  living  subject,  as 
soon  as  it  has  lost  the  sole  bony  supi)ort,  sinks 
in  toward  the  middle  line  of  the  body,  and 
its  outline  becomes  more  sloping,  so  that  it 
gives  the  appearance  of  depression  ;  but  though 
this  is  often  real  and  very  considerable,  in 
^       /^  _-"^_~^''^*>y  MJ  many  ca.ses  it  is  almost,  if  not  altogether,  absent. 

v^r--^»^^>^_^i^  jn  fractures   through   other   parts  of  the 

"^  '■'fLy'''''^     ywi  bone  the  degree  and  nature  of  the  deformity 

'  are  very  variable.     When   it   is   close   to   the 

sternal  end  the  fracture  is  usually  transverse, 
and  the  disi)lacement  only  concerns  the  outer 
fragment ;  if  it  lies  in  the  region  of  the  coraco- 
clavicular  ligaments  there  may  be  none  at  all. 

Fig.  117. —  Displacement  in  Fracture  of  the  i   -i      ■  r  .i  •    i  i         .    •   i      ^i  •     i        i      _ 

Clavicle.  while  if  the  acromial  end  outside  them  is  broken 

off,  the  small  portion  that  is  detached  may  be 
rotated  to  such  an  extent  as  to  be  almost  at  right  angles  to  the  rest. 


FRACTURE  OF  THE  CLAVICLE.  387 

Symptoms. — The  ordinary  sij^ns  of  fracture  are  usually  all  present,  and 
well  marked.  The  patient  stands  with  his  head  inclined  toward  the  injured  side 
and  supports  the  elbow  with  the  other  hand.  'I'he  outline  of  the  shoulder  is  altered  ; 
it  is  more  sloi)ing,  and  the  point  of  it  is  brought  much  nearer  the  middle  line  of 
the  body.  The  .projection  can  often  be  seen  at  once,  or  it  may  be  necessary  to  run 
the  fingers  along  the  bone.  Crepitus  is  present  in  all  but  greenstick  fractures,  and 
may  be  elicited  by  drawing  the  shoulders  backward  so  that  one  fragment  rubs  against 
the  other  ;  but,  as  a  rule,  it  is  scarcely  worth  while  giving  the  patient  so  much 
pain.  The  same  may  be  said  of  undue  mobility.  Fractures  through  the  coraco- 
clavicular  ligaments  are  an  exception,  as  in  them  the  only  signs  are  localized  ten- 
derness and  a  slight  degree  of  crepitus  ol)tained  by  direct  pressure.  The  loss  of 
power,  not  only  in  greenstick  fractures,  but  even  when  the  bone  is  broken  com- 
pletely in  two,  is  by  no  means  absolute.  It  is  not  uncommon  to  find  that  the 
patient  is  able  to  place  his  hand  upon  the  back  of  his  head,  if  he  is  sufficiently 
resolute  to  stand  the  pain. 

Treatment. — ///  Greenstick  Fractures. — There  is  little  or  no  trouble  in  the 
case  of  the  greenstick  fractures  that  are  so  common  in  children.  The  deformity  must 
be  rectified  as  far  as  possible.  It  rarely  happens  that  the  shape  of  the  bone  can  be 
exactly  restored  ;  direct  pressure  is  the  only  means  that  can  be  applied,  and  if  the 
jagged  edges  of  the  broken  part  are  so  far  displaced  that  they  fit  against  instead  of 
between  each  other,  this  is  of  little  service.  Generally,  however,  the  angle  is 
merely  an  exaggeration  of  the  normal  curve,  and  it  gradually  becomes  smoothed 
down  as  the  child  grows  older.  All  that  is  needed  is  to  confine  the  arm  to  the  side 
with   a  bandage   under   the  clothes, 

taking  care  to    have  the  skin    tho-  ?i,,, 

roughly  dried  and   dusted    to  avoid  ,^'!:'   v 

excoriations.      In  every  case  of  frac-  /      ^a'^   '"■ 

tured  clavicle  it  is  as  well  to  have  the  ^^^f^^.    "■/—  , 

edges  of  the  bandages  sewn  together  ^■^'''"^'"^  h  \  \'-  \ 

in  two  or  three  vertical  lines,  to  avoid  /'  //  \  H  V 

displacement;  strapping   should    be  /        \.   /    |    \% 

si)aringly  used  in  the  case  of  children.  /  V./      |j     t  ' 

Union    occurs    very    soon,    and    all  I  ..f       '       \ 

bandages  may,  as  a  rule,  be  left  off         |  'i./.  js 

at  the  end  often  days  or  a  fortnight,  |s        i'^^A^.      ' 

though  it  is  as  well  to  keep  the  arm  1^  /  !^-^"'  '  ' 

inside    the    clothes   for   a    few  days  'Mi/ 

longer.  yy,  --r) 

In    fractures   without   displace-     \      |.  -  V      ,    ,  .' 

jnent  nothing  more  is  required  than      \     ^''<:'' 
to  support  the  weight  of  the  elbow       \  ._        ;;  ^,-1 

and  forearm,  and  protect  the  shoulder         \  ^        ■*;-•.         -^ 

from  any  accidental  movement.   The  \ 

simplest  apparatus  during  the  day-  \ 

time  is  the  triangular  bandage  used  \ 

as  a  sling.     This  is  made  from  half  \ 

a  square    yard   (cut    diagonally)    of  \ 

unbleached  calico,  or  any  other  ma-  \  / 

terial  that   is  sufficiently  strong  and  \  / 

unyielding,  and    is   applied   so  that  \  / 

the  two  acute  angles  are  tied  together  \       / 

round  the  back  of  the  neck,  while  \  / 

the  forearm   rests  in  the  sling  thus  '' 

made.        The  long  side  of  the  triangle     ^'^-  "^.-Xhe  TriangulY  Bandage  Arranged  as  a  Sling.  The 
o  <='  dotted  line  represents  the  position  before  the  end  is  brought 

corresponds  to    the    hand;     the  right         over  the  shoulder  of  the  injured  side. 

angle  to    the  elbow,  and  the  layer 

that  comes  up  in  front  of  the  forearm  passes  over  the  neck  on  the  injured  side. 


388     DISEASES  AND   INJURIES   OE  SPECIAL   STRUCTURES. 


'riiis  leaves  tlie  right  angle  projecting  between  the  arm  and  the  body,  and  the  flap 
so  formed  is  brought  round  the  elbow  and  jjinned  on  to  the  front  layer,  so  as  to 
inclutle  the  joint  in  a  kind  of  cap  (Fig.  ii8).  At  night  the  elbow  is  secured  to 
the  side  with  a  bandage,  ami  the  patient  is  directed  to  lie  on  his  back,  with  only 
a  small  j)illow  beneath  the  head. 

///  Eraitiircs  with  Displacement. — In  adults,  if  there  is  the  ordinary  displace- 
ment, shortening  is  the  rule,  not  the  excei)tion,  no  matter  what  appliance  is  used. 
Fortunately  it  does  not  interfere  with  the  utility  or  strength  of  the  arm  ;  but  often 
it  is  very  unsightly.  The  method  that  gives  the  best  result  is  to  keej)  the  patient 
permanently  on  his  back,  in  bed,  on  a  well-made  hair  mattress,  with  only  a  small 
jmIIow  beneath  the  head  ;  and  where,  as  in  ladies,  it  is  essential  to  avoid  deformity, 
this  is  the  only  plan.  Even  when  the  position  is  too  irksome  to  be  kejjt  u])  with- 
out intermission  for  three  weeks,  the  requisite  length  of  time,  it  is  of  great  .service 
if  it  can  be  managed  for  the  first  i^w  days.  All  that  is  necessary  is  a  bandage  to 
confine  the  forearm  to  the  front  wall  of  the  thorax,  and  a  cushion  to  support  the 
elbow.  The  angle  and  vertebral  border  of  the  scapula  are  fixed  by  the  pressure 
of  the  body,  the  point  of  the  shoulder  is  held  back,  and  the  weight  of  the  part, 
instead  of  causing  downward  displacement,  assists.  All  the  muscles  are  relaxed  ; 
the  amount  of  shortening  is  reduced  to  a  minimum,  especially  if  the  forearm  is 
l)rought  across  the  chest ;  and  if  the  position  can  only  be  kejJt  up,  union  is  almost 
perfect. 

The  number  of  appliances  that  have  been  suggested  and  tried  in  fractures  of 
the  clavicle  is  sufficient  proof  that  no  one  of  them  is  satisfactory  ;  and  complicated 
ones,  even  when  they  can  be  obtained  in  time,  and  have  not  to  be  made  to  fit  the 
[)atient,  are  no  whit  better  than,  if  they  are  as  good  as,  the  simplest.  It  is  impos- 
sible to  depress  the  inner  fragment  if  it  is  tilted  upward  ;  the  head  may  be  kept 
bent  to  relax  the  sterno-mastoid,  but  that  is  all.  Direct  pressure  only  causes  slough- 
ing ;  and  though,  according  to  Sayre's  plan,  the  clavicular  part  of  the  pectoralis 
major  may,  when  the  humerus  is  drawn  l)ehind  the  trunk,  possibly  tend  in  some 

slight  degree  to  pull  it  downward,  it 
Ijecomes  relaxed  again  as  soon  as  the  arm 
is  flexed  in  its  permanent  position. 

More  may  be  done  with  the  outer 
fragment.  The  downward  displacement 
gives  no  trouble  ;  all  are  agreed  that  the 
elbow  must  be  raised  either  by  means  of 
a  sling  or  by  a  bandage  carried  over  the 
opposite  shoulder  ;  this,  however,  is  the 
least  serious  of  the  three.  Rotation  for- 
ward is  more  difficult,  but  it  may  l)e  met 
in  various  ways.  One  plan  is  to  pull  the 
whole  arm,  including  the  elbow,  back 
h  behind  the  median  lateral  line  of  the 
\  trunk  ;  if  this  is  done  an  axillary  pad 
must  be  used  to  prevent  its  being  pulled 
inward  as  well,  and  so  making  the  short- 
ening worse  (Fig.  119).  Another  is  to 
bring  the  elbow  so  far  forward  that  the 
hand  rests  on  the  wall  of  the  chest,  above 
"  the  opposite  breast  ;  and  then,  by  means 
of  a  bandage  carried  under  the  point  of 
the  elbow,  attemi)t  to  force  the  shoulder  back.  This  method  is  also  of  .service  in 
correcting  the  amount  of  .shortening,  as  it  tends  to  some  extent  to  drive  the  shoulder 
out  a.s  well.  A  third  relies  on  fixing  the  scajjula  against  the  trunk  by  firmly  strap- 
ping it  down.  The  shoulder  must  be  held  in  position,  a  pad  accurately  adjusted 
over  the  angle  and  vertebral  border,  and  then  fixed  by  strapping  carried  obliquely 
upward  from  the  sternum  toward  the  backbone.     Of  these  three  the  first  is  the 


Fig.  119. — BamLige  for  Fracture  of  Clavicle,  with  Pad 
Axilla. 


FRACTURE  OF  THE  CLAVICLE. 


389 


one  that  in  actual  j)ractice  succeeds  l)e.st ;  the  second,  though  it  is  of  assistance 
in  correcting  shortening,  relies  too  much  on  force,  and  is  very  uncomfortable; 
the  third  answers  exceedingly  well  in  the  recumbent  position,  but  if  a  patient 
is  allowed  to  get  about  it  is  not  possible  to  fix  the  scapula  efficiently. 

Shortening  is  the  most  difficult  of  all ;  indeed,  if  the  fracture  is  oblique,  and 
the  patient  is  not  confined  to  bed,  it  is  almost  impossible  to  counteract  the  muscles 
passing  from  the  thorax  to  the  arm,  without  using  an  amount  of  force  that  would 
be  unreasonable  and  injurious.  It  is  true  that  by  jjlacing  a  pad  of  sufficient  size 
in  the  axilla  and  then  l)an(!aging  the  elbow  firmly  to  the  side,  a  great  amount  of 
leverage  can  be  obtained,  in  spite  of  the  shape  and  of  the  yielding  of  the  wall  of 
the  thorax,  but  it  is  at  the  risk  of  injury  to  the  important  structures  running 
down  the  inner  side  of  the  humerus  ;  and  there  is  a  strong  suspicion  that  many  of 
the  instances  in  which  the  brachial  plexus  has  suffered  have  really  been  due  rather 
to  the  pad  than  to  the  fracture.  As  a  splint  a  pad  is  invaluable,  but  it  is  of  very 
limited  utility  as  a  lever.  Further,  the  elbow,  as  already  mentioned,  may  be  forced 
up  for  a  short  time,  so  as  to  press  the  shoulder  out,  but  it  is  generally  found,  after 
the  strapping  has  been  on  a  {^w  hours,  either  that  the  pressure  is  intolerable  or 
that  something  has  yielded  a  little.     The  same  may  be  said  of  Sayre's  api^aratus. 


Fig.  :2o. 


Fig.  121. 
Sayre's  Method  for  Fracture  of  the  Clavicle. 


in  which  a  band  of  strapping  round  the  arm  is  used  as  a  fulcrum  and  the  elbow  as 
the  long  arm  of  a  lever  to  force  the  shoulder  back  and  out.  In  short,  there  is  no 
thoroughly  satisfactory  method  that  can  be  applied  to  all  cases  alike  ;  the  best  is  to 
place  the  patient  in  the  recumbent  position,  so  that  the  muscles  are  relaxed  ;  the 
next,  to  make  use  of  a  moderate-sized  axillary  pad  as  a  splint,  and  bring  the  whole 
arm  a  little  behind  the  median  line  ;  if  this  fails,  bringing  the  elbow  forward  and 
raising  it  forcibly  may  be  tried  ;  but  probably  the  deformity  will  persist  to  a  great 
extent. 

The  axillary  pad  should  be  wedge-shaped,  about  three  inches  thick  at  the  base 
in  the  case  of  an  adult,  and  should  be  held,  base  upward,  in  the  axilla  by  means 
of  tapes  tied  over  the  opposite  side  of  the  neck.  Then,  the  fracture  having  been 
adjusted  as  well  as  possible,  and  the  arm  and  elbow  held  in  the  position  it  is  wished 
to  attain,  the  bandage  should  be  fastened  round  the  arm,  close  up  to  the  axilla, 
and  carried  behind  the  back,  round  the  thorax,  including  the  forearm  and  arm, 
until  the  whole  is  encased  in  horizontal  turns,  drawing  the  elbow  well,  but  not  too 
forcibly,  into  the  side.  Finally,  a  few  turns  are  taken  obliquely  under  the  forearm 
and  the  point  of  the  elbow,  over  the  opposite  shoulder,  to  prevent  dropping  of  the 
outer  fragment ;  and  the  whole  is  secured  either  with  starch  or  by  stitching  the 
layers  together.     Union  is  usually  complete  in  children  in  about  three  weeks,  in 


390     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 


adults  in  four  or  five  ;  but  the  arm  should  be  carried  in  a  sling  for  a  week  or  so 
longer.  If  there  is  any  rigidity  about  the  shoulder-joint  afterward,  the  limb  may 
be  worked  while  the  patient  is  under  an  aricesthctic  . 

I^Ilis's  s])lint  consists  of  a  well-padded  short  crutch,  which  is  pressed  up  into 
the  axilla  by  a  straj)  carried  over  the  o])]JOsite  shoulder,  and  of  a  band,  embracing 
the  arm,  passing  through  two  slits  in  the  crutch,  and  then  surrounding  the  thorax. 
The  head  and  elbow  are  sui)ported  by  a  sling  in  the  ordinary  way. 

Sayre  makes  use  of  strapping  sjjread  on  moleskin  without  any  axillary  pad. 
Two  pieces  are  required,  each  three  and  a  half  inches  wide.  The  first  is  sewn 
loosely  in  a  loop  round  the  humerus  (the  non-adhesive  side  next  the  skin)  just 
below  the  axilla,  and  then  carried  behind  the  back  round  the  chest  until  the  circle 
is  completed  ;  this  draws  the  shoulder  back  and  acts  as  a  fulcrum.  Then,  while  an 
assistant  brings  the  ell)Ow  forward  and  j^ushes  it  up,  a  second  strip  is  carried  from 
the  opposite  shoulder,  obli(|uely  across  the  first,  under  the  point  of  the  elbow  (which 
fits  into  a  slit  cut  to  receive  it),  and  under  the  forearm  as  it  lies  upon  the  chest,  up 
to  the  point  from  which  it  started.  The  theory  is  that  when  the  elbow  is  forced 
ujjward  and  forward  in  this  manner,  the  shoulder,  owing  to  the  way  it  is  held,  is 

driven  outward  and  backward,  in  this  way 
correcting  the  tendency  to  displacement 
inward  and  forward  ;  but,  though  this  plan 
succeeds  fairly  w-ell  in  ordinary  ca.ses,  it  is 
doubtful  how  far  it  is  due  to  the  leverage 
(Figs.  1 20,  121,  122). 

The  figure-of-eight  bandage  is  practi- 
cally abandoned;  it  is  exceedingly  un- 
\  comfortal)le,  very  insecure,  and  tends  to 
I  depre.ss  still  fiirther  the  outer  fragment. 
Pick's  four-tailed  bandage  is  very  useful  in 
i  the  case  of  children.  It  is  made  of  a 
;  stout  piece  of  calico,  long  enough  to  go 
';  more  than  round  the  body,  and  (for  an 
\  adult)  fourteen  inches  wide.  This  is  slit 
up  from  either  end  to  within  six  inches  of 
the  middle,  but  one  tail  on  each  side  is 
four  inches  wide  and  the  other  ten.  An 
axillary  pad  is  adjusted  ;  the  patient  is 
placed  in  the  recumbent  position,  with  his 
arm  by  his  side,  and  the  forearm  flexed 
across  the  chest  ;  and  then  the  bandage  is 
arranged  so  that  the  point  of  the  elbow  is  opposite  the  untorn  strip  in  the  middle 
(a  vertical  slit  may  be  made  in  it  here  for  the  purpose  of  supporting  the  joint), 
and  the  broad  ends  surround  the  arm  and  the  chest.  These  secure  the  arm  to  the 
side,  and  then  the  narrow  ones  are  brought  up  from  under  the  elbow,  and  tied 
over  the  opposite  .shoulder.  This  bandage  has  the  very  great  merit  of  being  much 
less  easily  disarranged  than  most  of  the  others  (Fig.  123). 

Compound  fractures  of  the  clavicle  are  nearly  always  the  result  of  direct 
violence,  and  may  be  either  comminuted  or  complicated  by  the  presence  of  injuries 
to  other  structures  near.  In  one  or  two  ca.ses  the  fragments  have  been  wired  together. 
Ununited  fracture  is  very  unusual,  even  when  the  deformity  is  very  great  and 
the  part  is  not  kept  properly  at  rest.  The  loss  of  power  to  the  arm  is  by  no 
means  so  marked  as  might  be  expected. 


Fig.  123.- 


-Pick's  Quadrangular  Bandage  Arranged  as 
Sling  for  Arm. 


FRACTURE  OF  THE  SCAPULA. 

Fracture  of  the  scapula  may  involve  the  body,  the  acromion,  the  surgical 
neck,  or  the  coracoid  process.  Fracture  of  the  anatomical  neck  (leaving  the  cora- 
coid  on  the  body  of  the  bone  and  detaching  the    glenoid  fossa  only)  is  doubtful. 


FRACTURE  OF  THE   SCAPULA. 


391 


Fig.  124. — Fractures  of  the  Anatomical  and 
Surgical  Necks  of  the  Scapula. 


Sometimes,  in    dislocalions  of  the  humerus,  portions  of  the  margin  are   chipped 
off  (Fig.  124). 

Fracfiircs  of  the /)ot/y  ?,cvircc\y  c.\ex  occnx  except  from  direct  violence  ;  they 
may  be  single,  stellate,  or  comminuted,  and  may  traverse  the  spine  or  not.  The 
signs  are  usually  distinct,  though,  owing  to  the  dense  fascia,  and  to  the  muscles 
attached  to  both  surfaces  of  the  bone,  dis|)lacement  is  rarely  considerable,  and  it  is 
difficult  to  obtain  distinct  crepitus.  Pain,  swell- 
ing, and  loss  of  power  are  always  ])resent. 

A  firm  pad  must  be  moulded  on  to  the 
scapula  to  retain  it  in  position  by  direct  pressure, 
and  the  arm  fastened  to  the  side  with  a  small 
pad  in  the  axilla  ;  but  unless  there  is  great  com- 
minution or  bruising,  in  a  few  days  it  is  sufficient 
to  have  the  thorax  bandaged  and  to  carry  the 
hand  or  forearm  in  a  sling.  Some  deformity 
commonly  persists,  but  there  is  rarely  any  perma- 
nent loss  of  power. 

Fracture  of  the  acromion  from  direct  violence 
is  not  uncommon,  though  many  of  the  cases  in 
which  it  has  been  found  detached  post-mortem  are 
really  examples  of  rheumatoid  arthritis  with  sepa- 
ration at  the  epi[)hysial  line,  or  of  delayed  union. 
It  may  give  way  at  the  tip  or  close  to  the  spine. 
The  signs  are  quite  definite  :  the  arm  hangs  help- 
less by  the  side,  the  shoulder  is  flattened,  the  line 
of  the  acromion  interrupted,  the  outer  fragment  depressed  and  freely  movable, 
and  the  patient  is  either  unable  to  abduct  the  arm,  or  can  only  do  so  to  a  slight 
extent  and  with  great  pain.  Crepitus  can  be  obtained  by  direct  manipulation, 
either  on  pushing  the  elbow  upward  or  abducting  and  rotating  the  arm.  If  only 
the  tip  is  broken  all  that  is  necessary  is  a  triangular  bandage  to  raise  the  elbow ; 
but  for  the  first  few  days  it  is  advisable  to  strap  the  scapula  closely  to  the  thorax 
and  to  bandage  the  arm  lightly  to  the  side,  so  as  to  prevent  accidental  movement. 
Union,  if  the  fracture  is  near  the  spine,  may  take  place  by  bone  ;  in  front  of  this 
it  is  nearly  always  fibrous,  but  this  does  not  interfere  with  the  strength  or  the 
range  of  movement  of  the  joint. 

The  coracoid  process  may  be  broken  off  by  direct  violence  or  by  muscular 
action,  but  it  is  very  rare.  In  the  former  case  the  injury,  which  may  be  caused 
either  by  a  bloAv  or  by  crushing,  as  when  a  cart-wheel  passes  over  the  axilla,  is 
generally  very  extensive  ;  in  the  latter  there  is  scarcely  any  dis])lacement,  owing 
to  the  strength  of  the  ligaments  connecting  the  process  to  the  clavicle. 

Fracture  of  the  neck  of  the  scapuhi  is  almost  equally  rare.  It  can  only  occur 
by  direct  violence.  The  symptoms  at  first  sight  resemble  those  of  dislocation  of 
the  arm,  but  the  intense  pain,  undue  mobility,  and  crepitus  render  the  presence 
of  a  fracture  certain.  Moreover,  the  displacement  returns  as  soon  as  reduction 
has  been  accomplished,  unless  means  are  taken  to  prevent  it.  Fracture  of  the 
surgical  neck  of  the  humerus  can  be  excluded  at  once  by  the  fact  that  the  head 
of  the  bone  in  the  axilla  rotates  with  the  shaft ;  but  unless  the  coracoid  process  is 
movable  it  is  almost  impossible  to  make  certain  of  the  exact  line  of  fracture  in 
the  scapula,  especially  as  the  amount  of  swelling  is,  generally  speaking,  very  great, 
and  dislocations  are  sometimes  accom])anied  by  injury  to  the  glenoid  fossa.  The 
treatment  is  almost  the  same  as  in  the  other  fractures  of  the  scapula  ;  the  body  of 
the  bone  must  be  fixed  as  well  as  possible,  the  elbow  raised  to  take  the  weight  of 
the  limb  off,  a  small  pad  placed  in  the  axilla  to  act  as  a  splint,  and  the  arm  band- 
aged to  the  side.  Passive  motion  should  be  commenced  early,  not  later  than  the 
third  week.  Even  then  it  is  probable  that  there  will  be  a  considerable  degree  of 
stiffness  about  the  shoulder. 


392    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


FRACTURES  OF  THE  HUMERUS. 


The  Upper  Extremity. 

Varieties. — These  may  involve  the  surgical  or  the  anatomical  neck  ;  or  the 
epiphysis  may  be  detached  from  the  shaft ;  or  the  intracapsular  portion  may  be 
split  longitudinally  and  the  head  dragged  forward  so  as  to  give  the  appearance  of 
a  dislocation. 

Of  these,  fracture  of  the  surgical  neck  is  by  far  the  most  common,  especially 
in  the  aged,  when  the  medullary  canal  of  the  shaft  is  beginning  to  enlarge. 
Separation  of  the  epijjhysis  can  only  take  place  under  twenty ;  longitudinal 
fractures  detaching  the  great  tuberosity  are  not  often  met  with  unless  there  is  a 
dislocation  at  the  same  time,  while  fractures  of  the  anatomical  neck  are  among 
the  rarest  known. 

( I )  77/1?  Surgical  Neck. 

Causes. — Fractures  of  the  surgical  neck  of  the  humerus  may  be  the  result 
either  of  direct  or  of  indirect  violence,  of  blows  upon  the  shoulder,  or  of  falls 
upon  the  outstretched  arm  ;  muscular  action  by  itself  is  very  rarely  sufficient.  The 
line  of  separation  lies  between  the  base  of  the  tuberosities  and  the  upper  margin 
of  the  insertion  of  the  teres  major.  In  general  the  fracture  is  transverse,  but  it 
may  be  oblique  to  a  greater  or  less  extent,  and  impaction  may  take  place,  the 
upper  end  of  the  lower  fragment  being  wedged  into  the  cancellous  tissue  of  the 
tuberosities  (  Fig.  125). 

Displacement. — The  'displacement  affects  both  fragments,  but  in  very 
different  degrees.  In  many  cases  there  is  scarcely  any,  the  fracture  is  transverse, 
and  the  broken  ends  are  kept  in  the  same  straight  line  by  the  biceps  tendon.  In 
others,  especially  if  the  direction  is  at  all  oblique,  it  is  very  con- 
siderable, and  it  may  be  a  matter  of  great  difficulty  to  retain  the 
fragments  in  position.  The  upper  of  the  two  is  abducted  by  the 
supra-spinatus  and  rotated  outward  by  the  infra-spinatus  and  the 
teres  minor.  The  lower  is  drawn  upward  chiefly  by  the  deltoid, 
and  inward  by  the  muscles  passing  from  the  thorax  to  the  upper 
part  of  the  arm,  so  that  it  may  completely  overlap  the  other  and 
form  a  projection  that  stands  out  under  the  skin  in  the  front  wall 
of  the  axilla. 

Symptoms. — In  some  instances  the  amount  of  shortening  is 

considerable,  as  much  as  three-quarters  of  an  inch,  though  this  is 

unusual.     The  rounded  shape  of  the  shoulder  is  not  lost,  but  there 

is  a  depression  some  little  distance  below  the  acromion  ;  the  axis 

of  the  limb  is  altered  ;  the  elbow  points  backward  and  outward, 

though  it  may  be  brought  into  the  side  with  very  little  i)ressure  ; 

and  there  is  a  certain  amount  of  fullness  about  the  front  fold  of  the 

axilla.      Undue  mobility  and  crepitus  are  easily  made  out  if  the 

fragments  are  not  impacted  ;  the  glenoid  fossa  is  still  filled  by  the 

head  of  the  bone,  and  the  upper  end  of  the  lower  fragment  can  be 

3   fl  felt  projecting  in  front.      Loss  of  power  is  complete,  and  often  the 

*^  pain  is  very  severe,  running  down  the  arm,  owing  to  pressure  upon 

the  brachial  plexus. 

c*Jk'iir  Many  of  these  symptoms  are  wanting  when    the  fracture  is 

impacted,  but  there  is  great  pain,  especially  at  the  seat  of  injury, 

complete  loss  of  power  over  the  limb,  a  slight  amount  of  deformity 

and  distinct  shortening.      Extravasation  is  extensive,  as  a  rule,  and 

the  swelling  very  distinct,  especially  on  the  inner  side  of  the  arm. 

In  some  cases  it  may  be  due  to  rupture  of  the  circumflex  arteries  ;  in  others  it  is 

merely  the  result  of  bruising  and  laceration  of  the  muscles. 

Treatment. — Xo  attempt  should  be  made  to  reduce  an  impacted  fracture 


\ 


Fig.  125.  —  Frac- 
ture of  Neck  of 
Humerus. 


FRACTURES  OF  THE  HUMERUS. 


39: 


unless  the  axis  of  the  limb  is  seriously  distorted.  It  is  often  difficult  to  bring  the 
fragments  into  good  position,  and  always  harder  to  keep  them  there.  All  that  is 
needed  for  such  injuries  is  a  pad  in  the  axilla  to  act  as  a  support,  and  a  bandage 
round  the  arm  to  confine  it  to  the  side.  In  all  fractures  of  the  humerus  the  hand 
should  be  carried  in  a  sling,  but  this  should  never  be  allowed  to  extend  untler  the 
elbow. 

When  there  is  no  impaction  the  uiJjjer  fragment  is  ])ractically  out  of  control. 
It  is  so  short  and  so  deeply  covered  that  very  often  it  is  difficult  to  be  certain 
how  far  it  is  displaced.  Nlore  may  be  done  with  the  lower,  though  sometimes  it 
is  impossible  to  bring  this  into  position  and  adjust  it  properly.  It  may  be 
nece.ssary  to  place  the  patient  under  an  anaesthetic  and  to  abduct  and  raise  the 
arm  from  the  side  before  the  ends  can  be  disengaged.  The  displacement  inward 
is  most  easily  met  by  placing  a  firm  pad  in  the  axilla,  or,  as  Erichsen  suggests,  a 
piece  of  leather  bent  into  the  shape  of  a  U,  one  side  applied  to  the  thorax  and 
the  other  to  the  arm.  If  this  is  placed  well  up  in  the  axilla,  and  if,  at  the  same 
time,  the  elbow  is  carried  slightly  forward  and  fastened  to  the  side  of  the  chest 
by  means  of  a  bandage,  the  upper  end  of  the  lower  fragment  is  carried  outward 
and  backward  and  the  broken  surfaces  can  generally  be  brought  into  good 
apposition.  Then  the  hand  is  arranged  in  a  sling,  as  already  mentioned  in  the 
case  of  impacted  fractures,  and  a  cap  of  gutta-percha,  or,  what  is  better,  as  it  is 
not  so  hot,  of  poroplastic  felt, 
adjusted  over  the  shoulder  and 
down  the  arm,  taking  care  not  to 
bring  it  so  far  on  to  the  neck  that 
it  becomes  displaced  by  the  move- 
ments of  the  head,  or  so  far  on  to  the 
thorax  that  it  loses  its  grasp  on  the 
arm.  This  is  fastened  by  a  bandage 
carried  round  the  opposite  side  of 
the  chest.  It  must  be  admitted, 
however,  that  even  when  every  care 
is  used,  union  in  a  faulty  position 
cannot  always  be  avoided.  Band- 
aging the  hand  and  forearm  is  quite 
unnecessary  (Fig.  126). 

Union  is  generally  complete  in 
from  five  to  six  weeks,  but  the  arm 
remains  stiff  and  powerless  for  some 
time  after.  Passive  motion  should 
be  commenced  at  the  third  week  at 
the  latest ;  in  many  cases  it  answers 
well  to  begin  even  before  this,  very 
quietly  and  gently,  with  the  object 
rather  of  preventing  the  formation  of  adhesions  by  straightening  out  the  folds  of 
the  capsule  than  of  breaking  them  down.  If  this  is  not  done  the  joint  is  sure  to 
become  rigid,  owing  to  the  mobility  of  the  scapula,  and  it  may  be  necessary  at  a 
later  period  to  place  the  patient  under  an  anaesthetic  and  work  the  part  thoroughly. 
Delayed  union  and  even  complete  failure  occasionally  occur. 


Fig. 


126. — Bandage  with  Shoulder-cap  and  SUng  for  Fracture  of 
Surgical  Neck  of  Humerus.      Part  of  sling  cut  away. 


(2)  Separation  of  the  Upper  Epiphysis. 

This  is  not  an  uncommon  accident  under  twenty  years  of  age,  and  presents 
practically  the  same  features  as  fracture  of  the  surgical  neck.  True  crepitus, 
however,  is  wanting,  even  when  the  line  of  separation  runs  between  the  cartilage 
and  the  bone ;  only  an  indistinct  soft  rubbing  can  be  felt,  and  the  upper  end  of 
the  lower  fragment,  when  it  is  made  to  project  beneath  the  coracoid,  is  smooth 
and  rounded  instead  of  being  sharp  and  angular.  In  some  instances  there  is 
26 


394    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

consideral)le  difficulty  in  reduction  ;  the  under  surface  of  the  upper  fragment  is 
cup-shaj)ed  and  prolonged  downward  upon  its  inner  and  anterior  aspect,  and  it  is 
said  that  the  edge  of  the  lower  fragment  may  be  caught  by  this.  To  release  it, 
the  arm  must  be  forcil)ly  abducted  and  extended.  In  other  cases  it  arises  from 
the  upper  end  of  the  lower  fragment  being  driven  through  the  capsule. 

Union,  especially  al)out  the  time  of  puberty,  is  very  likely  to  be  osseous, 
impairing  the  growth  of  the  limb.  This,  however,  is  not  invariable,  probably 
because  in  many  of  these  cases  the  injury  is  really  a  fracture,  running  through  the 
recently  formed  bone  without  involving  the  cartilage.  Comijlete  failure  has  been 
known,  and  even  suppuration,  although  the  skin  was  unbroken.  In  two  instances 
in  which  union  had  taken  place  in  so  distorted  a  position  that  the  arm  was  almost 
useless,  Bruns  separated  the  fragments  again,  resected  part  of  the  diaphysis,  and 
wired  them  together  with  a  good  result.  In  one  or  two  cases,  in  which  the  bones 
could  not  be  brought  into  proper  apposition,  the  joint  has  been  laid  open  from 

the  front,  the  interposing  tissues  divided,  and  the  two 
fragments  fixed  together  by  means  of  a  long  drill  driven 
through  the  skin.     This  was   removed  on  the  eighth 
^>        day,  as  soon  as  sufficient  lymph  had  been  poured  out 
i';' ;^.:^v^-,;-;^A(ryi:  to  uiake  the  ends  secure. 

I  '  :■'':' V^^:^'- ■■'■:'"-  •'  It  is  possible  for  the  joint  to  escape  without  being 

V    ^  ■:,'-•■_,,  •        opened;     the   capsule    is   so    firmly    attached    to    the 

J       ''':•,.;:';:      -      ■.:;      epiphysis  that   it  may  rematin   in   connection   with   it, 
..., ,  :  •.     \:-- j       stripping   off  the   periosteum   from   the  shaft.      More 

•    .1  ?:■•;;;■•?{,.../  '  ■■'  often  it  gives  way  upon  the  inner  side. 


1' 


■i:s 


(3)  Eracture  through  the  Tuberosities. 

Longitudinal  fractures  through  the  upper  end  of 
the  humerus  are  not  common.     Sometimes,  however. 


4^ J,^'-  ' '-i/£_li  the  great  tuberosity  is  torn  off  by  the  contraction  of 

^  the  muscles  when  the  head  of  the  bone  is  dislocated  ; 

^'f;-  i27--yert'cai  Section  through  ^nd  occasionally  the  imrt  is  split  by  direct  violence. 

Upper  Epiphysis  of  Humerus,  show-  ■'  '■  1  •  1  1 

ing  the  sh.ipe  of  the  End  of  the  \\  hcn   this  occurs,  the  great  tul)erosity  alone  may  be 

Diaphysis.  dctachcd  ;  or  the  line  of  separation  may  run  through 

the  head,  or  even  along  the  bicipital  groove,  so  that 

most  of  the  articular  surface  is  broken  off,  and  the  small  tuberosity  is  left  almost 

by  itself  on  the  end  of  the  shaft. 

Symptoms. — The  character  of  the  displacement  is  the  same  in  all,  though 
it  varies  in  degree.  If  the  tough  tendinous  periosteum  at  the  insertion  of  the 
muscles  is  not  torn,  there  is  exceedingly  little;  in  general  it  is  very  considerable. 
The  breadth  of  the  shoulder  is  the  most  prominent  feature ;  this  is  immensely 
increased  owing  to  the  way  in  which  one  fragment  is  pulled  forward  and  the  other 
backward  ;  and  the  axis  of  the  limb  is  altered  so  that  the  elbow  points  backward 
and  outward.  Very  little  pressure,  however,  is  required  to  bring  it  again  into  its 
normal  position.  As  a  rule  there  is  no  shortening,  but  there  may  be  a  great 
amount  of  bruising  and  extravasation,  especially  in  cases  in  which  the  injury  is 
caused  by  direct  violence.  Loss  of  power  is  complete.  Crepitus  is  sometimes 
difficult  to  obtain  on  account  of  separation  of  the  fragments  ;  but  the  most  char- 
acterise! sign  is  the  presence  of  a  bony  projection  under  the  coracoid  in  front, 
resting  on  the  anterior  surface  of  the  glenoid  fossa,  and  under  the  acromion 
behind,  with  a  deep  furrow  in  between.  The  anterior  follows  the  movements  of 
the  shaft,  and  corresponds  more  or  less  to  the  head  of  the  bone  ;  the  posterior  is 
the  greater  tuberosity  drawn  upward  and  backward  by  the  muscles  attached  to  it. 
The  diagnosis  of  this  jjeculiar  accident  recjuires  especial  care,  as  subcoracoid 
dislocation  of  the  head  of  the  humerus  may  be  associated  with  it,  and  if  it  is  not 
made  out,  serious  deformity  is  certain  to  result. 

Treatment. — If  the  displacement  is  only  slight,  all  that  is  necessary  is  to 


FRACTURES  OF  THE  HUMERUS.  395 

place  a  pad  in  the  axilla  as  a  splint,  and  to  support  the  elbow,  either  by  means  of 
a  triangular  sling  or  a  four-tailed  bandage  ;  but  this  is  (juite  exceptional.  In 
general  it  is  very  considerable,  and  bony  union  may  fail,  as  it  is  not  at  all  easy 
either  to  bring  the  fragments  together  or  to  maintain  them  in  that  position.  The 
simplest  plan  is  to  place  a  pad  in  the  axilla,  and  try,  with  the  aid  of  a  bandage 
round  the  upjier  i)art  of  the  humerus,  to  bring  the  upi)er  end  of  the  lower  fragment 
backward  and  outward,  while  an  attemjjt  is  made  to  press  the  other  forward  by 
strai^jMng  a  pad  firmly  on  it.  If  this  fails  the  only  alternative  is  to  place  the 
jiatient  in  bed,  with  a  small  pillow  under  the  head,  and  to  keep  the  arm  extended 
and  rotated  out  so  that  the  hand  lies  on  its  dorsum.  Even  if  union  is  bony  it  is 
a  long  time  before  full  use  of  the  joint  is  regained  ;  the  fracture  often  involves 
part  of  the  articular  surface,  and  lips  of  callus  are  thrown  out  around  it ;  or  the 
capsule  becomes  thickened  and  rigid,  so  that  the  range  of  movement  is  limited  ; 
or  rheumatoid  arthritis  sets  in  afterward  and  leaves  the  joint  permanently 
cripi>led. 

(4)  Fracture  of  the  Anatomical  IVeck. 

Fracture  of  the  anatomical  neck  is  exceedingly  rare  and  can  only  be  produced 
by  direct  violence  ;  most  of  the  cases  have  occurred  in  old  people,  or  at  any  rate 
after  middle  life,  probably  owing  to  the  changes  that  take  place  in  the  substance 
of  the  bone.  The  line  of  separation  is  supposed  to  follow  the  anatomical  neck  of 
the  humerus,  but  it  nearly  always  lies  partly  inside,  partly  outside  the  capsule.  It 
is  very  doubtful  if  such  a  thing  as  intracapsular  fracture,  in  the  strict  sen.se  of  the 
term,  has  been  proved.  The  head  of  the  bone  does  not  undergo  necrosis,  though 
union  maybe  only  fibrous  or  may  fail  completely;  impaction  is  common,  the 
upper  fragment  being  driven  into  the  substance  of  the  tuberosities  ;  where  this 
does  not  take  place  an  amount  of  nutrition  sufficient  to  maintain  life,  though  it  is 
seldom  enough  to  repair  the  injury,  is  kept  up  by  the  reflected  portion  of  the 
capsule  on  the  under  surface  of  the  neck. 

Displacement. — In  a  i^w  extraordinary  instances  the  position  of  the  upper 
fragment  has  been  found  completely  reversed,  the  cartilaginous  surface,  that  is  to 
say,  facing  the  tuberosities.  It  is  very  difficult  to  see  how  this  is  produced,  but  it 
is  almost  certain  that  it  must  be  the  result  of  forces  acting  subsequently  to  the 
fracture,  perhaps  long  after.  In  other  ca.ses  it  is  very  slightly  displaced,  unless 
there  is  impaction,  when  it  may  be  driven  so  far  into  the  substance  of  the  tuber- 
osities as  to  split  them  in  two.  The  lower  fragment  is  held  by  the  attachment  of 
the  capsule  and  the  insertion  of  the  muscles  immediately  below,  so  that  it  is  only 
drawn  upward  and  inward  to  a  very  slight  extent. 

Symptoms. — The  most  prominent  symptoms  are  those  due  to  the  contusion. 
The  loss  of  power  is  complete  ;  the  shoulder  is  swollen,  tense,  and  painful ;  signs 
of  bruising  show  themselves  very  soon,  especially  along  the  margins  of  the  deltoid, 
and  the  whole  of  the  upper  and  inner  part  of  the  arm  may  be  blackened.  If 
anything,  there  is  a  slight  amount  of  shortening,  and  probably  this  is  greater  in 
impacted  fracture  ;  deformity  is  very  little  marked  and  is  easily  rectified  ;  there  is 
no  undue  mobility  ;  but  when  the  arm  is  raised  from  the  side,  and  the  head  of  the 
bone  is  felt  in  the  axilla,  a  certain  amount  of  irregularity  can  usually  be  detected. 
Crepitus  is  easily  produced,  unless  there  is  impaction,  by  pressing  the  elbow  upward 
so  as  to  bring  the  broken  surfaces  in  contact. 

Kind  of  Union. — If  the  fragments  are  impacted,  union,  generally  speaking, 
takes  place  by  bone.  In  other  cases  it  may  fail  completely,  the  two  surfaces  be- 
coming hard  and  smooth  from  constant  friction  ;  or  there  may  be  a  certain  amount 
of  fibrous  tissue  formed  between  them  ;  or  the  head  may  be  enclosed  l)y  a  growth 
of  bone,  like  a  coronet,  around  it,  so  that  it  becomes  quite  fixed.  In  true  intra- 
caj«ular  fractures  union  can  hardly  take  place  without  impaction. 

Treatment. — No  attempt  should  be  made  to  reduce  impaction  ;  it  is  true 
that  the  shortening  and  the  deformity  are,  generally  speaking,  greater,  l)ut  they 
are  never  serious,  and  impaction  affords  the  surest  promise  of  bony  union.      In 


396    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

other  cases  all  that  can  be  done  is  to  protect  the  shoulder,  and  carry  the  forearm 
in  a  sling,  with  the  elbow  bandaged  to  the  side,  but  no  axillary  pad.  Care  must 
be  taken  not  to  tear  the  capsule  of  the  joint  any  further,  as  union  depends  upon 
this  to  some  extent.  It  is  possible  that  the  head  of  the  bone  may  remain  loose  in 
the  cavity  of  the  joint,  and  give  rise  to  such  an  amount  of  inconvenience  that  its 
removal  may  be  recjuired  ;  but  such  an  occurrence  is  very  doubtful. 

Fracture  and  Dislocation  Combined. 

Fracture  of  the  surgical  neck  of  the  humerus  with  subcoracoid  dislocation 
occurring  at  the  same  time  is  not  so  rare  an  accident  as  might  be  imagined. 
Nearly  seventy  cases  of  it  have  been  recorded.  In  all  probability  the  dislocation 
occurs  first,  and  the  neck  of  the  bone  gives  way  from  a  continuance  of  the  same 
force.  The  injury  itself  is  not  an  easy  one  to  make  out,  as  all  the  ordinary  signs 
of  dislocation  that  depend  upon  the  alteration  in  the  axis  of  the  limb  are  not  only 
wanting,  but  ])oint  directly  to  fracture.  The  most  characteristic  feature  is  the 
absence  of  the  head  from  the  glenoid  fossa. 

The  patient  must  be  placed  under  an  anaesthetic,  and  every  effort  made  to 
reduce  the  dislocation  by  squeezing  the  bone  in  the  direction  of  the  glenoid  fossa 
when  all  the  muscles  are  relaxed.  If  this  fails  it  is  generally  recommended  to  put 
the  fracture  up,  and  when  it  is  fairly  well  united  to  make  another  attempt ;  but  at 
any  rate,  in  the  case  of  a  young  and  healthy  patient,  to  whom  it  is  of  some  conse- 
quence to  retain  full  use  of  the  limb,  it  is  questional)le  whether  it  would  not  be 
advisable  to  open  up  the  joint  and  replace  the  head  of  the  bone  at  once. 

Co7npound  Fractures. 

Compound  fractures  of  the  upper  extremity  of  the  humerus  are  not  common, 
except  as  a  result  of  gunshot  injuries  or  of  machinery  accidents.  The  latter  gen- 
erally require  amputation  as  soon  as  the  shock  has  passed  off,  but  the  question 
must  be  decided  in  each  case  by  the  condition  of  the  soft  parts.  Where  they  are 
not  seriously  hurt  every  attempt  must  be  made  to  save  the  limb,  even  if  the  bone 
is  extensively  splintered.  The  ends  may  be  removed,  the  head  of  the  bone  excised, 
or  resection  of  a  more  or  less  formal  character  be  performed  with  excellent  results. 
Six  inches  of  the  bone  have  before  now  been  removed. 

Where,  on  the  other  hand,  the  soft  parts  are  extensively  injured,  the  skin 
stripped  up,  and  the  muscles  badly  torn,  it  is  very  doubtful,  even  if  there  is  no 
comminution,  whether  any  attempt  of  the  kind  would  succeed  in  leaving  a  service- 
able arm.  The  artery  may  be  divided  and  tied  at  both  ends  ;  and  the  same  may 
be  done  with  the  vein,  without  amputation  being  necessary,  if  the  collateral  circu- 
lation has  not  been  injured — practically  that  is  to  say,  where  the  fracture  is  not 
due  to  direct  violence.  The  nerves  rarely  give  way  unless  the  arm  is  almost  torn 
off;  if,  however,  one  of  them  has  been  divided,  the  two  ends  should  be  carefully 
sutured  tofrether  with  catfrut. 


Fracture  of  the  Shaft  of  the  Humerus. 

These  are  generally  due  to  direct  violence  ;  sometimes  they  are  caused  by  falls 
upon  the  elbow,  and  in  a  it\\  instances  they  have  been  known  to  occur  from  mus- 
cular contraction  ;  but  though  this  is  more  common  here  than  in  any  other  bone, 
the  total  number  is  not  large. 

Displacement. — The  seat  of  injury  is  more  often  below  the  insertion  of  the 
deltoid  than  above,  and  the  fracture  is  generally  oblique  from  above  downward 
and  outward.  In  children,  however,  and  in  fractures  from  muscular  action,  it 
may  be  nearly  transverse.  The  lateral  displacement  is  almost  entirely  dependent 
on  the  direction  of  the  fracture,  and  the  action  of  the  muscles.  In  injuries  above 
the  deltoid  it  is  worse  than  in  those  below^ ;  in  the  former  the  muscles  that  pass 


FRACTURES  OF  THE   HUMERUS. 


397 


from  the  thorax  to  the  arm  i)ull  the  up])er  iViii^Miient  inward,  while  the  deltoid 
carries  the  lower  one  outward,  and  raises  it  at  the  same  time  ;  in  the  latter,  these 
muscles  antagonize  each  other  to  a  great  extent,  so  that  the  jjarts  may  remain  in 
api)osition.  Shortening  is  rarely  considerable,  and  in  transverse  fractures,  especi- 
ally if  the  i)eriosteum  is  not  torn,  is  absent  altogether. 

Symptoms. — All  ordinary  symptoms  are  well  marked.  The  deformity 
when  the  arm  is  hanging  by  the  side  may  not  be  conspicuous,  but  crepitus,  undue 
mobility,  ecchymosis,  intense  pain,  and  utter  helplessness  are  nearly  always 
present.  In  general  there  is  no  difficulty  in  feeling  the  fragments  through  the  skin. 
The  artery  rarely  suffers,  but  the  musculo-spiral  nerve,  as  might  be  expected  from 
its  peculiar  relation  to  the  bone,  is  often  hurt,  and  still  more  frequently  is  injured 
by  being  conn)res.sed  in  the  callus  that  is  thrown  out. 

Treatment. — Fractures  of  the  upper  part  of  the  shaft  are  treated  in  the 
same  way  as  those  of  the  surgical  neck  ;  only  a  short  inside  splint,  coming  down 
to  the  internal  condyle,  is  better  than  an  axillary  pad  ;  and  the  shoulder  cap 
should  be  continued  down  the  limb  to  the  elbow,  and  be  made  to  fit  accurately 
round  at  least  two-thirds  of  the  arm.  When  they  occur  lower  down,  various 
appliances  may  be  used.  Four  short,  well-padded,  wooden  splints  may  be  adjusted 
round  the  limb,  the  inner  one  reaching  from  the  axilla  to  the  inner  condyle,  the 
outer  from  the  acromion  to  the  external,  and  the  anterior  resting  on  the  bend 
of  the  elbow.  When  these  are  secured  by  webbing-straps  and  buckles,  or  even 
with  sticking-plaster,  movement  is  hardly  possible.  Instead  of  the  three  outer 
ones,  Gooch's  splint  may  be  employed.  This  consists  of  narrow  strips  of  wood 
fastened  parallel  to  each  other,  on  one  surface  of  a  piece  of  wash-leather  or  mole- 
skin, after  the  fashion  of  some  kinds  of  dinner  mats,  so  that  it  can  easily  be  rolled 
round  a  limb.  In  several  instances  I  have 
used  the  ornamental  flower-pot  holders  that 
are  made  of  diagonal  interlacing  bars,  and 
can  be  opened  or  closed  to  any  requisite 
width  (Fig.  128).  A  layer  of  cotton-wool 
or  of  lint  must  be  placed  round  the  arm 
first,  and  care  must  be  taken  to  cut  away  suf- 
ficient material  to  accommodate  the  elbow^ 
and  the  axilla ;  but  when  this  is  done  they 
can  be  fixed  with  the  greatest  ease,  and 
they  are  sufficiently  elastic  to  fit  without 
being  unpleasantly  rigid.  Poroplastic  felt 
may.be  used  in  the  same  way.  Plaster-of- 
Paris  is  rather  heavy.  With  all  of  these 
the  hand  must  be  carried  in  a  sling,  and 
the  elbow  allowed  to  drop,  and  of  course 
the  condition  of  the  circulation  in  the 
hand  and  fingers  must  be  carefully  watched. 

Sometimes  there  is  a  considerable 
amount  of  shortening  in  oblique  fractures. 
This  can  only  be  prevented  by  confining 
the  patient  to  bed  ;  hanging  weights  upon  the  elbow  is  useless  so  long  as  he  is 
allowed  to  move  about.  The  arm  must  be  laid  upon  an  inside  splint,  a  stirrup 
fixed  above  the  elbow^  and  a  weight  carried  from  it  by  means  of  a  cord  running 
over  a  pulley  placed  at  a  convenient  angle  by  the  side  of  the  bed. 

Where  the  upper  fragment  is  much  displaced  or  where,  from  the  age  of  the 
patient  or  other  causes,  it  is  not  considered  advisable  to  carry  a  bandage  round 
the  thorax,  Middledorpf  s  triangle  is  the  best  contrivance.  This  consists  of  a 
light,  well-padded  triangular  framework  ;  one  side  runs  down  from  the  axilla  to 
the  hip,  a  second  from  the  axilla  to  the  elbow,  and  a  third  joins  the  lower  ends  of 
the  other  two.  The  object  is  to  secure  the  elbow  and  shoulder,  and  at  the  same 
time  keep  the  arm  fixed  in  abduction. 


Fig.  128. — Splint  and  Sling  for  Fracture  of  the  Sh;ift 
of  the  Humerus.     Part  of  sling  cut  away. 


398     DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 

Union  generally  takes  place  in  five  or  six  weeks,  but  total  failure  and  false 
joint  are  more  common  in  the  shaft  of  this  hone  than  in  any  other.  It  has  nothing 
to  do  with  the  j)Osition  or  direction  of  the  nutrient  artery,  nor  is  it  in  any  way  the 
result  of  separation  of  the  fragments  for  want  of  support  at  the  elbow  joint.  It 
has  been  assigned,  with  more  probability,  to  the  fact  that  neither  the  shoulder  nor 
the  elbow  joint  is  properly  fixed,  so  that  more  movement  tiikes  jjlace  at  the  seat  of 
injury  than  is  advisable ;  but  it  is  very  doubtful  whether  the  means  adopted  to 
obviate  this  do  not  do  more  harm  than  good.  Angular  splints,  for  example,  as 
Hamilton  pointed  out,  soon  make  the  elbow  stiff,  so  that  if  the  forearm  drops  at 
all,  or  if  any  attempt  at  mo\ement  is  made,  the  fracture  yields,  and  not  the  joint. 
Certainly,  in  many  instances  of  ununited  fracture,  the  elbow  joint  is  stiff.  Fur- 
ther, if  an  inside  angular  splint  is  api)lied  to  the  arm,  and  then  the  hand  placed 
in  a  sling,  the  elbow  becomes  abducted  at  once,  and  this  movement  takes  place 
more  easily  at  the  seat  of  fracture  than  it  does  at  the  shoulder.  Probably  the  real 
cause,  in  the  majority  of  instances,  is  the  interposition  of  some  foreign  substance — 
generally  speaking,  muscle  ;  and  its  "frequency  may  be  explained  by  the  very  exten- 
sive surface  of  the  shaft  that  affords  attachment  to  the  brachialis  anticus  and  triceps. 
If  the  direction  of  the  fracture  is  in  the  least  oblicjue,  either  fragment  may  be 
easily  driven  so  far  into  the  soft  parts  that  it  is  almost  impossible  to  disengage  it. 
In  one  or  two  instances  the  musculo-spiral  nerve  has  been  found  between  the 
fragments. 

The  treatment  dei)ends  upon  what  can  be  made  out  with  regard  to  the  posi- 
tion of  the  fragments ;  if  they  are  in  apposition  with  each  other,  any  of  the 
methods  already  mentioned,  in  speaking  of  delayed  union,  may  be  adopted  ;  but 
if  it  is  practically  certain  that  there  is  some  intervening  substance,  union  is  impos- 
sible until  this  is  removed.  It  is  essential,  before  attempting  any  operation  of 
this  kind,  to  encourage  the  circulation  through  the  limb  by  galvanism,  friction, 
and  whatever  kind  of  movement  is  possible.  When  an  arm  has  been  confined  in 
splints,  or  carried  in  a  sling  for  many  months  together,  the  nutrition  becomes  so 
much  impaired  that,  not  unfrequently,  even  such  a  proceeding  as  wiring  the  frag- 
ments is  entirely  unattended  by  the  formation  of  callus. 

Frj^cture  oy  the  Lower  End  of  the  Humerus. 

A  certain  amount  of  confusion  has  arisen  with  regard  to  these  from  the  variety 
of  names  employed.  This  may  be  avoided  by  making  use  of  the  term  epicondyle 
for  that  part  of  the  bone  (internal  or  external)  which  lies  outside  the  cajjsule  and 
gives  attachment  to  the  muscles,  reserving  the  word  condyle  to  include  part  of 
the  joint. 

The  line  of  fracture  may  either  lie  wholly  outside  the  capsule  of  the  joint  or 
may  traverse  this  in  part. 

1.  In  the  former  class  are  included  transverse  fracture  above  the  olecranon 
fossa  (supra-condyloid)  :  separation  of  the  internal  epicondyle,  and  separation  of 
the  corresponding  epiphysis  by  itself.  The  external  epicondyle  does  not  project 
sufficiently. 

2.  In  the  latter  are  T-sha]jed  fracture;  .separation  of  either  condyle,  the  line 
passing  from  above  the  corresponding  epicondyle  oblicpiely  into  the  centre  of  the 
joint,  and  detaching  either  the  ca])itellum  or  the  trochlea  ;  and  separation  of  the 
lower  epiphysis.  It  is  true  that,  owing  to  the  firmness  with  which  the  capsule  of 
the  joint  is  fastened  to  the  margin  of  the  epii^hysial  cartilage,  it  is  possible  to 
detach  this  from  the  shaft  by  stripping  up  the  periosteum  without  opening  the 
synovial  cavity  ;  but  it  is  very  unlikely  that  this  really  happens  in  c^ses  of  fracture. 
Separation  of  the  epiphysis  for  the  internal  epicondyle  may  take  place  by  itself 
without  involving  the  joint,  but  if  the  whole  ma.ss  is  detached,  or  if  the  three  outer 
ones  together  are  separated,  there  is  nearly  certain  to  be  some  rent  in  the  synovial 
membrane. 

The  line  of  attachment  of  the  fibrous  capsule  surrounds  the  coronoid  depres- 


FRACTURES  OF  THE  HUMERUS. 


399 


sion  on  the  front  of  the  l)one,  and  on  either  side  encloses  the  trochlear  and 
cai)itellar  surfaces,  skirting  the  cartilage  of  the  latter  very  closely.  IJehind  it 
includes  the  whole  of  the  olecranon  fossa,  but  not  that  part  of  the  bone  that  lies 
above  and  behind  the  radial  surface  ;  this  is  altogether  uncovered.  The  line  of 
junction  between  the  epiphysis  and  the  shaft  separates  off  both  epicondyles  and 
the  whole  of  the  cartilaginous  surface,  running  transversely  across  the  centre  of 
the  bone  and  turning  upward  at  either  end,  so  that,  as  the  external  epicondyle  is 
never  detached  by  itself,  separation  of  the  internal  is  the  only  form  of  injury  that 
can  take  place  without  throwing  an  immense  strain  upon  the  capsule,  a  strain  so 
great  that  practically  it  always  gives  way. 

The  relative  situation  of  the  olecranon  and  the  two  epicondyles,  as  compared 
with  those  on  the  opposite  arm,  is  of  the  highest  importance  in  the  diagnosis  of 
injuries  in  the  neighborhood  of  the  elbow  joint.  Measurements  should  be  taken 
in  all  positions  of  the  limb,  and  the  transverse  diameter,  from  the  tip  of  one 
epicondyle  to  the  tip  of  the  other,  should  not  be  neglected. 

Fractures  of  the  lower  end  of  the  humerus  are  more  common  in  children  than 
in  adults  ;  they  are  often  complicated  with  dislocations ;  and  if  the  diagnosis  is 
not  made  at  once  they  are  always  attended  with  such  a  degree  of  swelling  that  it 
can  hardly  be -made  at  all.  Impairment  of  mobility  is  a  very  common  result, 
especially  when  the  joint  is  involved  ;  the  fragments  are  exceedingly  difficult  to 
retain  in  position  ;  a  large  amount  of  callus  is  often  thrown  out  by  the  extra- 
articular part,  so  that  the  fossje  are  filled  up  and  the  bones  lock  too  soon,  and  the 
capsule  is  very  likely  to  become  thickened  and  rigid  from  the  development  of 
extra-articular  adhesions.  In  children  an  accident  to  the  elbow  is  not  an  uncom- 
mon precursor  of  tubercular  mischief. 


I .  Fractures  Extcrtial  to  the  Joint. 

Transverse  fracture  above  the  condyles  :  supra-condyloid.  In  some  cases  this 
involves  the  reflection  of  the  synovial  membrane  in  the  olecranon  fossa  ;  usually 
it  is  situated  a  little  above. 

It  is  generally  produced  by 
falls  upon  the  elbow,  the  tip  of 
the  olecranon,  perhaps,  acting 
like  the  apex  of  a  wedge,  split- 
ting the  bone  across  ;  but  it  may 
be  caused  by  direct  violence,  or 
by  the  cross-breaking  strain  in 
over-extension  of  the  elbow  joint 
in  place  of  dislocation.  The 
line  of  separation  is  fairly  trans- 
verse from  side  to  side,  but  very 
often  is  oblique  from  above 
downward  and  forw^ard,  and  this 
determines  the  displacement. 

The  deformity  is  almost  the  same  as  that  of  dislocation  of  both  bones  of  the 
forearm  backward,  but  it  is  not  at  the  same  spot.  The  elbow  joint  is  flexed  and 
the  hand  generally  pronated  ;  the  olecranon  projects  behind  with  a  great  depres- 
sion above,  in  which  the  tendon  of  the  triceps  stands  out  distinctly  ;  in  front  there 
is  a  prominence  due  to  the  lower  end  of  the  upper  fragment ;  but  as  soon  as  the 
injury  is  examined  with  the  hand  it  is  found  that  the  relation  of  the  olecranon  to 
the  two  condyles  is  unaltered,  and  that  the  projection  in  front  is  not  the  articular 
surface  of  the  humerus,  but  is  on  a  distinctly  higher  level.  In  addition  to  this 
the  length  of  the  humerus  is  altered  ;  crepitus  is  present ;  there  is  undue  mobility, 
instead  of  the  joint  being  fixed  ;  and,  what  is  most  important  of  all,  if  the  deformity 
is  rectified,  it  returns  as  soon  as  the  arm  is  released.     In  cases  in  which  the  amount 


Fig.  i2g. — Fracture  of  the  Lower  End  of  the  Humerus. 


400     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES, 

of  swelling  is  so  great  as  to  obscure  all  the  bony  prominences,  this  test  may  be 
relied  on  absolutely  ;   the   only  other  injury  in  which   it   is  present  is  dislocation 

backward  combined  with  fracture  of  the  coronoid 
J  ^^..i  process,  and   this  is  distinguished   by  the  fact  that 

Vil^    '    f  the  condyles  of  the  humerus  still  retain   their  rela- 

i  tion  to  the  shaft. 

1  \\hen  the  line  of  fracture  runs  in  the  opposite 

\  direction  across  the  bone,  the  symptoms  are  not  so 

/  ^•  characteristic,  as  there  is  no  projection  of  the  ole- 

/     t,  cranon  ;  but  all   the   ordinary  signs  of   fracture — 

"  shortening,  crepitus,  undue  mobility,  and  pain — are 

i  well  marked. 

Treatment. — Reduction    is    easily   effected, 
^  '.  but  when  the  fracture  is  oblique  there  is  some  diffi- 

culty in  maintaining  the  length  of  the  limb,  owing 
^      ■  to  the  strength  of  the  muscles.     Swelling  is  often 

.     very  considerable   if  the   fracture   is  not  put  up  at 
t^/        f    .  ;w'"'      "^"^s-     ^^  ™^y  "ot  be  so  bad  as  when  the  injury 

^""—^  ''■  ..T  traverses  at  the  joint,  but,  if  it  is  at  all  serious,  the 

-  /  patient  should   be  confined   to  bed,  and   the  limb 

y'  fastened  lightly  to  an  inside  angular  splint.      Cold 

\ — .  applications  are  generally  recommended,  and  they 

Fig   130— Common  Form  of  Maiposi-   are  of  great  usc  at  first ;  the  vessels  become  con- 

tion   after    Fracture   of  Lower    End   of       .    •    .      i*"      _  j  ^u    •        •     n  ^i. 

Humerus.  strictcd   undcr   their  influence,    the    extravasation 

ceases,  the  exudation  of  lymph  is  limited,  and  the 
swelling  of  the  joint  is  checked  ;  but,  after  the  first  few  hours,  gentle  compression, 
if  it  can  be  managed  with  safety,  is  much  more  effectual.  It  requires,  it  must  be 
confessed,  the  utmost  care  ;  a  thick  layer  of  cotton-wool  must  be  used,  the  fingers 
must  be  constantly  watched  to  see  that  the  circulation  is  being  carried  on  properly  ; 
the  pulse  at  the  radial  must  be  felt  from  time  to  time,  and  the  bandages  must  be 
put  on  after  the  limb  is  in  position  (most  of  the  disastrous  cases  of  gangrene  have 
been  caused  by  the  dressing  being  applied  to  the  limb  when  it  was  extended,  so 
that  as  soon  as  it  was  flexed  the  bandage  cut  deeply  into  the  fold  of  the  joint)  ; 
but  if  it  is  properly  carried  out  there  is  nothing  that  succeeds  so  rapidly  or  so 
surely  in  removing  the  swelling  and  preparing  the  limb  for  a  more  permanent 
apparatus.  It  is  of  great  importance  to  limit  the  amount  of  exudation  poured  out 
around  the  end  of  the  bone ;  sometimes,  especially  when  the  fracture  involves  the 
joint,  it  is  so  excessive  that  the  lower  part  of  the  humerus  appears  to  be  converted 
into  an  almost  shapeless  block,  and  movement  is  checked  in  all  directions. 

The  most  convenient  form  of  splint  is  rectangular,  made  of  some  plastic 
material,  arranged  along  the  posterior  asi)ect  of  the  arm  and  the  under  surface  of 
the  forearm  from  the  axilla  to  the  wrist.  With  this  there  should  be  a  short  anterior 
one  down  the  arm,  thickly  padded  opposite  the  bend  of  the  elbow,  so  as  to  correct 
as  far  as  jiossible  the  tendency  to  forward  displacement  of  the  upi)er  fragment. 
The  hand  must  be  carried  in  a  sling.  In  some  few  cases  an  anterior  angular  one 
appears  to  answer  better,  but  the  ordinary  metal  or  wooden  inside  splint,  with  a 
joint  at  the  bend,  is  of  little  use  unle.ss  the  patient  is  confined  to  bed. 

Passive  motion  should  be  commenced  not  later  than  the  end  of  the  second 
week,  but  extraordinary  precautions  must  be  taken.  There  is  danger  on  both  sides  ; 
if  the  elbow  is  allowed  to  become  stiff,  non-union  may  occur,  though  it  is  not  so 
frecjuent  as  higher  up  in  the  shaft ;  if,  on  the  other  hand,  the  seat  of  injury  is  not 
securely  held,  the  soft  callus  yields,  and  is  liable  to  become  broken  up  and 
absorbed.  If  the  fracture  is  low  down,  extension  is  often  limited,  owing  to  the 
way  in  which  the  olecranon  fossa  becomes  filled  up,  but  this  is  not  nearly  so  bad 
as  in  T-shaped  fractures ;  and  even  in  the  worst  cases  great  improvement  takes 
place  in  the  course  of  a  year  or  two. 


FRACTURES  OF  THE  HUMERUS.  4ci 

Separation  of  the  Internal  Kpiiondylc. — This  occurs  more  fre(niently  than  is 
generally  suspected,  but  from  its  being  associated  cither  with  extensive  bruising,  or 
with  dislocation,  the  symjjtonis  to  which  it  gives  rise  are  often  overlooked.  It  may 
be  produced  by  direct  violence  (a  fall  or  a  blow  on  the  inner  side  of  the  elbow- 
joint),  in  which  case  there  is  not  much  separation  of  the  fragments,  or  by  dis- 
location of  the  bones  of  the  forearm  outward,  when  it  may  be  dragged  a  consider- 
able distance.     Sometimes  it  is  wrenched  off  by  muscular  action  alone. 

The  symptoms  and  importance  of  this  accident  depend  upon  the  way  in  which 
it  is  caused.  So  long  as  the  line  of  fracture  lies  entirely  outside  the  capsule,  as  it 
does  in  the  majority  of  instances,  it  is  of  little  consequence.  Movement  in  the 
direction  of  fle.xion  and  e.xtension  is  free  and  almost  painless  until  the  extremes 
are  reached  and  the  tension  falls  upon  the  fibres  of  the  internal  lateral  ligament. 
Pronation  is  very  painful.  Sometimes  an  interval  can  be  i'elt  in  following  down 
the  line  of  the  internal  condyle  ;  and  occasionally  the  detached  portion  can  be 
plainly  made  out  and  moved  freely  from  side  to  side.  Crepitus  can  only  be 
obtained  when  the  degree  of  separation  is  slight.  When,  on  the  other  hand,  the 
violence  is  direct,  the  swelling  may  be  so  great  as  to  obscure  the  outline  of  the 
bones ;  and,  not  improbably,  in  many  of  these  cases  the  fracture  extends  further 
outward  into  the  substance  of  the  bone,  so  that  the  injury  approximates  in  character 
to  the  separation  of  the  internal  condyle. 

In  most  cases  it  is  sufficient  if  the  forearm  is  carried  in  a  sling,  with  the  elbow 
at  a  right  angle.  Union  is  only  fibrous  if  the  epicondyle  has  been  dragged  down 
to  any  extent  by  the  traction  of  the  muscles,  but  this  interferes  very  little  with  the 
strength  of  the  arm.  When  the  cause  is  direct  violence,  a  large  amount  of  callus 
is  sometimes  thrown  out,  probably  because  the  splintering  extends  further  than  is 
apparent ;  and  there  may  be  some  impairment  of  movement  at  the  elbow  joint, 
even  when  there  was  no  evidence  of  its  having  been  involved.  I  have  known  one 
instance  in  which,  for  a  long  time  after,  there  was  persistent  pain  in  the  course 
of  the  ulnar  nerve. 

Separation  of  the  epiphysis  for  the  internal  epicondyle  may  take  place  up  to  the 
age  of  eighteen  or  nineteen.     The  symptoms  are  practically  the  same. 

2.  Fractures  that  hivolve  the  Joint. 

~^ -shaped  Fracture. — In  this  there  is  a  transverse  fracture  passing  across  the 
lower  extremity  of  the  humerus,  and  a  vertical  split  running  down  from  it  into  the 
centre  of  the  joint,  separating  the  two  condyles.  It  is  always  the  result  of  direct 
violence ;  the  apex  of  the  olecranon  and  the  ridge  that  traverses  the  greater 
sigmoid  cavity  from  before  backward  are  driven  violently  against  the  lower  end  of 
the  humerus,  and  split  the  bone  like  a  wedge.  I  have  known  the  T  incomplete, 
and  only  the  vertical  portion  of  the  fracture  produced  in  this  way. 

The  symptoms  are  the  same  as  those  of  the  supra-condyloid  fracture,  of  which 
it  seems  a  more  severe  form  ;  but  the  swelling  is  much  greater  ;  the  condyles  can 
be  moved  independently  of  each  other  and  of  the  lower  end  of  the  shaft ;  the  dis- 
placement is  more  serious,  and  is  even  harder  to  rectify ;  and  perfect  freedom  of 
movement  is  rarely  restored. 

In  many  of  these  cases,  owing  to  the  great  rapidity  with  which  the  swelling 
sets  in,  and  the  enormous  size  the  joint  assumes,  all  that  can  be  done  is  to  lay  the 
arm  on  a  pillow,  or  to  fasten  it  lightly  on  an  inside  splint,  and  try  to  limit  the 
amount  of  exudation  by  means  of  cold  and  pressure.  The  joint  must  be  kept  at  a 
right  angle,  or  even  a  little  less,  so  that  in  case  ankylosis  does  take  place,  the 
arm  may  be  in  the  most  useful  position.  With  the  elbow  fixed  at  this  angle  the 
hand  can  be  placed  behind  the  head,  and  brought  sufficiently  near  for  the 
patient  to  feed  himself;  if  it  is  more  open  the  joint  is  almost  useless.  The 
earlier  the  fracture  is  set,  the  better  the  prospect  of  good  adjustment.  The 
olecranon  must  be  dislodged  from  between  the  fragments,  and  these  must  be 
brought  close  together  and  into  the  same  straight  line  with  the  shaft.     A  great  deal 


402    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


may  be  done  by  careful  readjustment  up  to  the  end  of  the  first  week  ;  and  some 
improvement  may  be  effected  for  a  few  days  longer  ;  but,  as  a  rule,  at  the  end  of 
a  fortnight  the  fragments  are  too  firmly  fixed  to  allow  anything 
further.  Passive  movement  must  be  commenced  as  soon  as  possible, 
the  joint  being  thoroughly,  but  quietly,  flexed  and  extended  once 
a  day,  while  the  fragments  are  held  in  position  as  firmly  as  they 
can  be.  Hamilton  states  that  it  should  be  commenced  by  the 
seventh  day. 

Fracture  of  the  Internal  or  External  Condyle. — In  this  the  line 
of  separation  nms  from  above  the  corresponding  ej)icondyle  through 
the  articular  surface  of  the  humerus  into  the  middle  of  the  joint. 
The  internal  can  only  be  detached  by  direct  violence  :  the  external 
may  be  separated  either  in  this  way,  or  by  a  fall  upon  the  hand 

(Fig-  131)- 

The  symptoms  are  very  much  the  same  as  those  of  the  T-shaped 
fracture,  but  less  severe,  as  there  is  scarcely  more  than  half  the  injury. 
The  displacement  varies  very  much  :  if  the  trochlear  surface  is  left 
intact,  it  is  very  slight ;  if,  on  the  other  hand,  the  articulation  for  the 
ulna  is  separated  from  the  shaft,  it  may  be  sufficient  to  suggest  back- 
ward dislocation  of  both  bones.  Treatment  must  be  carried  out  on 
the  same  principle,  and  early  ]>a.ssive  motion  must  be  insisted  ujjon. 

When   the   internal   condyle  is  broken  off,  leaving  merely  the 

capitellum,  the  limb   may  be  kept  in  a  position  of  extension  with 

advantage,   at    least    for    the    first    fortnight,    and    then    gradually 

flexed.     Care  must  be  taken  to  preserve  the  outward  angle  that  the 

r  F  forearm  makes  with  the  arm. 

riG.131. — rracture  •  y       > 

of  the   Internal  Separation  of  the  Lower  Epiphysis. — In    infants    this  is    not 

H°u"merus.°  '  ^  uncommou ;  the  whole  of  the  cartilaginous  mass  at  the  lower 
end  of  the  humerus  is  detached  from  the  shaft,  without  of  neces- 
sity the  joint  being  opened,  though  it  probably  is,  in  nearly  every  case. 
In  children  it  is  equally  frequent ;  but  the  line  of  separation  rarely  corresponds 
exactly,  for  its  whole  length,  to  that  of  the  epiphysis;  and  the  internal  con- 
dyle is  seldom  separated  with  the  rest.  The  outer  part  is  the  one  that  suffers,  as  a 
rule;  it  consists  of  three  osseous  nuclei,  that  which  represents  the  capitellum 
being  much  the  largest  and  forming  a  considerable  share  of  the  trochlea  ;  the 
line  of  fracture  runs  from  above  the  external  epicondyle  into  the  centre  of  the 
joint,  to  one  side  or  other  of  the  trochlear  surface  ;  if  the   latter  is  included,  the 

lower  fragment  is  carried  backward  with  the  bones, 
so  that  it.closely  resembles  a  dislocation. 

The  most  frequent  cause  is  violent  abduction 
or  adduction  of  the  forearm  coml)ined  with  hyper- 
extension.  The  symptoms  are  nearly  the  same  as 
those  of  the  supracondyloid  and  condyloid 
fractures,  and,  as  a  rule,  the  same  treatment  is 
required.  Only  where  the  line  is  immediately 
above  the  joint,  and  it  is  difficult  to  retain  the 
fragments  in  position,  it  is  recommended  to  put  up 
the  injured  limb  in  a  position  of  com])lete  flexion, 
care  of  course  being  taken  not  to  interfere  with  the 
circulation. 

In  addition  to  these,  other  forms  of  fracture 
are  occasionally  met  with  which  do  not  admit  of  classification.  Sometimes  the 
lower  end  of  the  humerus  is  completely  comminuted  ;  or  dislocation  of  the  radius, 
or  ulna,  or  both  together,  occurs  at  the  same  time  ;  or  the  injury  is  complicated  by 
fracture  of  the  bones  of  the  forearm. 

Compound  Fractures  into  the  Elboiu-foint. — These  are  not  uncommon,  and 
frequently  the  ulna  or  the  radius  is  involved,  as  well  as  the  humerus.     The  treat- 


M 


Fig.  132  — Vertical  Section  through  the 
Lower  End  of  Humerus  at  fifteen  years 
of  age.  Showing  the  Relative  Size  and 
Position  of  the  Epiphyses. 


FRACTURE  OF  THE  RADIUS.  403 

nient,  as  in  the  case  of  compound  fractures  into  other  joints,  must  he  guided  l)y 
the  age  and  constitution  of  the  patient,  and  by  the  extent  of  injury  to  the  soft  parts 
and  the  bones  res])ectively  ;  but  this  is  modified  to  a  certain  extent  as  regards  the 
elbow  by  the  excellent  results  that  are  obtained  by  excision.  If  there  is  but  little 
comminutit)n,  and  the  wound  is  small  and  clean  cut,  the  part  should  be  thoroughly 
cleansed  with  corrosive  sublimate,  the  wound  sealed  With  a  dressing  of  wood-wool 
or  some  similar  absorbent  material,  and  the  limb  arranged  upon  an  angular  splint, 
and  slung  with  a  counterpoise  from  a  pole  over  the  bed,  as  in  an  excision.  But  if 
the  bone  is  extensively  injured  or  the  skin  much  bruised,  so  that  the  amount  of 
movement  in  the  joint  afterward  is  a  matter  of  some  doubt,  it  is  better  to  excise 
the  part  at  once.  Amputation  is  only  required  when  the  soft  tissues  are  destroyed 
to  such  an  extent  that  there  is  no  prospect  of  the  limb  recovering. 

FRACTURE  OF  THE  RADIUS. 

This  may  involve  the  head,  the  neck,  the  shaft  above  the  insertion  of  the  pro- 
nator radii  teres,  or  the  lower  extremity.  When  the  shaft  is  broken  the  ulna, 
generally  speaking,  gives  way,  too. 

Fractures  of  the  head  dixe  very  rare,  but  occasionally  they  are  produced  either 
by  direct  violence  crushing  the  external  condyle  or  by  falls  upon  the  hand.  They 
have  been  found  in  several  of  the  instances  in  which  the  coronoid  process  was 
broken.     The    line    of   fracture    is    usually 

longitudinal,   splitting  off  more   or  less  of  ..._^- --- ''!S3^v. 

the  circumference  of  the  bone.  v  ,\ 

Fracture    of  the    neck  of  the  bone   is  \  >■ 

still  more  uncommon,  though  it  is  an  injury  \.^-. 

that  is  often  suspected   during  life.      It  may  /  V    V 

occur  in    children   or    in    adults,   probabl\-      /-  -    •■ 

from    direct  violence,    though  one   or  two      [  __  .     _  / 

instances  are  recorded  in  which  it  has  been      -^  <.    ^'-^- •— ,,  .   / 

due  to  falls  upon  the  hand.      The  head  of        -  •^'-^' 

the  bone  is  unduly  movable  and   does  not  ,  %' 

rotate  with   the  shaft ;   pronation  and  supi- 
nation are  impossible,  and  when   the  hand  '.  ^^  -^^r-stsy' 
is  moved  in  either  direction  there  is  intense           \^ 
pain  at  the  seat  of  injury  ;  a  slight  amount             Vi 

of  crepitus  is  usually  present.      I  have  met  *•  -        „     ,  ->*5k-s^js^-> - 

with  one  instance  in  which   the  upper  epi-  "^        >  '^^^S*^/ 

physis  Avas  separated,  the   external   condyle  .'  y^ 

of  the  humerus  being  considerably  crushed  yy. 

at  the  same  time.     The  only  treatment  that  !\  -         , 

can  be  adopted  is  to  retain  the  elbow  joint  \  ^^  '     f 

in  a  light   form  of  rectangular  splint  with  a  v  v^^      ^i^'      ) 

firm  pad  over  the  front  of  the  forearm,  and  Ki'-*^       ^F"      ^ 

.  .  .     ^  i  r  »  < 

to  commence   passive  motion  as  m  fractures 

of  the  lower  extremity  of  the  humerus.      If, 

owing  to  the  contraction  of  the  biceps,  the  1 

displacement    cannot    be    rectified    in    any  'I 

other  way,   the  arm    must  be  put  up  fully  -'^ 

flexed;    but   it  must  be   recollected,   when  |.  ,        . 

passive  motion  is  begun,  that  the  muscle  is  S-i,:„,-^ 

very  likely  to  have  become  rigidly  contracted  Fig.  133.— Separation  of  Upper  Epiphysis  of  Radius 
r  „  1 1  .  rj^i  ■.■  r    ii  with  Crushing  of  Capiteliar  Surface  and  External 

from  prolonged  rest.      1  he  position  of  the     Epicondyie. 

posterior  interosseous   nerve   in  relation   to 

the  bone  must  not  be  forgotten  in  connection  with  this  fracture. 

Fractures  of  the  shaft  of  the  radius  alone  are  due  either  to  falls  upon  the  hand 
or  blows  upon  the  arm,  and  may  take  place  either  above  or  below  the  insertion 


404    DISEASES  AND  INJURIES  OE  SPECIAL  sfRUCTURES. 

of  the  pronator  radii  teres.  In  tlie  former  case  the  ui>per  fragment  is  acted  on 
by  the  supinator  brevis  and  the  biceps,  the  lower  by  the  jjronators,  so  that  the 
relative  position  of  the  radius  and  ulna  is  not  the  same  above  and  below  the 
seat  of  injury.  In  the  latter  the  upper  fragment,  owing  to  the  attxichment  of  the 
l^ronator  teres,  is  not  much  disi^laced  ;  but  the  lower  is  tilted  inward  toward 
the  ulna,  ])artly  by  the  supinator  longus,  partly  by  the  pronator  quadratus. 

So  long  as  the  ulna  is  intact  the  amount  of  deformity  is  very  slight.  The 
other  signs  are  well  marked  :  there  is  intense  pain  over  the  seat  of  injury ;  pro- 
nation and  supination  are  imjiossible  ;  when  the  hand  is  grasped  and  made  to 
rotate,  the  upper  end  of  the  radius  does  not  move  with  it,  and  crepitus  can  be 
felt  at  once. 

Fractures  of  the  upper  part  of  the  bone  should,  if  possible,  be  jnit  up  in  a 
position  of  complete  supination.  The  upper  fragment  is  already  in  that  position, 
and  if  the  lower  is  partly  pronated  it  is  clear  that  a  certain  amount  of  supination 
must  be  lost,  and  though  this  can  be  supplemented  to  a  great  extent  by  rotation 
at  the  shoulder-joint,  especially  after  long  practice,  the  movement  at   the  elbow 


Fig  134. — Section  through  the  Lower  End  of  the  Radius,  the  Carpus,  and  Metacarpus,  to  show  the  Position  in  a 
Fall  upon  the  Hand  and  the  Influence  of  the  Inferior  Radio-carpal  Ligament.  If  the  force  were  continued,  the 
hard,  compact  anterior  surface  of  the  radius  would  be  driven  into  the  cancellous  tissue  of  the  lower  fragment. 

is  exceedingly  awkward.  It  seldom  happens,  however,  that  patients  will  endure  it ; 
if  they  are  confined  to  bed  the  arm  may  be  laid  on  its  back  and  completely 
extended  ;  if  not,  all  that  can  be  done  is  to  fit  a  posterior  rectangular  splint 
down  the  arm  and  forearm  and  to  arrange  a  sling  so  that  the  hand,  resting  on 
its  dorsum,  is  as  much  in  front  of  the  median  lateral  line  of  the  body  as  the 
elbow  is  behind. 

When  the  seat  of  injury  is  below  the  insertion  of  the  i)ronator  teres,  the 
danger  is  that  the  upper  end  of  the  lower  fragment  may  be  drawn  inward  and  at 
length  unite  with  the  ulna,  when,  of  cour.se,  both  pronation  and  su])i nation  are 
lost.  To  prevent  this,  straight  back  and  front  splints  must  be  u.sed,  wider  than 
the  limb,  so  as  to  take  off  all  lateral  pre.ssure,  and  well  padded,  esjiecially  down 
the  centre,  so  that  the  muscles  may  be  squeezed  as  far  as  may  be  into  the  inter- 
osseous space  ;  and  the  limb  should  be  put  up  midway  between  pronation  and 
supination,  that  is  to  say,  with  thumb  uppermost  and  the  dorsum  of  the  hand 
looking  forward.  The  sling  should  only  take  the  forearm,  so  that  the  hand  may 
hang  down  in  a  position  of  adduction. 


FRACTURE  OF  THE   RADIUS.  405 

Fracture  of  the  Lower  End  of  the  Radius. — With  the  exception  of  the  clavicle 
this  bone  is  broken  more  fre(iiiently  than  any  other.  The  fracture  is  usually 
transverse  from  side  to  side,  though  in  the  vertical  direction  it  may  incline  from 
above  downward  and  forward,  and  it  nearly  always  lies  within  an  inch  of  the 
carpal  surface.  The  size  of  the  lower  fragment,  however,  varies  considerably ;  it 
may  be  merely  a  plate  of  bone  carrying  the  articular  cartilage. 

The  cause  is  almost  always  indirect  violence,  a  fall  upon  the  hand.  If  the 
palm  is  toward  the  ground,  the  displacement  is  dorsal  (Colics'  fracture),  and  it 
may  be  impacted,  or  non-impacted,  or  comminuted  ;  if,  as  occasionally  happens, 
the  hand  is  doubled  imderneath  so  that  the  back  is  downward,  the  lower  fragment 
is  forced  in  the  opposite  direction. 

Colics'  Fracture. — For  many  reasons  this  is  of  special  interest ;  it  is  exceed- 
ingly common  ;  it  is  much  more  often  met  with  in  women  past  middle  life  than 
in  men  ;  it  is  distinguished  l)y  dis|)lacement  of  a  very  striking  character  ;  and 
it  often  leaves  behind  it  unsightly  deformity  and  a  very  serious  degree  of 
stiffness. 

The  structure  of  the  lower  end  of  the  radius  favors  its  occurrence.  The 
compact  tissue  of  the  shaft  is  firm  and  strong,  but  over  the  articular  end  it  is 
scarcely  thicker  than  paper,  and  one  part  passes  very  abruptly  into  the  other.  In 
men  of  good  muscular  development  the  bony  ridges  in  the  back  and  at  the  sides 
strengthen  it  sufficiently  ;  but  in  women  these  are  almost  wanting  and  the  whole 
bone  is  more  smooth  and  rounded.  As  age  advances  the  medullary  canal  enlarges 
and  encroaches  upon  the  centre  of  the  articular  end,  the  cancellous  tissue  grows 
more  open,  and  the  trabeculae  becomes  thinner  and  fewer  in  number. 

The  immediate  cause  is  a  fall  upon  the  hand,  but  not,  as  usually  described, 
outstretched.  This  may  dislocate  the  elbow  or  the  shoulder,  or  it  may  break  the 
surgical  neck  of  the  humerus,  but  it  can  hardly  cause  a  transverse  fracture  through 
the  radius.  The  hand  is  really  almost  under  the  body,  the  radius  is  much  more 
vertical  than  horizontal,  the  wrist  is  violently  over-extended,  the  lower  fragment 
is  fixed  by  the  inferior  radio-carpal  ligament,  and  the  cross-breaking  strain  snaps 
the  bone  in  two.  In  men  it  occurs  most  frequently  in  falls  from  some  considerable 
height,  when  they  pitch  ujjon  their  hands,  or  in  accidents  on  the  ice  from  the  feet 
suddenly  slipping  up.  (I  have  known,  on  a  frosty  morning  when  the  roads  were 
very  slippery,  seven  patients,  one  after  the  other,  come  to  the  hospital  with  this 
form  of  fracture.)  In  women  it  comes  from  slighter  falls,  for  not  only  is  the 
bone  relatively  much  weaker  in  proportion  to  their  weight,  but,  partly  from  their 
mode  of  dress,  partly  from  their  inability  to  save  themselves,  they  come  down 
upon  their  hand  with  much  greater  force. 

If  the  violence  is  only  moderate  in  degree,  the  bone  is  merely  broken  across  ; 
if  it  is  more  severe  there  is  impaction  (in  at  least  two-fifths  of  the  cases  and 
probably  many  more)  ;  the  compact  tissue  of  the  dorsal  surface  of  the  upper 
fragment  is  driven  into  the  cancellous  tissue  of  the  lower,  without  the  periosteum 
on  the  back  being  torn  ;  if  the  violence  is  greater  still,  there  is  comminution,  the 
impaction  being  carried  so  far 
that  the  lower  fragment  is  split 
into  pieces. 

Displacemc?it.  —  The  d  i  s- 
placement  is  threefold  ;  the  upper 
fragment  is  held  fixed  by  the 
pronators,  the  lower  is  carried 
bodily  toward  the  dorsal  surface, 
so  that  it  no  longer  lies  in  the 
same  plane ;  it  is  rotated  round 

a  transverse    axis  so   that  its  artic- Fig.  13;.— Section  through  Forearm  showing  Displacement  in  Colles* 

ular  surface,   instead  of  looking  Fracture. 

almost    directly    forward,    looks 

forward  and  upward,  and  the  outer  side  is,  as  a  rule,  displaced  much  more  than 

the   inner,    partly  because  the   latter   is  held   by  the   triangular   fibro-cartilage. 


4o6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

partly  because  in  falling  upon  the  hand  the  radial  side  of  the  carpus  receives 
the  brunt  of  the  shock.  The  original  displacement  is  due,  there  can  be  little 
doubt,  to  the  crushing  force  ;  but  CoUes  himself  attached  much  importance 
to  the  contraction  of  the  extensor  muscles  of  the  thumi),  which  pass  over  the 
posterior  surface  of  the  radius  in  sheaths  firmly  connected  to  the  bone. 

Symptoms.  —  If  the 
bone  is  merely  broken  across, 
the  deformity  is  not  very 
marked,  but  if  there  is  im- 
jjaction  or  comminution,  it  is 
most  conspicuous.  Looked 
at  from  the  radial  side  the 
back  of  the  hand  appears 
strangely  long,  the  natural  de- 
pression of  the  wrist  seems  to 
Fig.  i36.-Outiine  of  Hand  in  coiies' Fracture.  havc  disappeared,  and   in  its 

place  there  is  another  an  inch 
and  a  half  or  two  inches  higher  up.  Opposite  this,  on  the  flexor  surfaca,  the 
tendons  are  rai.sed  and  thrust  prominently  toward  the  skin,  while  the  wrist  itself 
is  unusually  arched.  Seen  from  above  it  is  still  more  striking;  the  hand  is  dis- 
placed toward  the  radial  side  and  abducted,  the  ulna  stands  out  as  if  it  were 
coming  through,  the  fingers  are  flexed,  pronation  and  supination  are  impossible, 
and  the  patient  carefully  supports  the  injured  wrist  in  the  palm  of  the  other  hand. 
Swelling  sets  in  very  soon.  The  flexor  tendons  are  always  hurt  by  lieing  strained 
over  the  end  of  the  bone,  and  their  synovial  sheath  becomes  filled  with  fluid  at 
once  ;  but  this  rather  serves  to  exaggerate  the  deformity  than  to  conceal  it.  The 
margin  of  the  ulna  can  be  traced  down  without  any  difficulty  ;  and  by  firm  pres- 
sure on  the  outer  border  of  the  radius  it  is  nearly  always  possible  to  make  out  the 
line  of  separation  ;  but  crepitus  and  undue  mobility  are  rarely  very  distinct  unless 
there  is  comminution. 

Sprains  of  the  flexor  tendons  of  the  wrist  are  sometimes  mistaken  for  Colles' 
fracture;  they  are  caused  in  the  same  way,  and  it  is  difficult  to  prove  that  the 
bone  has  escaped  unhurt  and  that  the  tendons  by  themselves  have  been  sufficiently 
strong  to  stand  the  strain. 

The  reduction  of  the  deformity  is  often  a  matter  of  the  greatest  difficulty. 
Colles  states,  it  is  true,  that  a  moderate  degree  of  extension  is  sufficient  to  restore 
the  limb  to  its  natural  shape,  and  that  it  slips  back  again  at  once  ;  but  this  only 
occurs  when  there  is  comminution.  Gordon,  who  denies  impaction,  and  who 
describes  the  broken  surface  of  the  upper  fragment  as  convex  from  within  out- 
ward, and  also  from  before  backward,  believes  that  the  difficulty  is  entirely  due  to 
the  rotation  of  the  lower  fragment ;  if  the  upper  one  is  fixed,  the  lower  pressed 
forward,  and  the  hand  flexed  to  an  angle  of  45°,  the  concavity  of  the  radius  is 
restored  at  once.  If  there  is  no  impaction,  the  obstacle  must  of  course  be  due 
to  locking  of  the  fragments  or  muscular  spasm  ;  but  there  can  be  no  question 
that  it  is  present  in  a  very  large  number  of  instances  (jjrobably  the  majority)  ;  and 
that  the  difficulty  arises  partly  from  this,  partly  from  the  small  size  of  the  lower 
fragment,  which  makes  direct  extension  almost  impossible. 

Direct  manipulation  of  the  fragments  while  extension  is  being  made  from  the 
hand  is  very  often  successful.  If  this  fails,  adduction  may  be  tried  at  the  same 
time,  the  lower  end  of  the  ulna  being  used  as  the  fixed  jjoint,  and  the  forearm 
being  held  in  a  position  of  sujiination  with  the  elbow  flexed  ;  but  care  must  be 
taken  not  to  put  too  much  strain  upon  the  ligaments.  If  this  does  not  succeed, 
another  trial  may  be  made  at  the  end  of  a  week,  when  the  fragments  have  become 
softened  to  a  certain  extent  ;  but  it  is  not  likely  to  be  successful,  and  it  is  advis- 
able to  caution  the  patient  from  the  first  that  there  will  probably  be  a  certain 
amount  of  permanent  deformity. 

Treatment. — This  depends  upon  the  success  with  which  reduction  is  accom- 
plished.     If  the  fragments  cannot  be  separated,  all  that  is  required  (so  far  as  the 


FRACTURE  OF  THE  RADIUS. 


407 


fracture  is  concerned)  is  a  simple  wristlet,  made  of  some  light  material,  to  j^rotect 
the  part  from  further  injury.  Union  in  these  cases  is  very  rapid,  but  it  must  not 
be  forgotten  that  the  flexor  tendons  are  generally  hurt  at  the  same  time,  and  that, 
unless  steps  are  taken  to  prevent  it,  stiffness  of  the  wrist  and  rigidity  of  the  fingers 
are  almost  certain  to  follow. 

If,  on  the  other  hand,  the  fracture  is  transverse  without  impaction,  or  if  it  is 
comminuted,  and  the  deformity  has  really  been  reduced,  the  broken  surfaces  can 
be  kejit  in  contact  with  the  simplest  of  contrivances.  lOither  Carr's  or  Gordon's 
splint  answers  p'erfectly  ;  l)ut  eipially  good  results  may  be  obtained  by  fixing  the 
forearm  midway  between  pronation  and  supination,  in  two  straight  wooden 
ones,  reaching  from  the  ell)ow  to  the  bases  of  the  metacarpal  bones.  After  a  week 
or  ten  days  they  may  be  replaced  by  a  well-devised  poroplastic  gauntlet,  including 
the  thumb  and  the  flexor  surface  of  the  forearm. 

Adduction  is  of  no  use  unless  there  is  comminution  ;  but  then,  in  some 
instances  it  is  of  great  ser\ice.  It  is  managed  most  easily  by  means  of  a  pistol- 
shajjed  splint,  arranged  either  on  the  dorsal  or  the  palmar  surface,  with  a  short 
one  on  the  opposite  side  for  counter-pressure.  The  pads  should  be  arranged  as 
they  are  in  Gordon's. 


Fig.  137. — Gordon's  Splint  Applied. 

Gordon's  splint  consists  of  a  dorsal  and  a  palmar  portion  ;  the  former  is 
much  the  longer  and  is  bent  down  at  its  lower  extremity  so  as  to  maintain  the 
wrist-joint  in  a  position  of  semiflexion  ;  the  latter  is  very  short,  and  is  either 
carved  or  padded  so  as  to  fit  into  the  concavity  of  the  radius.  If  it  is  padded  the 
edge  of  the  splint  projects  like  a  flange  so  as  to  avoid  lateral  pressure.  It  should 
be  kept  well  up  on  the  forearm,  not  allowed  to  encroach  upon  the  wrist. 

Carr's  is  simpler.  The  flexor  splint  is  made  of  wood  and  is  about  eleven 
inches  long  and  two  wide  ;  across  the  end  of  this  is  a  round  bar  placed  obliquely, 
so  that  when  the  fingers  are  flexed  over  it  the  hand  is  slightly  adducted.  It  should 
be  stoutly  padded  opposite  the  upper  fragment  on  the  radial  side.  A  dorsal 
splint  may  be  used  with  it,  but  in  many  cases  it  is  not  necessary. 

Stiffness. — It  is  always  necessary  to  warn  patients  that  CoUes'  fracture  is  liable 
to  be  followed  by  stiffness,  afiecting  both  the  fingers  and  the  wrist,  especially  if 
there  is  any  tendency  to  gout  or  rheumatism.  It  is  due,  in  many  cases,  to  strain 
of  the  flexor  tendons  ;  but  it  is  made  tenfold  worse  by  rigid  confinement,  and  it  is 
by  no  means  unlikely  that,  in 
certain  circumstances,  this  is  .suf-  - 
ficient  of  itself.  So  far  as  the 
fingers  are  concerned,  it  can  gen- 
erally be  avoided  ;  they  should 
never  be  bandaged  ;  one  great 
merit  of  Carr's  splint  is  the  free- 
dom of  movement  it  gives  them  ; 
and  passive  motion  must  be  com- 
menced and    thoroughly  carried 

out  from  the  first  day.      With  the  Fig.  iss.-Carr'sSpiim. 

wrist  it  is  more  difficult,  but  on 

several   occasions  I  have  .  begun   gentle  manipulation  on  the   fourth   or  fifth  day 
with  an  excellent  result.      Pressure  should   be  carefully  applied  along  the  forearm 


4o8    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

if  there  is  much  effusion  into  the  sheath  of  the  tendons  ;  and  as  soon  as  the 
fracture  is  fairly  firm,  massage,  counter-irritants,  and  steaming  must  be  com- 
menced;  but  not  uncommonly  it  is  necessary  to  place  the  i>atient  under  an 
anaesthetic,  and  work  every  joint  thoroughly,  before  there  is  much  improvement. 
If  there  is  comminution  of  the  lower  fragment,  or  if  the  impaction  is  not  reduced 
and  the  plane  of  the  articular  surface  restored,  some  limitation  of  movement 
usually  persists. 

Fracture  of  the  lower  end  of  the  radius  with  palmar  displacement  is  very  rare, 
and  does  not  present  any  special  features.  Separation  of  the  lower  epiphysis  may 
occur;  and,  if  union  takes  place  by  bone,  the  growth  of  the  ulna  may  lead  to 
serious  distortion  of  the  hand. 

Compound  and  even  comminuted  fractures  of  the  lower  end  of  the  radius 
may  be  produced  by  direct  violence,  without  of  necessity  the  joint  being  involved. 
In  one  case  under  my  care,  in  which  a  man's  wrist  was  pinned  against  the  ground 
by  the  sharp  edge  of  a  beer-cask,  though  the  bone  was  broken  to  pieces,  the  joint 
and  both  the  arteries  escaped  unhurt. 

FRACTURES  OF  THE  ULNA. 

These  may  involve  the  olecranon,  the  coronoid  process,  or  the  shaft. 

Fractures  of  the  Olecranon. — This  process  is  frequently  broken,  especially  in 
adults,  in  falls  upon  the  point  of  the  elbow ;  and  it  has  been  separated  by  muscu- 
lar action.  As  a  rule  it  gives  way  at  its  narrowest  part,  laying  open  the  joint,  but 
occasionally  the  tip  only  is  detached,  and  then  it  is  jjossible  for  the  synovial 
membrane  to  escape.     Stellate  fractures  are  sometimes  met  with. 

The  amount  of  separation  depends  upon  the  extent  to  which  the  aponeurosis 
of  the  triceps  and  the  fibres  of  the  capsule  at  the  side  give  way.  If  they  are  torn 
the  upper  fragment  is  raised  by  muscular  contraction  and  the  distention  of  the 
joint  cavity  until  there  is  a  wide  gap  between  them.  More  rarely  the  broken  sur- 
faces remain  in  contact,  and  crepitus  can  be  obtained.  Loss  of  extension  is  com- 
plete, manipulation  and  i)ressure  are  exceedingly  painful,  and  the  amount  of 
swelling  is  generally  very  great. 

Treatment. — If  the  bruising  is  severe,  the  arm  should  be  laid  upon  a  pillow 
for  the  first  i^tw  days,  in  a  position  of  easy  extension,  and  cold  and  pressure  ap- 
plied until  the  swelling  is  in  some  measure  reduced.  In  most  instances  all  that  is 
necessary  is  a  light  wooden  splint  running  down  the  front  of  the  limb,  sufficiently 
long  to  hold  both  arm  and  forearm  firmly.  It  should  be  thickly  padded  opposite 
the  joint,  as  absolute  extension  is  uncomfortable,  and  has  a  tendency  to  tilt  the 
surfaces.  Sometimes  the  fragments  can  be  brought  closer  together  by  a  figure-of- 
eight  bandage,  or  by  loops  of  strapping,  so  arranged  as  to  pull  the  upper  one 
downward  ;  but  in  many  instances  this  seriously  increases  the  swelling  of  the  limb. 
It  is  more  satisfactory  to  bandage  the  part  carefiiUy  and  evenly  with  abundance 
of  wool  around  the  joint,  so  as  to  insure  early  absori)tion  of  the  fluid  and  tho- 
rough relaxation  of  the  muscles.  This  jiosition  should  be  maintained  for  three 
weeks,  and  then  the  arm  may  be  gradually  bent,  until  in  about  ten  days  the 
forearm  rests  easily  in  a  sling.  If  there  is  much  separation,  union  is  nearly 
sure  to  be  fibrous ;  but  so  long  as  it  is  fairly  close  and  strong  it  does  not 
interfere  with  the  use  of  the  limb.  Stellate  fractures  unite  by  bone.  Flexion 
from  the  first  has  been  recommended  by  some,  on  the  ground  that  if  ankylosis 
were  to  occur  the  arm  would  be  in  a  more  convenient  position  ;  but  there  is 
scarcely  any  reason  to  fear  this  (Fig.  139). 

If  union  fails,  or  is  so  weak  that  there  is  no  power  of  extension,  the  frag- 
ments must  be  drilled  and  wired  together.  I  have  seen  one  instance  in  which 
the  use  of  the  triceps  was  lost,  owing  to  the  upper  portion  becoming  united  to 
the  humerus. 

Compound  fracture  is  not  uncommon.  If  it  is  merely  transverse,  the  frag- 
ments should  be  fastened  together  at  once ;   if  there  is  comminution,  every  effort 


T'RACTURES  OF  THE  ULNA.  409 

must  be   made  to  save   the  part;  l)ut   if  there   is  any  fear  of  supimration,  it  is 
better  to  jierform  excision. 

Fracture  of  t]u-  coronoid process  is  a  very  rare  form  of  acci- 
dent, and  is  nearly  always  associated  with  backward  dislocation 
of  the  bones  of  the  forearm.  It  may  be  produced  l)y  direct 
violence  crushing  the  bone,  or  by  falls  upon  the  hand  when  the 
elbow  is  extended  ;  the  shock  must  be  transmitted  from  the 
radius  to  the  ulna,  and  from  this  to  the  trochlear  surface  of  the 
humerus.  The  tip  also  may  be  detached  by  violent  abduction, 
or  adduction,  of  the  forearm.  The  brachialis  anticus  is  attached 
to  its  anterior  surface,  near  the  base,  so  that  fracture  from 
muscular  action  alone  can  hardly  take  place,  and  separation  of 
the  tip  from  this  cause  is  im])ossible.  I'he  most  important 
symptom  is  the  disi)lacement  l)ackward  of  the  bones  of  the 
forearm,  when  the  elbow  joint  is  extended,  returning  as  .soon  as 
the  reducing  force  is  relaxed.  In  addition  there  is  intense  pain 
on  pressure,  increased  by  attempts  at  flexion,  and,  unless  it  is 
merely  the  tip,  there  is  a  considerable  amount  of  swelling.  It 
is  recommended  to  keep  the  elbow  joint  flexed  at  a  little  le.ss 
than  a  right  angle,  secured  by  plaster  or  a  fixed  bandage,  and  Fig.  139— Fracture 
commence  passive  motion  at  the  end  of  a  week.  If  the  frag-  Fibrouru"n°ion.""' 
ments  are  at  all  separated,  union  is  sure  to  be  ligamentous. 

Fracture  of  tlie  shaft  of  the  ulna  by  itself  is  usually  the  result  of  direct  vio- 
lence, and,  because  of  the  exposed  situation  of  the  bone,  is  often  compound.  It 
may  give  way  at  any  part,  but  owing  to  its  comparative  weakness  it  is  more  com- 
mon below  the  middle.  The  line  of  separation  is  usually  distinct,  unless  the 
amount  of  bruising  is  too  great,  and  the  movements  of  the  arm  are  restricted  and 
very  painful.  The  displacement  is  not  conspicuous,  unless  the  radius  is  broken 
or  dislocated  at  the  same  time. 

If  there  is  any  tendency  for  the  ends  to  be  displaced  outward  toward  the 
radius,  the  fracture  should  be  put  up  as  if  both  bones  were  broken.  In  other  cases 
a  shield  of  gutta-percha,  long  enough  to  grasp  the  whole  of  the  forearm  and  the 
ulnar  side  of  the  hand,  is  quite  sufficient.  As  the  hand,  when  placed  in  a  sling, 
rests  upon  the  ulnar  border,  care  must  be  taken  that  the  fragments  are  not  dis- 
placed by  direct  pressure. 

Fracture  of  the  styloid  process  of  the  ulna  is  not  uncommon  when  the  lower 
end  of  the  radius  is  broken  and  the  hand  much  abducted.  Union  is  usually 
fibrous. 

Fracture  of  the  radius  and  ulna  together,  in  the  middle  of  the  forearm,  may 
occur  from  direct  violence,  or  from  a  fall  upon  the  hand.  In  children  the  fracture 
is  often  partial  or  greenstick  ;  and  the  only  prominent  sign  is  an  angular  deform- 
ity, generally  an  exaggeration  of  the  normal  curve.  When  the  separation  is  com- 
plete, crepitus  and  undue  mobility  are  present.  Pain,  swelling,  and  loss  of  power 
occur  in  all  alike. 

Greenstick  fractures  must  be  straightened  as  far  as  possible  ;  sometimes  this 
cannot  be  done  without  making  them  complete;  but  if  there  is  only  a  small 
angle,  not  sufficient  to  interfere  with  pronation  and  supination,  it  disappears  to  a 
great  extent  as  the  child  grows  older.  When  the  injury  is  above  the  level  of  the 
pronator  radii  teres,  the  forearm  should  be  put  up  in  the  position  of  complete 
supination,  as  already  described  in  speaking  of  fracture  of  the  shaft  of  the  radius 
alone.  When  it  is  lower  down,  two  straight  splints  should  be  used,  wider  than 
the  limb  and  thoroughly  well  padded,  especially  down  the  centre,  so  as  to  avoid 
as  far  as  possible  any  risk  of  cross  union  ;  and  the  fracture  should  be  set  with  the 
limb  midway  between  pronation  and  supination,  that  is,  with  the  thumb  upward 
and  the  dorsum  of  the  hand  forward.  Passive  motion  should  be  commenced  in  about 
three  weeks,  as  there  is  some  risk  of  the  interosseous  membrane  becoming  thick- 
ened in  the  region  of  the  fracture  and  losing  its  flexibility.  No  bandage  should 
27 


41  o    niSEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

ever  be  ajiplied  under  the  splints,  and  care  must  be  taken  to  examine  the  fracture 
every  day  for  at  least  the  first  week.  It  is  in  this  form  of  injury  that  gangrene  is 
especially  common,  to  some  extent,  as  already  mentioned,  from  flexion  of  the 
elbow,  but  also  because  both  radial  and  ulnar  arteries  are  easily  compressed  against 
the  bones  for  a  considerable  portion  of  their  course. 


Fractures  of  the  Carpus  and  Mf:tacarpus. 

Fracture  of  the  carpus  is  not  common,  owing  to  the  mobility  and  protected 
position  of  the  bones,  and  to  the  way  in  which  the  pressure  is  distributed  among 
them.  They  may  give  way,  however,  from  direct  violence.  Exact  diagnosis,  unless 
the  injury  is  compound,  can  rarely  be  obtained,  especially  as  the  amount  of 
bruising  is  always  extensive.  As  a  rule  it  is  sufificient  to  carry  the  hand  in  a  sling, 
and  for  the  first  few  days  to  protect  the  part  from  careless  movements  by  means  of 
a  light  palmar  splint  of  gutta-percha,  recollecting  that  the  natural  position  for  the 
joint  is  one  of  slight  extension.  Unless  there  is  comminution  or  fear  of  suppura- 
tion, passive  motion  should  be  commenced  as  early  as  possible,  so  as  to  avoid 
permanent  rigidity. 

The  victacaj-pal  bones  are  often  broken  from  direct  blows,  as  in  fighting, 
the  first,  from  its  exposed  situation,  giving  way  the  most  frefjuently,  the  third  the 
least.  The  dis[)lacement  is  nearly  always  toward  the  dorsum  of  the  hand,  an 
exaggeration  of  the  natural  curve,  so  that  the  head  is  turned  to  the  palm.  If  seen 
at  once,  it  can  easily  be  rectified  by  direct  manipulation  ;  but  often  the  patient 
does  not  apply  for  some  days,  considering  it  a  mere  bruise.  The  plan  recommended 
by  Astley  Cooper,  of  placing  a  ball  in  the  palm  of  the  hand,  and  extending  the 
finger  over  it,  answers  very  well,  and  maintains  thoroughly  the  natural  curve  ;  but, 
as  a  rule,  a  simple  gutta-percha  splint,  well  moulded,  is  quite  sufficient  and  is 
much  less  cumbersome.  The  metacarpal  bone  of  the  thumb  is  liable  to  a  peculiar 
form  of  fracture  which  can  easily  be  mistaken  for  dislocation,  as  it  does  not 
involve  the  dorsal  surface  of  the  bone.  The  palmar  half  of  the  ba.se  is  broken 
off;  the  length  of  the  bone  is  unaltered,  but  the  security  of  the  articulation  with 
the  trapezium  is  lost,  and  the  bone  keeps  constantly  slipping  back.  Crepitus 
can  be  felt  by  pressing  the  detached  fragment  from  the  palm  outward  toward 
the  rest  of  the  bone.  Union  is  generally  attended  with  some  impairment 
of  movement. 

Simple  fracture  of  the  phalanges  is  very  common,  and  may  be  treated  either 
with  a  light  pasteboard  splint  or  a  gutta-percha  trough,  keeping  the  finger  nearly 
extended. 

Compound  fractures  extending  into  the  wrist  joint  are  very  serious  ;  the  bones 
are  generally  crushed,  the  joints  torn  open,  and  often  the  soft  parts  extensively 
injured  as  well.  The  question  of  amputation  must  be  decided  by  the  last-men- 
tioned consideration  ;  I  have  on  several  occasions  treated  fractures  of  this  descrip- 
tion, it  which  it  was  necessary  to  remove  fragments  of  bone  from  both  rows  of 
the  carpus,  with  corrosive  sublimate  baths  for  an  hour  each  day,  not  only  without 
suppuration,  but  with  an  excellent  result  so  far  as  movement  was  concerned.  If 
inflammation  and  suppuration  once  set  in,  the  whole  carpus  is  almost  sure  to 
become  involved,  the  bones  undergo  necrosis,  and  the  pus  is  very  likely  to  spread 
from  the  articulations,  either  into  the  synovial  sheaths  of  the  tendons,  or  into  the 
deeper  planes  of  cellular  tissue,  until  the  whole  limb  is  implicated.  If  this  sub- 
sides, the  hand  and  wrist  are  almost  useless  ;  more  often  than  not  amputation  is 
required  to  prevent  more  serious  consequences. 

Compound  fractures  of  the  hand,  if  they  are  at  all  extensive,  if  for  example 
the  palm  or  several  fingers  are  badly  crushed,  should  be  treated  in  the  same  way. 
It  is  often  impossible  to  tell  at  the  first  how  much  of  the  bruised  and  damaged 
tissue  will  live,  and  every  fragment  is  of  importance.  The  sloughs,  it  is  true,  are 
somewhat  slow  in  separating,   but,  owing   to   the  amount  of  the  antiseptic  dead 


FRACTURE  OF  THE  PELVIS.  411 

tissues  absorb,  putrefaction  does  not  take  i)lace  ;  there  is  no  fear  of  cellulitis  or 
other  inflammatory  comi)lications ;  granulations  gradually  spring  up,  and  the 
whole  of  the  tissue  that  is  not  too  much  damaged  by  the  accident  is  preserved. 


FRACTURE   OF  THE  PELVIS. 

The  innominate  bone  may  be  broken  by  direct  violence  or  by  muscular  action  ; 
or  the  pelvic  girdle  may  be  squeezed  until  it  gives  way  under  the  pressure.  In 
this  case  the  position  and  direction  of  the  fracture  are  often  definite  ;  under  other 
circumstances  they  are  very  variable. 


Fractures  of  the  False  Pelvis. 

Portions  of  the  crest  of  the  ilium  are  occasionally  broken  off  by  direct  blows  ; 
in  a  few  rare  instances  the  anterior  superior  spine  has  been  detached  by  muscular 
action  ;  and  the  same  thing  has  been  known  to  occur  in  the  case  of  the  epiphysis 
that  forms  the  crest ;  but  unless  there  is  great  comminution,  injuries  of  the  false 
pelvis  are  rarely  attended  by  serious  consequences  ;  the  shock  may  be  severe ;  the 
ordinary  signs  of  fracture  are  well  marked  ;  but  the  viscera  very  seldom  suffer  ; 
and  repair  takes  place  readily,  though  there  is  often  a  certain  amount  of  difficulty 
about  retaining  the  fragments  in  proper  position. 


Fracture  of  the  Acetabulum. 

This  may  be  produced  in  two  ways  :  in  the  first,  and  the  most  serious,  the 
head  of  the  femur  is  driven  inward  with  such  violence  that  it  splits  the  cavity  into 
pieces  ;  in  the  second  a  portion  of  the  lip  only  is  detached.  The  former  of  these 
never  occurs  except  as  the  result  of  extreme  violence  applied  to  the  great  trochanter  ; 
the  bone  is  very  much  comminuted  fthe  three  portions  that  form  the  acetabulum 
being  driven  asunder),  the  shock  extreme,  and  the  danger  of  injury  to  the  viscera 
very  great. 

The  position  the  limb  assumes  closely  resembles  that  of  fracture  of  the  neck 
of  the  femur,  but  the  trochanter  is  more  sunken.  The  amount  of  mobility  varies 
a  good  deal  ;  in  many  instances  it  is  unusually  free,  probably  owing  to  the  small 
relative  size  of  the  neck  compared  with  the  head  ;  crepitus  is  generally  distinct, 
and  manipulation  exceedingly  painful.  If  there  is  any  doubt,  an  attempt  may  be 
made  to  feel  the  head  of  the  bone  through  the  rectum  or  vagina.  The  accident 
frequently  proves  fatal  from  shock  or  from  injury  to  the  viscera ;  if  the  patient 
rallies  sufficiently,  an  attempt  must  be  made  to  extract  the  bone,  but  it  is  not  very 
likely  to  succeed  ;  if  it  does,  the  limb  must  be  put  up  as  in  fracture  through  the 
base  of  the  neck.      Movement  is  sure  to  be  much  impaired. 

Fracture  of  the  lip  of  the  acetabulum  is  more  common.  It  is  caused  by  the 
sudden  impact  of  the  head  of  the  femur  against  the  upper  and  back  part  of  the 
cup,  and  may  be  produced  by  fdlls  upon  the  feet.  In  one  instance,  however,  under 
my  own  observation,  it  was  clearly  shown  that  the  upper  part  of  the  body  struck 
the  ground  first,  so  that  in  all  probability  it  was  produced  in  the  same  way  as  the 
fracture  that  is  met  with  at  the  base  of  the  skull  from  the  sudden  shock  of  the  atlas 
coming  upon  the  occipital  condyles  with  the  weight  of  the  body  behind  it.  The 
position  the  limb  assumes  is  almost  identical  with  that  of  dislocation  backward  ; 
reduction  is  easy,  but  as  soon  as  the  hand  is  removed  the  head  of  the  bone  slips 
back.  Crepitus  can  generally  be  felt  if  deep-seated  pressure  is  applied  above  and 
behind  the  great  trochanter  while  extension  is  being  made.  This  injury  must  be 
treated  in  the  same  way  as  fracture  through  the  base  of  the  neck  of  the  femur. 
The  patient  is  to  be  kept  in  bed  with  a  long  splint  and  weight-extension,  pro- 


412    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

portionate  to  the  strength  of  the  muscles,  for  at  least  three  weeks.  After  this  a 
permanent  appliance  is  to  be  worn  for  six  weeks,  or  two  months  more  ;  the  foot 
must  be  slung,  and  no  weight  allowed  to  rest  uj^on  the  limb  until  at  least  this 
length  of  time  has  elapsed,  though  j)assive  motion  may  be  commenced  much 
earlier.  In  most  cases  there  is  a  certain  amount  of  shortening  afterward,  but  the 
use  of  the  limb  is  not  imiraired. 


Fr.vcture  of  the  Sacrum  and  Coccyx. 

The  sacnon  is  occasionally,  but  very  rarely,  broken  by  direct  violence.  The 
lower  portion  suffers  more  fretpiently  than  the  rest,  owing  partly  to  its  weaker 
construction.  If  the  fracture  is  compound,  as  it  often  is,  it  must  not  be  forgotten 
that  the  spinal  canal  runs  down  the  middle  of  the  bone,  and  that  meningitis  may 
occur.  When  there  is  great  comminution,  the  structures  on  the  anterior  surface, 
in  particular  the  nerves  as  they  issue  from  the  foramina,  may  be  involved 
as  well. 

The  coccyx,  on  the  other  hand,  is  frequently  injured  by  falls  in  a  sitting 
position  upon  something  hard,  or  by  kicks.  Sometimes  it  is  broken  right  across 
and  displaced,  so  that  crepitus  can  be  distinctly  felt  when  it  is  grasped  between  two 
fingers,  one  in  the  rectum,  the  other  on  the  skin,  and  moved  backward  and  for- 
ward ;  more  often  it  is  only  bent  or  partially  broken.  Perhaps,  sometimes,  the 
injury  is  really  a  dislocation.  The  most  ])rominent  symptom  is  the  pain  caused 
when  any  of  the  muscles  attached  to  the  bone  are  called  upon  to  act ;  sitting, 
stooping,  walking,  coughing,  and  especially  defecation  are  attended  with  much 
suffering.  The  displacement  is  easily  reduced,  but  is  very  liable  to  return.  The 
only  treatment  is  to  keep  the  patient  in  the  recumbent  position  for  a  few  days  until 
the  pain  has  to  a  certain  measure  subsided,  and  to  keep  the  motions  relaxed 
so  as  to  avoid,  as  far  as  possible,  any  undue  strain  upon  the  sphincter  or  the  levator 
ani. 

Injuries  of  the  coccyx  are  very  frequently  followed  by  persistent  pain,  and 
great  tenderness  of  skin  over  the  region  supplied  by  the  lower  sacral  nerves.  This 
is  especially  the  case  in  women,  though  it  is  not  coniined  to  them.  Sometimes  it 
can  be  traced  to  gouty  or  rheumatic  inflammation  of  the  fibrous  tissue  surround- 
ing the  bone,  and  it  may  be  relieved  by  iodide  of  potash,  and  by  counter- 
irritants ;  but  in  many  instances  it  is  rather  a  sign  of  uterine  derangement,  and 
nearly  always  it  becomes  worse  at  each  menstrual  period.  In  the  worst  cases  it  is 
necessary  to  provide  the  sufferer  with  a  circular  cushion,  so  that  the  tuberosities  of 
the  ischium  may  sustain  the  whole  weight,  and  the  coccyx  lie,  as  it  were,  buried. 
Subcutaneous  section  of  the  tissues  around  the  bone  and  excision  of  the  bone 
itself  have  been  performed,  when  the  distress  was  very  great,  but  not  always  with 
success. 

Fracture.s  Throuc.h  the  Pelvic  Girdle. 

When  the  pelvis  is  crushed  it  gives  way  at  the  weakest  spot,  rather  than  at  the  , 
sides  of  the  circle  ;  the  line  of  fracture  nearly  always  ])asses  across  the  bone  at  the 
inner  margin  of  the  obturator  foramen,  and  then  if  the  force  continues,  at  or  near 
the  sacro-iliac  synchondrosis  on  the  opposite  side.  Sometimes,  when  the  force 
comes  from  in  front,  the  fracture  is  almost  symmetrical,  the  whole  of  the  body  of 
the  pubes  being  separated  from  the  rest,  and  both  the  articulations  opened  up 
behind.  In  a  few  cases  the  displacement  is  perceptible  at  once  ;  more  often  the 
existence  of  a  fracture  is  only  suspected  from  the  extreme  shock,  the  intense  pain 
at  certain  points,  greatly  aggravated  by  any  attempts  to  separate  or  bring  together 
the  crests  of  the  ilium,  and  the  injury  to  the  neighboring  viscera.  The  urethra 
suffers    most    often  ;    it    may  give    way   either    on    the    superficial    or    the   deep 


FRACTURES  OF  THE   FEMUR. 


413 


surface  of  the  triangular  ligament  ;  in  the  former  case  the  urine  is  extrava- 
sated  into  the  scrotum,  in  the  latter  into  the  deep  cellular  tissue  of  the  i)elvis. 
The  bladder,  however,  may  be 
ruptured,  the  rectum,  or  even  the 
contents  of  the  abdomen  se- 
verely injured,  and  the  large 
vessels  torn  across.  The  injury, 
even  when  it  is  not  complicated 
in  any  way,  is  always  serious  ; 
and  as  the  soft  parts  and  the 
viscera  are  generally  torn, 
crushed,  or  wounded  by  splinters, 
the  prognosis  in  accidents  of  this 
kind  is  most  unfavorable.  So 
far  as  the  fracture  itself  is  con- 
cerned, very  little  is  required  ; 
the  part  must  be  kept  at  ])erfect 
rest  and  over-examination  care- 
fully avoided,  but  the  condition 
of  the  viscera  must  be  ascertained 

with  the  least  possible  delay.  Fig.  140.— Fracture  of  Pelvis. 


FRACTURES  OF  THE  FEMUR. 

I.  The  Upper  Extremity. 

These  were  divided  by  Sir  Astley  Cooper  into  (i)  fractures  of  the  neck  entirely 
within  the  capsule,  (2)  fractures  at  the  base  of  the  neck  where  it  joins  the  trochan- 
ters, external  to  the  capsule,  and  (3)  fractures  through  the  trochanter  major,  to 
which  may  be  added  (4)  separation  of  the  epiphyses.  As,  however,  wholly  extra- 
capsular fracture  of  the  neck  of  the  femur  is  an  anatomical  impossibility,  so  far,  at 
least,  as  the  front  of  the  bone  is  concerned  ;  and  as  this  does  not  take  into  considera- 
tion the  question  of  impaction  (on  which  repair  depends  to  a  very  great  extent), 
it  seems  better  to  divide  them  into — 

(i)  Impacted  fracture. 

(2)  Non-impacted  fracture,  of  which  there  are  tw^o  varieties  :  — 
{a)   Intra-articular,  wholly  within  the  joint ;  and 

(J))  Through  the   line  of  attachment  of  the  capsule,  at  the  base  of  the 
neck,  partly  within,  partly  without. 

(3)  Fracture  through  the  trochanter. 

(4)  Separation  of  epiphyses. 

It  is  true  that  a  certain  number  of  cases  cannot  be  grouped  under  any  one  of 
these,  but  it  holds  good  for  the  vast  majority.  They  are  to  be  regarded  as  types  of 
common  occurrence,  presenting  perfectly  definite  symptoms,  and  requiring  entirely 
different  methods  of  treatment. 

It  is  as  well  to  leave  impacted  fractures  until  the  other  forms  have  been  con- 
sidered. 

Jtitra-articular  Fracture. 

This  is  peculiar  for  several  reasons  :  it  is  very  rare  under  fifty  years  of  age, 
very  common  afterward  ;  it  is  produced  by  exceedingly  slight  degrees  of  violence  ; 
it  is  more  common  in  women  than  in  men  ;  and  unless  it  is  impacted,  or  the  frag- 
ments are  in  some  way  held  together,  bony  union  never  takes  place.  The  line  of 
separation  lies  wholly  within  the  capsule,  immediately  below  the  head.  If  the  force 
acts  vertically  the  fracture  is  stated  to  be  generally  oblique  ;  if  from  in  front,  trans- 
verse. Occasionally  the  under  surface  only  gives  way,  the  tissue  at  the  upper  part  of 
the  neck  being  bent  rather  than  broken.  When  it  is  impacted  the  compact  tissue  on 
the  under  surface  of  the  neck  is  driven  into  the  cancellous  substance  of  the  head. 


414     DISEASES  AND  INJURIES   OE  SPECIAL   STRUCTURES. 


'I'his  may  be  explained  in  great  measure  by  the  structure  of  the  part  and  by 
the  changes  the  bone  undergoes  as  age  advances. 

The  angle  which  the  neck  of  the  femur  forms  with  the  shaft  is  commonly 
stated  to  be  about  128°  in  the  adult,  and  to  diminish  gradually  in  old  age;  in 
women  it  is  less  than  in  men,  and  certainly  the  smaller  it  becomes  and  the  more 
nearly  it  approaches  a  right  angle,  the  more  likely  it  is  to  give  way.  It  is  not 
true,  however,  that  this  change  is  invariably  associated  with  age.  In  many  old 
people  the  angle  of  the  femur  is  quite  unaltered  ;  and,  on  the  other  hand,  in  ex- 
amining the  bodies  of  well-developed  adults  without  a  sign  of  rheumatoid  arthritis, 
I  have  on  several  occasions  found  the  top  of  the  trochanter  higher  than  the  head, 
and  this  rotated  so  far  that  a  flattened  facet  was  develojied  on  the  front  surface, 
corresi>onding  to  the  tendon  of  the  ilio-psoas. 

The  changes  in  the  substance  of  the  bone  are  more  constant,  but  even  they 
are  proi)ortionate  rather  to  the  amount  of  disuse  than  to  the  years  of  the  jjatient. 
The  cavity  of  the  shaft  extends  upward  with  the  cancellous  tissue  of  the  neck  ; 
the  trabeculge  are  thinner  and  softer,  the  bone  itself  is  infiltrated  with  fat,  and 
the  compact  layers  on  the  exterior  waste,  until,  in  extreme  cases,  they  are  almost 
translucent.  When  this  is  far  advanced  it  is  scarcely  surprising  that  a  very  slight 
strain  is  sufficient  to  break  it  across. 

The  causes  are  always  of  the  most  trivial  description.  Sometimes  it  is  a 
sudden  vertical  shock,  as  in  slipping  from  off  a  curb-stone ;  in  other  cases  it  is  a 
twist,  as  when  in  walking  the  inner  side , of  the  great  toe  catches  against  a  fold  of 
the  carpet ;  the  ilio-femoral  band  acts  as  the  fulcrum  of  a  lever ;  the  leg  is  the 
long  arm,  the  neck  the  short  one  ;  the  head  of  the  bone  cannot  move,  the  liga- 
ment is  much  too  strong  to  yield  ;  so  if  the  force  is  severe  and  sudden  enough 
the  short  arm  must  break  across  at  its  weakest  spot.  Even  turning  round  in  bed 
will  sometimes  do  it.  In  a  third  set  the  bone  is  broken  by  a  fall  upon  the 
trochanter,  and  then  there  is  often  impaction  ;  the  thinnest  part  of  the  neck  gives 
way,  and  a  continuance  of  the  force  drives  the  compact  tissue  upward  and  inward 
into  the  cancellous  substance  of  the  head. 

Signs. — No  attempt  should  ever  be  made  to  elicit  crepitus,  and  manipulation 
of  all  kinds  should  be  avoided  as  much  as  possil)le.  The  fragments  at  first  are 
close  together,  and  the  only  hope  in  obtaining  union  lies  in  keeping  them  there; 
any  movement  that  would  cause  crepitus  is  sure  to  separate  them. 

Displacement. — The  direction  is  nearly  always  the  same,  but  the  extent  is 
very  variable.  The  neck  of  the  femur  is  invested,  especially  on  its  under  surface, 
by  dense  bands  of  fibrous  tissue,  which  pass  upward  from  the  line  of  attachment 
of  the  capsule  to  the  margin  of  the  head.  These  are  the  reflected  fibres  which 
form  a  kind  of  periosteum  for  the  neck  and  convey  to  the  head  its  most  important 
vessels.  In  intra-articular  fracture  they  rarely  give  way  at  the  time  of  the  accident, 
and  partly  from  this,  partly  because  the  capsule  is  not  torn,  much  separation  of 
the  fragments  is  unusual.  The  muscles  that  pass  from  the  trunk  to  the  thigh  pull 
the  femur  upward  and  inward  toward  the  middle  line,  so  that  the  trochanter  sinks 
in  and  the  limb  is  slightly  shortened,  but  the  amount  of  this  rarely  exceeds 
three-quarters  of  an  inch.     After  two  or  three  days,  however,  when,  owing  to  the 

exudation  that  takes  place,  all  the 
fibrous  tissue  is  infiltrated  and  soft- 
ened, it  often  increases  to  an  inch 
and  a  half,  or  even  two  inches, unless 
care  is  taken  to  prevent  it. 

As  accuracy  in  measurement 
is  very  essential,  various  methods 
have  been  devised  for  estimating 
the  amount  of  alteration.  Which- 
ever plan  is  adopted,  care  must  be 
taken  that  the  position  of  the  two 

Fig.    141.— Bryant's   Triangle.      C  B,   test-line   for  fracture   or     1  :,,-,K<  ;«  olicnlntpl v  <:vmmptrirnl  •  the 

shortening  of  the  neck  of  the  thigh-bone.  iimus  IS  aijsoiuteiy  Symmetrical ,  inc 


FRACTURES  OF  THE  FEMUR, 


4'5 


least  deviation  is  sufficient  to  vitiate  the  result  comi)letely.  A  roui^^h  guess  may 
be  made  by  comparing  the  position  of  the  two  malleoli,  having  first  made  sure 
that  the  body  is  perfectly  straight,  and  that  the  pelvis  is  not  tilted.  Measure- 
ment, either  by  means  of  tape,  or  better,  with  a  sliding  graduated  rod,  from  the 
anterior  superior  spine  of  each  side  to  the  internal  malleolus,  is  more  accurate  ; 
but  neither  of  these  methods  can  i)rove  where  the  shortening  is.  To  effect  this 
three  different  plans  have  been  recommended  :  Nelaton's  line,  Bryant's  triangle 
(Fig.  141),  and  Morris'  bi-trochanteric  measurement. 

Nelaton's  test  consists  in  stretching  a  taj)e  from  the  anterior  su[)erior  spine 
of  the  ilium  to  the  most  prominent  part  of  the  tuberosity  of  the  ischium.  In  the 
healthy  adult  the  top  of  the  trochanter  never  comes  above  this  ;  if  it  does,  the 
neck  of  the  bone  must  have  been  shortened  either  by  disease  (rheumatoid  arthritis 
or  rickets)  or  by  fracture.      Bryant's  triangle  is  made  up  of  the  perpendicular  line 


Fig.  142. — Intra-articular  Fracture  of  Neck  of 
Left  Femur.  No  uuiou  has  taken  place;  the 
neck  has  been  absorbed  ;  and  the  under  part 
of  the  head  glides  up  and  down  a  polished 
surface  corresponding  to  the  anterior  inter- 
trochanteric line. 


Fig.  143. — Vertical  Section  through  Upper 
End  of  Right  Femur,  from  the  same  patient, 
showing  the  changes  undergone  in  extreme 
atrophy. 


from  the  anterior  superior  spine  (when  the  patient  is  lying  down)  ;  the  line  from 
the  same  point  to  the  great  trochanter ;  and  a  third  drawn  from  this  at  right 
angles  to  the  vertical  one.  The  difference  in  the  length  of  this  third  line  on  the 
two  sides  gives  the  amount  of  shortening.  Morris'  bi-trochanteric  measurement 
compares  the  distance  on  each  side  from  the  median  line  to  the  top  of  the  great 
trochanter.  It  indicates  the  inward  displacement  of  the  trochanter,  and  can  only 
be  taken  satisfactorily  by  having  a  rod,  graduated  on  each  side  from  the  middle, 
with  two  pointers  sliding  on  it,  so  that  when  it  is  held  over  the  body  they  may 
come  into  contact  with  the  top  of  the  great  trochanter. 

The  appearance  of  the  limb  is  very  characteristic.  It  lies  on  its  outer  side, 
completely  everted  from  the  hip  to  the  foot,  with  the  knee  slightly  flexed  ;  there 
may  be  a  slight  swelling  in  front  over  the  hip-joint,  due  to  the  rotation  of  the 
lower  fragment ;  the  trochanter  is  sunken  inward  and  drawn  nearer  the  anterior 
spine,  and  there  is  from  half  an  inch  to  an  inch  of  shortening.     There  is  no 


41 6     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

superficial  bruising  or  contusion  ;  the  trochanter  is  not  thickened,  and  though  it 
is  painful  when  pressed  upon,  the  pain  is  not  like  that  of  fracture  through  the 
base  of  the  neck.  The  most  tender  spot  is  generally  on  the  inner  side  of  the 
thigh,  about  the  insertion  of  the  ilio-psoas  or  a  little  lower  down.  In  some  rare 
ca.ses  the  patient  is  able  to  raise  the  heel  from  the  bed,  ])robably  because  the 
reflected  fibres  are  intact  or  the  fragments  interlocked  ;  more  often  the  knee  can 
be  Hexed  a  little,  Init  any  attempt  to  lift  the  leg  fails  completely.  In  a  few 
exceptional  cases  there  has  been  inversion  of  the  foot.  The  eversion  is  due 
mainly  to  the  weight  of  the  limb  ;  at  least  there  is  no  doubt  this  is  sufficient  to 
cause  it,  though  possibly  the  contraction  of  the  ilio-psoas  may  a.ssist  (the  short 
muscles  attached  to  the  great  trochanter  when  the  neck  is  broken  would  scarcely 
have  any  rotatory  power)  ;  inversion,  when  it  is  present,  must  be  produced  by  the 
direction  of  the  violence  that  caused  the  fracture,  and  is  probably  kept  up  by  the 
accidental  locking  of  the  fragments.  In  most  cases  the  fascia  lata  on  the  outer 
side  of  the  thigh,  extending  from  the  crest  of  the  ilium  to  the  head  of  the  tibia, 
is  distinctly  relaxed,  both  above  the  trochanter  and  again  above  the  knee  joint. 

Manipulation  should  be  avoided  as  much  as  possible,  but  when  it  is  really 
necessary  for  the  diagnosis  extension  readily  restores  the  limb  to  its  proper  length, 
and  often,  at  the  same  time,  gives  rise  to  the  sensation  of  crepitus,  especially  if 
the  limb  is  rotated  inward  at  the  same  time.  Further,  if  the  trochanter  is  grasped 
while  this  is  being  done,  it  clearly  does  not  move  through  the  same  range  as  the 
other.      Movement  in  all  directions  is  abnormally  free  and  very  painful. 

The  constitutional  disturbance  in  these  cases  is  always  slight  at  first ;  there 
is  no  fever  and  but  little  shock,  but  very  often  the  patient  never  really  rallies,  the 
circulation  remains  feeble,  the  heart's  action  never  recovers,  the  mind  begins  to 
wander,  and  congestion  of  the  lungs,  retention  of  urine  and  cystitis,  or  bed-sores, 
make  their  appearance  in  spite  of  every  care.  The  prognosis,  therefore,  is  always 
.serious,  especially  in  the  aged. 

Repair.  —  Union  by  bone  probably  never  occurs  unless  the  fracture  is 
impacted.  The  broken  surfaces  are  not  in  contact.  Even  if  the  action  of  the 
mu.scles  and  the  weight  of  the  part  could  be  set  aside,  the  distention  of  the 
capsule,  partly  from  hemorrhage,  partly  from  exudation,  would  be  enough. 
Further,  the  head  is  often  rotated  in  its  socket,  so  that  it  no  longer  faces  the 
broken  surface  of  the  neck;  and  as  its  blood-supply  is  cut  off,  no  callus  is  ever 
found  on  the  upper  fragment.  As  Astley  Cooper  pointed  out,  most  of  the  vessels 
that  supply  this  part  of  the  bone  enter  the  neck  on  its  under  surface,  and,  of 
course,  are  torn  ;  recently,  too,  it  has  been  shown  that  the  artery  running  in  the 
ligamentum  teres  does  not  enter  the  bone  at  all.  The  blood-vessels  in  the  neck 
probably  dilate,  because,  in  a  large  proportion  of  cases,  this  part  of  the  bone  is 
completely  absorbed.  The  main  bond  of  union  is  the  capsule,  which  becomes 
enormously  thick.  Sometimes  there  is  a  certain  amount  of  fil)rous  tissue  formed 
between  the  fragments,  passing  from  the  under  surface  of  the  neck,  and  also  from 
its  cancellated  structure,  to  the  head  ;  but  in  many  there  is  no  union  at  all,  the 
surfaces  become  hard  and  polished,  the  neck  disapjjears,  and  the  head  of  the  bone 
rests  on  the  lesser  trochanter,  or  spurs  are  thrown  out  round  the  base  of  the  neck 
to  catch  the  rim  of  the  acetabulum.  Many  patients  after  accidents  of  this  kind 
remain  almost  bedridden,  or  can  only  get  about  with  assistance  ;  others,  especially 
if  they  are  not  corpulent,  can  lay  aside  their  crutches  after  a  time  and  walk 
with  a  stick — a  few  can  dispense  even  with  this;  but,  in  sj^ite  of  a  high  heel  to 
compensate  for  the  shortening,  a  certain  amount  of  lameness  is  always  left. 

Treatment. — This  must  be  guided  entirely  by  the  condition  of  the  patient. 
Many  old  people  never  really  lie  down  at  all,  and  to  keej)  them  on  their  back  by 
means  of  a  long  splint  would  inevitably  bring  on  congestion  of  the  lungs.  Astley 
Cooper  recommended  that  they  should  be  i)roi)]ied  up  in  bed,  with  the  limb 
supported  by  pillows  in  the  most  comfortable  position,  for  ten  days  or  a  fortnight, 
until  the  ])ain  in  some  measure  had  subsided  ;  then  they  should  sit  up  every  day 
in  a  high  chair,  so  as  to  avoid  flexion  of  the  limb,  and  begin  to  use  crutches  as 


FRACTURES  OF  TJIF   FEMUR.  417 

soon  as  possible,  bearing  a  little  more  weight  upon  the  foot  each  day,  until  the 
capsule  had  become  sufficiently  strengthened.  In  the  meantime  water-cushions 
must  be  used  freely  so  as  to  avoid  the  occurrence  of  bed-sores  ;  the'most  scrupulous 
cleanliness  must  be  observed,  especially  as  urinary  trouble,  i)artly  from  age,  partly 
from  the  confinement  in  bed,  is  very  common  ;  and  the  skin  must  be  sponged 
with  spirit  every  day  to  harden  it.  .As  soon  as  the  patient  begins  to  sit  up,-  the 
limb  nuist  be  enclosed  in  a  shield  made  of  leather  or  felt,  large  enough  to  grasp 
the  pelvis  and  the  thigh,  running  completely  round  the  body  and  two-thirds  round 
the  limb,  as  low  as  the  knee.  This  should  be  made  with  straps  and  buckles,  so 
that,  while  it  is  able  to  hold  the  part  firmly  and  give  it  sufficient  support  to 
protect  it  from  injury,  it  may  also  be  removed  every  few  days  for  the  purpose  of 
attending  to  the  skin. 

In  younger  patients,  especially  when  the  amount  of  .separation  is  not  great, 
an  attempt  may  be  made  to  ])rocure  union  between  the  fragments,  though  it  is 
very  unlikely  that  it  will  be  osseous.  A  long  splint  must  be  applied  to  the  outer 
side  of  the  limb  from  the  axilla  to  below  the  foot,  as  in  fractures  of  the  shaft,  and 
a  moderate  weight  attached  to  the  leg,  counter-extension  being  made  by  raising 
the  foot  of  the  bed.  Particular  care  must  be  taken  to  correct  the  eversion  ;  it  is 
not  sufficient  for  the  foot  to  be  merely  straight,  the  great  toe  must  be  a  little 
inverted,  or  when  the  bandages  are  removed  it  will  be  found  that  the  correction 
is  not  sufficient.  If  possible,  this  must  be  kept  up  for  six  weeks,  though  if  the 
patient's  health  begins  to  fail,  or  if,  in  spite  of  water-cushions,  there  is  any  fear 
of  bed-sores,  it  is  possible  to  do  with  a  fortnight  less  ;  then  the  limb  may  be 
secured  either  in  a  Thomas's  hip-s]jlint  or  in  a  leather  shield,  and  the  patient 
allowed  up  on  crutches,  the  foot  being  slung  and  not  allowed  to  touch  the  ground 
for  six  weeks  or  two  months  more.  Unless  rheumatoid  arthritis  sets  in,  there  is 
very  little  fear  of  the  hip  joint  becoming  unduly  stiff. 

In  one  or  two  instances  the  hip  joint  has  been  laid  open  from  in  front  and 
the  fragments  wired  together.  The  operation  was  successful  and  apparently 
osseous  union  followed  ;  but  cases  in  w^hich  such  a  proceeding  could  be  recom- 
mended must  be  very  rare. 

Fracture  through  the  Base  of  the  Neck. 

This  stands  out  in  clear  contrast  to  the  former.  The  line  of  separation  fol- 
lows the  intertrochanteric  line  in  front;  behind  it  is  a  little  internal  to  it,  so  that 
the  fracture  is  partly  within,  partly  without  the  capsule ;  the  whole  of  the  neck  is 
detached  and  the  trochanter  often  comminuted.  It  may  occur  at  any  time,  but 
is  most  common  in  adult  life,  and  in  men, 
because  it  is  never  caused  but  by  an  ex- 
treme degree  of  violence  applied  directly 
to  the  hip.  A  moderate  amount  of  force 
breaks  the  bone  across,  drives  one  fragment 
into  another,  and  leaves  it  impacted  there  ; 
when  it  is  more  severe  the  wedge -shape 
neck  splits  the  trochanter  into  pieces  and 
frees  itself  again.     There  is  a  great  deal  of  "-■<;.5vv^'3>^'  '<^ 

bruising  all  round  the  hip  ;  the  trochanter 

■  1           J               1         r^           ^1         r                    «.  Fig.  144. — Horizontal  Section  through  Neck  and 

is    Widened,     and     often     the    fragments    are  Trochanterof  Femur,  to  ilU.strate  the  method  of 

Ciuite     loose;      crepitus     is     always  present;  production  of  fracture  through  the  base  of  the 

'    .         .                '              '                                   ^  '                  . '  neck.       1  he  anterior    layer   of   compact   tissue 

pain     is    very    great;      usually    the  shock     is  bends   when    the    posterior    is   driven   into   the 

^-                                 r  ,.    1   .          r-.  1       fVi  trochanter,  and   then   breaks.     Probably  partial 

severe,      sometimes      even      latai  ,  ana      tne  fractures  are  of  common  occurrence. 

amount  of  shortening  at  the  first  is  rarely 

under  an  inch  and  a  half,  and  may  be  as  much  as  three.  Eversion  is  present  in 
the  vast  majority,  but  occasionally  inversion  occurs,  as  it  does  in  the  intra- 
articular form. 

Eigelow  has  shown,  in  reference  to  these  injuries,  the  way  in  which   the 


4i8    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

fracture  occurs.  If  a  horizontal  section  is  made  through  the  neck  and  head  of 
the  femur,  the  anterior  layer  of  compact  tissue  is  seen  to  be  ecjually  strong 
throughout,  perhaps  rather  stronger  in  the  middle  than  elsewhere,  owing  to  the 
section  passing  through  the  tubercle ;  the  posterior,  on  the  other  hand,  ends 
abruptly  in  the  cancellatous  tissue  of  the  trochanter.  In  a  fall  upon  the  hip  this 
part  gives  way  first;  the  anterior  layer  splits  more  or  le.ss  vertically,  .so  that  the 
shaft  is  everted  upon  the  neck  ;  and  if  the  force  continues  the  jjosterior  compact 
layer  is  driven  further  and  further  into  the  trochanter  until  it  sfjlits  into  fragments. 
The  difference  in  the  mode  of  repair  is  equally  striking.  Union  by  bone  is 
almost  invariable,  and  the  amount  of  callus  thrown  out  is  often  greatly  in  excess 
of  what  is  needed.  In  these  cases,  therefore,  every  effort  must  be  made  to  restore 
the  length  of  the  limb  and  the  position  of  the  fragments  as  thoroughly  as 
possible.  Very  often  it  is  of  great  advantage  to  give  the  patient  an  anaesthetic ; 
the  manipulation  is  painless  ;  the  broken  surfaces  can  be  adjusted  more  accurately  ; 
the  mu.scles  are  relaxed  so  that  th«  limb  can  be  extended  to  its  full  length  at 
once  ;  and  when  consciousness  returns,  owing  to  the  compression  and  extension 
to  which  they  are  subjected,  there  is  not  the  same  amount  of  spasmodic  contrac- 
tion. The  most  efficient  method  is  by  means  of  a  long  splint  and  a  weight,  the 
amount  employed  being  regulated  in  each  case  by  the  condition  of  the  mu.scles 
and  the  degree  of  shortening.  If  it  is  attached  to  the  limb  alone,  and  there  is  no 
friction  against  the  bed-clothes,  eight  or  ten  pounds  are  usually  sufficient,  though 
in  exceptional  cases  much  more  may  be  required.  The  rapidity  with  Avhich  re- 
pair takes  place  depends  upon  the  age  of  the  patient  and  on  the  bruising  and 
comminution  to  which  the  parts  have  been  subjected.  Generally  the  patient  may 
be  allowed  to  get  about  at  the  end  of  four  weeks  with  a  Thomas's  hip-splint,  or 
a  leather  .shield,  or  a  firm  spica  (made  extra  strong  in  front  and  on  the  outer 
side),  but  no  weight  can  be  allowed  upon  the  limb  for  at  least  six  weeks  or  two 
months  more.  Union  rarely  fails,  but  there  is  nearly  always  a  certain  degree  of 
lameness  and  shortening  afterward. 

Impacted  Fracture  of  the  Upper  End  of  the  Femur. 

This,  again,  is  entirely  different.  There  are  two  varieties,  corresponding  to 
the  two  described  already,  but  they  can  rarely  be  distinguished  from  each  other ; 
and,  as  they  require  precisely  the  same  treatment,  it  is  doubtful  if  there  is  much 
advantage  in  attempting  to  do  .so.  In  the  one  the  line  of  separation  follows  the 
ba.se  of  the  neck,  and  this  is  forced  into  the  substance  of  the  trochanter  until  it 
is  fixed  there  (Fig.  145)  ;  in  the  other  the  fracture  is  immediately  below  the 
cartilage,  and  the  under  surface  of  the  neck  is  driven  into  the  cancellous  tissue  of 
the  head  (Fig.  146).  The  former  is  not  confined  to  any  age  and  sometimes  may 
be  diagnosed  from  the  condition  of  the  trochanter;  the  latter  (the  intra-articular 
form)  rarely  occurs  except  in  old  people,  but  it  is  .seldom  possible  to  distinguish 
one  from  the  other.     The  important  feature  is  the  existence  of  impaction. 

The  cause  is  always  direct  violence,  a  fall  or  a  blow  upon  the  hip.  The  symp- 
toms are  almost  the  .same  as  those  described  already,  but  they  are  not  nearly  so 
marked.  The  shortening  is  rarely  more  than  half,  or  at  the  most  three-quarters  of 
an  inch  ;  and  so  long  as  the  impaction  continues  it  does  not  vary.  There  may  be  in- 
version in  this  as  in  the  other  fractures,  but  it  is  very  rare  ;  the  limb  is  either  straight 
or  everted,  and  it  is  not  possible  to  rotate  it  inward,  as  it  is  when  the  bone  is  not 
impacted.  Sometimes  the  patient  can  lift  the  limb  from  the  bed  ;  walking,  even, 
is  possible  ;  and  Astley  Cooper  mentions  the  case  of  a  man  who- went  about  for 
four  days  and  pa.ssed  inspection  before  the  impaction  gave  way.  Crepitus  and 
undue  mobility  of  course  are  wanting;  while  the  amount  of  pain  and  the  severity 
of  the  shock  naturally  vary  with  the  nature  of  the  accident.  The  condition  of 
the  fascia  lata  on  the  outer  side  of  the  thigh,  whether  it  is  relaxed  or  not, 
is  in  many  cases  the  only  sign  by  which  it  is  possible  to  distinguish  between 
impacted  fracture  of  the  neck  of  the  femur  and  a  severe  contusion  of   the  hij) 


FRACTURES  OF  THE  FEMUR. 


419 


in  an  old  or  rheumatic  patient.    Sometimes  even  this  fails,  and  then  the  diagnosis 
can  only  be  made  by  the  length  of  time  that  it  takes  for  the  liml)  to  recover. 

The  important  point  in  these  fractures  is  the  presence  of  impaction.  If  this 
can  be  ])reserved,  repair  by  bone  is  fairly  certain,  with  the  minimum  of  deformity; 
if  it  is  broken  down,  in  the  one  case  there  will  be  only  ligamentous  union,  perhaps 
none  at  all  ;  in  the  other  the  deformity  and  shortening  will  almost  certainly  be 
increased,  and  the  period  of  confinement  much  lengthened.  The  limb  must  be 
handled  with  the  utmost  care,  and  any  manipulation  that  is  not  absolutely  neces- 
sary strictly  avoided.  For  security's  sake  it  should  be  bandaged  to  a  long  splint, 
or,  if  there  is  any  fear  of  congestion  of  the  lungs,  fixed  between  sand-bags  with  a 
weight  of  two  or  three  pounds  attached,  not  for  the  purpose  of  keeping  up  exten- 
sion, but  merely  to  prevent  spasmodic  contraction.  In  three  or  four  weeks'  time 
a  Thomas's  sjilint  may  be  applied,  or  the  limb  encased  in  a  shield  or  a  spica,  and 
the  patient  allowed  to  get  about  on  crutches  with  the  foot  suspended  in  a  sling. 
A  shorter  time  than  this  is  rarely  advisable  ;  and  if  the  injury  is  very  severe,  or  the 
patient  corpulent,  it  may  be  extended  with  advantage.     The  accident  is  a  serious 


'vm 


Fig.  145. — Impacted  Fracture  through  Base  of 
Neck  of  Femur. 


.,=^r^r:^ 


4^ 


Fig.  146.— Impacted  Intra-articular  Fracture  of  Neck 
of  Femur. 


one,  the  weight  and  the  leverage  of  the  limb  are  very  great,  and  it  is  rarely  worth 
w'hile  running  any  risk.  The  shortening  is  easily  compensated  for,  but  if  much 
eversion  of  the  limb  is  left  the  position  of  the  foot  is  very  awkward. 


Fracture  Through  the  Trochanter. 

Two  forms  of  this  have  been  described,  but  they  are  both  rare.  The  first  is 
merely  a  variety  of  the  fracture  through  the  base  of  the  neck  without  impaction, 
the  line  of  separation  running  obliquely  through  the  trochanter  a  little  further 
outward,  so  that  one  half  remains  attached  to  the  head  and  neck,  the  other  to  the 
shaft.  The  symptoms  depend  upon  the  amount  of  displacement,  which,  unless 
the  fragments  become  locked  in  some  way,  is  generally  very  great.  In  one  case 
the  injury  closely  simulated  dislocation  on  to  the  sciatic  notch,  but  the  presence 
of  crepitus  and  undue  mobility,  the  results  of  measurement  in  the  flexed  position 
of  the  limb,  and  the  absence  of  the  hollow  in  Scarpa's  triangle,  are  sufficiently 
characteristic  to  prevent  serious  difficulty. 

In   the   other  variety  the  trochanter  is  detached   from  the  rest  of  the  bone 


420     DISEASES  AND   INJURIES    OF  SPECIAL    STRUCTURES. 

by  direct  violence.     Several   instances  are  on   record,  but  as  the  patients  were 
young,  in  all  probability  they  were  examples  of  separation  of  the  epiphysis  (Fig. 

147).  Tlie  swelling  and  ecchymosis  may  be  so  great 
as  to  render  diagnosis  difficult ;  jjassive  movement  of 
the  joint  is  unimpaired,  though  very  painfid  ;  crepitus 
( an  rarely  be  felt,  owing  to  the  way  in  which  the 
troclianter  is  pulled  upward  by  the  glutei  and  the  short 
rotators,  and  the  length  of  the  limb  is  unaltered.  In 
one  case  the  broken  surfaces  were  held  together  by  the 
fascia,  which  was  not  torn.  Union,  unless  this  is  pre- 
served, is  almost  sure  to  be  fibrous,  and  for  some  time 
at  least  there  is  considerable  loss   of  power  over  the 

Fig.  147— Separation  of  Great       ''mb. 

Trochanter  of  Femur.  Sejjaration  oi  the  epiphysis  forming  the  head  of 

the  femur  may  occur,  but  it  ha.s  not  been  proved. 
The  symptoms  would  be  the  same  as  those  of  the  intra-articular  variety. 

Diagnosis. — The  diagnosis  of  fracture  of  the  neck  of  the  femur  must  be 
made  from  sciatic  dislocation,  impaction  of  the  head  of  the  bone  into  the  floor  of 
the  acetabulum,  fracture  of  the  lip  of  the  acetabulum,  and  contusion,  especially  in 
cases  of  rheumatoid  arthritis.  If  there  is  the  least  doubt,  the  examination  should 
be  completed  under  an  anesthetic  ;  to  say  nothing  of  the  pain,  it  is  almost  impos- 
sible to  manipulate  the  thigh  of  a  muscular  adult  satisfactorily  unless  the  muscles 
are  relaxed. 

1.  Sciatic  Dislocation. — The  difficulty  is  due  to  the  fact  that  in  this  form  of 
injury  the  limb  is  often  almost  straight,  and  retains  (especially  at  first)  a  very  un- 
usual degree  of  mobility  ;  and  also  that  the  head  of  the  bone  can  rarely  be  felt. 
Unless,  however,  the  patient  is  very  stout,  an  emj^ty  space  can  always  be  made  out 
in  Scarpa's  triangle  ;  the  femoral  vessels  can  be  felt  to  dip  down  suddenly  ;  abduc- 
tion of  the  limb  when  it  is  flexed  at  a  right  angle  is  impossible,  and  the  measure- 
ment of  the  length  of  the  thigh,  when  the  hip  is  in  this  position,  shows  very 
considerable  shortening. 

2.  Impaction  into  the  Floor  of  the  Acetabulitni. — This  is  a  very  rare  accident, 
but  on  several  occasions  the  mistake  has  occurred.  The  injury  is  produced  in  the 
same  way  ;  the  violence  is  extreme  and  the  amount  of  bruising  sufficient  to  conceal 
everything.  Movement  may  be  very  free,  probably  owing  to  the  extent  to  which 
the  bone  gives  way.  The  chief  distinction  is  the  extreme  inward  disi)lacement  of 
the  trochanter  ;  in  addition  there  may  be  signs  of  injury  to  the  innominate  bone  ; 
and  it  may  be  possible  to  feel  the  head  of  the  femur  through  the  rectum  or  vagina. 

3.  Fracture  of  the  Lip  of  the  Acetabulum. — When  the  upper  and  back  i)art  is 
chipped  off,  the  head  of  the  bone  slips  out  of  the  cavity  and  rests  on  the  dorsum, 
almost  in  the  jjosition  of  a  dislocation.  In  one  case  under  my  care  the  displace- 
ment was  exactly  that  of  a  sciatic  dislocation,  and  was  reduced  as  such,  but  it 
immediately  returned,  and  when  the  limb  was  manipulated  the  head  of  the  bone 
could  be  easily  felt  above  and  behind  the  trochanter. 

4.  Severe  Contusions. — In  these  the  difficulty  is  very  much  greater,  and  if  the 
limb  is  shortened  and  everted  from  old  rheumatoid  arthritis  ;  if  (as  is  often  the 
case)  the  trochanter  is  thickened,  and,  owing  to  the  disappearance  of  the  articular 
cartilage,  there  is  a  certain  amount  of  crepitus  on  movement,  it  may  be  impossible 
to  feel  certain  until  a  sufficient  length  of  time  has  elapsed  for  the  muscles  to  re- 
cover. The  limb  lies  perfectly  helpless  and  everted  ;  the  muscles  cannot  act,  o\ving 
to  the  way  in  which  they  have  been  bruised,  and  it  is  im])ossible  to  say  whether 
the  whole  of  the  shock  has  been  expended  on  the  soft  tissues,  or  if  the  bone  has 
suffered  too.  Not  imjjrobably  in  many  of  these  cases  the  neck  is  splintered  on  its 
anterior  surface,  though  it  may  not  actually  be  broken  across.  The  history  is  of 
little  service,  sui)posing  it  could  be  relied  upon  ;  the  existence  of  rheumatoid 
arthritis  would  not  in  any  way  preclude  fracture.  The  only  distinguishing  sign  is 
the  condition  of  the  fascia  lata  on  the  outer  side  of  the  thigh  ;  if  the  shortening  is 


FRACTURES  OF  THE   FEMUR.  421 

gradual  (as  from  disease)  this  is  tense  ;  if  siuiden,  it  must  be  relaxed  ;  Init  it  must 
be  admitted  that  it  is  not  always  jjossible,  even  when  the  two  sides  are  compared, 
to  make  certain  of  the  difference. 

At  a  later  jieriod  the  diagnosis  of  contusion  without  fracture  is  occasionally 
called  in  (juestion,  owing  to  a  peculiar  alteration  that  takes  place  in  the  substance 
of  the  bone.  It  sometin-.es  happens  tliat,  within  a  twelvemonth  of  an  accident  of 
this  kind,  the  neck  of  the  femur  almost  disappears,  the  limb  becomes  everted  and 
shortened  an  inch  or  even  an  inch  and  a  half,  the  muscles  waste,  the  movements 
are  crippled,  and  the  appearance  is  almost  identical  with  that  left  after  fracture  of 
the  neck.  This  is  known  as  interstitial  absorption  of  the  neck  of  the  femur.  In 
many  of  its  features  it  closely  resembles  rheumatoid  arthritis,  and  it  is  well  known 
that  this  sometimes  attacks  a  single  joint,  almost  to  the  exclusion  of  the  rest, 
especially  after  injury  ;  but  these  changes  are  not  unfrequently  met  with  in  young 
adults,  who,  at  the  time  at  least,  show  no  other  sign  of  this  disease  ;  and  an  altera- 
tion of  a  somewhat  similar  character  is  found  occasionally  in  connection  with  other 
bones,  the  humerus,  for  example,  after  fracture.  All  that  can  be  said  is  that  injuries 
of  this  description  are  sometimes  followed  by  ])rofound  alterations  in  the  nutrition 
of  the  part. 

Fractures  of  the  Shaft  of  the  Femur. 

These  may  be  caused  by  direct  or  indirect  violence,  or  l)y  muscular  action, 
and  may  affect  any  part  of  the  bone  from  the  lesser  trochanter  to  the  base  of  the 
condyles.  In  infants  and  children  they  are  transverse  and  usually  subperiosteal  ; 
in  adults  they  are  more  frequently  oblique,  sometimes  even  spiral.  Compound  and 
comminuted  fractures  are  not  uncommon,  but  impaction  is  rare,  except  at  the  lower 
extremity. 

Displacement. — The  relative  position  of  the  two  fragments  is  dependent 
mainly  upon  the  direction  of  the  fracture.  When  it  is  transverse  and  the  perios- 
teum is  not  torn,  there  is  merely  a  certain  amount  of  angular  bending  ;  in  all  other 
cases  the  lower  part  of  the  limb  rolls  outward,  from  its  weight, /intil  it  lies  com- 
pletely upon  its  outer  side,  and  is  pulled  upward  toward  the  u-unk  by  the  con- 
traction of  the  muscles.  There  may  be  as  much  as  three  or  even  four  inches  shorten- 
ing in  a  muscular  adult.  The  position  of  the  upper  fragment  is  not  constant ;  it 
is  generally  rotated  outward  to  a  certain  extent,  especially  if  the  fracture  is  high 
up,  by  the  muscles  attached  to  the  great  trochanter,  but  never  so  far  as  the  lower 
one,  and  it  is  usually  flexed  and  tilted  upward,  partly  by  the  action  of  the  ilio-psoas, 
partly  by  the  pressure  of  the  lower  fragment  against  its  under  surface.  When  the 
fracture  is  immediately  below  the  lesser  trochanter  I  have  known  it  tilted  to  such 
an  extent  that  the  broken  surface  projected  underneath  the  skin  upon  the  front  of 
the  thigh. 

Symptoms. — The  ordinary  signs  of  fracture  are  well  marked  ;  the  limb  is 
shortened,  everted,  and  absolutely  helpless  ;  undue  mobility  and  crepitus  are 
always  present,  and  there  is  always  extreme  pain  about  the  seat  of  injury. 
Ecchymosis,  however,  owing  to  the  deep  situation  of  the  bone,  often  does  not  show 
itself  for  some  considerable  time,  in  many  cases  not  at  all.  Sometimes  it  is  difficult 
to  make  certain  of  the  exact  position  and  direction  of  the  broken  ends,  especially 
if  they  are  very  oblique  or  driven  deeply  into  the  substance  of  the  surrounding 
muscles,  and  it  is  never  easy  to  appreciate  the  amount  of  comminution.  The  soft 
tissues  rarely  suffer  to  any  serious  extent  in  simple  fractures,  except  when  the  injury 
is  low  down  in  the  thigh  ;  in  those  that  are  compound  by  direct  violence,  on  the 
other  hand,  they  are  often  hopelessly  disorganized. 

Union  is  generally  sufficiently  firm  at  the  end  of  three  weeks  to  allow  the 
patient  to  get  about  on  crutches  with  some  fixed  apparatus,  but  no  weight  must  be 
placed  upon  the  foot  for  at  least  ten  weeks  from  the  date  of  the  accident,  and  in 
many  instances,  when  the  patient  is  corpulent  or  the  fracture  oblique,  this  time 
may  be  extended   with  advantage.      Except  in   transverse  fractures,  shortening  to 


42  2     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


ii>.\ 


o  o 


the  extent  of  half  an  inc  h  is  so  common,  in  spite  of  every  precaution,  that  it  must 
be  regarded  as  the  rule  :  sometimes  it  is  even  worse  than  this,  without  its  being 
possible  to  say  that  the  case  has  been  treated  badly.  Delayed  union  is  not  uncom- 
mon, and  false  ;oint  may  occur,  especially  when  the  fragments  are  oblique  or  are 
driven  into  the  muscles  around. 

Treatment. — The  simplest  and  most  useful  method  for  all  ordinary  cases  is 
a  combination  of  Liston's  (Fig.  148)  or  Desault's  (Fig.  149)  long  splint,  with  ex- 
tension by  means  of  a  weight  attached  to  the  limb.  Counter-extension  is  made, 
not  with  a  perineal  band,  which  is  very  apt  to  gall  the  patient,  and  in  women  is 
peculiarly  objectionable,  but  by  raising  the  foot  of  the  bed,  .so  that  the  body  lies 
on  an  inclined  plane  [and  itself  constitutes  the  counter  extending  force.]    The  splint 

must  be  sufficiently  long  to  reach  from 
the  axilla  to  below  the  foot,  the  outer 
malleolus  fitting  into  the  hollow  made 
to  receive  it,  and  sufficiently  broad  to 
be  really  on  a  level  with  the  thigh  ;  in 
cases  in  which  the  hips  are  prominent, 
the  padding  must  be  especially  thick 
or  the  patient  cannot  lie  straight,  and 
there  should  always  be  a  cross-bar 
screwed  to  the  under  surface  at  the 
lower  end,  to  serve  the  double  purpose 
of  raising  the  heel  well  off  the  bed 
and  of  preventing  any  rotation  of  the 
limb.  A  flannel  bandage  is  first  placed 
round  the  foot  and  the  lower  part  of 
the  calf;  and  then  a  piece  of  strapping 
two  inches  and  a  half  wide,  and  twice 
the  length  of  the  distance  from  just 
above  the  patient's  knee  to  six  inches 
below  the  sole,  is  fastened  to  the  limb, 
so  that  the  two  ends  lie  one  on  each 
side,  and  the  loop  projects  below  the 
foot.  If  the  strips  are  arranged  ob- 
liquely, the  outer  end  winding  round 
the  limb  toward  the  posterior  surface, 
and  the  inner  to  the  anterior,  the  ex- 
tension helps  as  soon  as  the  weight  is 
on,  to  correct  the  eversion  of  the  limb. 
Transverse  strips  are  then  placed  round 
the  limb  to  hold  this  in  position,  the 
centre  of  each  corresponding  to  the 
posterior  surface  of  the  leg  and  the 
ends  crossing  obliquely  in  front,  until 
the  whole  is  covered  in  from  the 
middle  of  the  calf  to  the  condyles  of 
the  femur.  The  loop  is  held  open 
with  a  wooden  stirrup,  which  is  per- 
forated in  the  centre  to  allow  of  a 
cord  being  passed  through  and  is  wide 
enough  to  jirevent  any  pressure  upon 
the  malleoli,  and  the  weight  suspended 
from  the  other  end  of  the  cord  by 
means  of  a  pulley  at  the  foot  of  the 
bed.  The  amount  depends  upon  the  degree  of  shortening  and  the  strength  of 
the  muscles,  but  eight  or  ten  pounds  are  usually  sufficient  (Fig.  150). 

If  the  patient  is  under  an  anaesthetic  the  splint  may  be  bandaged  on  at 


FRACTURES  OF  THE   FEMUR. 


423 


once  ;  in  other  cases  it  is  sometimes  advantageous  to  wait  until  the  next  day,  when 
the  fragments  have  resumed  their  normal  situation  ;  the  part  in  the  meantime  is 
kept  steady  by  means  of  sand-bags.  The  long  splint  is  fastened  to  the  outer 
side  of  the  limb,  from  the  foot  to  above  the  knee,  beginning  with  figure-of-eight 
turns,  wide  enough  to  pass  through  the  notches  at  the  lower  end  of  the  splint 
and  to  come  well  above  the  ankle  ;  if  any  pressure  falls  upon  the  back  of  the 
heel,  a  sore  is  sure  to  form.  In  fractures  near  the  middle  of  the  shaft  it  is 
advisable  to  place  a  splint  behind  the  limb  to  maintain  the  natural  arch  of 
the  bone  ;  the  inner  and  anterior  surfaces  may  be  covered  with  felt  or  with 
Gooch's   splint,   cut   to  fit  the   part,   and   fastened  on  with  straps  and  buckles 


Fig.  150.— Mode  of  Applying  Stirrup  for  Weight-Extension. 

(Fig.  151).  In  Other  cases  it  is  sufficient  to  carry  the  bandage  up  from  the 
knee  over  the  seat  of  fracture.  In  bandaging  a  fractured  femur  the  turns 
should  be  carried  from  the  outer  side  over  the  front  of  the  limb  down  the  inner 
one,  as  this  is  of  considerable  help  in  correcting  the  eversion.  Finally  the  splint 
must  be  secured  round  the  waist,  either  by  means  of  a  broad  bandage,  or  a  belt 
provided  with  straps  and  buckles,  and  bandages  starched. 

Liston's  splint  is  made  of  wood  four  inches  wide,  and  half  an  inch  thick, 
long  enough  to  reach  from  the  axilla  to  six  inches  below  the  foot.  The  upper  end 
is  perforated  for  the  attachment  of  a  perineal  band  ;  the  lower  notched,  so  as  to 
afford  a  better  grip  for  the  bandage.      Desault's  differs  in  having  a  foot-piece  to  fit 


Fig.  151.— Liston's  Splint  Applied  with  Gooch's  round  Seat  of  Fracture. 

on  the  outer  side,  in  being  hollowed  out,  and  in  being  much  wider  at  the  upper 
end  than  at  the  lower. 

At  the  end  of  a  fortnight  or  three  weeks,  according  to  the  age  of  the  patient 
and  the  direction  of  the  fracture,  this  maybe  replaced,  either  by  a  fixed  apparatus 
of  gum  and  chalk,  a  starched  bandage  with  longitudinal  strips  of  torn  pasteboard, 
or,  better  still,  by  a  Thomas's  knee  splint.  This  consists  of  a  well-padded  circle, 
fitted  obliquely  round  the  thigh  as  high  up  as  it  will  go,  two  straight  rods  coming 
down  from  this,  one  on  each  side  of  the  limb,  and  a  small  patten  at  the  bottom, 
below  the  foot,  to  connect  them  together.  If  the  stirrup  has  been  well  applied  the 
long  splint  can  be  removed,  a  Thomas'  splint  fitted  on,  the  weight  cut  off,  and  the 
cord  fastened  to  the  patten  at  the  bottom  without  disturbing  the  limb  in  the  least 


4  24     DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 


(Fig.  152).  In  most  instances  it  is  advantageous  to  replace  the  cord  by  an  elastic 
band,  so  as  still  to  keep  up  a  certain  degree  of  extension,  or  the  sides  of  the  splint 
may  be  made  so  that  the  length  can  be  altered  at  will.  Anterior  and  jxjsterior 
wooden  or  felt  splints  are  necessary  to  protect  the  seat  of  injury,  and  the  leg  and 
thigh  must  be  firmly  bandaged  to  the  side  rods.  As  soon  as  this  is  secure  the 
patient  may  l)e  allowed  to  get  about  on  crutches,  with  a  patten  under  the  oppo- 
site foot ;  but,  though  the  whole  of  the  weight  would  be  transmitted  directly  from 
the  fjelvis  to  the  ground,  it  is  not  advisable  to  let  him  rest  upon  the  splint  i^atten 
for  some  weeks  longer  :  the  leg  should  hang  from  the  hip-joint  as  a  mere  appendage. 
In  some  cases  Thomas's  splint  is  used  from  the  first,  but  it  is  difficult  to  obtain  the 
requisite  amount  of  e.xtension  without  galling  the  patient ;  after  being  kept  steadily 
on  the  stretch  for  two  or  three  weeks,  the  tendency  to  contract  on  the  part  of  the 
muscles  is  very  much  diminished. 

In  fractures  below  the  trochanters  another  plan  must  be  adopted.  Extension 
in  a  straight  line  does  not  in  any  way  correct  the  deformity,  and  as  it  is  impossible 
to  influence  the  upper  fragment  materially,  the  lower  must  be  adjusted  to  it.  This 
is  accomplished  either  by  laying  the  patient  upon  the  injured  side,  and  flexing  the 
thigh  upon  the  abdomen  as  recommended  by  Pott,  or  by  making  use  of  a  double- 
inclined  plane.  The  latter  is  the  more  comfortable  ;  the  patient  can  be  propped 
up  in  bed  so  as  to  relax  the  ilio-psoas  still  more,  and  there  is  less  risk  of  bed-sores. 
A  Maclntyre  splint  answers  better  still,  and  is  less  cumbersome.  Whichever  plan 
is  adopted,  extension  is  made  from  the  lower  half  of  the  thigh  by  means  of  a 
stirrup  and  a  weight  suspended  over  a  pulley  at  a  convenient  angle  (Fig.  154;. 
In  cases  in  which  there  is  a  wound  on  the  posterior  surface,  or  the  hip  or 
knee  is  ankylosed  in  an  awkward  position,  an  anterior 
splint,  either  Hodgen's  or  Nathan  Smith's,  may  be  used. 
The  former  of  these  consists  of  two  parallel  metal  rods, 
long  enough  to  reach  from  the  groin  to  below  the  foot, 
held  apart  from  each  other  by  cross-bars.  The  limb  is 
suspended  from  between  these  by  cotton  sacking,  or  broad 
strips  of  flannel,  so  that  it  rests  and  makes  a  bed  for  itself 


Fig.  152 — Thomas'  Brace  Splint  with  Stirrup- 
Extension.  The  anterior  and  posterior  splints 
on  the  thigh  and  the  bandaging  are  not  repre- 
sented. 


Fig.  153. — Badly  United  Fracture  of  Femur. 


FRACTURES  OF  THE  FEMUR. 


425 


in  a  kind  of  trough  (Fig.  155).  Tlie  foot  is  fixed  by  a  stirrup  to  the  cross-bar 
at  the  end,  and  the  whole  is  slung  from  a  pole  over  the  bed  at  such  an  angle  that 
a  certain  amount  of  extension  is  kejjt  up,  the  weight  of  the  body  acting  as  a 
counter-extending  force.  The  knee  joint  nuist  be  kept  nearly  straight.  Nathan 
Smith's  is  either  formed  of  a  similar  framework  with  the  rods  closer  together,  or 


^^c 


Fig.  134- — Maclntyre  Splint  with  Weight-extension  from  the  Knee  in  Fracture  of  the  Femur  below  the  Trochanter. 


of  a  single  flat  median  bar.  The  limb  is  bandaged  directly  to  its  under  surface, 
so  that  it  must  be  bent  to  fit  accurately,  and  then  it  is  suspended  in  the  same  way. 
When  properly  adjusted  these  splints  are  exceedingly  comfortable,  but  they  are 
very  difficult  to  arrange  (suspending  hooks  should  be  made  so  that  they  can  be 
fixed  at  any  point)  ;  they  do  not  secure  the  same  degree  of  immobility, 
or  maintain  extension  so  well,  and  it  is  very  difiicult  to  prevent 
eversion  with  them. 

Transverse   fractures  of  the  shaft  in   children  may  be 

treated  in  various  ways.      In  very  young  infants,  where 

the  thick  periosteum  is  probably  intact 

all  round,  it  is  sufficient  in  many 

cases   merely  to   lay  the  child 

upon  a  pillow  on  its  injured 

side,  with  the  hip  and 

knee  flexed.     As  a 

rule  thev  lie  re- 


Fig.  155. — Dr.  J.  T.  Hodgen's  Suspension  Splint,  as  used  at  Guy's. 


Fig.  156. —  Plaster 
Bandages  and  Verti- 
cal Extension  for 
Fracture  of  Femur 
in  an  infant. 


markably  quiet,  and  though  the  bone  may  not  be  perfectly  straight,  the  angle  is 
so  slight,  and  the  subsequent  changes  so  rapid  and  extensive,  that  in  a  year  or 
two  it  is  scarcely  perceptible.  Union  is  fairly  firm  in  ten  days  or  a  fortnight. 
In  those  a  little  older,  vertical  suspension  of  both  legs  is  more  satisfactory  ;  a 
miniature  stirrup  is  fastened  on  to  each  in  the  ordinary  way ;  the  cords  are 
28 


426    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

passed  over  two  pulleys  attached  to  a  cradle  or  a  horizontal  bar  over  the  child's 
body,  and  a  weight  is  suspended  from  each  just  sufficient  to  keep  the  leg  straight 
in  a  vertical  position.  A  starclied  l)an(lage  is  then  placed  round  the  thigh. 
The  child  soon  becomes  accustomed  to  the  constraint,  and  the  bandages  remain 
dry  and  clean  to  the  last.  Bryant's  splint,  which  is  made  of  two  long  ones, 
one  on  either  side  of  the  body,  connected  together  by  an  arch  over  the  trunk, 
and  a  bar  below  the  feet,  is  especially  useful  in  the  case  of  older  children. 
Extension  can  be  applied  by  a  weight  to  the  injured  leg  ;  it  is  impossible  for  the 
child  to  twist  its  body  round,  and  the  limbs  are  kept  exactly  parallel. 


Fractures  of  the  Lower  Extre.mitv  of  the  Femur. 

These  may  be  classifietJ  in  the  same  way  as  fractures  of  the  lower  extremity  of 
the  humerus.     The  bone  may  be  broken  across  altogether  above  tlie  knee-joint. 


—->^ 


F1G.157. — Shaft  and  Epiphysis  of  Femur  Sepa- 
rated by  maceration.  The  epiphysis  had 
been  split  in  two  about  a  year  before  the 
limb  was  removed,  and  union  across  the 
epiphysial  line  was  osseous. 


Fig.  158. — Fracture  of  Lower  End  of 
Femur  with  Displacement  of  Upper 
Fragment  Backward.  About  a  year 
after  the  accident  the  projecting  end 
wore  a  hole  in  the  popliteal  artery 
and  gave  rise  to  an  arterial  haema- 
toma. 


supracondyloid  ;  in  addition  to  this  the  lower  extremity  may  be  split  vertically 
in  two,  by  the  wedge-like  action  of  the  patella,  T-shaped  ;  one  or  other  condyle 
may  be  detached  ;  or  the  epiphysis  may  be  separated.  Imi)acted  fractures  are  not 
uncommon,  the  lower  end  of  the  upper  fragment  being  driven  into  the  cancellous 
tissue  of  the  other  with  sufficient  force  to  become  fixed  in  it,  but  not  sufficient  to 
break  it  into  pieces.  The  lower  end  of  the  femur  may  be  split  vertically  by  the 
impact  of  the  patella,  without  any  transverse  separation  (Fig.  157). 


Supra-cotidyloid  and  T -shaped. 

These  mav  be  produced  by  direct  or  indirect  violence ;  in  the  latter  case  the 
bone  gives  way  at  the  junction  of  the  compact  tissue  of  the  shaft  with  the  ex- 
panded lower  extremity;  impaction  is  not  unusual;   and,   if  the   force  is  very 


FRACTURES  OF  THE  FEMUR.  427 

severe,  the  lower  fragment  is  split  into  two  (or  even  more  pieces),  the  fracture 
assmiies  a  T-shape,  ami  the  knee  joint  is  opened  up.  In  the  supra-condyloid 
form  there  is  peculiar  danger  from  the  position  of  the  popliteal  vessels.  The 
fracture  is  generally  oblique  from  above  downward  and  forward  ;  the  gastroc- 
nemius, pulling  on  the  lower  fragment,  causes  it  to  rotate;  the  fractured  surface 
is  directed  backward,  the  normal  anterior  one  upward  ;  and  if  any  extension  is 
made  upon  the  leg  the  vessels  are  almost  certain  to  be  compressed,  perhaps 
even  torn. 

The  same  thing  occurs  when  the  displacement  is  in  the  opposite  direction, 
if  the  lower  end  of  the  upper  fragment  comes  in  contact  with  the  artery  (Fig. 
158).  The  synovial  membrane  of  the  knee  joint  may  be  torn  under  the  quadri- 
ceps tendon  so  as  to  communicate  with  the  fracture,  even  when  there  is  no 
vertical  fissure  running  down. 

Signs. — Shortening,  deformity,  pain,  and  swelling  are  so  conspicuous  that, 
even  if  the  fragments  are  impacted,  there  is  little  difficulty  in  the  diagnosis.  If 
they  remain  loose,  crepitus  and  undue  mobility  are  present  as  well.  When  the 
knee  joint  is  involved  the  synovial  cavity  becomes  distended  with  blood ;  if  the 
condyles  are  separated,  they  can  be  made  to  work  backward  and  forward  upon 
each  other  by  pressing  on  them  alternately  ;  and  there  is  an  increase  in  the 
transverse  measurement  of  the  part.  When  the  popliteal  artery  is  torn,  or 
w^ounded,  an  immense  sw-elling  forms  with  great  rapidity  in  the  popliteal  space, 
filling  it  up  completely,  and  the  limb  becomes  cold  and  pulseless  ;  if  it  is  merely 
pressed  upon,  the  temperature  of  the  limb  falls  more  gradually,  but  in  spite  of 
the  collateral  circulation  the  same  result  generally  ensues. 

Treatment. — This  depends  to  a  great  extent  upon  the  direction  of  the 
fracture  and  the  amount  of  injury  done  to  the  knee  joint.  Shortening  is  very 
common,  unless  the  fracture  is  transverse,  and  nearly  always  there  is  some 
impairment  of  movement,  partly  owing  to  the  difficulty  of  restoring  exactly  the 
outline  of  the  articular  surfaces,  partly  from  the  formation  of  adhesions.  The 
condition  of  the  posterior  tibial  artery  requires  even  more  than  ordinary  atten- 
tion. Liston's  long  splint  and  weight  extension  from  the  leg  may  be  used,  if  the 
upper  fragment  has  a  tendency  to  back\vard  displacement :  in  all  other  cases 
either  the  limb  must  be  placed  on  a  double  inclined  plane  (or  a  Mclntyre 
splint),  or  the  tendo-Achillis  must  be  divided.  The  latter  is  preferable,  as, 
owing  to  the  small  size  of  the  lower  fragment  of  bone,  it  is  almost  impossible 
to  make  satisfactory  extension  from  it  with  the  knee  flexed.  If  the  knee  joint  is 
involved,  the  distention  of  the  synovial  sac  must  be  reduced  as  soon  as  possible 
by  cold,  pressure,  and  even  aspiration,  though  this  should  only  be  resorted 
to  when  the  case  is  really  urgent.  Then  the  fragments  must  be  replaced  by  man- 
ipulation, and  fixed  by  pressure,  taking  care  to  cover  them  with  a  thick  even  layer 
of  cotton-wool.  Passive  motion  of  the  joint  should  be  commenced  not  later  than 
the  end  of  the  fourth  w^eek.  If  the  popliteal  artery  is  wounded,  an  attempt  may 
be  made  to  secure  the  two  ends  by  ligature ;  but  very  often  the  vein  is  injured  as 
well,  or  the  fracture  communicates  with  the  joint,  and  either  gangrene  sets  in  or 
the  knee  is  disorganized  to  such  an  extent  that  the  limb  has  to  be  amputated. 

Separation  of  a  Condyle. 

It  occasionally  happens  as  a  result  of  direct  violence,  or  even  it  is  said  from 
forcible  rotation,  that  one  of  the  condyles  is  detached  from  the  rest  of  the  bone 
without  the  shaft  being  broken  across.  The  symptoms  depend  upon  the  amount 
of  comminution  ;  the  joint  becomes  distended  with  blood,  generally  at  once,  but 
in  one  case  under  my  care  this  was  not.  marked  in  degree  for  several  hours  ;  the 
length  of  the  limb  is  not  altered  ;  pain  on  pressure  is  very  great ;  and  crepitus  and 
undue  mobility  are  usually  distinct.  A  fixed  bandage,  with  a  thick  layer  of  cotton- 
wool over  the  joint,  should  be  applied  as  soon  as  the  fragments  can  be  manipulated 
into  position  ;  but  as  absorption  proceeds  it  will  probably  require  to  be  replaced  in 


428    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES, 

Ihe  course  of  a  few  days.      Passive  motion  should  be  commenced   not   later  than 
the  third  week. 

Separation  of  the  loivcr  epiphysis  is  not  an  uncommon  form  of  accident  ;  it 
can  only  occur  under  twenty  years  of  age,  and  is  rarely  met  with  over  sixteen. 
Generally  speaking  it  is  produced  by  indirect  violence,  forcible  wrenching  or 
twisting,  but  it  may  be  caused  by  direct.  The  knee  joint  is  almost  certain  to  be 
involved,  though  it  is  anatomically  po.ssible  to  separate  the  epiphysis  without  open- 
ing the  synovial  membrane.  The  symj^toms  are  almost  the  same  as  those  of  the 
supra-condyloid  variety,  from  which  it  can  only  be  distinguished  by  the  age  of 
the  patient,  the  absence  of  true  crepitus,  and  the  position  of  the  adductor  tubercle. 
The  displacement  and  the  treatment  are  the  same,  though  owing  to  the  concave 
shape  of  the  upper  surface  of  the  epiphysis  there  is  not  the  same  tendency  to 
backward  rotation  of  the  lower  fragment. 


Compound  Fractures  of  the  Femur. 

These  may  occur  either  from  direct  or  indirect  violence.  The  latter  are  not 
common,  partly  because  the  bone  is  situated  at  such  a  depth,  partly  because  it  is 
so  impossible  for  a  patient  with  a  broken  thigh  to  try  to  stand  ;  most  of  them 
occur  at  or  near  the  lower  third,  and  frequently  they  involve  the  knee  joint. 

When  they  are  due  to  direct  violence,  the  injury  to  the  soft  parts  is  generally 
so  extreme  that  there  can  be  little  hope  of  saving  the  limb,  especially  as  the  skin 
is  not  unfrequently  destroyed  far  above  the  point  at  which  the  bone  is  crushed. 
The  only  question  is  when  amputation  should  be  performed.  In  the  case  of  the 
upper  part  of  the  femur,  this  operation,  when  primary,  affords  so  little  hope,  that, 
unless  in  exceptional  instances,  it  is  practically  abandoned  ;  hemorrhage  must  be 
checked,  not  merely  that  from  the  main  artery,  which  seldom  bleeds,  but  the  capil- 
larv  oozing,  for  this,  though  almost  imperceptible  at  any  given  moment,  is  very 
serious  from  its  persistence  ;  putrefaction  must  be  prevented,  especially  in  the  region 
of  the  bone,  where  it  is  exceedingly  prone  to  occur  ;  and  every  effort  must  be  made 
to  restore  the  patient's  temperature  and  tide  him  over  the  shock.  When  reaction 
has  fully  set  in,  the  mangled  part  may  be  removed  and  the  stump  trimmed  without 
so  much  risk.  If  the  injury  involves  the  lower  half,  amputation  may  be  performed 
as  soon  as  the  patient  is  in  a  fit  state  to  bear  it  ;  but,  unless  it  is  done  immediately 
after  the  accident,  so  that  the  operation  is  really  primary,  it  is  better  to  treat  the 
case  in  the  same  way  as  a  fracture  of  the  upper  half,  and  wait  till  the  second  or 
even  the  third  day. 

In  fractures  that  are  compound  by  indirect  violence  the  prospect  is  much 
better,  and  even  when  the  knee  joint  is  involved  the  limb  can  usually  be  saved. 
The  treatment  must  be  guided  by  the  age  and  constitution  of  the  patient  and  by 
the  nature  of  the  injury.  A  mere  puncture  may  be  dusted  over  w'ith  iodoform 
and  sealed  beneath  an  absorbent  dressing,  the  wound  and  the  bone,  if  it  pro- 
truded, having  first  been  thoroughly  cleansed  with  corrosive  sublimate  or  some 
other  antiseptic.  A  larger  opening  should  be  carefully  exi)lored  with  the  finger, 
washed  out  to  its  utmost  recesses,  and  either  drained  with  counter-openings  or  left 
gaping  to  a  certain  extent.  If  the  bone  is  comminuted,  any  loose  s{)linters  may 
be  removed,  and  if  the  fragments  are  much  displaced  they  may  be  sutured 
together,  but  this  is  rarely  possible  in  the  case  of  the  femur  without  enlarging  the 
opening  very  considerably.  Wound  of  the  femoral  artery  does  not  of  itself  require 
amputation  in  a  case  of  compound  fracture  ;  injury  to  the  vein  appears  to  be  more 
serious. 

The  same  line  of  treatment  must  be  pursued  when  the  fracture  extends  into 
the  knee  joint,  but  it  must  not  be  forgotten  that,  though  the  opening  on  the  sur- 
face may  be  small,  the  real  size  of  the  wound  is  equal  to  that  of  the  synovial 
membrane.  Every  effort  must  be  made  to  prevent  inflammation  ;  the  part  itself 
must  be  thoroughly  cleansed  ;  the  wound,  if  more  than  a  puncture,  washed  out 


FRACTURES  OF  THE  PATELLA. 


429 


from  the  bottom  with  an  antiseptic  and  drained  ;  the  limb  placed  upon  a  Mac- 
Intyre  splint ;  cold  and  gentle  pressure  applied  to  the  joint ;  and  an  ice-bag  laid 
upon  the  femoral  artery  if  there  is  the  least  sign  of  heat  in  the  limb.  If,  in  spite 
of  these  precautions,  the  joint  swells  up  and  becomes  tense,  and  if  the  skin  over  it 
becomes  red  and  (L'dematous,  and  the  patient's  temperature  begins  to  rise,  free 
incision  should  be  made  on  each  side  into  the  joint  and  thorough  drainage  carried 
out.  Even  then  the  articulation  may  recover,  though  suppuration,  with  destruction 
of  the  cartilages  and  ankylosis,  is  a  more  probable  result  ;  and  secondary  amputa- 
tion may  be  required  to  prevent  the  patient  sinking  from  exhaustion. 


l-KACTLRES  OF  THE  PATELLA. 

These  are  nearly  always  the  result  of  muscular  action  ;  occasionally 
produced  by  direct  violence.  In  the  for- 
mer case  the  line  of  separation  is  always 
transverse,  though  it  may  run  across  any 
part  of  the  bone ;  the  fascia  is  torn  to  a 
greater  or  less  extent ;  the  amount  of  sepa- 
ration is  generally  considerable  ;  and  union 
by  bone  is  the  exception,  not  the  rule.  In 
the  latter  the  fracture  may  be  stellate,  verti- 
cal, transverse,  or  comminuted  ;  the  fascia 
covering  it  and  attached  to  the  sides  is  not 
torn  ;  the  amount   of  separation   between 

the  fragments  is   not  exceptional,  and  union  nearly  always  takes  place 
(Figs.  159  and   160). 


Fig.  159. 
Transverse  and  Stellate  Fractures  of 


by  bone 


Fracture  by  Muscular  Action. 

I'he  frequency  with  which  this  takes  place 
is  accounted  for  by  the  anatomical  relation  of 
the  part.  When  the  knee  is  flexed,  the  lower 
half  of  the  patella  rests  uijon  the  prominent 
portion  of  the  condyles  of  the  femur,  the  upper 
is  entirely  unsupported,  and   the  plane  of  the 


Fig.  161. — Section  through  Knee  after  Fracture 
of  Patella,  showing  Displacement. 


Fig.  162. 


-Knee  in  a  case  of  Fractured 
Patella. 


bone  is  almost  at  right  angles  to  the  direction  of  the  quadriceps.  If  this  muscle 
suddenly  contracts,  the  whole  of  the  strain  falls  upon  one  spot,  and  the  bone 
gives  way  just  as  when  a  stick  is   snapped   across    the  knee.     The  patient  is 


430     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES, 

conscious  of  something  breaking  before  he  falls,  and  it  sometimes  happens  that, 
in  the  desperate  effort  to  save  himself,  the  other  patella  snajw  across  as  well. 
I  liave  known  this  occur  to  a  man  in  the  first  stride  of  a  race. 

Displacement. — The  amount  is  very  variable,  and  depends  ui)on  the  lacer- 
ation of  the  fascia;  if  this  does  not  give  way  there  is  no  separation.  At  the  first 
instant  it  is  caused  by  muscular  contraction,  and  it  is  often  made  worse  by  attemj^t- 
ing  to  stand  or  walk.  Afterward  the  broken  surfaces  are  forced  asunder  by  the 
effusion  into  the  joint,  and  the  separation  is  kept  up  by  clotting  of  the  blood  in 
between,  or  by  tilting  of  the  fragments  owing  to  the  insertion  of  the  tendon  into 
the  edge  of  the  anterior  surface  of  the  bone ;  or  by  shreds  of  fascia  and  some- 
times even  the  skin  being  driven  down  into  the  gap.  In  old  cases  the  upper 
fragment  is  often  practically  immovable,  either  because  it  is  fi.xed  to  the  femur  or 
because  the  muscular  substance  of  the  quadriceps  has  undergone  degeneration. 
The  outer  edge  of  the  patella  is  longer  than  the  inner,  so  that  when  the  two 
fragments  are  brought  together  they  do  not  meet  on  the  inner  side,  and  in  cases  of 
fibrous  union  the  inner  part  is  usually  longer  than  the  outer  (Fig.  162). 

Symptoms. — There  is  rarely  any  difficulty  in  the  diagnosis,  though  occa- 
sionall}  when  there  is  a  thickening  in  the  bursa  over  the  bone,  or  extravasation  of 
blood  into  the  periosteum,  a  deceptive  transverse  depression  may  be  felt.  As  a 
rule  there  is  wide  separation,  the  fragments  are  distinct  and  can  be  moved  from 
side  to  side,  or  one  can  be  tilted  by  direct  pressure  without  the  other  ;  swelling 
sets  in  at  once  and  assumes  the  shape  of  the  synovial  membrane  of  the  joint ; 
crepitus,  of  course,  is  not  present  unless  the  upper  fragment  can  l)e  pressed  down 


■'tA  -^ 


S^--^^ 


^ 


Fig,  163. — Osseous  Union  of  Transverse  Frac- 
ture of  Patella.  From  a  subject  in  the  dis- 
secting room.  There  was  no  scar  visible 
on  the  skin. 


Fig.  164. — Fibrous  Union  of  the  Corresponding 
Bone  on  the  Opposite  Side. 


and  brought  into  contact  with  the  lower ;  the  loss  of  power  over  the  quadriceps  is 
complete  in  proportion  to  the  separation  of  the  fragments  and  the  tearing  of  the 
fascia  ;  in  a  very  few  instances  the  patient  has  been  able  to  raise  and  extend  the 
limb. 

Prognosis. — Union  may  take  place  by  bone,  though  this  is  rare,  or  by 
fibrous  tissue,  the  broken  surfaces  being  united  directly  to  each  other  face  to  face  ; 
or  there  is  no  true  union  at  all,  but  merely  a  thickened  layer  of  fascia  passing 
over  the  anterior  surface  of  the  fragments  from  one  to  the  other.  In  no  case  does 
the  quadriceps,  especially  that  part  of  the  vastus  internus  just  above  the  knee 
joint,  completely  recover.  If  there  is  good  fibrous  union,  with  not  more  than 
half  an  inch  interval,  the  use  and  the  strength  of  the  limb  are  scarcely  impaired  ; 
when  the  fascia  is  the  only  uniting  medium,  though  the  interval  may  be  small  at 
first,  it  is  sure  to  elongate,  until  it  may  be  as  much  as  five  and  even  six  inches 
(Figs.  163  and   164). 

Flexion  is  permanently  impaired  in  many  cases  ;  in  a  few  the  knee  remains 
quite  stiff,  and  occasionally  the  upper  fragment  becomes  attached  to  the  femur. 

As  vertical  fractures  almost  invariably  unite  by  bone,  and  as  in  some  few 
cases  the  amount  of  callus  thrown  out  is  so  great  as  to  interfere  with  the  gliding 
of  the  patella  on  the  femur,  it  is  clear  that  the  failure  of  union  is  due  mainly  to 
the  fragments  not  being  in  contact — they  are  kept  apart  either  by  the  effusion,  or 
by  being  tilted,  or  by  the  fascia  being  pressed  down  between  them  and  entangled 
by  the  broken  surfaces ;  and   the  amount  of  callus  formed  is  not  sufficient  to 


FRACTURES  OF  THE  PATELLA. 


431 


bridge  the  interval  ;  none  is  thrown  out  by  the  articular  surface,  and  very  little 
by  the  cutaneous. 

Treatment. — Where  the  effusion  is  only  slight,  and  the  fascia  at  the  sides 
of  the  jxxtella  is  not  torn,  there  is  little  difficulty  in  maintaining  the  fragments  in 
contact,  esjiecially  if  they  are  of  equal  size.  The  knee  must  be  kei)t  straight  on 
an  inclined  plane,  the  hip  slightly  bent,  and  the  whole  limb  encased  in  a  starch 
bandage,'carried  in  figure-of-eight  turns  over  the  knee  right  up  to  the  groin.  A 
short  back  splint  or  a  firm  pad  in  the  popliteal  space  is  advisable  to  make  it  more 
secure.  The  effusion  rapidly  becomes  absorbed,  the  fragments  are  drawn  together 
by  the  bandage,  the  amount  of  tilting  is  very  slight,  and  the  even  pressure  round 
the  quadricei)s  checks  any  tendency  to  spasmodic  contraction.  No  lateral  move- 
ment of  any  kind  should  be  allowed  for  at  least  six  weeks,  even  to  test  the  degree 
of  union  ;  little  bony  spicules  are  occasionally  found  shooting  through  the  lymph 
from  one  fractured  surface  to  the  other,  and  all  of  these  should  be  broken  off  at 
once. 

In  the  majority  of  instances,  however,  something  more  than  this  is  required. 
Every  effort  must  be  made  to  get  rid  of  the  effusion  as  soon  as  possible  ;  not  only 
does  it  force  the  two  fragments  apart,  but  it  stretches  the  membrane,  and  makes  it 
thick  and  stiff,  so  that  it  interferes  with  the  freedom  of  movement  afterward. 
Cold  is  of  great  service  at  first,  but  it  can  only  check  exudation,  not  assist  absorp- 
tion ;  pressure  properly  applied  over  a  thick  layer  of  cotton-wool  is  much  more 


Fig.  165. — Transverse  Fracture  of  Patella  Treated  by  Extension  from  a  Poroplastic  Shield. 


effectual ;  but  if  at  the  end  of  three  days  there  is  much  left,  the  joint  should  be 
aspirated.  It  is  true  that,  unless  proper  precautions  are  taken,  this  proceeding  is 
attended  with  a  certain  amount  of  risk  ;  and  that  sometimes  it  is  impossible,  owing 
to  the  density  of  the  coagula,  to  empty  the  articulation  completely  ;  but  many  of 
the  cases  obstinately  resist  for  such  a  length  of  time  that  nothing  else  is  of  any 
avail.  The  opening,  which  is  best  made  above  and  to  the  inner  side  of  the  patella, 
should  be  valvular,  and  if  a  cannula  is  used  it  should  be  cleaned  well  first  by  boil- 
ing it  in  a  solution  of  caustic  potash. 

Sometimes  after  this  is  done  the  fragments  come  into  apposition  almost  of 
themselves  ;  more  often  something  further  is  required  to  bring  them  together. 
The  simplest  apparatus  is  a  back  splint,  rather  wider  than  the  limb,  and  hollowed 
out  to  fit  the  knee.  Two  hooks  are  screwed  into  each  side  about  eight  inches 
apart,  one  above  the  joint,  the  other  below  ;  and  two  elastic  bands  are  fastened  to 
these,  so  as  to  loop  over  the  limb  in  a  figure-of-eight.  The  lower  one  passes  above 
the  patella,  and  tends  to  draw  the  upper  fragment  down  ;  the  u])per  one,  crossing 
this,  catches  the  ligamentum  patellae  and  forms  a  fixed  point.  The  skin,  which  is 
very  freely  movable  over  the  knee,  should  be  stretched  a^svay  from  the  seat  of 
fracture  as  far  as  possible  before  this  is  applied,  or  it  may  be  forced  down  between 
the  broken  surfaces.  The  chief  disadvantage  is  the  liability  to  tilting  of  the 
fragments. 

A  better  plan  is  to  mould  a  piece  of  thin  poroplastic  felt  or  thick  moleskin 
over  the  front  of  the  thigh,  cutting  it  out  so  as  to  fit  round  the  upper  margin  of 


432    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  patella,  ami  leavin^^  on  either  side  a  looj^  or  a  i)rojertioii  to  which  an  elastic 
band  can  be  attached.  The  limb  should  be  fixed  in  a  Maclntyre  or  a  'I'homas's 
knee-splint,  and  the  elastic  bands  drawn  down,  one  on  each  side,  and  secured  to 
the  foot-piece.  At  the  same  time  a  stri}j  of  bandage  or  plaster  must  be  carried 
over  the  ui)per  fragment  to  ])revent  it  rising.  At  the  end  of  a  fortnight  or  three 
weeks  the  whole  limb  maybe  incased  in  a  fixed  apparatus  and  the  patient  allowed 
to  get  about  on  crutches  (Fig.  165). 

If  due  precautions  are  taken,  Malgaigne's  hooks  may  be  used  with  a  fair  de- 
gree of  safety  (Fig.  166)  ;  and,  so  far  as  mechanical  reasons  are  concerned, 
nothing  can  answer  better,  especially  if  the  instrument  is  divided 
longitudinally,  so  that  there  are  two  halves,  right  and  left,  which 
can  be  screwed  up  separately.  The  limb  must  be  secured  to  a  back 
splint,  so  as  to  keep  it  at  i)erfect  rest  in  complete  extension  ;  the 
fragments  must  be  brought  down  to  their  definite  position  ;  and  a 
minute  puncture  made  with  a  sharp-pointed  scalpel  at  the  spot  the 
hooks  are  intended  to  penetrate.  The  two  upper  should  be  carried 
right  down  to  the  bone,  and,  as  suggested  by  Treves,  may  be  made 
use  of  to  evacuate  the  fluid  from  the  joint  ;  the  lower  do  not  in- 
volve the  synovial  membrane.  Then  the  hooks  are  inserted,  the 
lower  ones  being  fixed  first,  and  screwed  up  until  everything  is  in 
position.  If  there  is  any  tendency  on  the  part  of  the  upper  frag- 
ment to  ride  forward,  it  may  be  checked  by  carrying  a  tape  round 
the  limb  and  the  splint,  and  tightening  it  up  as  required.  The 
Fig  166  1-*^^'^  ^^  ^'^"-y  ^^iftl'it'  i''ot  sufficient  to  recpiire  an  anaesthetic  ;  the 
Malgaigne's  Hooks,  fragments  Can  be  adjusted  perfectly  ;  and  if  the  little  wounds  are 
dusted  over  with  iodoform  and  kei)t  dry  and  quiet,  there  is  little 
risk  of  inflammation.*  In  former  days  there  is  no  doubt  this  was  not  an  unfre- 
quent  consequence.  The  hooks  may  be  kept  in  for  six  or  eight  weeks  without  any 
ill  consequence  ;  but  there  is  no  advantage  in  retaining  them  for  more  than  three  ; 
at  the  end  of  that  time  the  limb  is  generally  sufficiently  secure  to  be  enclosed  in  a 
fixed  apparatus.  The  plan  of  fixing  the  hooks  into  crescents  of  felt  or  moleskin 
strapping,  fastened  to  the  skin  above  and  below,  does  not  present  any  advantage 
over  other  methods. 

Many  other  plans  have  been  devised  for  bringing  the  fragments  together  by 
means  of  pins  or  hooks  fixed  in  the  bones.  Transverse  channels  have  been  drilled 
through  the  two  fragments  from  side  to  side,  and  wires  or  pins  passed  through. 
Longitudinal  ones  have  been  tried,  without  any  incision  other  than  that  required 
to  admit  the  point  of  the  drill.  Pins  have  been  driven  into  the  ligamentum 
patellae  and  the  tendon  of  the  quadriceps,  so  as  to  obtain  some  fixed  point.  They 
have  all  succeeded,  but  they  are  none  of  them  devoid  of  risk. 

Laying  open  the  knee  joint,  and  converting  a  simple  fracture  into  a  compound 
one,  has  been  strongly  recommended,  even  in  recent  cases  ;  and  it  is  worthy  of 
consideration  in  exceptional  instances  in  which  it  is  impossible,  in  spite  of  every 
endeavor,  to  bring  the  two  fragments  face  to  face.  The  risk,  however,  even  with 
the  strictest  antiseptic  precautions,  is  much  too  great  ;  especially  as  in  young  and 
healthy  subjects,  firm  fibrous  union,  leaving  a  strong  and  useful  limb,  may  be 
reasonably  counted  upon  without.  A  vertical  incision,  two  inches  in  length,  is 
made  over  the  anterior  .surface  of  the  bone  with  its  centre  opposite  the  line  of 
fracture.  The  joint  is  opened  freely  ;  all  blood-clots  turned  out  ;  and  then  two 
holes  are  drilled  obliquely,  from  the  cutaneous  to  the  fractured  surface,  so  as  not 
to  involve  the  cartilage.  A  stout  silver  wire  is  inserted  through  these  ;  a  drainage- 
tube  passed  through  the  deepest  part  of  the  joint  upon  the  outer  side;  the  frag- 
ments brought  together  ;  the  wire  twisted  up  and  the  ends  cut  ofl"  and  hammered 
down.     Others  recommend  a  transverse  incision  above  or  below  the  line  of  frac- 

*  The  hooks  as  originally  devised  by  Malgaigne  were  very  sharply  curved  so  that  the  points 
should  not  penetrate  the  joints. 


FRACTURES  OF  THE  PATELLA. 


433 


ture,  on  the  ground  that  if  suppuration  occurs  in  the  skin  wound  the  deep  one  is 
less  liable  to  be  infected.  It  is  true  that  bony  union  has  taken  place  in  the  major- 
ity of  cases  operated  on  ;  but  suppuration  has  occurred  in  several,  in  spite  of  anti- 
septic precautions;  ankylosis  of  a  greater  or  less  degree  has  followed  in  many; 
and  in  one  or  two  the  bond  of  union  has  broken  down  again  and  further  opera- 
tion has  been  required. 

The  only  other  plan  that  requires  special  mention  is  that  first  devised  by 
Kocher.  It  consists  in  passing  a  stout  silver  wire  completely  round  the  patella. 
A  needle  in  a  handle  (such  as  is  used  for  sewing  up  a  lacerated  perineum,  only 
longer,  stouter,  and  with  a  wider  curve)  is  passed  through  the  ligamentum  patellre, 
through  the  tendon  of  the  quadriceps  and  out  through  the  skin.  It  is  then 
threaded  and  drawn  back  again  ;  the  broken  fragments  are  brought  together  ;  the 
wire  twisted  up,  over  something  to  protect  the  skin  ;  and  the  openings  dusted  over 
with  iodoform.  The  limb  is  then  jjlaced  upon  a  back  splint,  and  carefully 
bandaged,  for  three  weeks.  At  the  end  of  that  time  the  wire  is  cut,  drawn  out  of 
the  wound,  and  the  little  ulcers  that  are  left  dusted  over  again  with  iodoform  until 
they  are  healed.  I  have  known  this  employed  in  a  large  number  of  cases  without 
untoward  result  of  any  kind  ;  and  the  union  was  always  exceedingly  close,  though 
I  am  bound  to  confess  it  was  not  possible  to  prove  in  the  majority  that  it  was 
osseous. 

The  after-treatment  of  a  case  of  fractured  patella  rer[uires  just  as  much  care. 
It  is  not  uncommon  to  find  that  the  distance  between  the  fragments,  even  though 
it  is  scarcely  half-an-inch  at  the  first,  in  a  few  months  grows  larger  and  larger, 
until  it  may  be  as  much  as  five  or  even  six  inches.  In  the  majority  no  doubt  this 
is  due  to  the  fact  that  there  is  no  true  union  at  all ;  but 
in  very  many  it  is  the  result  of  allowing  the  joint  to 
bend  too  soon  and  throwing  an  undue  strain  upon 
newly-formed  fibrous  tissue.  In  all  cases  of  transverse 
fracture  the  limb  should  be  thoroughly  encased,  without 
being  touched,  for  at  least  six  or  preferably  eight 
weeks  ;  and  then  an  apparatus  must  be  worn,  so  that 
there  can  be  no  attempt  at  flexion  for  at  least  as  many 
months.  The  best  are  made  of  leather,  laced  up  at  the 
sides,  with  an  opening  in  front  for  the  patella,  and  a 
steel  rod  behind,  so  that  bending  is  impossible  ;  but  a 
very  serviceable  splint  may  be  made  from  poroplastic 
felt,  or  even  from  gum  and  chalk.  At  first  it  should  be 
left  off  at  night  only,  and  then  by  degrees  more  and 
more,  until  at  the  end  of  a  twelvemonth  it  may  be 
dispensed  with  altogether.  For  a  time,  of  course,  the 
joint  is  stiff,  and  the  quadriceps  wasted,  but  (with  the 
exception,  as  already  mentioned,  of  a  portion  of  the 
vastus  internus)  this  soon  passes  off ;  and  if  there  is  good 
fibrous  union  it  does  not  stretch,  no  matter  what  strain 
falls  upon  it.      Massage,  hot  douching,  galvanism,  and 

gentle  passive  motion  may  be  used  to  expedite  matters,  but  as  a  rule  (unless  the 
patient  is  gouty  or  rheumatic),  the  stiffness  disappears  at  length  of  its  own  accord 
(Fig.  167). 

Imperfect  Repair. — The  question  of  operation  in  these  cases  rests  upon 
entirely  different  grounds  ;  union  by  ordinary  methods  has  been  tried  and  failed  ; 
and  it  depends  upon  the  degree  of  utility  the  limb  possesses,  upon  the  strength  and 
occupation  of  the  patient,  whether  he  shorUd  be  recommended  to  get  about  with 
the  support  afforded  by  a  knee-cap,  or  whether  an  attempt  should  be  made  to  ob- 
tain firmer  union.  The  operation  itself  is  carried  out  in  exactly  the  same  way  : 
the  tissue  between  the  broken  surface  must  be  removed  thoroughly,  and  either  the 
fragments  drilled  together  or  a  wire  passed  round  them  after  Kocher's  plan  ;  which- 
ever is  adopted  it  is  essential  that  the  apposition  should  be  accurate.      If  an  opera- 


FlG. 


167. — Apparatus  for  Fibrous 
Union  of  Patella. 


434    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

tion  of  this  kind  is  attempted,  it  is  advisable  not  to  wait  too  long  ;  when  the 
quadriceps  has  once  undergone  degeneration,  it  is  almost  impossible  to  bring  the 
upi>er  fragment  down  sufficiently  ;  tlie  adhesions  between  it  and  the  femur  may 
be  torn,  the  tendon  divided,  and  even  V-shaped  incisions  made  in  the  muscular 
substance  above  it,  without  its  being  i)ossil)le  to  bring  it  close  enough  to  ensure 
good  union. 

Refracture  occasionally  takes  place,  the  fd^rous  band  tearing  across,  or  the 
bone  giving  way  at  a  fresh  ijlace.  If  it  is  simple,  it  may  be  treated  in  the  ordinary 
manner,  and  it  is  surprising  how  far  recovery  can  take  place,  and  how  useful  the 
limb  can  prove  ;  if  compound,  the  fragments  had  better  be  wired  together  at  once. 
In  one  or  two  instances,  in  which  the  interval  was  too  great,  resection  of  the  knee 
joint  was  performed  in  the  hope  of  giving  firmer  support. 

Fractures   rv   Direct  Violence. 

In  these  the  fascia  attached  to  the  bone  is  seldom  torn,  and  the  degree  of 
separation  is  slight,  even  when  the  joint  is  fdled  with  blood.  The  treatment  is  the 
same  as  for  transverse  fracture  without  displacement ;  but,  a.s  union  is  nearly 
always  osseous,  passive  flexion  of  the  limb  may  be  commenced  much  sooner. 

Co.MPOuxD  Fractures. 

When  the  accident  is  the  result  of  direct  violence  the  injury  is  rarely  confined 
to  the  patella  :  generally  the  other  bones  are  involved  as  well,  and  often  the  soft 
parts  are  extensively  destroyed.  In  former  days  amputation  was  regarded  as  inevi- 
table for  such  injury  as  this  ;  at  present,  if  the  part  can  be  thoroughly  cleansed  and 
thoroughly  drained,  a  successful  result  may  be  hoped  for,  even  when  such  an  amount 
of  bone  is  removed  that  practically  it  becomes  a  primary  resection.  If,  however, 
the  skin  is  extensively  damaged,  or  if  the  i)opliteal  artery  or  vein  has  been  torn  or 
punctured,  there  is  no  alternative. 

Fractures  by  muscular  action  are  occasionally  compound,  especially  when  the 
bone  gives  way  for  the  second  time.  In  one  case  under  my  care  the  skin  was  torn 
across  from  one  side  of  the  joint  to  the  other  ;  but  though  the  patient  (who  was  a 
coalheaver)  was  not  brought  to  the  hospital  for  some  hours  after  the  accident,  union 
took  place  by  the  first  intention,  without  the  least  fever.  If  it  is  feasible  the  frag- 
ments should  be  wired  together  at  once  ;  if  it  cannot  be  done  the  joint  may  be  re- 
sected ;  but  probably  a  better  limb  would  be  left  by  drawing  the  fragmentsasclo.se 
together  as  jiossible  and  making  the  ]atient  wear  a  support  for  the  rest  of  his  life. 


FRACTURES  OF  THE  LEC. 

Both  bones  may  be  broken  ;  or  the  tibia  or  the  fibula  may  give  way  by  itself. 
If  the  violence  is  indirect,  the  tibia  generally  breaks  across  at  the  junction  of  the 
lower  with  the  middle  third  (the  weakest  part),  and  the  line  of  separation  runs  from 
above  downward  and  forward  ;  the  fibula  usually  gives  way  higher  up.  If  direct 
it  depends  upon  the  nature  and  locality  of  the  injury.  In  either  case  com])ound 
fracture  is  very  common,  owing  to  the  thinness  of  the  covering  over  a  great  portion 
of  the  tibia  ;  and  all  kinds  of  comjilications  are  frecpiently  present.  The  bone  may 
be  comminuted,  even  when  the  force  is  indirect  ;  the  neighboring  joints  may  be 
involved,  though  the  seat  of  injury  is  a  long  way  off.  owing  to  the  way  in  which 
fi.ssures  run  obliquely,  or  even  spirally,  in  the  thickness  of  the  bone  ;  the  veins  and 
arteries  may  be  compres.sed,  punctured,  or  torn  comjjletely  in  two  ;  the  muscles 
extensively  lacerated  ;  the  nerves  stretched  across  sharp-edged  fragments  ;  and  the 
skin,  even  when  it  does  not  give  way,  stripped  up  to  such  an  extent  from  the  deep 
fascia,  that  it  seems  to  float  \\\>ox\  a  kind  of  water-bed,  and  is  in  imminent  danger 
of  gangrene. 


FRACTURES  OF  THE   LEG.  435 

Fractures  of  the  Tiisia  and  Fiiui.a. 

This  is  the  most  common  form,  whether  the  accident  is  the  result  of  direct 
or  indirect  violence.  In  the  former  case  the  fractures  may  be  transverse  and  on 
the  sanie  level ;  or  they  may  be  comminuted  to  any  degree  ;  in  the  latter  they  are 
usually  more  or  less  oblique  (esjjecially  if  there  is  much  twisting  of  the  limb),  and 
the  broken  ends  are  sharply  pointed.  In  falls  upon  the  feet,  i>articularly  when 
the  force  is  very  considerable,  and  combined  with  rotation,  as  in  jumping  from  a 
carriage  in  motion,  the  bones  are  frequently  broken  in  more  places  than  one. 

The  displacement  is  usually  distinct  at  the  first  glance,  though  sometimes, 
when  the  fracture  is  exactly  transverse,  and  through  the  upper  part  of  the  leg,  or 
when  the  surfaces  are  much  serrated,  the  broken  ends  retain  their  normal  position. 
The  causes  of  the  deformity  are  the  continuance  of  the  force  after  the  bones  have 
given  way,  the  weight  of  the  part  and  the  spasmodic  contraction  of  the  muscles  ; 
its  i)ersistence  (unless  there  is  inqjaction)  is  due  entirely  to  the  two  last,  and 
especially  the  muscles.  The  direction  depends  upon  the  obliquity.  If  it  runs 
from  above,  downward  and  forward,  the  lower  end  of  the  upper  fragment  projects 
beneath  the  skin,  being  driven  to  the  front  by  the  pressure  of  the  other  ;  if  it  has 
the  opposite  direction,  the  lower  of  the  two  is  the  more  prominent.  The  fibula 
has  very  little  influence. 

Signs. — These  are  usually  definite,  though  a  few  cases  are  on  record  in  which 
a  person  with  both  bones  broken  has  been  able  to  stand,  and  even  walk.  Crepi- 
tus, undue  mobility,  and  deformity  are  almost  invariable ;  pain  is  intense,  and 
increased  by  the  slightest  pressure ;  and  loss  of  power  is  practically  complete. 
The  greatest  care  must  be  taken  in  manipulation  to  prevent  the  skin  giving  way ; 
and,  for  the  same  reason,  the  limb  must  always  be  made  secure  at  once.  It  should 
be  a  rule  to  examine  the  condition  of  the  arteries,  particularly  the  posterior  tibial, 
in  all  fractures. 

Treatment. — Fractures  of  both  bones  may  be  divided  roughly  into  three 
classes. 

(d)  If  the  limb  is  so  badly  crushed  that  it  is  doubtful  whether  it  can  live,  it 
is  better  to  arrange  it  as  comfortably  as  possible  between  sand-bags,  or  to  tie  it  up 
in  a  pillow,  so  as  to  make  it  secure  against  any  incautious  movement,  and  raise  it 
well,  in  the  hope  that  the  circulation  may  recover. 

{b)  If  the  fracture  is  transverse,  or  nearly  so,  and  if,  as  usually  happens  in 
these  cases,  the  surrounding  structures  have  almost  escaped,  there  is  no  reason 
why  the  limb  should  not  be  put  up  at  once  in  some  form  of  immovable  apparatus. 
This  holds  good  with  even  greater  force  when  only  one  bone  is  broken  and  the 
other  is  left  as  a  splint. 

{c)  If  the  fracture  isvery  oblique,  particularly  if  it  is  of  that  variety  which  is 
sometimes  called  pen-nib,  from  the  way  in  which  the  point  of  one  of  the  fragments 
projects  beneath  the  skin,  or  if  the  bone  is  extensively  comminuted,  or  the  soft 
parts  much  injured,  and  the  swelling  already  serious,  it  is  safer  to  postpone  this 
for  ten  days  or  a  fortnight,  and  to  make  use  of  ordinary  splints,  until  the  tendency 
on  the  part  of  the  muscles  to  cause  displacement  has  in  some  measure  disappeared, 
and  the  swelling  and  tension  are  beginning  to  subside ;  with  such  an  injury  there 
can  be  no  object  in  getting  the  patient  out  of  bed.  • 

The  variety  of  splints  that  have  been  devised  for  fractures  of  this  kind  is 
almost  endless.  The  great  object  is  to  secure  muscular  relaxation  ;  the  fragments 
should  fall  of  themselves  into  their  natural  position  ;  force  must  be  avoided  as 
much  as  possible,  though  in  a  few  cases  continuous  extension  answers  where 
nothing  else  will.  One  of  the  simplest  and  most  efficient  appliances  consists  of 
a  back  and  two  side  splints  swung  from  a  cradle.  The  former  is  made  of 
metal,  sufficiently  strong  to  retain  its  shape,  but  capable  of  being  bent,  and 
should  reach  half-way  up  the  thigh  to  form  a  sole-piece  for  the  foot.  At  the  heel 
there  is  a  large  perforation  to  avoid  pressure,  and  two  cross-bars  to  sling  it  by  are 
soldered  to  the  under  surface.      It  should  be  fitted  accurately  into  all  the  curves 


436    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

of  the  opi^osite  limb  before  being  padded,  and  esjiecial  rare  must  be  taken  to 
make  the  bend  corresi)ond  with  the  position  of  the  knee;  extra  pads  to  exert 
special  pressure  on  certain  ))oints  should  be  used  as  little  as  possible.  If  the  sole- 
piece  is  at  right  angles  to  the  leg  for  with  advantage  a  little  less),  and  if  the  knee 
is  sufficiently  flexed  (as  much  as  60°  if  necessary)  the  broken  fragments  fall  into 
their  natural  jx)sition  of  themselves.  Division  of  the  tendo-Achillis.  though  jjer- 
fectly  safe,  is  very  rarely  required,  and  continuous  extension  is  seldom  of  service, 
except  in  those  rare  instances  in  which,  owing  to  the  direction  of  the  fracture  and 
spasmodic  contraction  of  the  quadriceps,  the  lower  end  of  the  upper  fragment  is 
tilted  forward.  The  secret  is  to  keep  the  knee  well  bent,  the  foot  at  right  angles, 
and  the  inner  side  of  the  great  toe,  the  inner  malleolus,  and  the  inner  border  of 
the  patella  in  the  same  line.  Strapping  may  be  used  to  secure  the  foot,  but  ban- 
dages only  should  be  allowed  above  the  seat  of  injury,  and  for  the  sake  of  neat- 
ness they  are  to  be  starched.  The  side  splints  are  simply  straight  jMeces  of  deal, 
well  padded,  sutificiently  long  to  reach  from  the  condyles  of  the  femur  to  the  foot 
and  sufficiently  broad  to  project  well  above  the  level  of  the  limb.  Webbing  straps 
and  buckles  are  used  to  hold  them  together,  and  the  whole  is  suspended  by  leather 
bands  from  a  cradle  sufficiently  large  to  allow  it  to  swing  freely.  No  moderate 
movement  of  the  patient  can  have  any  influence  upon  the  fragments  ;  but  he 
should  not  be  allowed  to  lie  upon  the  injured  side,  for  fear  of  the  upper  part  of 
the  limb  becoming  rotated  while  the  lower  is  held  fixed. 

Another  plan  is  to  lay  the  limb  upon  its  outer  side,  on  a  well-padded  wooden 
spMnt,  with  the  hip  and  knee  flexed,  and  the  foot  kept  at  a  right  angle  by  means 
of  a  sole-piece.  The  splint  should  be  hollowed  to  fit  the  limb,  sufficiently  long  to 
reach  up  to  the  knee,  with  a  prolongation  along  the  side  of  the  foot,  and  the  sole- 
piece  screwed  to  it  at  a  right  angle.  Opposite  the  malleolus  there  should  be  a 
perferation  to  avoid  pressure.  The  patient  is  placed  upon  the  injured  side  ;  the 
fragments  manipulated  into  position,  and  the  limb  secured  by  bandages.  Care 
must  be  taken  to  keep  the  heel  well  down,  and  the  foot  at  a  right  angle,  for  fear 
of  the  ankle  becoming  rigid.  If  there  is  any  tendency  to  lateral  projection,  a 
short  inside  splint  may  be  added  with  advantage. 

In  some  instances  the  limb  may  be  suspended  from  an  anterior  sjjlint,  either 
Hodgen's  (Fig.  155)  or  Nathan  Smith's,  as  already  described,  the  angle  and  the 
point  of  suspension  being  altered  to  fit  the  case  ;  it  is  easy  to  make  extension,  and 
the  limb,  when  it  is  once  adjusted,  is  exceedingly  comfortable,  but  it  is  very  difficult 
to  prevent  the  foot  from  pointing,  and  they  certainly  do  not  secure  the  same 
degree  of  immobility  as  the  others.  Probably  the  majority  of  the  fractures  that 
admit  of  being  treated  in  this  way  might  as  well  be  put  up  at  once  in  one  of  the 
many  forms  of  immovable  apparatus. 

At  the  end  of  ten  days  or  a  fortnight,  according  to  the  condition  of  the  frac- 
ture, the  splints  may  be  removed  and  some  form  of  immovable  appliance  substi- 
tuted, such  as  an  ordinary  plaster-of-Paris  or  gum  and  chalk  bandage.  Care  must 
be  taken  first  to  get  rid  of  all  (edema  by  means  of  elevation  and  pressure.  The 
following  plan,  for  the  details  of  which  I  am  indebted  to  Mr.  E.  N.  Xason,  is  in 
common  use  at  the  London  Hospital.  Equal  parts  (by  weight)  of  finely  powdered 
prepared  chalk  and  common  gum  acacia  are  taken  ;  the  latter  is  made  into  mucil- 
age, somewhat  stronger  than  the  B.  P.  strength,  and  is  then  thoroughly  mixed  with 
the  chalk,  until  the  whole  is  about  the  consistence  of  cream  ;  this  is  strained 
through  coarse  muslin  in  order  to  get  rid  of  the  lumps.  The  leg  is  then  thoroughly 
oiled,  and  a  common  cotton  stocking,  with  the  point  of  the  toe  cut  off  and  large 
enough  to  fit  easily,  is  put  on,  outside  inward,  a  piece  of  stout  tape  being  arranged 
along  the  front  of  the  leg  beneath  it.  A  second  stocking,  slightly  larger  than  the 
first,  is  put  on  over  this,  the  leg  is  supported  in  position,  taking  care  that  the  foot 
is  at  a  right  angle,  and  the  mixture  of  gum  and  chalk  is  thoroughly  rubbed  in.  A 
third  stocking  of  the  same  size  as  the  second  one  is  now  drawn  over  the  other  two, 
right  side  outward,  and  more  of  the  mixture  rubbed  in  until  no  more  can  be  ab- 
sorbed, and  the  ribs  of  the  stocking  show  up  clearly.     The  whole  is  then  suspended 


FRACTURES  OF  THE   LEG. 


437 


by  tlic  tape,  which  lies  beneath  all  the  stockings,  shing  from  a  cradle  and  left  to 
dry.  This  takes  eighteen  hours,  unless  (juickened  by  placing  the  patient  near  the 
fire,  or  putting  hot-water  bottles  on  either  side,  the  limb,  of  course,  being  kept 
outside  the  bed-clothes.  If  silicate  of  potash  is  used  instead  of  gum,  a  somewhat 
better  splint  results.  The  solution  (which  can  l)e  obtained  in  gallon  jars;  is  mi.xed 
with  the  chalk  in  the  same  way,  but  not  so  much  chalk  is  recjuired,  and  it  only 
takes  si.\  hours  to  dry.  When  the  splint  is  firm,  it  is  cut  down  the  middle  line  in 
front,  along  the  tape,  trimmed  up,  and  the  edges  bound  with  strapping  to  prevent 
fraying.  Eyelet  holes  are  then  punched  on  each  side,  and  eyelets  put  in  and 
clamped  with  the  instruments  commonly  used  l)y  shoemakers.  The  leg  is  enveloped 
in  a  domett  or  soft  flannel  bandage,  the  splint  put  on  and  laced  up  the  front  as 
tightly  as  may  be  reepiired.  For  lightness  combined  with  strength  these  splints 
can  hardly  be  surpassed  ;  the  fit  is  perfect,  and  at  the  same  time  they  are  sufficiently 
elastic  to  be  taken  on  and  off  if  required  without  injury.  The  plan  of  suspending 
the  limb  by  the  tape  is  not  only  of  assistance  in  dividing  the  splint,  but  helps 
materially  to  keep  the  foot  at  a  right  angle  ;  unless  this  position  is  obtained  the 
splint  must  be  condemned  at  once. 

Many  cases  of  fracture,  especially  if  only  one  bone  is  broken,  as  already  men- 


FiG.  168. — Stocking  Splint. 


tioned,  may  be  put  up  immediately  ;  but  either  the  splint  must  be  made  in  two 
halves  or  it  must  be  cut  down  the  centre,  and  laced  or  fastened  up  again  in  some 
other  way,  so  that  in  case  of  swelling  the  seat  of  injury  is  accessible  at  once.  As 
a  matter  of  precaution  the  limb  should  be  raised  for  forty-eight  hours  after  the 
splint  is  applied,  and  the  circulation  in  the  toes  must  be  constantly  examined. 
.'Absence  of  pain  is  not  by  any  means  incompatible  with  gangrene. 

Poroplastic  felt  splints  (which  may  be  obtained  in  sizes  shaped  already  to 
some  extent  at  most  instrument  maker.s)  answer  admirably.  They  should  be 
fitted  roughly  to  the  other  leg  so  as  to  make  sure  that  the  length  and  breadth  are 
correct,  and  softened  with  heated  air  or  water,  and  then  moulded  to  the  fractured 
limb  while  it  is  held  in  position.  They  become  dry  and  firm  in  a  few  minutes, 
and  then  they  can  be  removed,  lined  with  wash-leather,  and  either  fitted  with  eye- 
let holes  and  laces,  or  fastened  on  directly  with  webbing  straps  and  buckles. 

Plaster-of- Paris  is  more  extensively  used  for  this  purpose,  especially  since  what 
is  called  the  Bavarian  splint  became  known  ;  before  this,  bandages  of  crinoline 
muslin,  into  which  the  dry  plaster  had  been  rubbed,  were  w^ound  round  and  round 
the  limb  until  the  requisite  degree  of  strength  was  obtained  ;  and  if  it  was  desired 
to  loosen  or  remove  this,  it  had  to  be  cut,  and  probably  was  spoiled.  The  plaster 
must  be  the  finest,  such  as  modelers  use,  and  freshly  prepared,  or,  if  there  is  the 


438    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

least  doubt,  baked  ;  the  setting  may  be  quickened  by  the  addition  of  a  small  quan- 
tity of  alum  to  the  water.  Two  pieces  of  coarse  house-flannel  are  taken,  long 
enough  to  reach  from  the  })Oijliteal  space  to  the  balls  of  the  toes  and  three  inches 
wider  than  the  circumference  of  the  limb  ;  these  are  sewn  together  down  the 
middle  line  for  the  length  of  the  leg  ;  below  this  (for  the  length  of  the  foot)  they 
are  cut  in  two.     A  very  good  idea  of  the  shape  and  size  required  may  be  obtained 

by  taking  a  stocking,  cutting  the 
toes  off,  slitting  it  down  the  middle 
line  in  front  for  the  whole  length, 
and  down  the  middle  line  of  the 
sole  behind  ;  but  the  flannel  must 
be  three  inches  wider.  The  leg  is 
'  -  then    placed  upon    the  flannel  so 

1  A         "  ~  '  that  the  seam  runs  down  the  back 

(  "^\  ^"^  ends  at  the  point  of  the  heel ; 

I  ^^        and    the    inner   layers   are  folded 

\  over  and   fastened  together  down 

^- _  --.;  the  front.     The  end  portions  are 

Fig.  i69.-Bavanan  spi.nu  "sed  to    cover  in  the  foot,  which 

must  be  kept  exactly  at  a  right 
angle.  The  leg  is  then  placed  upon  one  side,  and  held  accurately  in  position  ;  a 
layer  of  plaster  the  consistence  of  cream  is  spread  over  the  inner  layer,  from  the 
fold  in  front  to  the  seam  behind,  and  the  outer  one  pressed  down  upon  this  before 
it  has  set  (Fig.  169). 

As  soon  as  it  is  firm  the  leg  is  turned  over  and  the  process  repeated  on  the 
other  side.  Finally,  the  fastening  down  the  front  is  undone,  and  two  side  splints, 
fitting  accurately  to  the  leg  and  foot,  fall  apart  from  the  limb,  bending  at  the  hinge 
formed  by  the  stitching  behind.  The  edges  are  finished  off  afterward,  the  inner 
layer  being  fastened  down  to  the  outer  on  the  surface  of  the  splint. 

Modifications  of  this,  introduced  by  Croft  and  Gamgee,  are  simpler  of  execu- 
tion, as  the  side  splints  are  separate  throughout.  For  the  former,  four  pieces  of 
house-flannel  are  taken,  the  size  and  shape  of  the  patient's  stocking  when  flattened 
out ;  two  of  these  (one  for  each  side  of  the  limb)  are  dipped  in  warm  water,  to  go 
next  the  skin  ;  the  two  others,  the  outer  ones,  are  thoroughly  soaked  in  plaster  the 
consistence  of  cream.  A  bed  is  then  prepared  for  the  leg,  consisting  first  of  a 
layer  of  stout  muslin  cut  so  as  to  act  after  the  fashion  of  a  many-tailed  bandage  ; 
then  one  of  the  pieces  that  have  been  dipped  in  plaster,  and  a  second  simply 
wetted.  On  this  the  leg  is  placed,  the  surgeon  making  extension  and  adjusting 
the  fragments  as  far  as  possible  ;  then  the  other  pieces  are  laid  upon  the  ujiper 
surface,  and  the  muslin  is  brought  up  and  fastened  over  the  limb  so  as  to  press  the 
layers  of  flannel  against  it.  In  this  way  two  strong  plaster  moulds  are  made,  one 
for  each  side,  fitting  the  leg  accurately  ;  and  as  soon  as  the  plaster  sets  they  can  be 
separated  by  simply  cutting  the  muslin. 

In  Gamgee's  method  the  principle  is  the  .same,  but  instead  of  house-flannel, 
absorbent  cotton-wool  is  used,  one  layer  next  the  skin,  the  other  dipped  in  plaster 
cream,  moulded  on  the  outside  of  this. 

Fr.\cture  of  the  Tibi.\. 

The  shaft  rarely  gives  way  by  itself  except  as  the  result  of  direct  violence  ;  the 
internal  malleolus,  however,  may  be  wrenched  off;  the  tubercle  torn  away  by 
sudden  contraction  of  the  quadriceps  ;  and  the  spine,  and  even  the  head  of  the 
bone,  split  in  two  by  the  tension  of  the  crucial  ligaments  in  violent  twists  of  the 
knee.  Asa  rule  there  is  no  difiiculty  in  the  diagnosis;  but  if  the  line  of  separa- 
tion is  exactly  transverse,  especially  in  the  upper  part  of  the  bone,  and  if  there 
is  much  ecchymosis,  so  that  it  is  not  possible  to  feel  the  edge  of  the  crest,  it  may  be 
necessary  to  wait  for  some  days,  treating  the  case  as  a  fracture  in  the  meantime. 


FRACTURES  OF  THE  LEG.  439 

The  deformity  so  long  as  the  fibula  is  intact  cannot  be  serious,  though  there  is 
sometimes  a  certain  amount  of  rotation  at  the  lower  articulation.  Union  takes 
place  readily  ;  but  in  a  few  cases,  in  which  the  patient,  in  spite  of  the  pain,  has 
continued  to  use  the  limb,  a  false  joint  has  formed,  the  fibula  becoming  bowed  and 
greatly  strengthened,  so  as  to  take  more  than  its  share  of  the  weight.  In  all  cases 
of  fracture  near  the  upper  extremity  of  the  tibia  the  condition  of  the  knee-joint 
must  be  carefully  examined,  as  it  is  not  uncommon  for  fissures  in  the  bone  to  run 
ui)ward  as  well  as  downward  in  the  shaft. 

Fracture  of  the  Fibula, 

on  the  other  hand,  is  of  very  common  occurrence.  It  may  be  due  to  direct  or 
indirect  violence  ;  in  the  former  case  the  situation  of  the  fracture  depends  upon 
the  locality  of  the  force  ;  in  the  latter,  when  the  foot  is  twisted  round  between  the 
malleoli,  it  generally  takes  place  at  the  weakest  spot,  two  to  four  inches  above  the 
anlvle-joint ;  sometimes,  however,  it  is  higher  up,  under  cover  of  the  muscles,  and 
occasionally  in  both  places  at  the  same  time.  In  many  instances  the  diagnosis  is 
very  difficult ;  and  it  is  not  improbable  that  fracture  is  present,  without  being 
detected,  in  a  large  number  of  sprains.  A  slight  degree  of  mobility  and  crepitus 
can  generally  be  made  out  by  pressing  alternately  with  the  thumbs  side  by  side  over 
the  seat  of  injury,  or  by  forcibly  twisting  the  foot;  deformity  is  exceptional  in 
uncomplicated  fractures.  In  other  cases  the  only  sign  is  the  loss  of  spring  when 
the  bones  are  squeezed  together  ;  the  fibula  yields  and  gives  instead  of  recoiling ; 
or  ecchymosis  makes  its  appearance  days  after  the  accident ;  or  there  is  one  spot 
at  a  distance  from  the  apparent  seat  of  injury,  very  tender  on  pressure  ;  and  it  is 
of  unusual  significance  if  this  spot  remains  constant  when  the  bones  are  squeezed 
together  higher  up  or  lower  down. 

Fractures  of  the  head  and  neck  of  the  fibula  are  far  from  common  ;  but  they 
sometimes  occur  from  .direct  violence,  or  from  muscular  action,  the  tendon  of  the 
biceps  and  the  external  ligament  combined  tearing  the  upper  part  off  from  the 
rest.      In  many  of  these  cases  the  peroneal  nerve  is  injured  too. 

Complications. — Pott' s Fracture. — Fracture  extending  into  the  ankle  joint 
may  be  caused  in  various  ways.  The  most  common  is  violent  eversion  of  the 
foot ;  the  astragalus  is  twisted  round  in  its  socket ;  the  external  malleolus  is  forced 
outward  until  the  fibula  gives  way  and  breaks  inward  toward  the  tibia ;  and  the  in- 
ternal lateral  ligament  is  stretched  until  it  either  tears  across  itself,  or  drags  off 
part  of  the  internal  malleolus  (Fig.  170).  If  the  force  continues  after  the  bone 
is  broken,  or  if  the  patient  tries  to  walk,  the  foot  is  displaced  to  such  a 
degree  that  a  kind  of  dislocation  (Pott's  fracture)  is  produced.  In  very  severe 
cases  the  interosseous  ligament  between  the  tibia  and  fibula  is  torn  as  well,  or  a 
portion  of  the  tibia  is  split  off  (Fig.  172);  in  the  worst  of  all  the  displacement 
is  carried  so  far  that  the  whole  of  the  foot  and  the  external  malleolus  are  dis- 
placed to  the  outer  side  of  the  leg  (Dupuytren's  fracture). 

Forced  inversion  causes  an  injury  of  a  similar  character  ;  only  the  strain  falls 
upon  the  external  lateral  ligament,  and  the  lower  end  of  the  fibula  is  pulled  in- 
ward until  the  bone  breaks  at  its  weakest  spot  (Fig.  171).  If  the  force  is  not 
exhausted,  the  internal  malleolus  or  the  lower  end  of  the  tibia  gives  way  as  well. 

In  other  cases  a  fissure,  starting  from  an  oblique  fracture  of  the  tibia,  runs 
down  in  the  substance  of  the  bone  until  it  traverses  the  ankle  joint ;  or  the  tibia 
and  fibula  are  separated  from  each  other  and  the  astragalus  driven  up  between 
them  ;  or  both  malleoli  are  broken  off  so  that  the  foot  can  be  moved  freely  in  all 
directions  upon  the  leg.  These  complications,  however,  are  much  more  rare.  As 
a  rule  the  diagnosis  does  not  present  any  difficulty  ;  the  character  of  the  displace- 
ment and  the  shape  of  the  swelling  (for  the  synovial  sac  becomes  distended  with 
blood  at  once)  can  be  recognized  immediately  ;  but  in  every  case  of  fracture  of 
the  fibula  by  indirect  violence,  if  there  is  the  least  tenderness  on  pressure  over  the 
internal  malleolus,  the  patient  should  be  warned  that  the  joint  is  very  likely  to 


440    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

be  stiff  and  weak  for  a  considerable  time  after  the  accident.  Most  of  these  frac- 
tures can  be  put  up  at  once,  either  in  the  Bavarian  splint  or  in  some  modification 
of  it  ;  the  foot  falls  into  its  natural  position  as  soon  as  the  muscles  are  relaxed, 
liut  every  now  and  then  cases  are  met  with  in  which  the  deformity  obstinately  re- 
turns, and  one  or  two  are  recorded  in  which,  in  spite  of  division  of  the  tendo- 
Achillis,  it  could  not  be  reduced  at  all,  probably  from  splintering  of  the  bones  and 
inability  to  disengage  the  fragments.  For  such  as  these,  either  an  outside  splint 
with  a  foot-piece,  as  already  described,  or  Dupuytren's  (Fig.  173),  answers  better. 
The  latter  consists  of  a  straight  piece  of  wood  about  four  inches  broad,  and  suf- 
ficiently long  to  reach  from  below  the  foot  to  above  the  knee.  The  ]jadding  is 
doubled  opposite  the  malleolus  and  does  not  extend  below  it.     The  splint  is  first 


w 


Fig.  170. — Eversion  of  Foot,  forcing  Fibula  inward, 
and  throwing  strain  on  internal  Lateral  Ligament. 


A  > 


P-. 


^'    \ 


\-:- 


-t=^5:>^ 


Fig.  171. — Inversion  of  Foot,  forcing  Fibula  out- 
ward. 


bandaged  to  the  inner  side  of  the  leg  (the  knee  being  well  flexed)  and  then  the  foot 
is  drawn  over  the  projecting  pad  and  secured  to  the  lower  part  by  a  figure-of-eight, 
no  turn  of  which  mast  be  allowed  to  come  above  the  ankle.  A  foot-piece 
corresponding  to  the  sole  may  be  added  with  advantage. 

In  all  these  fractures  the  greatest  care  is  necessary  to  prevent  any  drooping 
of  the  toes  or  carrying  backward  of  the  foot ;  if  the  distance  between  the 
malleoli  is  altered  in  the  least,  whether  it  is  increased  or  diminished,  lameness 
and  serious  disability  are  sure  to  follow.  Passive  motion  should  be  commenced 
in  three  weeks,  and  to  allow  of  this  it  is  essential  that  the  apparatus  used  should 
either  be  laced  up  or  so  arranged  that  it  may  readily  be  taken  off  and  on. 
Stiffness,  cedema,  and  a  sense  of  weakness  about  the  joint  are  very  common 
after-troubles,  and  must  be  met  by  massage,  galvanism,  friction,  and  shampooing. 


FRACTURES  OF  THE   LEG. 


441 


If  the  internal  lateral  ligament  has  given  way  and  the  weight  of  the  body  is 
allowed  to  fall  too  soon  \.\\)0\\  the  injured  jmrt,  an  obstinate  form  of  flat-foot  may 
result. 

Separation  of  Epiphyses. — This  is  more 
common  at  the  ankle  than  at  the  knee  ;  in  the 
latter  situation  it  has  been  produced  by  forcibly 
attem])ting  to  straighten  a  case  of  genu  valgum  ; 
and  when  the  cartilage  has  been  softened  by 
neighboring  inflammation  partial  displacement 
is  not  rare.  The  lower  epiphysis  of  the  tibia 
is  sometimes  separated  in  a  violent  strain  of 
the  ankle  joint,  and  this  may  be  followed  by 
impaired  growth.  When  this  occurs,  the  axis 
of  the  bone  appears  to  be  altered  ;  the  internal 
malleolus  remains  small ;  the  fibula  becomes 
much  stronger,  so  as  to  support  some  of  the 
weight  of  the  leg,  and  is  bowed  outward  ;  and 
the  external  malleolus  grows  so  much  longer  and 
larger  than  the  other  that  the  sole  of  the  foot 
is  turned  inward. 

Wounds  of  Arteries. — The   anterior  and  ^  ,,,,,.,  ^ 

.,   .    ,  .  ,  .....      Fig.  172. — Old   United    Fracture   through   lower 

posterior     tibial     arteries      may     be      injured      in      endofTlbia,  with  separation  of  the  two  bones, 

simple  as  well  as  compound  fractures ;  and  [|jfjt"'"°'"°"'  L'g-'^ent  having  remained 
the  former  may  be  torn  as  it   passes  between 

the  bones,  even  when  the  seat  of  injury  is  some  distance  off.  If  the  skin  is 
unbroken  and  the  soft  parts  are  not  too  much  crushed,  hemorrhage  from  the 
anterior  tibial  can  generally  be  checked  by  pressure  ;  either  the  blood  is  absorbed 
and  the  artery  closed,  or  a  traumatic  aneurysm  forms,  to  be  dealt  wnth  later  on. 
When  the  upper  part  of  the  posterior  is  torn  this  rarely  happens ;  as  a  rule,  the 
swelling  is  so  great  that  the  collateral  circulation  is  cut  off,  and  the  foot  soon 
becomes  cold  and  gangrenous ;  or  it  may  hang  in  the  balance  for  a  day  or  two, 
and  then  require  amputation.  In  one  or  two  cases,  however,  in  which  the  foot 
retained  its  warmth,  ligature  of  the  femoral  has  been  successful,  and  compression 
might  very  reasonably  be  tried.      In  compound  fractures,  either  both  ends  must 


Fig.  173. — Dupuytren's  Splint. 


be  tied  (and,  owing  to  the  extent  of  the  injury  and  the  retraction  of  the  vessels, 
this  operation  is  very  often  impo.ssible),  or  the  limb  must  be  amputated.  Wound 
of  the  posterior  tibial  at  its  lower  part  is  an  exception  ;  in  one  instance,  in  which 
the  ends  could  not  be  found,  I  .succeeded  in  saving  the  limb  by  applying  pressure 
at  the  expense  of  a  small  superficial  slough. 


Compound  Fractures  of  the  Leg. 

Owing  to  the  superficial  position  of  the  bones  these  are  very  common.  Many, 
fortunately,  are  slight,  the  skin  being  merely  punctured  from  beneath  by  one  of 
the  pointed  ends,  through  carelessness  in  carrying  the  patient,  or  from  his  attempt- 
ing to  stand.  These  should  be  sealed  at  once  and  covered  with  iodoform,  the 
bone,  if  it  is  still  projecting,  being  first  thoroughly  cleansed  with  corrosive 
29 


442    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

sublimate  or  some  otiier  antiseptic.  Sometimes  it  is  necessary  to  enlarge  the 
wound  a  little  or  cut  off  a  protruding  spike. 

At  the  opjiosite  extreme  are  those  injuries  caused  by  direct  violence,  where 
the  bone  is  so  crushed  and  the  soft  tissues  so  disorganized  that  it  is  clearly  hope- 
less to  try  to  save  the  limb. 

Between  these  two  every  grade  is  met  with,  and  the  question  of  treatment 
must  be  decided  in  each  case,  first  by  the  age  and  constitution  of  the  patient 
(especially  the  condition  of  his  arteries  and  kidneys),  and  then  by  the  amount  of 
injury  done  to  the  limb  and  the  complications  that  are  pre.sent.  The  arteries 
must  be  examined  first ;  if  they  can  be  felt  pulsating,  and  if  the  skin  is  not 
stripjied  up  too  far,  an  attempt  may  generally  be  made  to  save  the  limb.  The 
wound  must  be  explored  with  the  finger,  enlarged  if  need  be,  and  thoroughly 
washed  out  with  an  antiseptic.  Loose  splinters  must  be  removed,  and  if  the  ends 
of  the  bone  are  bared  of  their  periosteum,  or  so  jagged  that  they  cannot  fit,  they 
may  be  resected  and  sutured  together.  Then  dependent  openings  must  be  made 
for  drainage,  all  oozing  stopped,  the  wound  dressed  with  some  absorbent  material 
so  that  no  fluid  can  collect,  and  the  limb  arranged  upon  an  interrupted  splint  with 
l)ads  covered  with  oiled  silk. 

If  no  pulse  can  be  felt  in  the  foot  below,  the  line  of  treatment  must  be 
determined  by  the  warmth  of  the  skin  and  the  amount  of  sensibility  it  retains. 
Next  to  the  arteries,  the  condition  of  the  skin  is  perhaps  the  most  important;  if 


Fig.  174. — Compound  and  Comminuted  Fracture  of  the  Leg. 

it  is  destroyed  over  a  large  area,  or  if  it  is  stripped  up  so  that  it  is  in  danger  of 
sloughing,  the  chance  of  saving  the  limb  is  immensely  diminished  ;  and  even 
if  this  is  accomplished  it  often  hai)ijens  that  such  an  obstinate  degree  of  oedema 
and  ulceration  persists  that  the  limb  is  not  only  useless,  but  a  constant  source  of 
danger  and  annoyance. 

[It  is  in  such  cases  that  the  use  of  hot  water  made  antiseptic  shows  its  highest 
value.  The  limb  should  be  enveloped  in  a  sheet  wrung  out  from  a  hot  antiseptic 
solution,  and  changed  as  often  as  necessary.  By  enveloping  the  wet  sheet  in  a 
rubber  cloth  the  heat  will  be  retained  for  a  longer  period.] 

Everything  depends  upon  the  next  few  days.  Sometimes,  in  spite  of  every  care, 
the  foot  becomes  colder  and  colder,  the  skin  more  dusky,  and  the  sensibility  less. 
Too  much  has  been  tried,  and  local  traumatic  gangrene  is  setting  in.  The  only 
hope  then  lies  in  immediate  amputation  ;  the  part  cannot  be  kept  aseptic  ;  the 
sloughing  is  sure  to  spread,  and  it  will  not  stop  at  the  seat  of  injury.  If  the 
patient  is  young  and  healthy,  there  is  a  fair  amount  of  hoi)e  still,  provided  the 
operation  is  done  at  once  ;  if  old  or  broken-down,  so  that  the  gangrene  is  rather 
the  result  of  impaired  vitality  than  of  extensive  injury,  the  prognosis  is  as  bad  as 
it  can  be. 

Sometimes,  on  the  other  hand,  acute  inflammation  sets  in  and  rapidly  be- 
comes diffuse  ;  the  temperature  rises,  the  skin  becomes  hot  and  burning,  and  in- 
tense fever,  with  perhaps  delirium,  follows.   The  leg  is  red,  glazed,  and  immensely 


FRACTURES  OF  THE   LEG.  443 

swollen;  the  discharge  from  the  wound  is  offensive,  and  soon  becomes  profuse; 
the  swelling  rapidly  extends  up  the  thigh,  especially  on  its  inner  side,  and  the 
neighboring  lymphatic  glands  become  enlarged.  The  extravasated  blood  has  de- 
composed ;  the  poison  is  pent  up,  unable  to  escape,  and  may  infect  every  tissue 
in  the  leg — skin,  cellular  tissue,  periosteum,  medulla,  lymphatics,  and  even,  per- 
haps, the  veins.  The  issue  depends  upon  which  is  the  stronger,  the  irritant  or 
the  ti.ssues  ;  if  the  former,  hopeless  gangrene  sets  in  and  the  patient  is  almost  cer- 
tain to  die  from  acute  septicaemia.  If  the  latter,  a  wall  of  vascular  lymph  is  grad- 
ually formed,  and  the  poison  shut  off.  Even  then  the  course  is  not  always  straight. 
Cellulitis,  recjuiring  incisions  to  be  made  all  over  the  leg,  may  set  in,  leaving  the 
limb  almost  useless  ;  necrosis,  sometimes  involving  a  large  portion  of  the  bone,  is 
almost  invariable  ;  phlebitis  and  pyaemia  may  occur  at  any  time  ;  the  inflammation 
may  involve  the  neighboring  joints,  either  by  direct  extension,  or  by  spreading 
along  the  lymphatics  into  the  synovial  cavity  ;  and  the  patient,  if  he  survives  the 
immediate  dangers  of  septicaemia  and  pyaemia,  may  sink  later  on,  from  exhaustion. 
Amputation,  so  long  as  the  fever  continues  high,  is  i)ractically  hopeless  ;  when 
the  temperature  begins  to  drop  of  a  morning  a  favorable  moment  can  sometimes 
be  seized  ;  until  this  occurs,  all  that  can  be  done  is  to  meet  the  symptoms  as  they 
arise. 

Fractures  of  the  Bones  of  the  Foot. 

The  posterior  extremity  of  the  os  calcis  is  sometimes  torn  off  with  the  tendo- 
Achillis  by  violence  ;  and  occasionally  the  body  of  the  bone  is  crushed  to  pieces 
by  falling  or  jumping  down  upon  the  heel.  The  astragalus  may  be  broken  in  the 
same  way  and  at  the  same  time  ;  or  the  neck  may  be  twisted  off  in  violent  wrenches 
of  the  foot.  Very  often  the  bone  is  partially  displaced.  The  existence  of  the 
fracture  can  generally  be  made  out  without  difificulty,  but  it  rarely  happens  that 
an  exact  diagnosis  as  to  its  seat  and  direction  is  practicable.  The  fragments  should, 
in  all  cases,  be  manipulated  as  much  as  possible  into  position  while  the  patient  is 
under  an  anaesthetic,  and  then  fixed  with  a  plaster  bandage.  Passive  motion  should 
not  be  delayed  for  more  than  ten  days  or  a  fortnight,  for  fear  of  permanent  stiff- 
ness of  the  ankle. 

Compound  (open)  fractures  of  the  bones  of  the  foot  are  common,  but  no 
definite  rules  can  be  laid  down  as  to  their  treatment.  In  any  operation  the  tread 
of  the  sole  .should  be  interfered  with  as  little  as  possible  ;  and  it  must  always  be 
remembered  that  stability  is  the  first  consideration.  [The  hot  antiseptic  pack 
should  generally  be  applied  for  the  first  twenty-four  hours,  preliminary  to  applying 
the  immovable  plaster.] 


444    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


SECTION  III.— DISEASES  OF  BONE. 


ATROPHY. 

Ill  old  age  the  bones  undergo  a  natural  process  of  wasting,  the  central  canal 
enlarges  and  encroaches  on  the  cancellous  tissue  at 
either  end,  the  compact  portion  of  the  shaft  becomes 
thinner  and  thinner,  until  in  some  cases  it  is  scarcely 
capable  of  sustaining  the  weight  of  the  i)art,  and  the 
medulla  is  replaced  by  fat.  The  same  thing  may  oc- 
cur from  prolonged  disuse,  as,  for  examjjje,  in  cases  of 
old  joint-disease  (Fig.  175),  and  must  be  remembered 
in  the  reduction  of  old  dislocations. 

(Gradual  absorption  of  bone,  as  of  other  tissues, 
Ls  caused  l)y  constant  pressure.  An  aneurysm,  for  ex- 
ample, may  perforate  the  sternum  or  eat  away  the 
bodies  of  the  vertebrae  until  the  strength  of  the  spinal 
column  is  seriously  impaired.  The  blood-vessels  are 
compressed,  the  bone  wastes  away,  and  though  the 
compact  layer  is  to  a  great  extent  retained,  the  cancel- 
lous tissue  is  more  or  less  exposed. 

Arrest  of  growth  is  not  uncommon  as  a  conse- 
of  quence  of  rickets,  hereditary  syphilis,  and  other  affec- 
tions of  the  growing  portion  of  the  bone  during  child- 
Not  only  is  the  length   of  the  bone   less  than   natural,  but  sometimes, 

The 


Fig.  175. — .Atrophy  of  Bone 
section  through  lower 
femur. 


vertical 
end 


hood. 

as  in  the  case  o-f  the   pelvis,  there  is  an  arrest  of  development  as  well 

same  thing  may  occur  from  injury. 


HYPERTROPHY. 

True  hypertrophy  may  be  congenital,  the  bones  becoming  involved  together 
with,  and  in  the  same  proportion  as,  the  other  tissues  of  the  part ;  or  it  may  arise 
from  over-use,  as  a  measure  of  compensation  ;  the  fibula,  for  example,  being 
immensely  strengthened,  without  undergoing  any  material  change  of  proportion, 
in  cases  of  partial  or  complete  loss  of  the  tibia. 

Chronic  inflammation  not  unfrequently  gives  rise  to  great  alterations  in  size  ; 
but  in  this  case  the  structural  details  of  the  bone  undergo  modification  at  the  same 
time.  In  hereditary  syphilis,  for  example,  and  in  osteitis  deformans,  the  bones 
often  increase  in  length  as  well  as  in  circumference,  but  on  section  the  normal 
proportion  of  compact  and  cancellous  tissue  is  not  preserved.  Increase  of 
length  from  chronic  inflammation,  affecting  the  epiphysial  line  during  the 
growing  period,  is  still  more  common. 


INFLAMMATION. 

The  changes  that  take  place  in  inflammation  of  bone  are  similar  to  those  that 
occur  in  inflammation  of  other  tissues  ;  the  aj)parent  difference  is  due  to  the 
presence  of  a  solid  framework  which  i)lays  an  entirely  passive  and  secondary 
part. 

In  compact  bone  the  active  vascular  tissues  lie  partly  on  the  exterior  (the  soft 
layer  of  the  periosteum),  partly  in  the  central  canal  (the  medulla),  and  to  a  much 


INFLAMMATION  OF  BONF.  445 

smaller  extent  in  the  substance  of  the  bone  itself,  in  the  Haversian  canals,  and  the 
lacunai.  Intlammation  may  commence  in  any  one  of  these,  as  periostitis,  osteo- 
luyclitis,  or  osteitis,  and  althougii  it  never  remains  confined  to  one,  but  very  soon 
involves  tlie  whole,  it  is  often  so  much  more  marked  in  one  than  in  the  other  that 
they  may  well  be  described  as  separate  affections. 

In  cancellous  bone,  on  the  other  hand,  interstitial  osteomyelitis  or  osteitis  is 
practically  the  only  form  ;  there  is  no  central  canal,  the  medulla  is  distributed 
evenly  through  the  whole,  and  although  there  is  a  periosteum,  the  layer  of  com- 
pact tissue  which  it  sup])orts  is  so  thin  that,  even  if  an  affection  begins  distinctly 
in  one  part,  the  rest  of  the  bone  becomes  involved  almost  at  once. 

Pathology. — The  pathological  changes  are  the  same  as  in  the  other  tissues  of 
the  l)ody  ;  hyper;-emia,  dilatation  of  the  blood-vessels,  and  increased  rajjidity  of 
the  flow,  followed  at  a  later  period  by  stasis,  if  the  attack  is  sufficiently  acute. 
Lymph  pours  out  through  the  walls  of  the  vessels,  the  tissues  become  engorged  and 
swollen  (so  far  as  they  can,  for  therein  lies  the  difference),  the  matrix  becomes 
softened  (if  there  is  time),  new  blood-vessels  are  formed,  the  amount  of  exudation 
continues  to  increase,  and  at  length  periosteum  and  medulla  are  replaced  by  layers 
of  soft,  exceedingly  vascular  lymph  or  granulation-tissue,  as  deep  and  as  thick  as 
space  will  allow. 

The  subsequent  course  depends  upon  whether  the  inflammation  is  acute  or 
chronic,  and  whether  the  portion  of  bone  involved  is  compact  or  cancellous. 

I.  Acute  Inflammation. 

When  connective  tissue  is  inflamed,  the  intercellular  substance  rapidly  be- 
comes softened  (unless  it  is  a  sheet  of  very  dense  fascia),  the  vessels  can  expand 
and  enlarge  in  all  directions,  and  there  is  scarcely  any  limit  to  the  amount  of 
lymph  that  can  be  poured  out.  This  is  not  the  case  in  bone,  especially  when  it  is 
compact.  It  is  true  that  as  soon  as  inflammation  commences  the  osseous  frame- 
work begins  to  change  in  a  similar  way  ;  it  gradually  becomes  softened  and  eroded 
on  its  surface  (whether  under  the  periosteum,  round  the  medulla,  or  in  the  Hav- 
ersian canals),  and  special  multi nuclear  cells  to  which  this  function  is  assigned 
(osteoclasts)  are  found  in  all  these  places,  lying  in  little  recesses  (Howship's 
lacunse)  which  they  have  eaten  out  for  themselves ;  but,  while  fibrous  tissue  can 
soften  and  yield  at  once,  it  takes  time  in  the  case  of  bone,  and  consequently,  if 
the  attack  is  acute,  either  stasis  occurs,  without  the  possibility  of  any  collateral 
circulation,  or  the  blood-vessels  become  strangled  in  their  own  canals  by  the 
exudation  around  them.  In  other  words,  as  in  carbuncle  at  the  back  of  the  neck, 
if  inflammation  is  acute,  the  circulation  is  stopped,  the  tissues  perish,  and  gangrene 
(necrosis)  occurs. 

In  compact  bone  this  is  the  rule.  Acute  inflammation,  if  it  is  not  followed 
by  immediate  resolution,  ends  in  necrosis.  If  the  periosteal  surface  is  involved 
{acute periostitis),  the  sequestrum,  as  it  is  called,  is  superficial;  if  the  medulla 
{acute  osteomyelitis),  it  is  central  and  tubular  in  shape,  formed  from  the  layers 
that  immediately  line  the  canal ;  if  both  together,  the  whole  shaft  perishes  {total 
necrosis') . 

In  cancellous  bone,  where  the  spaces  are  larger  and  wdder,  necrosis  is  more 
rare  ;  the  vessels  have  more  room,  dilatation  and  exudation  are  possible,  and  there 
is  less  solid  bone  to  be  absorbed  ;  but  if  the  inflammation  is  so  intense  as  to  cause 
thrombosis  or  stasis  over  any  extent,  the  result  is  the  same,  and  as  a  matter  of  fact 
small  rounded  sequestra  of  cancellous  bone  are  not  uncommon  in  the  centre  of 
suppurating  foci. 

When  a  sequestrum  is  formed,  the  dead  portion  acts  as  a  constant  irritant 
until  it  is  separated  and  thrown  off  by  a  process  of  rarefying  osteitis ;  so  that  an 
acute  attack  of  inflammation  causing  necrosis  must  be  followed  by  a  chronic 
one. 


446    DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 


2.   Chronic  Ini'lammaiion — Rakki'vinc;   Dsif.itis. 

When  the  exciting  cause  is  not  an  acute  one  the  bony  trabecule  have  tim^ 
to  soften  ;  the  amount  of  exudation  increases,  more  vessels  are  formed,  the  spaces 
enlarge,  the  solid  walls  that  surrounded  them  are  removed  little  by  little,  and  the 
affected  portion  of  bone  becomes  oi)en  and  jjorous.  Compact  tissue  becomes 
cancellous,  cancellous  tissue  so  soft  that  it  can  be  cut  with  a  knife. 

If  this  commences  on  the  outside  the  periosteum  becomes  softer,  thicker,  and 
more  vascular,  the  tough  fibrous  layer  is  lifted  up  from  the  bone  beneath  by  masses 
of  newly-formed  lym|jh  (forming,  if  the  bone  lies  immediately  under  the  skin, 
what  is  commonly  called  a  /iO(/i')  ;  and  if  it  is  torn  off,  it  leaves  a  surface  that  is 
not  white  and  smooth,  but  rough,  uneven,  covered  with  little  bony  spicules,  and 
dotted  all  over  with  minute  openings  (Fig.  176).  If  the  medulla  is  involved  first, 
the  changes  are  essentially  the  same  ;  the  old  spaces  are  enlarged,  new  ones  are 
formed  by  the  disappearance  of  the  partitions,  and  the  medullary  canal  is  filled 
with  soft  masses  of  vascular  granulation-tissue. 

The  simplest  type  of  chronic  inflammation  is  seen  in  the  process  by  which  a 
necrosed  portion  is  separated  from  the  rest.  The  living  bone  all  around  becomes 
more  vascular,  the  Haversian  canals  expand   and   become   filled   with   lym]jh,  the 

solid  matrix  next  to  the  sequestrum  is  absorbed  and 
replaced  by  granulation -tissue,  and  by  degrees  a 
line  of  demartation  cuts  it  out.  The  necrosed 
part  is  detached  by  the  irritation  it  causes,  at  the 
expense  of  the  living  bone  around  it,  and  lies  in  a 
cavity,  the  walls  of  which  are  formed  everywhere 
of  granulation-tissue,  springing  from  rarefied  bone. 
In  the  majority  of  instances  su])i)uration  occurs,  but 
it  is  not  an  essential  part  of  the  process. 

The  subsequent  changes  depend  partly  upon 
the  intensity  and  persistence  of  the  cause,  partly 
upon  the  strength  of  constitution  of  the  patient. 

(a)  Resolution. — When  the  irritant  is  but 
slight  and  transient,  resolution  soon  begins:  the 
vascularity  diminishes,  some  of  the  lymph  becomes 
absorljed,  the  rest  is  organized,  and  in  a  short  time 
the  natural  condition  of  the  part  is  perfectly  re- 
stored. The  changes  that  take  place  after  a  simple 
fracture  are  a  very  good  illustration. 

ij))  Persistence  {Caries  sicca  or  fitngosd). — In 
other  ca.ses  the  process  continues  without  altering  in  character  until  the  whole  of 
the  bony  framework  is  absorbed  ;  nothing  but  a  mass  of  soft  granulation-tissue  is 
left.  The  whole  body  of  a  vertebra  may  be  removed  in  this  way  so  as  to  cause 
angular  curvature  of  the  spine,  and  the  phalanges  of  a  finger  may  simply  disappear 
until  the  nail  rests  upon  the  head  of  the  metacarpal.  Extreme  forms  of  this  kind 
appear  usually  to  be  associated  with  tubercle,  but  there  is  no  caseation.  Deatl 
bone  may  be  aljsorbed  as  well  as  living ;  a  sequestnuii,  so  long  as  it  is  surrounded 
by  living  granulation-tissue  (not  by  pus),  gradually  diminishes  in  size,  being 
eroded  and  eaten  into  from  the  surface  in  the  same  way  as  an  ivory  peg. 

{c)  Organization  {Osteosclerosis). — In  some  diseases,  rheumatism  for  examj^le, 
and  not  unfrequently  syphilis,  the  vascular  granulation-tissue  becomes  organized 
and  converted  into  bone.  This  is  especially  prone  to  happen  at  a  little  distance 
from  a  focus  of  suppuration,  and  not  uncommonly  extends  all  round  and  enclo.ses 
it  (Fig.  178).  When  it  occurs  in  the  substance  of  a  bone,  the  trabeculne,  instead 
of  softening  and  disa])pearing,  become  hardened  and  thickened  ;  the  cells  that  lie 
upon  their  surface  are  incorporated  with  them  ;  the  spaces  left  between  filled  with 
soft  granulation-tissue,  become  smaller  and  smaller  ;  the  Haversian  canals  are 
narrowed  ;  and  at  length  the  affected  portion  of  the  bone  is  converted  into  a  dense, 


Fig.  176. — Chronic  Infliunmation  of  Hone. 
The  Tibia  and  Fibula  from  an  old  ampu- 
tation, showing  excessive  vascularity 
with  great  production  of  new  bone. 


RAREFYING  OSTEITIS. 


447 


hard,  and  heavy  mass,  like  ivory.  If  the  medulla  is  involved,  the  canal  simply 
disappears  ;  it  is  completely  filled  in  ;  if  the  periosteum,  the  changes  are  essen- 
tially the  same  ;  layer  after  layer  of  lymph 
is  thrown  out  upon  the  surface  and  con- 
verted into  bone,  until  the  natural  exterior  of 
the  shaft  is  coated  over  with  a  ring  of  newly- 
formed  osseous  tissue,  and  the  thickness 
of  the  wall  is  doubled  or  trebled  (Fig.  179). 
The  so-called  expansion  of  bone  over  cen- 
tral sequestra  or  sarcomata  is  produced  in  a 
similar  way  :  as  the  interior  becomes  hol- 
lowed out  and  weakened,  the  periosteum  on 
the  outside  maintains  the  strength  of  the  part 
by  the  new  bone  it  forms,  until  perhaps  the 
whole  of  the  original  shaft  disappears,  and  a 
new  shell  with  a  much  larger  cavity  is  de- 
veloped in  its  place  (Fig-  188). 

For  the  most  part  this  change  is  to  lie 
regarded  as  reparative  in  character,  but 
sometimes  it  leads  to  consequences  which, 
instead  of  being  beneficial,  make  matters 
worse.  One  has  been  mentioned  already  : 
a  suppurative  focus  in  the  cancellous  end  of 
a  long  bone  may  be  completely  locked  in  ; 
layer  after  layer  of  dense  osseous  tissue  is 
formed  around  it  until  escape  is  impossible  ; 
but  unhappily,  this  process  is  rarely  uniform  ; 
the  periosteal  surface  becomes  thickened 
(Fig.  178),  but  not  the  articular,  so  that  if 
a  joint  is  near  and  suppuration  continues, 
the  pus  is  almost  certain  to  work  its  way  into 
the  cavity  and  lead  to  destructive  arthritis. 

In  other  cases  the  Haversian  spaces  and 
the  medullary  canal  become  so  constricted 
that  the  amount  of  blood  going  to  the  part 
is  scarcely  sufficient  to  maintain  its  life,  and 
the  least  irritant  causes  necrosis.  Sometimes 
apparently  none  is  required.  Paget  has  described  a  form  of  quiet  necrosis  in 
which  there  is  no  suppuration,  or  exceedingly  little  ;  the  sclerosis  simply  con- 
tinues until  the  vascular  canals  are  obliterated  and  the  central  portion  of  the 
affected  area  dies.  The  sequestrum  formed  in  this  way  may  take  years  before  it 
is  completely  detached.  Meanwhile  it  acts  as  a  continual  irritant,  the  bone 
around  is  kept  in  a  state  of  chronic  inflammation,  and  either  rarefying  osteitis  sets 
in,  and  the  strength  of  the  part  is  so  much  impaired  that  spontaneous  fracture  takes 
place,  or  it  becomes  denser  and  harder,  and  layer  after  layer  of  new  bone  is  laid 
down,  until  at  length  the  circumference  is  doubled.  In  either  case,  the  diagnosis 
from  malignant  disease  is  exceedingly  difficult,  and  not  infrequently  the  actual 
condition  has  only  been  recognized  after  amputation. 

Syphilitic  inflammation  of  bone,  especially  the  inherited  form  that  occurs  at 
puberty,  is  often  followed  by  an  extreme  degree  of  sclerosis.  The  whole  of  the 
shaft,  generally  of  the  tibia,  becomes  enlarged  and  condensed  ;  superficial  sequestra 
form,  probably  from  gummatous  infiltration  of  the  periosteum  ;  and  owing  to  the 
extreme  density  of  the  bone  beneath,  it  may  be  years  before  they  are  loose  enough 
to  be  removed.  The  same  thing  is  not  uncommon  after  acute  necrosis  of  the 
lower  end  of  the  femur  ;  the  sequestrum,  especially  when  the  posterior  surface  is 
involved,  may  remain  adherent  for  the  rest  of  life. 

Closely  allied  to  this  are  the  changes  in  shape  and  size,  as  well  as  in  density. 


Fig.  177. — Suppurative  Periostitis  and  Osteomyelitis 
of  Tibia;  the  sequestrum,  which  is  locked  in,  in- 
volved the  whole  thickness  of  the  bone.  Owing 
to  the  constant  irritation  near  the  epiphysial  line 
the  upper  end  of  the  tibia  has  grown  obliquely. 


448    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

which  are  sometimes  met  with  in  achilts.  In  most  instances  (osteitis  deformans,  for 
example)  they  are  the  result  of  some  general  disorder  of  nutrition,  antl  the  whole 
skeleton  is  affected  more  or  less;  but  occasionally  alterations  of  a  similar  descrip- 
tion— elongation,  curving,  irregularity  of  the  surface,  disaijpcarance  of  the 
medullary  canal,  and  condensation — are  produced  l)y  jjurely  local  irritants. 

In  children,  before  the  epiphyses  have  united,  the  growth  of  the  bone  in 
length,  as  well  as  the  shape,  may  be  very  seriously  affected  by  premature  conden- 
sation. Ossification  sets  in,  the  epiphysis  is  joined  to  the  shaft  before  full  size  is 
reached,  and  development  is  stopped.  In  other  cases,  exactly  the  opposite  result 
follows;  owing  to  the  greatly  increased  vascularity  of  the  part  unnatural  growth 
takes  i^lace  and  the  bone  becomes  very  much  elongated.  This  may  occur  on  one 
side  of  the  bone  only,  so  that  the  axis  of  the  limb  is  seriously  distorted  (Fig.  177); 
or  in  one  of  a  i)air  and  not  in  the  other,  in  the  tibia,  for  example,  and  not  in  the 
fibula,  so  that  the  neighboring  joint  is  rendered  almost  useless. 

3.  Caries. 

Of  this  there  are  two  varieties  :  {a)  simple  or  non-specific,  in  which  pyogenic 
organisms  only  are  present ;  and  (//)  specific,  in  which  the  destruction  is  due  to 
tubercular,  syphilitic,  or  lejirosy  germs,  with  or  without  the  others.  In  the  first 
variety  the  granulation -tissue  breaks  down  into  pus  directly  ;  in  the  second  fatty 
degeneration  and  caseation  set  in  first,  and  suppuration  is  a  complication.  In  both 
the  trabeculns  that  are  not  absorbed  are  deprived  of  their  nutrition  and  perish  ;  and 
small  fragments  of  dead  bone  drop  off  into  the  fluid  that  surrounds  them.  When 
the  inflammation  is  acute,  the  sequestra  may  be  of  some  size  {caries  necroticd)  ; 
ordinarily  they  are  very  minute. 

Caries  may  occur  either  on  the  surface  of  compact  bone  or  in  cancellous  tissue. 
The  former  is  most  often  met  with  in  connection  with  syphilis.  A  gummatous 
deposit  forms  in  or  under  the  periosteum,  softens  and  breaks  down,  leaving  a  foul- 
looking  ulcer,  the  floor  of  which  is  formed  of  roughened  bone,  soft,  and,  as  pyogenic 
germs  are  always  present  in  sloughing  gummata,  covered  over  with  pus.  Under- 
neath, if  this  is  scraped  away,  there  is  a  border  of  rarefying  osteitis  ;  and  as  a  rule, 
further  off,  one  of  sclerosis,  the  difference  depending  upon  the  diminishing  in- 
tensity of  the  irritant. 

In  cancellous  tissue  it  is  much  more  common.  The  carpus  and  tarsus,  the 
bodies  of  the  vertebrre  and  the  articular  ends  of  the  long  bones,  are  the  favorite 
places.  It  begins  as  rarefying  osteitis  ;  the  Haversian  canals  become  dilated  ;  the 
trabeculte  are  absorbed,  all  the  spaces  enlarge,  and  very  soon  the  affected  part  is 
converted  into  granulation-tissue  with  only  a  {q.\\  bony  spicules  left.  If  the  cause 
is  a  transient  one,  resolution  or  organization  follows,  and  the  damage  is  repaired. 
If,  on  the  other  hand,  living  organisms  are  present,  and  they  continue  to  grow, 
the  newly-formed  lymph  is  killed,  the  solid  tissues  break  down  and  become 
liquid,  the  trabecule  that  are  not  absorbed  die  and  drop  off  as  a  minute  sequestra  ; 
and  in  a  little  while  a  cavity  is  formed,  filled  with  fluid  debris,  and  surrounded  by 
a  wall  of  softened,  congested  bone. 

{a)  Simple  Caries. — In  a  chronic  abscess  of  the  cancellous  end  of  one  of  the 
long  bones,  such  as  is  sometimes  caused  by  injury  (Fig.  178),  all  these  changes 
may  be  found  existing  together,  side  by  side.  In  the  centre  is  a  sequestrum  ; 
thrombosis  occurred  in  some  of  the  vessels  at  the  time  of  the  accident,  the  collateral 
circulation  could  not  I)e  established,  and  necrosis  resulted.  Around  this  is  a  cavity 
filled  with  pus,  a  few  (but  only  a  few)  germs  having  reached  it  through  the  blood. 
The  bone  which  originally  occupied  this  space  has  been  absorbed  ;  the  inflamma- 
tion was  not  sufficiently  severe  to  kill  the  part  en  masse  as  it  did  in  the  centre  ; 
there  was  time  for  rarefying  osteitis  to  set  in  ;  the  bony  trabecules  were  removed  ; 
the  granulation-tissue  that  replaced  them  melted  away  into  pus,  and  an  abscess- 
cavity  resulted. 

The  wall  of  the  abscess  is  lined  with  a  so-called  pyogenic  membrane — in 


CARIES. 


449 


other  \vorcls,  vascular   lymph  or  granulation-tissue,  which  has  caused  the  removal 
of  every  particle  of  bone,  and  has  been  able  to  resist  the  action  of  the   i)yogenic 
organisms.     Around  this  is  a  circle  of  rarefying  osteitis,  gradually  becoming  less 
and    less   characteristic  as   the  distance   in- 
creases.      Close  to  the  cavity  there  is  only  a 
bony  spicule  left  here  and  there  ;   it  is  nearly 
all  soft   tissue,  continuous  with  that   lining 
the  abscess  and    furnishing   by  its  death  the 
pus  that  fdls  it.     Further  away  the  proportion 
is  reversed  ;  and  at  length,  quite  on  the  out- 
side, where  the  effect  of  the  irritant  is  scarcely 
felt,  organization  has  taken  place,  the  bone  is 
hard   and  dense  (sclerosed),  and    new  layers 
are  thrown  out  under  the  periosteum. 

These  changes  are  the  result  of  two 
forces  :  one  is  the  destructive  action  of  the 
irritant,  aided  by  the  pyogenic  organisms  ; 
the  other  is  the  effort  of  the  tissues  to  repair 
and  limit  the  damage.  The  same  may  be 
seen  when  caries  affects  the  surface  of  a 
bone,  provided  the  patient  is  otherwise 
healthy  ;  in  the  centre,  where  the  irritant  is 
most  active,  the  destruction  is  complete  ; 
around  the  margins  of  the  ulcer  (for  such  it 
really  is)  and  deep  down  under  its  floor  there 
is  a  deposit  of  new  and  dense  bone. 

(a)  Specific  Caries. — This  is  nearly  al- 
ways due  either  to  tubercle  or  syphilis  ;  the 
other  infective  organisms  are  more  rare,  and 
the  effects  they  i)roduce  not  characteristic. 

Tubercular  caries  is  especially  distinctive 
the  rest  by  the  entire  absence  of  repair.  So  long  as  the  tubercle  is  spreading,  the 
inflammation  is  never  confined,  either  by  sclerosis  or  a  deposit  of  new  bone.  The 
W'hole  structure  is  light  and  porous ;  there  is  no  evidence  of  organization,  no 
thickening  under  the  periosteum  or  sclerosis  in  the  cancellous  spaces.  The  centre 
is  filled  with  caseous  debris  or  a  thin  oily  fluid  mixed  with  minute  sequestra ; 
around  this  is  a  layer  of  granulation-tissue  studded  with  miliary  tubercles,  which 
constantly  spread  wider  and  wider,  while  they  decay  and  caseate  in  the  centre. 
If  the  nutrition  of  the  bone  imi)roves,  or  that  of  the  bacilli  deteriorates,  so  that 
the  former  gains  the  upper  hand  and  the  inflammation  ceases  to  be  tubercular, 
encapsulation  and  sclerosis  occur,  as  when  the  cause  was  traumatic.  If,  on  the 
other  hand,  the  bone-corpuscles  are  badly  nourished  or  in  a  state  of  fatty  degen- 
eration (which  is  said  to  be  common  in  tuberculous  subjects)  there  is  nothing  to 
oppose  the  spread  of  the  disease,  and  it  continues  until  the  whole  is  reduced  to  a 
periosteal  shell,  filled  with  caseous  debris.  There  is  no  suppuration  unless  the 
pyogenic  germs  enter  as  well  as  the  tubercle  bacilli,  and  in  sufficient  number  ;  if 
once  they  do,  the  destruction  becomes  infinitely  more  rapid. 

Syphilitic  caries  presents  no  special  features.  It  may  occur  by  itself  and  cause 
the  most  extensive  destruction  (Fig.  185),  but  suppuration  is  usually  associated 
with  it. 

Causes. — Inflammation  may  be  caused  either  by  organized  or  unorganized 
irritants:  the  latter  may  be  mechanical  (tension  or  the  presence  of  a  foreign  body), 
or  chemical  (mercury  or  phosphorus)  ;  the  mode  of  action  of  the  former  is  uncer- 
tain and  perhaps  not  always  the  same. 

I.  Mechaiiical Injury. — In  wounds  and  fractures  the  bones,  like  other  ti.ssues, 
become  inflamed  if  the  parts  are  not  kept  at  rest,  if  there  is  any  tension  or  if  there 


Fig.  178. — Diagrammatic  representation  of  an  Ab- 
scess in  the  Cancellous  End  of  the  Tibia,  showing 
a  central  sequestrum  lying  in  an  abscess-cavity 
with  vascular  bone  around,  and  further  away 
sclerosis  and  a  deposit  of  new  bone. 


It  is  marked  out  at  once  from  all 


45 o    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

is  a  foreign  body  present,  such  as  a  sequestrum,  and  sclerosis  or  rarefying  osteitis 
sets  in,  but  not  suppuration. 

2.  Chemical  Poisons. — Some  of  these,  b'ke  mercury  and  phosphorus,  are  in- 
troduced directly  from  the  exterior.  Others,  as  in  the  case  of  ^out  and  rheimia- 
tism,  are  in  all  probability  the  product  of  some  perversion  of  nutrition.  Whether 
certain  other  affections  of  bone,  which  are  not  so  distinctly  inflammatory  in  their 
character  (such  as  osteitis  deformans,  rickets,  and  osteomalacia)  are  also  due  to 
chemical  changes  in  the  blood,  is  perhaps  open  to  argument ;  but  at  least  no  clear 
line  can  be  drawn  between  them. 

3.  Infectious  Organisms. — {a)  Non-specific.  — Inflammation  of  the  most 
intense  character  may  occur  after  amputations  or  comjjound  fractures,  especially  if 
the  medullary  canal  has  been  laid  open  ;  or  by  infection  from  the  blood  (acute 
suppurative  periostitis,  osteomyelitis,  and  epiphysitis),  the  germ  entering  either 
through  some  cutaneous  boil,  or,  if  the  skin  is  unbroken,  through  the  alimentary 
or  respiratory  tracts,  and  finding  a  suitable  nidus  for  its  development  in  the  bone. 
It  is  not  uncommon  after  the  acute  exanthemata,  especially  typhoid  fever. 

As  in  all  forms  of  inflammation  of  bone  in  which  necrosis  or  suppuration 
occurs,  the  attack  does  not  cease  when  the  primary  cause  has  spent  its  energy  ;  the 
sequestrum  remains  behind  as  a  foreign  body  and  acts  as  a  constant  irritant,  keep- 
ing up  chronic  inflammation,  until  it  is  detached  and  the  loss  repaired. 

(J>)  Specific. — Periostitis  and  interstitial  osteomyelitis  are  exceedingly  common 
in  syphilis,  both  in  the  acquired  and  the  hereditary  form.  The  inflammation  may 
be  acute,  occurring  early  in  the  course  of  the  disea.se,  affecting  the  periosteum 
chiefly  and  ending  for  the  most  part  in  resolution,  or  chronic,  involving  the  bone 
as  well,  and  often  complicated  by  suppuration.  Sclerosis  and  hyperostosis  are 
more  common  in  the  hereditary  form.  Tubercle  usually  affects  young  subjects, 
and  nearly  always  cancellous  bones,  though  it  may  occur  upon  the  cranium.  Other 
specific  organisms,  such  as  those  of  leprosy  and  actinomycosis,  are  too  rare  to  re- 
quire special  mention. 

Secondary  inflammation  of  bone,  due  to  extension  from  structures  near,  is  fre- 
quently met  with.  Ulceration  of  the  skin,  for  instance,  may  extend  into  the  sub- 
stance of  an  underlying  bone  and  lead  to  caries  ;  or,  in  a  poisoned  wound  of  the 
finger,  the  inflammation  may  spread  along  the  lymphatics  to  the  tendon-sheath  and 
the  periosteum,  and  lead  to  acute  suppurative  periostitis. 


Varieties  of  Inflammation. 

Simple  Traumatic. 

Contusions  occasionally  give  rise  to  an  effusion  of  blood  under  the  periosteum 
or  in  the  cancellous  tissue  ;  but  except  in  children  it  is  rarely  extensive.  The  sub- 
periosteal extravasation  on  the  parietal  bone  in  infants  after  difficult  labor  {cephal- 
hcefnatoma)  is  an  exception.  This  may  attain  a  very  considerable  size,  though  it  is 
always  strictly  limited  by  the  sutures,  and  may  last  for  months  before  it  is  com- 
pletely absorbed,  the  edges  becoming  hard  and  organized  while  the  centre  remains 
soft  and  semi-fluid.  In  cases  of  fracture  the  extravasation  is  more  extensive,  fill- 
ing up  the  medullary  canal  and  spreading  into  all  the  tissues  around  as  well. 

The  subsequent  changes  are  the  same  as  in  other  tissues  :  the  blood  coagulates, 
the  liquid  portion  disappears,  the  vessels  dilate,  lymph  pours  out  through  their 
walls  into  the  remainder  of  the  clot,  and  all  the  tissues  around  become  softened 
and  swollen.  In  other  words,  the  tension  and  the  extravasated  blood  have  caused 
a  very  slight  degree  of  inflammation. 

(a)  In  the  vast  majority  this  is  followed  by  resolution  ;  the  broken-down  clot 
is  gradually  removed,  the  exudation  is  absorbed,  the  blood-vessels  shrink  to  their 
normal  diameter,  and  the  structure  of  the  part  is  completely  restored. 

{H)  Occasionally  organization  takes  place,  and  the  lymph  becomes  converted 
into  bone.     This  is  always  due  to  some  slight  but  persistent  irritant ;  it  maybe  a 


OSTEITIS.  451 

local  one,  as  when  organization  occurs  round  the  margin  of  a  cephalhrematoma  ; 
more  frequently  it  is  constitutional,  as  in  syphilis  or  rheumatoid  arthritis.  In  these 
diseases  the  general  nutrition  is  so  perverted  that  if  the  tissues  become  inflamed, 
no  matter  what  the  exciting  cause  may  be,  the  attack  is  not  allowed  to  subside;  it 
is  maintained  and  nuule  chronic  by  the  constitutional  comjilaint. 

{c)  In  rare  instances  the  death  of  the  part  of  the  bone  that  is  injured  takes 
place  ;  thrombosis  occurs,  and  if  the  collateral  circulation  fails  necrosis  results. 
In  the  soft  tissues  the  dead  part  is  removed  by  fatty  degeneration.  In  bone  what 
is  known  as  quiet  necrosis  follows.  A  jjortion  of  the  shaft  perishes,  acts  as  a  foreign 
body  keeping  up  a  slight  amount  of  irritation,  and  leads  to  the  formation  of  dense 
and  thick  layers  of  new  bone  around,  so  that  sometimes  an  enormous  degree  of 
enlargement  is  produced.  Suppuration  is  a  complication  and  not  an  essential 
feature  ;  but  generally  the  pyogenic  organisms  gain  access  to  the  injured  tissue 
through  the  blood-stream,  and  a  certain,  amount  of  \)\\s  is  formed.  If  this  occurs 
in  the  shaft  of  a  long  bone  it  is  known  as  chronic  osteomyelitis  (Fig.  179)  ;  if  in 
the  cancellous  end,  as  chronic  abscess  of  bone  (Fig.  178).  Probably  in  these  in- 
stances the  tissues  outside  the  immediate  seat  of  injury  are  well  nourished,  the 
pyogenic  irritants  are  few  in  number  and  capable  of  but  little  mischief,  and  sclerosis 
soon  shuts  them  in. 

Symptoms. — (<?)  Simple  acute  infla?nmation  (^traumatic  node').  The  symp- 
toms are  rarely  severe.  If  the  bone  is  superficial  the  skin  is  a  little  raised,  perhaps 
warmer  than  it  ought  to  l)e,  and  adherent  to  the  periosteum  beneath  ;  usually  it  is 
rather  whiter  than  natural,  owning  to  the  way  in  which  it  is  stretched;  only  when 
the  inflammation  reaches  it  does  it  become  much  reddened.  It  is  always  very 
tender  on  pressure  ;  if  there  is  any  muscle  attached  to  the  injured  spot  the  patient 
will  not  use  it ;  and  there  is  a  constant  dull  aching  pain  which  grows  worse  at 
night  as  the  limb  becomes  warm  in  bed,  and  gradually  subsides  toward  morning. 
In  children  there  may  be  slight  feverishness,  but  never  such,  in  simple  traumatic 
inflammation,  as  to  excite  anxiety. 

(b)  Chi'onic  inflammation  ;  chronic  osteitis,  periostitis,  or  osteomyelitis  ;  chronic 
abscess  of  bone.  The  s}mptoms  of  all  of  these  are  of  the  same  character,  though 
they  differ  very  much  in  intensity.  The  most  striking  is  the  constant,  dull,  aching 
pain,  worse  at  night  when  the  patient  gets  warm,  and  worse  in  wet  weather  or 
after  exercise.  In  subacute  attacks,  or  when  there  is  an  abscess  shut  in,  it  may 
be  very  severe.  The  whole  bone  is  enlarged  by  expansion  and  the  formation  of 
new  layers  on  the  surface,  though  this  often  appears  to  be  greater  than  it  really  is, 
owing  to  the  condensation  of  the  soft  tissues  over  it.  In  periostitis  the  swelling 
usually  involves  only  one  side,  and  is  irregular  and  nodular  on  the  surface  ;  when 
the  cause  is  more  deeply  seated  the  outline  is  generally  smooth  and  even.  The 
skin  rarely  shows  any  change,  though  it  may  pit  slightly  on  firm  pressure  if  the 
bone,  like  the  tibia,  is  subcutaneous.  As  a  rule,  there  is  tenderness  over  the  whole 
bone,  but  not  unfrequently,  especially  in  chronic  abscess  of  the  cancellous  end, 
one  spot  is  exquisitely  sensitive  ;  and  occasionally  it  is  a  little  reddened  and  puffy 
upon  the  surface.  There  is  no  local  rise  of  temperature,  unless  the  inflammation 
is  nearing  the  skin,  and  as  a  rule  little  or  no  constitutional  disturbance  ;  but  the 
muscles  are  not  unfrequently  w-asted,  and  if  the  articular  end  of  the  bone  is 
involved,  the  neighboring  joint  always  shows  signs  of  synovitis. 

Treatment. — Simple  acute  inflammation,  as  a  rule,  subsides  rapidly  if  the 
part  is  kept  at  rest  and  the  amount  of  blood  flowing  through  it  checked  by  eleva- 
tion, cold,  and  lead  lotion.  Whether  necrosis  takes  place  or  not  depends  upon 
the  extent  of  the  thrombosis  and  the  amount  of  bone  which  has  been  deprived  of 
its  blood-supply.  If,  for  example,  stasis  occurs  in  the  diploe  of  the  cranium,  the 
whole  thickness  of  the  bone  may  perish,  and  there  is  great  danger  (if  suppuration 
sets  in)  of  the  inflammation  spreading  to  the  meninges  or  the  sinuses  and  cau.sing 
pyaemia,  as,  for  instance,  in  Pott's  puffy  tumor ;  if  only  the  surface  is  affected, 
either  there  is  no  necrosis  at  all,  the  collateral  supply  maintaining  the  nutrition,  or 
the  sequestrum  is  superficial. 


45-'     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES, 


If  the  inflammation,  instead  of  subsiding,  persists  and  becomes  chronic,  the 
treatment  must  be  guided  by  the  cause  Sometimes  nothing  l)ut  osteosclerosis 
can  be  found  to  explain  it;  the  inflammatory  exudation,  under  the  influence  of  a 
rheumatic  or  a  syphilitic  constitution,  has  undergone  organization  ;  the  whole 
bone  has  become  hard  and  dense,  and  the  seat  of  a  chronic,  wearing  pain.  Some- 
times, on  the  other  hand,  a  secpiestrum  or  a  minute  (piantity  of  pus  is  locked  in, 
either  by  the  compact  tissue  of  the  bone  itself  or  by  layers  of  new  bone  thrown 
out  under  the  periosteum,  or  by  both  together. 

In  the  former  ca.se,  when  the  cause  is  purely  constitutional,  iodide  of  potash 
and  counter-irritants  (iodine  applied  locally,  blisters,  and  even  the  actual 
cautery)  are  the  chief  remedies,  special  attention  being  paid  to  the  diathesis  that 
is  present. 

In  the  latter,  when  the  pain  and  swelling  are  confined  to  one  part  of  a  bone, 
or  when,  though  the  whole  is  involved  more  or  less,  one  spot  is  distinctly  more 
tender  than  the  rest,  more  active  measures  are  po.ssible.  Iodide  of  potash  should 
be  tried  first,  and  may  give  relief  for  a  time,  but  if  the  symptoms  persistently 
return,  particularly  if  one  spot  in  the  skin  is  slightly  puffy  or  oedematous,  or  if 
the  neighboring  joint  is  liable  to  attacks  of  synovitis,  the  patient  should  be  placed 
under  an  anaesthetic,  Esmarch's  bandage  applied,  and  a  free  incision  made  down 
to  the  bone,  through  the  periosteum,  at  the  spot  where  the  tenderness  is  greatest. 
If  the  part  involved  is  the  cancellous  end  of  one  of  the  long 
bones,  a  trephine  should  be  ap])lied  and  a  circle  of  bone  re- 
moved, until  the  soft  cancellous  tissue  is  exposed.  If  there  is 
an  abscess,  free  exit  should  be  given  to  the  pus,  and  the  cavity 
should  be  thoroughly  wiped  out  with  an  antiseptic,  or  if  there  is 
a  suspicion  that  is  tubercular,  stuffed  with  iodoform.  If  noth- 
ing is  found,  the  surrounding  bone  may  be  explored  by  means 
of  a  drill.  Sometimes  the  amount  of  pus  is  so  small  that  its 
e.scape,  mixed  with  bone-debris,  is  unnoticed.  If,  on  the  other 
hand,  the  shaft  is  the  part  concerned,  the  operation  is  es.sentially 
the  same,  but,  instead  of  trephining,  linear  osteotomy  is  per- 
formed with  a  Hey's  saw,  the  cut  being  carried  down  until  the 
medullary  canal  is  exposed.  Even  when  nothing  is  found  to 
account  for  the  symptoms,  they  not  unfrequently  subside  and 
disappear  completely  after  the  operation,  possibly  from  the  relief 
of  the  tension,  possibly  from  the  rarefaction  and  softening  of  the 
compact  tissue  that  follows. 


Phosphorus  Necrosis. 

Inflammation  of  the  jaws,  of  a  peculiarly  progressive  and 
obstinate  character,  is  not  uncommon  among  those  exi)osed  to 
phosphorus  fumes.  So  long  as  the  teeth  are  absolutely  sound 
thev  aijpear   to  enjoy  immunity,   but  as  soon  as   thev  l>ecome 

Fig.  170. — Chronic  Ab-  r        '  '  -^    ^        .     ,,  '     .  ^      .  ,  •  ,,  , 

scess  in  the  Centre  of  carious  from  any  cause,  inflammation  sets  in  and  rapidly  spreads 
fchronic°*^su"puraTve  to  the  jieriosteum,  the  medulla,  and  the  substance  of  the  bone 
osteomyelitis) leading  itself.    The  spougy  part  of  the  alveolar  margin  becomes  exposed, 

the   surface   is 
which  there 


to   sclerosis   and    the 


deposit  of  new  bone  the  outcr   laycrs  of   the  bone   are  eaten    away, 
Th1;"i'ne''oy'the^"oTd''0"ghened,  the  medullary  spaces  filled  with  pus  in 
shaft  can    still    be  is  a  uumbcr  of  iiiinutc  .sequestra,  and  the  medulla  itself  is  com- 
pletely destroyed.     Sometimes  the  disease  remains  limited  to  the 
alveolar  margin  ;  more  frequently  the  sequestra  refuse  to  separate, 
and  it  extends  until  the  whole  of  the  bone  has  i)erished  and  is  detached  from  the 
periosteum.     In  the  case  of  the  lower  jaw  there  is  nearly  always  a  deposit  of  new 
bone  at  the  angle,  where  the  severity  of  the  inflammation  is  less  acute  ;  but  it  is 
of  a  peculiarly  soft  and  spongy  character,  and  adheres  to  the  dead  bone  beneath, 
so  that  when  the  sequestrum  is  removed  it  nearly  always  comes  away  with  it. 


ACUTE   NECROSIS.  453 

The  symptoms  may  be  of  great  severity.  The  gums  l)ecome  swollen  ;  the 
pain  is  very  intense;  there  is  a  profuse  discharge  of  jjus  into  the  mouth,  and 
partly  from  this  constantly  finding  its  way  down  into  the  lungs  and  the  stomach, 
partly  from  the  inability  to  take  a  proper  supply  of  nourishment,  the  health  soon 
begins  to  fail,  the  inflammation  extends  to  the  other  parts  of  the  face,  and  the 
patient  becomes  utterly  worn  out. 

Very  little  can  be  done  in  the  way  of  treatment  until  the  sequestra  become 
loose.  Dead  projecting  fragments  may  be  removed  from  time  to  time;  the  mouth 
must  be  kept  sweet  by  constantly  washing  it  out  with  Condy's  fluid  or  some  other 
antiseptic  ;  abscesses  may  have  to  be  opened,  and  the  strength  must  be  maintained 
as  far  as  possible.  In  some  cases  the  whole  of  the  lower  jaw,  with  the  exception 
of  the  condyles  and  the  attachment  of  the  temporal  muscle,  can  be  removed. 
Reproduction  usually  takes  place  abundantly,  and  a  massive  bar  of  bone  is  devel- 
oped in  its  place  ;  but  not  unfrecjuently  this  atrophies  again,  and  nothing  but  a 
fibrous  band  is  left  to  support  the  mucous  membrane.  It  has  been  recommended, 
where  possible,  not  to  remove  the  teeth,  in  the  hope  that,  if  their  attachment  to 
the  mucous  membrane  could  be  preserved,  they  might  retain  a  certain  degree  of 
vitality  and  become  sufficiently  firm  again  to  prove  of  use. 


Fig.  i8o. — Phosphorus  Necrosis,  most  marked  at  the  alveolar  border,  with  a  deposit 
of  new  and  adherent  bone  at  the  angle. 

Mercurial    Necrosis. 

Exposure  to  the  fumes  of  mercury  (as  in  a  long  since  abandoned  method  of 
silvering  glass),  or  its  administration  in  excess,  may  cause  necrosis  either  of  the 
subcutaneous  bones  (the  skull,  sternum,  tibia,  or  bones  of  the  nose,  for  example), 
or  of  the  jaws.  In  the  latter  case  the  origin  is  evidently  local ;  the  mucous 
membrane  first  becomes  affected,  especially  around  carious  roots  or  where  there  is 
an  accumulation  of  tartar ;  then  the  periosteum  and  the  lining  membrane  of  the 
alveoli ;  the  teeth  become  loose  and  drop  out ;  and  finally  the  bone  itself  becomes 
involved.     At  the  present  day  it  is,  fortunately,  very  rare. 

Acute  Suppurative  Osteitis. 

Acute  Necrosis. 

This  may  begin  either  in  the  medulla  or  the  periosteum  {acute  suppurative 
osteomyelitis  ox  periostitis')  ;  it  is  always  the  result  of  infection;  it  is  much  more 
common  in  children  (especially  in  boys)  than  in  adults,  owing,  in  all  probability, 
to  the  greater  vascularity  and  more  rapid  nutritive  changes  in  the  bones  during 
early  life ;  suppuration  sets  in  almost  at  once,  and  it  is  attended  with  the  most 
intense  fever,  so  that  it  may  prove  fatal  within  three  or  four  days,  with  all  the 
symptoms  of  general  blood-poisoning. 


454    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

A  closely  similar  form  occurs  in  infants,  attacking  the  growing  layer  at  the 
epiphyses  {acute  c/'//>/ivsi/is)  and  leading  to  suppurative  arthritis  ;  and  occasionally 
after  aniiMitation,  in  which  the  medullary  canal  has  been  ojjened.an  intense  form 
of  osteomyelitis  occurs  from  direct  infection. 

Acute  necrosis  is  most  often  met  with  between  the  ages  of  eight  and  eighteen, 
and  it  nearly  always  affects  the  long  bones,  sometimes  beginning  in  the  middle  of 
the  shaft,  but  more  often  in  the  neighborhood  of  the  epiphyses.  It  may  occur  in 
perfectly  healthy  children,  but  fatigue  and  exhaustion  are  certainly  predisposing 
causes.  One  of  the  most  acute  cases  I  have  ever  seen  developed  suddenly  in  the 
course  of  a  chronic  attack  without  its  being  possible  to  assign  a  reason.  It  has 
nothing  to  do  with  .scrofula. 

Causes. — There  is  usually  a  history  of  a  blow  or  of  some  slight  injury  a  day 
or  two  before  ;  but  although  this  may  determine  the  locality  of  the  outbreak,  and 
perhaps  (when  the  bone  is  superficial  and  the  inflammation  begins  in  the  perios- 
teum) assist  the  development  of  the  poison  by  the  extrava.sation  it  causes,  it  cannot 
be  held  resjjonsible  for  more.  The  immediate  agent  is  undoubtedly  an  infective 
germ  which  enters  the  blood,  either  from  .some  cutaneous  boil  or  through  the  ali- 
mentary or  respiratory  tracts,  and  which  finds  a  suitable  soil  in  the  injured  area. 
It  is  well  known  that  in  pyaemia  abscesses  are  prone  to  develop  at  the  seat  of  in- 
juries, and  that  suppuration  sets  in  around  simple  fractures  if  animals  are  fed  upon 
putrid  food  ;  and  it  is  jxjssible  a  similar  explanation  will  hold  good  for  this  ;  the 
germs  are  often  pre.sent,  but  cannot  develop  without  a  suitable  nidus  having  been 
prepared. 

Xo  specific  organisms  have  been  found  in  connection  with  the  disease  ;  the 
staphylococcus  pyogenes  aureus,  which  is  met  with  in  all  forms  of  acute  suppura- 
tion, occurs  abundantly,  so  also  does  the  staphylococcus  pyogenes  albus  ;  sometimes 
there  is  a  streptococcus  too  ;  and  not  seldom,  especially  in  the  worst  cases,  they  are 
all  found  together,  but  they  are  in  no  way  peculiar  to  it.  In  several  instances 
acute  necrosis  appears  to  have  been  secondary  to  infection  from  boils  ;  and  it  has 
been  shown  that  the  pus  from  a  case  of  this  kind  rubbed  into  the  skin  of  the  fore- 
arm is  capable  of  producing  pustules  and  furuncles  in  abundance. 

Morbid  Appearances. — In  acute  osteomyelitis  the  changes  are  practically 
confined  to  the  medulla;  outside,  the  periosteum  is  thickened  and  .softened ;  the 
fibrous  layer,  especially  near  the  ei)iphysis,  is  separated  by  a  purulent  exudation 
from  the  bare,  smooth  bone  beneath,  and  the  tissues  around  are  swollen  and  infil- 
trated with  lymph  ;  but  often  before  there  is  time  for  anything  further  the  case 
proves  fatal,  with  symptoms  of  the  most  intense  blood  poisoning.  The  medulla 
itself  disappears  ;  the  central  canal  is  filled  with  purple  extravasations  and  streaks 
of  yellow  pus  ;  and  in  the  worst  cases,  if  the  disease  has  lasted  more  than  a  few 
days,  even  the  cancellous  ti.ssue  at  the  ends  of  the  bones  is  loaded  with  blood-stained 
pus,  on  the  top  of  which  is  floating  a  scum  of  oily  drops. 

In  acute  suj^purative  periostitis  this  order  is  reversed  ;  and  if  the  tough,  fibrous 
layer  gives  way  in  time,  so  that  the  pus  is  not  retained  under  such  high  tension, 
the  morbid  process  spreads  to  the  tissues  around  and  causes  more  conspicuous 
changes.  It  usually  commences  on  the  shaft,  in  the  neighborhood  of  one  of  the 
epiphyses,  especially  on  the  posterior  surface  of  the  lower  end  of  the  femur.  Pos- 
sibly this  is  due  to  the  extensive  attachment  of  the  gastrocnemius  to  the  periosteum  ; 
a  sudden  contraction  might  tear  it  from  the  bone.  The  tibia,  however,  suffers 
almost  as  frequently  ;  the  bones  of  the  upper  extremity  less  often.  Pus  forms  almost 
at  once  ;  nearly  always  it  is  mixed  with  blood,  and  very  often  there  are  oil  globules 
floating  in  it,  coming  from  the  medulla  beneath.  If  it  begins  on  the  middle  of 
the  shaft,  the  whole  of  the  periosteum  may  be  stripped  up  within  a  few  hours  ;  if  it 
is  near  one  of  the  epij^hyses  it  extends  rapidly  to  the  growing  line,  and  then,  being 
checked  at  this  point  by  the  much  firmer  attachment  of  the  fibrous  layer,  turns 
inward  between  the  shaft  and  the  epiphysis  and  spreads  into  the  cancellous  tis.sue 
This  peculiar  limitation  to  the  shaft  is  one  of  the  most  characteristic  features  of  the 
disea.se. 


ACUTE  NECROSIS. 


455 


The 
it  is 


f 


How  far  the  bone  itself  takes  an  active  share  in  the  inflammatory  jjrocess  is 
still  an  oj)en  question.  Certainly,  if  the  disease  continues  unchecked,  the  super- 
ficial layers  are  killed  ;  and  if  it  extends  into  the  medulla  the  whole  thickness 
perishes ;  but  if  free  exit  is  given  to  the  pus  at  once,  even  though  the  bone  under- 
neath is  bare  and  white,  recovery  without  any  perceptible  loss  of  tissue  is  not  un- 
common. 

Left  to  itself,  the  further  progress  is  simply  a  question  of  destruction, 
fibrous  layer  of  the  periosteum  gives  way  ;  .sometimes  the  tension  to  which 
subjected  is  so  great  that  the  whole  of  it  sloughs.  The 
pus,  as  soon  as  it  gains  the  soft  loose  tissue  outside, 
spreads  in  all  directions,  and  forms  huge  diffuse  abscesses 
between  the  muscles.  The  epiphyses  become  detached 
from  the  shaft  ;  if  this  occurs  at  both  ends  the  whole 
length  perishes  (total  necrosis).  The  neighboring  joints 
become  involved  ;  synovitis  always  occurs  from  the  mere 
presence  of  such  intense  inflammation  near  ;  not  un- 
frequently  acute  suppurative  arthritis  follows  ;  either  the 
inflammation  spreads  along  the  fibrous  layer  until  it 
reaches  the  reflexion  of  the  synovial  membrane,  or,  as 
more  commonly  happens,  the  pus  spreads  in  the  soft 
medullary  tissue  of  the  epiphysis  until  it  reaches  the 
articular  lamella  underlying  the  cartilage  of  the  joint ; 
this  gives  way  ;  a  small  round  opening  like  a  minute 
trephine-hole  is  formed,  and  the  synovial  cavity  be- 
comes filled  at  once  with  intensely  infected  septic  pus. 
Other  tissues  do  not  fare  any  better  ;  diffuse  cellulitis 
spreads  up  and  down  the  limb  ;  the  skin  becomes  un- 
dermined ;  abscesses  form  and  point,  perhaps  a  long 
way  off,  and  at  last  symptoms  of  general  pyjemia  make 
their  appearance.  There  is  everything  to  favor  such  a 
termination — intensely  infective  pus,  high  tension, 
and  inflammation  of  bone.  Sometimes  numerous 
metastatic  abscesses  form  in  all  parts  of  the  bodv, 
e.specially  in  the  wall  of  the  heart,  causing  purulent 
pericarditis  :  sometimes  the  constitutional  infection  is 
so  severe  that  the  result  is  fatal  even  before  these  have 
time  to  develop. 

Repair. — If  the  case  does  not  prove  fatal  from 
acute  blood  poisoning  within  the  first  few  days,  the  pro- 
cess of  repair  commences ;  the  inflammation  ceases  to 
spread  ;  the  suppuration  becomes  limited  ;  the  tissues 
that  have  been  killed  are  gradually  detached,  and 
organization  begins. 

(a)  In  the  most  intense  form,  when  the  periosteiim 
and  medulla  are  both  involved,  the  whole  shaft  perishes, 
and  the  destruction  is  too  great  for  effective  restoration. 
Fortunately,' it  usually  falls  short  of  this  ;  the  growing 
layer  is  left ;  new  bone  is  thrown  out ;  the  sequestrum 
is  gradually  separated,  and  even  if  the  shaft  is 
destroyed  from  end  to  end  and  taken  away,  it  is  very 
fairly  reproduced. 

(^)  Repair  is  most  easy  in  periostitis.  As  soon  a.s 
the  tension  is  relieved,  and  the  inflammation  ceases  to 
spread,  the  living  bone  beneath  the  sequestrum  becomes 
more  va.scular ;  rarefying  osteitis  sets  in;   a   layer    of 

granulations  is  formed  ;  and  gradually  the  necrosed  fragment  is  entirely  detached. 
Further  away,  where   the  effect  of  the  irritant  is  not  felt  so  much,  the  lymph  be- 


M^'^.^ 


:-r^:^ 


I 


Fig.  i8i. — Acute  Suppurative  Perios- 
titis and  O'^teomyelitis  (Acute 
Necrosis)  of  Shaft  of  Tibia  from  a 
Child.  The  sequestrum  has  been 
removed,  and  the  new  shell,  de- 
ficient in  many  parts  where  the 
periosteum  sloughed  (cloacae), 
is  lef}.  The  epiphyses  are  in- 
tact. 


456    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


comes  organized  and  new  bone  is  formed  (osteosclerosis).  Similar  changes  take 
place  on  the  side  of  the  periosteum,  only  they  have  the  effect  of  locking  the  secjues- 
trum  in,  so  that  it  can  only  be  released  by  operation.  'I'he  under  surface  facing 
the  dead  bone  is  converted  into  vascular  granulation  tissue  ;  in  this  organization 
soon  begins  and  a  sheath  of  new  bone  is  formed,  covering  in  the  sequestrum,  and 
continuous  above  and  below  with  that  which  is  still  living.  At  first,  like  all  new 
bone,  it  is  soft  and  porous,  traversed  by  numljerless  little  vessels  running  inward 
from  the  surface,  just  as  in  callus  (Fig.  i8i)  ;  but  by  degrees,  if  the  sequestrum  is 
removed,  it  becomes  harder  and  denser;  and  in  proportion  as  this  occurs  the 
amount  diminishes,  until  at  length  the  gap  in  the  old  bone  is  filled  with  ti.ssue, 
which  in  size,  shape,  and  direction  of  blood-vessels,  is  practically  the  same  as  it 
was  before.  The  sequestrum  from  a  case  of  periostitis  may  always  be  recognized 
by  its  smooth  external  surface,  and  the  rough  worm-eaten  jjart  beneath,  where  it  has 
been  excavated  and  detached  by  granulations.  In  osteomyelitis  this  is  of  course 
reversed. 

The  amount  of  new  bone  thrown  out  depends  (so  far  as  local  conditions  are 
concerned)  partly  upon  the  intensity  of  the  inflammation,  partly  upon  the  length 
of  time  the  sequestrum  is  allowed  to  remain  and  act  as  a  foreign  body.  In  the 
most  severe  cases,  the  periosteum,  like  the  compact  tissue  beneath,  is  killed  at  the 
first,  and  no  new  bone  is  formed  :  the  shell  is  deficient  over  a  great  part  of  the 
gap,  although  there  is  usually  a  certain  amount  at  either  end.  \{  this  occurs  in 
the  tibia,  the  two  extremities,  provided  the  epiphysis  have  remained  intact,  some- 
times form  a  connection  with  the  fibula,  and  this,  because  of  the  increased  weight 
it  has  to  bear,  becomes  hypertrophied.  If  it  is  the  femur  or  the  humerus  nothing 
can  be  done,  except  possibly  transplantation  :  in  one  or  two  instances  a  bone  has 
been  built  up  by  this.  Even,  however,  in  moderately  acute  cases  portions  of  the 
periosteum  usually  slough,  and  deficiencies  are  left  here  and  there  in  the  new  shell. 

These  openings  are  known  as  cloaca  and  they  serve 
as  channels  to  convey  the  pus  from  the  interior  to 
the  sinuses,  by  which  it  is  discharged  through  the 
skin. 

Sometimes  when  the  tension  has  been  relieved 
by  free  incision  at  once,  no  necrosis  at  all  takes 
place;  the  bone  is  exposed,  bare  and  white,  but  as 
soon  as  the  pus  has  free  exit  the  inflammation  ceases 
and  the  periosteum  falls  down  on  to  its  place  again. 
Even  in  these,  however,  a  very  considerable  amount 
of  new  bone  is  thrown  out,  leaving  an  osseous  node 
which  becomes  absorbed  very  slowly. 

{c)  In  acute  osteomyelitis,  if  the  blood-poison- 
ing does  not  prove  fatal,  the  same  reparative  changes 
take  place  ;  but  in  most  cases  restoration  is  much 
less  complete.  This  arises  from  the  way  in  which 
the  sequestrum  is  locked  in.  If  the  i)eriosteum  and 
the  outer  portion  of  the  compact  tissue  escape  destruc- 
tion, and  if  (as  in  chronic  abscessj  layers  of  .sclerosed 
bone  are  formed  around,  the  removal  of  the  seques- 
trum becomes  exceedingly  difficult,  no  matter  how 
insignificant  the  size.  The  longer  the  irritation  lasts, 
the  deeper  it  becomes  buried  ;  and  in  old  cases  the 
bone  becomes  hardened,  rugged,  and  enormously 
F.G.  ,82.-chronic  Osteomyelitis  of  thickcncd,  over  pcrhaps  its  wholc  length.  Sequestra 
Lower  End  of  Tibia.   The  section    lockcd  in  in  this  way  in  carlv  life  often  give  rise  to 

across  the  shaft   was   solid,  and    the  t  ■    ^       ^  ^  i  i      ^i      ^      /  r        cr 

medullary  canal  completely  obiiier-  such  pcrsistcnt  trouble  that  after  many  years  of  suffer- 
:"thsinust":;.hichie^Tin'ai."ditc'  ^"g  ^^c  patient  bcgs  for  amputation.  It  is  not  un- 
tions  through  it.   it  was  amputated    common  at  the  lowcr  end  of  the  femur  :  a  discharg- 

because   of  the  disease   of  the  knee       •  •      i    r^  ^i  ^  j         r^i       i-      l 

joint.  ing  Sinus  IS  left  on  the  outer  or  inner  side  of  the  limb  ; 


ACUTE   NECROSIS.  457 

the  bone  is  enlarged,  hardened,  and  perforated  with  suppurating  channels  ;  the 
knee  joint,  from  repeated  attacks  of  synovitis,  is  utterly  disorganized  ;  and  the 
patient  becomes  a  hopeless  cripple  (Fig.  182). 

Symptoms. — The  onset  is  usually  very  insidious,  unless  the  inflammation 
develops  in  connection  with  an  already  existing  attack  of  pyaemia;  then  it  may 
begin  with  a  rigor.  The  first  and  most  prominent  feature  is  pain,  at  the  begin- 
ning flying  vaguely  all  over  the  body,  but  soon  settling  down  to  one  part,  and 
becoming  intense,  especially  at  night.  The  least  pressure  or  the  slightest  move- 
ment makes  it  simply  intolerable;  and  the  limb  is  kept  absolutely  rigid,  as  if  it 
were  paralyzed,  every  contraction  of  them  uscles  pulling  on  the  periosteum  causes 
such  agony.  From  the  commencement  the  prostration  appears  unaccountably 
great ;  the  pulse  is  small  and  quick  ;  the  temi)erature  begins  to  rise  at  once  ;  and 
in  severe  cases  may  reach  104°  F.  by  the  second  or  third  day ;  the  respiration  is 
hurried  ;  the  tongue  and  lips  dry  ;  the  skin  burning  hot ;  the  pupils  dilated  and 
staring,  and  the  face  peculiarly  dusky.  Delirium  soon  sets  in,  especially  at  night, 
and  by  the  third  or  fourth  day  the  general  aspect  is  that  of  the  most  intense  blood- 
poisoning. 

The  local  signs  depend  upon  the  situation.  If  the  bone  is  superficial,  as  in 
the  case  of  the  tibia,  the  swelling  can  be  detected  at  once ;  the  skin  soon  becomes 
red  and  oedematous,  and  it  is  tied  down  to  the  periosteum  beneath,  so  that  it  can- 
not move  freely  over  the  bone.  On  the  other  hand,  when  it  is  the  femur, 
especially  when  the  back  part  is  involved,  they  are  much  more  obscure  :  the  skin 
remains  white  until  pus  has  formed  and  worked  its  way  near  the  surface;  often  it 
is  whiter  than  natural,  from  the  tension  of  the  deeper  structures  beneath,  with 
slightly  enlarged  veins  passing  over  it ;  and  no  swelling  can  be  distinctly  made 
out.  Usually,  however,  if  the  limbs  are  compared,  the  affected  one  looks  more 
even  in  outline  and  more  rounded  than  the  other ;  the  intermuscular  depressions 
are  partly  filled  up  ;  and  at  the  same  time  it  feels  more  tense  and  firm,  especially 
over  the  part  where  the  pain  and  tenderness  are  most  distinct.  The  temperature, 
too,  is  higher  than  that  of  the  opposite  limb  ;  and  if  the  inflammation  is  near  a 
joint  there  is  always  a  certain  degree  of  synovitis.  In  osteomyelitis  the  difficulty 
of  diagnosis  is  even  greater  than  in  periostitis  ;  the  constitutional  symptoms  are 
much  more  severe  ;  the  local  signs  much  less  distinct. 

Later,  when  the  pus  has  escaped  from  under  the  periosteum  and  spread  into 
the  tissues  around,  there  is  little  or  no  difficulty.  Dusky  erythematous  patches 
make  their  appearance  upon  the  skin,  the  swelling  becomes  more  distinct  and 
localized,  and  deep-seated  fluctuation  is  usually  plain,  especially  if  the  patient  is 
under  an  anaesthetic.  The  constitutional  symptoms  do  not  begin  to  subside  until 
the  pus  has  been  evacuated. 

When  the  .medullary  canal  is  involved  the  patient  may  sink  from  acute  septi- 
caemia before  any  local  signs  other  than  tenderness  and  pain  have  time  to  develop. 
If  this  does  not  happen  various  complications  set  in,  according  to  the  direction  in 
which  the  inflammation  can  extend  most  easily.  Acute  suppurative  arthritis  is  one 
of  the  most  common,  the  inflammation  spreading  through  the  cancellous  tissue  of 
the  epiphysis,  or  outside  it  along  the  fibrous  covering.  Separation  of  the  epiphysis 
is  another,  causing  deformity  and  a  peculiar  soft  kind  of  crepitus  when  the  limb  is 
moved.  In  severe  cases  other  bones  may  be  involved,  one  after  another  being 
attacked  at  intervals  of  a  few  days  in  distant  parts  of  the  body ;  sometimes  each 
outbreak  is  attended  with  a  rigor,  more  frequently  pain  is  the  most  prominent 
symptom,  and  the  swelling  is  only  detected  on  examination.  Secondary  attacks 
of  this  kind  are  rarely  so  deep  or  so  extensive  as  primary  ones.  Fatty  embolism 
is  probably  nearly  always  present,  and  finally  pyaemia  with  metastatic  abscesses  may 
occur,  the  pericardium  being  involved  with  singular  frequency. 

Diagnosis. — Acute  suppurative  osteomyelitis  or  periostitis  may  be  mistaken 
for  typhoid  or  other  acute  specific  fevers,  especially  when  the  septicsemic  symptoms 
are  very  strongly  marked  and  fugitive  erythemata  are  present  upon  the  skin,  but 
30 


458    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

careful  examination  can  hardly  fail  to  reveal  a  local  cause.  Occasionally  it  is  mis- 
taken for  diffuse  cellulitis,  which,  however,  unless  it  is  due  to  a  poisoned  wound, 
rarely  or  never  occurs  in  children  ;  and  sometimes  for  acute  rheumatic  fever, 
especially  when  the  lower  end  of  the  femur  is  involved  on  the  posterior  surface,  so 
that  the  knee  joint  is  fdled  with  fluid  from  the  first. 

Treatment. — Division  of  fhc  Periosteum. — Whenever  there  is  a  suspicion 
of  acute  suppuration  in  connection  with  bone,  the  patient  should  be  ])laced  under 
an  aniiesthetic,  and  an  incision  made  through  the  soft  jjarts  and  the  i)eriosteum  on 
to  the  surface  of  the  compact  tissue,  selecting  the  spot  at  which  the  tenderness  is 
most  marked.  It  is  certainly  not  advisable  to  wait  for  a  distinct  sense  of  fluctua- 
tion ;  the  pus  may  separate  the  epiphysis  from  the  shaft,  or  detach  the  periosteum 
from  almost  the  whole  circumference,  before  it  forms  a  sufficiently  thick  layer  of 
fluid  for  this.  The  extent  of  the  incision  depends  upon  the  condition  of  the  peri- 
osteum ;  if  it  is  only  just  separated  from  the  bone  beneath,  a  simjjle  linear  division 
may  answer  all  requirements,  free  exit  being  provided  for  the  effusion  by  means  of 
a  large  drainage-tube.  If,  however,  the  separation  is  more  extensive,  the  finger  or 
a  probe  must  be  passed  down  to  explore  the  surface  thoroughly,  so  that  counter- 
openings  may  be  made  where  required. 

Drainage  of  the  Medulla. — Sometimes  the  symptoms  are  relieved  at  once,  the 
temperature  falls,  and  it  is  clear  the  chief  indication  has  been  fully  met.  The 
limb  must  be  kept  perfectly  quiet  upon  a  splint,  careful  watch  made  that  the  open- 
ing does  not  close  too  soon  or  become  valvular,  and  the  periosteum  will  fall  down 
on  to  the  bone  again,  and  very  possibly  there  will  be  no  necrosis.  In  other  cases 
there  is  but  a  very  short  respite  or  none  at  all ;  and  it  is  clear  that  further  exploration 
is  required,  that  the  separation  of  the  periosteum  was  not  the  primary  affection, 
but  merely  an  indication  of  more  deeply-seated  inflammation.  This  is  especially 
likely  to  happen  when  the  chief  seat  of  tenderness  is  close  to  the  epiphysial  line, 
and  when  there  is  at  the  same  time  effusion  into  the  neighboring  joints  ;  under 
these  conditions  it  is  more  than  probable  that  the  inflammation  involves,  if  it  did 
not  begin  in,  the  layer  of  soft  vascular  growing  bone  on  the  end  of  the  shaft,  and 
that,  if  it  has  not  done  so  already,  it  will  almost  certainly  spread  to  the  medullary 
canal.  It  is  this  form  of  necrosis  which,  if  left  to  itself,  leads  to  the  death  of  the 
whole  shaft  and  separation  from  the  epiphysis  at  both  ends.  Under  these  cir- 
cumstances, or  if  the  epiphysis  is  already  separated  before  the  incision  is  made, 
the  central  canal  of  the  bone  must  be  opened  and  drained  as  well.  When  the 
connection  is  already  severed  the  end  of  the  diaphysis  may  be  removed  at  once ; 
with  the  medullary  canal  containing  pus,  with  pus  under  the  periosteum,  and  sup- 
puration between  it  and  the  epiphysis,  that  part  of  the  bone  will  certainly  perish 
if  it  has  not  done  so  already.  By  this  free  drainage  is  gained  at  one  spot ;  but 
that  is  not  enough  ;  an  opening  must  be  made  into  the  central  canal  lower  down 
on  the  bone,  so  that  it  may  be  thoroughly  washed  out.  As  a  rule  there  is  no  diffi- 
culty in  ascertaining  the  proper  situation  for  this,  for  in  such  cases  the  disease  is 
always  far  advanced,  and  either  there  is  at  some  point  extreme  tenderness  on 
pressure,  or  the  periosteum  is  already  detached  and  suppurating,  the  pus  having 
worked  it  way  out  through  the  shaft  along  the  course  of  the  nutrient  vessels.  Then 
the  cavity  must  be  syringed  out  thoroughly  with  an  antiseptic  solution,  the 
medulla  itself  removed  as  far  as  possible,  iodoform  dusted  in,  and  a  drainage-tube 
passed  through.  In  one  case  in  which  this  was  done,  by  Jones,  of  Manchester, 
the  whole  of  the  shaft  of  the  humerus  was  drained,  from  its  upper  extremity  where 
it  faced  the  epiphysis  to  an  opening  made  a  short  distance  above  the  inner  con- 
dyle. 

Subperiosteal  Resection. — In  the  most  acute  cases,  owing  to  the  extreme  rapid- 
ity with  which  the  disease  progresses,  the  time  for  this  is  already  past.  If  the 
inflammation  involves  the  periosteum  only,  free  incision  must  be  made  down  to 
the  bone  wherever  fluctuation  can  be  detected  ;  if  the  medulla,  and  if  the  shaft  is 
already  detached  at  the  epiphysial  line,  the  whole  of  it  had  better  be  removed  at 


ACUTE  NECROSIS.  459 

once.  This,  w  hich  has  been  called  subperiosteal  resection,  is  most  easily  accom- 
plished by  dividing  the  bone  in  the  middle  with  a  chain  saw  ;  the  two  halves  can 
then  be  readily  twisted  out.  It  relieves  the  limb  at  once  of  what  is  practically  a 
foreign  body  keeping  up  a  very  great  deal  of  irritation  ;  it  lessens  the  danger  to 
the  neighboring  articulations,  and  it  obviates  the  necessity  for  a  long  and  tedious 
operation  afterward  when  the  new  shell  of  bone  has  been  formed.  An  extra 
amount  of  care,  of  course,  is  required  to  support  and  protect  the  limb  until  the 
new  bone  is  sufficiently  firm. 

Other  treatment  is  of  little  or  no  avail.  Iodine  and  counter-irritants  are 
worse  than  useless ;  they  simply  waste  valuable  time,  and  the  same  may  be  said 
of  iodide  of  potash.  Quinine  and  antipyrin  may  be  given  when  the  temperature 
is  very  high,  but  they  have  little  or  no  control  over  the  disease  itself.  Afterward, 
during  the  long  period  of  exhausting  and  wasting  illness  which  not  unfrequently 
follows,  the  former,  with  preparations  of  iron  and  cod-liver  oil,  is  often  indispens- 
able. 

The  limb  should  be  kept  at  perfect  rest  upon  a  suitable  splint,  especially  in 
those  cases  in  which,  owing  to  separation  at  the  epiphysial  line,  or  to  the  early 
removal  of  the  sequestrum,  the  central  support  is  lost,  and  sometimes  it  is  neces- 
sary to  maintain  a  slight  degree  of  extension  to  prevent  too  much  shortening. 
Cold  applications,  lead  and  spirit  lotion,  for  example,  may  be  used  at  first ;  but  as 
soon  as  there  is  an  escape  for  the  pus,  warmth  is  more  serviceable,  as  the  object 
then  is  to  encourage  the  discharge  of  the  poison  as  far  as  possible. 

Careful  watch  must  be  kept  that  the  pus  does  not  collect  in  the  deep  outlying 
recesses  of  the  part  and  undergo  decomposition,  especially  as  when  dead  bone  is 
present  it  is  often  peculiarly  offensive.  Counter-openings  are  often  required,  and 
drainage-tubes  must  be  used  freely.  If  the  neighboring  joint  becomes  involved, 
it  must  be  laid  open  thoroughly  on  both  sides  (and  in  the  case  of  the  knee  behind 
as  well)  and  freely  irrigated.  Even  after  this  has  happened  the  limb  ma\-  be 
saved  in  exceptional  instances  ;  the  upper  epiphysis  of  the  tibia,  for  example,  has 
been  removed,  with  some  of  the  shaft,  leaving  a  shortened  limb  riddled  with 
sinuses,  but  capable  of  bearing  some  weight ;  nearly  always,  however,  hectic  and 
profuse  suppuration  set  in ;  the  cartilage  becomes  eaten  out  by  granulations 
springing  from  the  opposite  bone ;  starting-pains  make  their  appearance  at 
night ;  the  patient  becomes  exceeding  emaciated,  and  amputation  is  necessary 
to  save  life. 

The  subsequent  progress,  if  pyaemia  and  other  complications  do  not  set  in,  is 
dependent  upon  the  situation  and  extent  of  the  sequestrum.  Sometimes,  as 
already  mentioned,  it  is  completely  separated  within  three  wrecks  or  a  month  :  the 
line  of  demarcation  corresponds  to  the  soft  vascular  bone  at  either  end,  no  time 
is  required  for  absorbing  compact  tissue,  and  the  whole  shaft,  even  of  such  a  bone 
as  the  tibia,  can  be  extracted  entire,  leaving  behind  a  great  space  lined  with 
periosteum,  which  rapidly  becomes  filled  with  new  bone.  In  other  cases  the  time 
required  is  much  longer,  and  in  some  exceptional  instances  it  may  be  a  matter 
of  years,  owing,  in  all  probability,  to  the  density  and  hardness  of  the  surround- 
ing osseous  tissue.  In  young  subjects  the  process  is  naturally  much  more  rapid 
than  in  old,  and  it  is  somewhat  quicker  when  the  bones  of  the  upper  extremity 
are  concerned. 

Where  the  periosteum  only  is  concerned  and  the  sequestrum  is  small  and 
superficial,  it  may  separate  of  itself  and  be  discharged  through  an  opening  in  the 
skin,  by  what  is  known  as  exfoliation,  without  the  necessity  for  any  further  opera- 
tion. This  is  not  uncommon  on  the  skull  (after  injury,  for  acute  necrosis  rarely 
affects  the  flat  bones)  and  on  the  subcutaneous  surface  of  the  tibia.  A  line  of 
rarefying  osteitis  gradually  forms  around  the  dead  part,  the  compact  tissue  that 
immediately  borders  it  becomes  more  and  more  open ;  at  length  it  is  completely 
absorbed,  and  the  sequestrum  is  left  resting  on  the  surface  of  a  bed  of  granula- 
tions. No  new  shell  on  the  outside  is  ever  formed  by  the  pericranium  to  lock 
the  dead  bone  in,  and  very  often  it  is  almost  as  defective  on  the  tibia,  owing  to  the 


46o     DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 

thinness  and  the  peculiarly  exposed  situation  of  the  periosteum.  As  soon  as  the 
line  of  demarcation  is  complete,  the  sequestrum  is  held  in  merely  by  the  skin, 
and  only  recpiires  the  apitlication  of  a  pair  of  forceps  to  remove  it.  In  those 
cases  in  which  no  outside  shell  is  formed,  whether  on  the  skull  or  elsewhere,  the 
deficiency  in  the  bone  is  rarely  made  good  :  the  granulations  gradually  fill  up  the 
hollow  and  become  organized,  and  the  deeper  layers  become  converted  into  bone, 
but  the  superficial  part  rarely  passes  beyond  the  stage  of  fibrous  tissue.  There  is 
no  doubt  the  periosteum  is  the  main  agent  in  reproduction,  although  it  may  not 
be  the  only  one. 

In  central  necrosis,  on  the  other  hand,  or  when  a  shell  of  new  bone  has  been 
formed  around  the  secpiestrum,  enclosing  it  and  locking  it  in,  extensive  operations 
may  have  to  be  undertaken  for  its  removal.  The  longer  it  is  left  after  it  has  once 
become  loose,  the  deeper  it  becomes  buried  and  the  more  serious  the  changes  that 
it  induces,  not  only  in  the  other  structures  near,  but  in  the  patient's  general  con- 
dition. The  acute  fever  may  have  subsided  long  since  and  there  may  be  only  a 
slight  evening  rise  of  temperature  ;  but  this,  if  continued,  especially  if  connected 
with  bone,  is  very  prone  to  end  in  either  hectic  or  amyloid. 

In  the  case  of  compact  tissue  it  rarely  happens  that  the  living  bone  can 
separate  itself  from  the  dead  under  two  or  three  months  ;  total  necrosis  is  an 
apparent  exception,  but  in  this  the  line  of  separation  runs  along  the  soft  vascular 
growing  layer.  During  this  time  the  appearance  of  the  limb  changes  very  con- 
siderably. The  heat  and  swelling  of  the  acute  stage  gradually  become  less  and 
less  ;  the  redness  fades  away,  there  is  no  longer  such  extreme  tenderness  on 
pressure,  and  the  incisions,  instead  of  gaping  widely  and  giving  exit  to  a  mixture 
of  pus  and  blood,  gradually  become  contracted  into  narrow  sinuses,  lined  with 
granulations  and  secreting  only  a  small  quantity  of  purulent  fluid,  which  oozes 
slowly  from  a  tiny  orifice  surrounded  by  a  button-shaped  mass  of  little  vascular 
buds.  A  probe  passed  into  the  centre  of  this  sinks  almost  of  its  own  weight 
down  a  devious  channel,  until,  after  passing  through  one  of  the  cloacae,  it  comes 
into  contact  with  the  sequestrum.  The  utmost  gentleness  must  always  be  used  ; 
if  it  is  forced  in  any  direction  it  is  certain  to  catch  somewhere  against  the  walls, 
making  them  bleed,  which  they  do  with  the  greatest  readiness,  and  causing 
pain. 

The  presence  of  a  sequestrum  must  be  gathered  from  the  sensation  the  probe 
conveys  ;  the  hard,  smooth  surface,  and  the  clear,  ringing  sound  produced  when  a 
dead  part  is  struck,  differ  completely  from  the  soft,  gritty  sensation  of  carious 
bone,  into  which  the  probe  can  be  driven  with  ease,  and  from  the  firm  but 
roughened  surface  of  uninjured  periosteum.  The  size  must  be  estimated  partly 
from  the  position  and  direction  of  the  sinuses,  partly  from  the  extent  of  the 
enlargement  and  the  range  of  the  original  attack.  Whether  it  is  loose  or  not  is 
very  often  a  matter  for  conjecture  rather  than  for  belief;  occasionally  it  is  possible 
to  move  it  slightly  by  firm  pressure  ;  or,  by  introducing  probes  into  two  distant 
sinuses  and  pressing  on  them  alternately,  to  convey  a  kind  of  shock  from  one  to 
the  other  ;  but  very  often  the  sole  evidence  is  the  peculiar  hollow  note  when  the 
sequestrum  is  sharply  struck,  and  the  length  of  time  that  has  elapsed. 

The  operation  itself  {sequestrotomy)  naturally  differs  in  every  case.  A  time 
for  it  should  always  be  selected  when  the  patient's  temperature  is  as  even  as  pos- 
sible ;  it  very  commonly  happens  when  there  is  a  sequestrum  of  any  size  that 
slight  attacks  of  feverishness  occur  from  time  to  time,  each  one  marking  the 
formation  of  a  fresh  abscess  in  the  neighborhood  of  the  old  inflammation.  The 
limb  should  be  raised  to  a  vertical  position  for  a  few  minutes  and  an  elastic  strap 
buckled  tightly  round  it ;  or  Esmarch's  bandage  may  be  used.  It  is  of  great 
advantage  not  only  to  control  the  hemorrhage  at  the  time  (and  it  is  often  very 
profuse),  but  to  be  able  actually  to  see  the  condition  of  the  bone.  If  the 
sequestrum  is  superficial,  all  that  is  necessary  is  to  make  an  incision  through  the 
soft  parts,  either  enlarging  a  sinus  or  connecting  two  that  are  close  together,  and 
twist  it  out  with  a  pair  of  strong  forceps  ;  but  when  it  is  central  a  great  deal  of 


ACUTE  NECROSIS.  461 

manipulation  may  be  required.  Sometimes  the  cloacae  are  large  enough  to  allow 
it  to  pass  through  :  a  very  long  sequestrum,  for  instance,  from  the  tibia  may,  if 
caught  fLiirly  at  the  end,  be  extracted  through  a  comparatively  small  opening. 
More  often  they  have  to  be  enlarged,  or,  like  the  sinuses  on  the  skin,  thrown  into 
one,  the  intervening  soft  new  bone  being  divided  with  a  chisel  or  cutting-forceps, 
and,  as  far  as  possible,  reflected  without  being  removed.  Occasionally,  as  in  sub- 
periosteal resection,  the  necrosed  portion  can  be  divided  with  a  chain-saw  and  ex- 
tracted in  two  halves. 

After  the  removal  a  smooth  cavity  is  left,  lined  with  granulations  which  bleed 
freely  as  soon  as  the  bandage  is  removed.  This  may  be  checked  to  a  certain  extent 
by  washing  out  the  interior  with  diluted  tincture  of  iodine,  or  with  very  hot  water, 
or  by  packing  it  with  some  antiseptic  dressing  ;  but  unless  the  cavity  is  of  very 
large  size  it  is  generally  sufficient  to  bandage  the  limb  carefully  and  keep  it  well 
raised  :  the  bleeding  only  comes  from  capillaries  which  have  been  torn  and  have 
lost  their  support  ;  it  rarely  happens  that  a  vessel  of  any  size  is  divided.  After- 
ward the  wound  must  be  washed  out  at  frequent  intervals  with  some  antiseptic,  as 
it  is  rarely  possible  to  drain  it  effectually,  and  such  an  amount  of  blood,  allowed 
to  collect  at  the  temperature  of  the  body  exposed  to  the  air,  might  prove  a  serious 
source  of  danger.  In  a  very  few  days  the  sides  begin  to  fall  in  and  contract';  and 
as  the  granulations  spring  up  and  become  organized,  the  amount  of  discharge  grows 
less  and  less,  until,  in  a  comparatively  very  short  time,  the  cavity  is  completely 
obliterated. 

It  is  not  always  that  the  operation  is  so  easy  or  is  followed  by  such  immediate 
success.  In  many  instances  the  sinuses  are  surrounded  by  structures  of  such  im- 
portance that  only  a  very  slight  degree  of  enlargement  is  possible.  Sometimes  the 
sequestrum  is  not  sufficiently  loose,  and  only  some  of  the  superficial  part  can  be 
chipped  off  or  cut  away  ;  or  it  is  so  deeply  buried  that  it  cannot  be  extracted  with- 
out almost  cutting  the  bone  in  two.  It  is  seldom  that  this  happens  as  a  result  of  acute 
osteomyelitis  ;  but  when  the  inflammation  has  been  chronic  (in  quiet  necrosis,  for 
example,  when  a  portion  of  bone  near  the  centre  perishes  without  causing  suppura- 
tion) the  compact  tissue  on  the  outside  becomes  thickened  to  such  an  extent  that 
it  is  scarcely  possible  to  make  an  opening  of  sufficient  size.  In  other  cases  again 
the  shell  of  new  bone  formed  by  the  periosteum  is  defective,  so  that  the  limb  is  in 
great  danger  of  what  has  been  called  spontaneous  fracture.  This  may  arise,  as  in 
subperiosteal  resection,  merely  from  the  early  removal  of  the  sequestrum,  and  then 
in  a  week  or  two  the  limb  becomes  sufficiently  firm  ;  but  occasionally  it  is  due  to 
sloughing  of  the  periosteum.  If  it  occurs  in  the  tibia,  the  limb  may  still  be  pre- 
served and  prove  of  use,  the  fibula  being  assisted  by  means  of  an  artificial  support ; 
in  the  femur,  however,  unless  firm  union  can  be  obtained  at  the  expense  of  the 
length  of  the  limb,  amputation  must  be  performed. 

All  these  difficulties  combined  are  not  unfrequently  met  with  in  necrosis  of 
the  lower  end  of  the  femur.  The  popliteal  vessels,  the  external  popliteal  nerve,  and 
the  synovial  membrane  of  the  knee  joint  are  all  in  danger  ;  so  that,  unless  the  ab- 
scess is  actually  pointing  elsewhere,  the  incision  must  be  made  in  the  outer  side  of 
the  limb  in  front  of  and  parallel  to  the  biceps  tendon.  The  sequestrum  is  very 
often  only  partially  detached,  even  after  years  ;  if  it  is  central  it  is  exceedingly 
hard  to  extract  before  the  knee  joint  is  involved,  owing  to  the  immense  thickening 
and  condensation  of  the  bone  above  and  around  it ;  if  it  is  superficial  and  on  the 
back  of  the  bone  (its  usual  situation),  it  is  often  in  actual  contact  with  the  artery, 
owing  to  the  absence  or  defective  development  of  proper  periosteal  sheath  ;  and 
instances  of  its  having  ulcerated  through  and  caused  fatal  hemorrhage  are  not  un- 
known. 

Other  troubles  may  follow  at  a  later  period.  A  certain  amount  of  chronic 
osteitis  is  not  uncommon  ;  there  are  frequent  attacks  of  tenderness  and  pain, 
especially  at  night ;  the  bone  becomes  immensely  thickened  and  irregular  in  shape  ; 
and  occasionally,  even  after  long  intervals,  residual  abscesses  form,  probably  from 
the  slow  decay  and  death  of  some  of  the  lowly  organized  inflammatory  exudation. 


462     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

Sometimes  sinuses  persist  for  years,  surrounded  by  dense,  hard  bone,  and  discharg- 
ing a  thin,  purulent  fluid  from  the  granulations  that  line  them.  Minute  sequestra 
not  unfret|uently  become  detached  and  slowly  separate  of  themselves.  In  other 
cases  the  growth  of  the  bone  is  arrested  owing  to  premature  ossification  of  the 
epiphysis  ;  or  the  neighboring  joint  becomes  stiff,  and  even  at  length  practically 
useless  from  the  repeated  attacks  of  synovitis  ;  and  finally  in  some  cases,  even  after 
the  limb  has  been  saved,  amputation  becomes  necessary  at  last,  either  becau.se  the 
part  is  useless,  or  to  save  the  patient  from  hectic  or  amyloid  disease. 

Acute  Epiphysitis. 

This  name  has  been  given  to  a  variety  of  acute  suppurative  osteomyelitis 
which  attacks  the  bony  nuclei  in  epiphyses,  or  more  often  the  growing  layer 
between  the  epiphysis  and  the  shaft.  Not  unfrequently  more  than  one  bone  is  in- 
volved, and  probably  it  is  always  pysemic  in  character,  but  nothing  is  known  with 
regard  to  any  exciting  cause,  other  than  it  is  usually  said  to  follow  some  slight  in- 
jury. 

'Fhe  larger  epiphyses  (at  the  hip  and  knee)  are  most  often  affected,  though  the 
smaller  ones  are  not  exempt.  In  children  it  usually  commences  at  the  line  of 
growth  and  spreads  from  there  to  the  periosteum,  or  to  the  medulla,  or  to  both 
together,  leading  to  one  of  the  worst  forms  of  acute  necrosis.  In  infants  (and  it 
is  not  uncommon  within  the  first  few  months  of  life)  it  sometimes  attacks  the 
bony  nucleus  embedded  in  the  centre  of  the  cartilage,  giving  rise  to  what  has 
been  described  as  acute  arthritis  of  ittfants.  Suppuration  sets  in  at  once  with 
the  greatest  intensity ;  the  articular  end  of  the  bone  Ijecomes  hollowed  out  into 
an  abscess-sac,  and  almost  always  the  pus  bursts  into  the  neighboring  joint, 
destroying  it  completely.  If  the  case  does  not  j)rove  fatal  from  blood-poisoning, 
or  later  from  hectic  and  prolonged  suppuration,  the  end  of  the  diaphysis  becomes 
united  to  the  opposite  bone,  and  the  limb  is  left  more  or  less  flail-like,  shortened 
and  incapable  of  its  proportionate  share  of  growth.  The  upper  end  of  the 
femur,  for  example,  as  soon  as  the  child  bears  any  weight  upon  the  limb, 
becomes  displaced  until  the  trochanter  is  on  a  level  with  the  anterior  superior 
spine. 

Septic   Osteomyelitis. 

Acute  suppurative  osteomyelitis,  after  compound  fractures  or  amputations  in 
which  the  medullary  canal  has  l)een  opened,  resembles  acute  necrosis  very  closely, 
though  it  differs  in  a  few  particulars.  The  infection,  for  example,  is  direct,  through 
the  wound,  not  through  the  blood  ;  the  pus  is  asually  very  offensive,  and  the  ten- 
sion, owing  to  the  fact  that  there  is  a  certain  though  an  insufificient  means  of  exit, 
is  not  so  high. 

Minute  sequestra  are  of  common  occurrence  after  amputations.  A  ring  of 
bone  on  the  end  of  a  stump  is  killed  by  the  saw,  or  by  the  separation  of  the  j^eri- 
osteum,  and  after  a  time  is  detached  without  causing  any  constitutional  disturbance, 
or  giving  rise  to  any  more  inconvenience  than  is  due  to  the  ])resence  of  a  sinus. 
Sometimes  the  whole  thickness  of  the  bone  perishes  in  this  way  just  at  the  end. 
If,  however,  septic  inflammation  sets  in  and  attacks  the  medulla,  the  result  is  very 
different.  Masses  of  sprouting  granulations  project  from  the  orifice  ;  the  central 
canal  becomes  filled  with  intensely  infectious  pus  which  cannot  escape  with  suffi- 
cient freedom  ;  the  fever  l)ecomes  exceedingly  severe,  the  periosteum  is  stripped 
up  from  the  bone,  and  if  pyaemia  does  not  set  in  and  prove  rapidly  fatal,  the  whole 
thickness  of  the  lower  end  of  the  bone,  and  the  inner  lamelK-e  for  a  very  consider- 
able distance  higher,  are  killed.  In  this  way  the  long  tubular  sequestra  are  formed 
which  are  sometimes  extracted  from  suppurating  amputation  wounds.  At  the  end, 
where  the  inflammation  is  most  intense,  the  periosteum  and  medulla  are  both 
killed,  and  the  whole  thickness  of  the  bone  perishes ;  higher  up,  the  periosteum 
and  the  outer  layers,  being  further  removed  from  the  central  irritant,  manage  to 


SEPTIC  OSTEOMYELITIS. 


463 


survive,  and  the  outer  surflice  of  the  secjuestrum  is  worm-eaten  all  over  by  the 
granulations  which  have  cut  it  off  from  the  rest;  higher  up  still,  the  sequestrum 
grows  smaller  and  smaller  until  it  ends  in  irregular  spikes  formed  from  the  layers 
immediately  bordering  the  medulla  (Fig.  184).  Above  this,  and  on  the  outer  sur- 
face of  the  bone,  under  the  periosteum,  organization  goes  on  all  the  time,  and 
layers  of  new  bone  are  formed,  filling  in  the  central  canal,  and  sheathing  the  com- 
pact tissue  of  the  shaft  (Fig.  183). 

The  symptoms  and  treatment  are  essentially  the  same  as  in  acute  infective 
osteomyelitis.  The  stump  becomes  red,  glazed,  and  swollen  ;  red  lines  run  up  the 
skin  to  the  neighboring  glands ;  all  the  tissues  on  the  inner  side  of  the  limb  are 
thickened  and  (edematous ;  the  edges  of  the  wound  separate  from  each  other ; 
sometimes  the  end  of  the  bone  projects,  bathed  in  pus,  with  the  periosteum  de- 
tached from  its  outer  surface  and  the  medullary  canal  filled  with  masses  of  sprout- 
ing granulations  ;  the  amount  of  discharge  increases  ;  frequently  it  pours  out  when 
a  probe  is  introduced;  if  it  is  retained  in  the  least  it  becomes  offensive  and  the 
pain  excruciating.  Usually  the  attack  commences  with  a  rigor  ;  the  fever  from  the 
first  is  extreme,  and  the  temperature  exceedingly  irregular,  the  pulse  is  rapid  and 
bounding,  the  face  flushed,  the  tongue  dry  and  brown,  and  the  skin  burning  hot. 
Delirium  sets  in  very  soon  ;  sometimes  there  is  profuse  diarrhoea  ;  in  other  cases 
rigors  occur  in  rapid  succession,  and  either  osteophlebitis  and  metastatic  abscesses 
make  their  appearance,  or  the  blood-poisoning  proves  fatal  before  there  is  time  for 
this. 

Such  cases  used  to  be  common  after  amputations  through  the  shaft,  and  they 

still  are  met    with  in    military  surgery  and  

where,  from  overcrowding  or  neglect  of  pro- 
per precautions,  septic  decomposition  is 
rife  ;  with  perfect  cleanliness  and  thorough 
drainage  they  ought  never  to  happen.  At 
the  first  indication,  as  soon  as  the  condition 
of  the  medulla  is  suspected,  the  patient 
should  be  placed  under  an  anaesthetic,  the 
end  of  the  bone  freely  exposed,  and  if  the 
suspicion  is  confirmed  and  the  cavity  is 
found  to  be  filled  with  offensive  pus,  the 
whole  of  the  fungating  suppurating  mass 
that  protrudes  must  be  thoroughly  scraped 
away.  Then  the  canal  must  be  washed  out 
with  an  antiseptic  by  means  of  a  long 
rubber  tube  or  catheter,  and  filled  with 
iodoform.  In  this  way  the  progress  of  the 
disease  has  several  times  been  arrested  with- 
out very  extensive  necrosis. 

In  compound  fractures  this  is  hardly 
practicable,  and  the  only  course  is  speedy 
amputation  before  the  disease  has  advanced 
too  far  and  the  constitutional  symptoms  are 
too  marked.  In  the  case  of  the  tibia  it  fig 
is  probable  that  disarticulation  at  the  knee 
would  be  the  safest  measure,  so  as  to  get 
well  above  the  disease ;  but  if  the  femur  is 
in  question  this  is  almost  hopeless.  Ampu- 
tation higher  up  may  be  tried,  on  the 
chance  that  the  medulla  at  the  seat  of  section 
is  sufficiently  healthy,  and  in  one  or  two  in- 
stances this  has  succeeded.  Possibly  this, 
combined  with  free  drainage  of  the  canal, 
would  afford  a  better  prospect  than  disarticulation  at  the  hip. 


( 


S3. — Section  through 
Bone  after  Amputation, 
showing  effects  of  Septic 
Osteomyelitis.  At  the 
end,  medulla  and  perios- 
teum have  both  been 
killed,  and  the  whole 
thickness  is  dead  ;  higher 
up,  the  periosteum,  not 
being  subjected  to  such 
tension,  survived, and  has 
thrown  out  a  sheath  of 
new  bone  ;  higher  still, 
the  medulla  has  been 
able  to  do  the  same. 


Fig.  184.  —  Tubular 
Sequestrum  from  a 
similar  case,  show- 
ing the  Smooth 
External  Surface, 
where  the  perios- 
teum was  killed, 
and  the  rough, 
worm-eaten  one  de- 
tached by  the 
granulations 
springing  from  the 
living  bone. 


464    D/SFAS/':s  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

E.xanthcmatous  Necrosis. 

Inllammation  of  the  periosteum  and  the  bone,  followed  by  suppuration  and 
very  often  by  necrosis,  is  not  an  unfrequent  complication  of  the  acute  exanthe- 
mata. Sometimes  it  occurs  during  the  height  of  the  attack,  but  much  more  fre- 
tpiently  it  breaks  out  during  the  period  of  convalescence.  In  some  instances  it  is 
probably  py;x;mic,  originating  by  infection  from  some  of  the  sores  or  ulcers  ;  but 
there  is  very  often  a  history  of  its  having  followed  a  slight  injury,  and  it  certainly 
is  prone  to  affect  superficial  bones.  It  is  quite  intelligible  that  a  trivial  bruise,  such 
as  would  not  be  noticed  during  health,  might,  under  such  circumstances,  be  fol- 
lowed by  supiniration  and  sloughing.  There  is,  moreover,  very  little  tendency  for 
this  form  of  necrosis  to  become  diffuse,  and  the  sequestra  are  usually  small. 

After  typhoid  fever  it  is  not  at  all  uncommon,  especially  on  the  tibia,  and 
sometimes  it  is  symmetrical ;  but  it  may  also  occur  upon  the  ulna,  scainda,  j^arietal 
bones,  or  upon  the  ribs,  sometimes  ending  in  necrosis,  sometimes  clearing  up.  The 
jaws  are  more  frequently  involved  after  scarlatina  and  variola. 


Syphilitic  Disease  of  Bone. 

(i)  ///  Acquired  Syphilis. 

In  all  stages  of  acquired  syphilis  inflammation  of  bone  is  exceedingly  com- 
mon. Like  the  other  manifestations,  in  the  early  period  of  the  disease  it  is  acute, 
attended  with  hypereemia,  but  with  only  a  slight  amount  of  exudation  ;  and  it 
begins  suddenly,  runs  a  rapid  course,  and  yields  readily  to  treatment.  In  the 
later,  on  the  other  hand,  it  is  much  more  chronic,  the  amount  of  exudation  is 
larger,  and  caries  and  necrosis  with  suppuration  are  very  prone  to  occur. 

At  the  beginning  of  the  secondary  symptoms  patients  often  complain  of  a 
feeling  of  soreness  in  the  bones,  sometimes  amounting  to  actual  pain,  keeping 
them  awake  at  night  and  flying  all  over  the  body,  the  so-called  ostcocopic  pains. 
The  bones  are  very  tender,  but  there  is  no  swelling  and  no  increased  heat  over 
them.  Probably,  as  the  parts  involved  are  those  in  which  secondary  syphilitic 
periostitis  is  especially  prone  to  occur,  they  are  due  to  a  transient  hypen^mia  of 
the  periosteum  scarcely  amounting  to  inflammation. 

A  little  later,  after  the  skin  eruption,  true  periosteal  nodes  make  their  ajjpear- 
ance.  A  slightly  raised,  exceedingly  tense  swelling  forms  upon  the  shaft  of  one 
of  the  long  bones  (the  til)ia,  ulna,  or  clavicle  i)articularly),  or  upon  the  skull.  It 
is  so  painful  and  so  tender,  that  the  patient  will  not  allow  a  finger  to  come  near 
it,  and  at  night  cannot  bear  the  contact  of  the  bed-clothes.  The  skin  over  it  is 
white  and  shining,  from  the  way  in  which  it  is  stretched  ;  the  temperature  is 
slightly  raised,  and  the  whole  bone  is  more  or  less  tender.  The  size  of  the  swel- 
ling is  very  small ;  there  is  no  definite  outline  to  it ;  it  is  very  low  and  shades  off 
gradually  at  the  margin.  Sometimes  it  is  single  ;  not  unfrecjuently,  however, 
more  than  one  bone  is  involved,  and  in  the  early  secondary  stage  it  is  very  often 
symmetrical. 

The  amount  of  exudation  jjresent  in  these  cases  and  the  changes  it  undergoes 
depend  to  a  great  extent  upon  the  period  of  the  disease.  Nodes  that  are  very 
acute  are  limited  in  size  and  attended  with  byt  a  slight  degree  of  small-celled 
infiltration,  so  that  absorption  takes  place  w^ith  great  rapidity  ;  the  pericsteum, 
especially  the  deeper  layer,  is  thickened,  softened,  and  more  vascular  ;  the  bone  is 
scarcely  affected,  or  it  may  be  slightly  too  porous  on  the  surface,  and  the  swelling 
disapjiears  under  treatment  without  leaving  behind  any  visible  alteration  of 
structure. 

Those  that  occur  later  are  more  chronic,  and  affect  the  bone  as  well  as  the 
periosteum.  The  pain  is  not  so  intense,  for  the  tissues  have  time  to  soften  and 
yield  ;   the  amount  of  exudation  is  much  greater  in  proportion  to  the  hyjiera^mia ; 


SYPHILITIC  DISEASE  OF  BONE.  465 

the  edges  of  the  swelling  are  more  distinct,  and  the  bone  underneath  plays  a  much 
more  im])ortant  part.  Rarefying  osteitis  sets  in  ;  the  cancellous  spaces  are  filled 
with  syi)hilitic  exudation,  and  even  when  resolution  occurs  comparatively  early, 
some  permanent  alteration  is  usually  left.  The  hypera;mia  disappears,  of  course, 
and  much  of  the  exudation  is  al)sorbed  ;  but  a  considerable  proportion  usually 
becomes  organized  and  forms  a  i)ermanent  enlargement  with  dense  osteosclerosis 
around  it  and  under  its  base  {an  osseous  iiodt-).  'i'he  skull  is  an  exception  :  peri- 
cranial nodes  do  not  ossify  ;  and  if  the  external  table  of  the  bone  is  absorbed,  the 
defect  is  not  filled  up  (except  with  fibrous  tissue)  and  the  depression  is  permanent. 

Later  still,  in  the  tertiary  stage  the  amount  of  gummatous  infiltration  is  very 
much  greater,  and  it  not  only  involves  the  superficial  part  of  the  bone,  but  spreads 
deeply  into  its  substance,  attacking  the  medulla  both  in  the  central  canal  and  in 
the  cancellous  spaces.  The  swelling  is  much  more  chronic;  instead  of  being 
sujierficial  and  limited,  it  may  extend  over  the  whole  length  and  circumference  of 
the  bone  ;  the  Haversian  canals  are  enlarged  ;  the  bony  trabecular  and  the  com- 
pact tissue  are  absorbed  ;  and  the  medulla  and  the  deeper  layers  of  the  periosteum 
are  converted  into  a  soft,  reddish-yellow  substance,  which  readily  undergoes  case- 
ous degeneration.  Interstitial  syphilitic  osteomyelitis,  or  what  has  been  called  dif- 
fuse gummatous  infiltration,  has  been  added  to  the  periostitis.  Sometimes,  on  the 
cranium  for  example,  the  exudation  is  greater  in  one  part  than  in  another ;  there 
is  immense  thickening  along  one  of  the  sutures  or  over  the  eminences ;  but  not 
unfrequently,  especially  when  one  of  the  long  bones  is  concerned,  the  whole  length 
is  irregularly  enlarged,  thickened,  and  tender,  and  the  soft  parts  and  the  skin 
around  and  over  it  are  swollen  and  reddened. 

Like  gummata  elsewhere,  these  tertiary  nodes  are  much  more  lasting,  and  lead 
to  much  more  serious  results  than  simple  periostitis.  The  exudation  may  be 
absorbed  almost  entirely  ;  more  often,  especially  at  the  edges  farthest  away  from  the 
chief  focus,  it  becomes  organized,  and  the  bone  becomes  hard,  heavy,  and  dense  ; 
in  most  cases,  unless  it  is  treated  very  soon,  suppuration  sets  in  ;  the  skin  gives 
way,  the  contents  of  the  abscess  are  discharged,  and  the  surface  beneath  is  left 
bare  and  rough,  necrosed  and  carious,  according  to  whether  it  is  compact  or  can- 
cellous. In  rarer  cases  the  bone  perishes,  apparently  from  condensation,  the 
Haversian  canals  at  length  becoming  so  narrow  that  the  compact  tissue  is  cut  off 
from  its  blood-supply  and  dies. 

On  the  cranium  syphilitic  nodes  are  exceedingly  common.  Early  ones  are 
soon  absorbed  ;  later  ones  are  more  chronic  and  leave  depressions  ;  tertiary  ones 
that  ulcerate  and  break  down  lead  to  the  most  extensive  destruction.  The  vault 
is  the  favorite  place ;  the  whole  of  the  exterior  may  be  covered  over  with  carious 
ulcers,  varied  here  and  there  with  patches  which  have  undergone  necrosis.  Some- 
times the  external  table  only  is  diseased,  although  the  internal  always  shows  signs 
of  increased  vascularity  ;  sometimes  the  whole  thickness  perishes,  and  more  or  less 
circular  sequestra  are  formed.  In  most  the  ulceration  is  annular  ;  the  bone  becomes 
rough  and  worm-eaten ;  a  circular  groove  forms  round  it,  and  gradually  the  granu- 
lations grow  beneath  it  and  separate  it  from  the  rest.  More  rarely  it  is  pitted  ;  the 
compact  tissue  of  the  outer  table  is  eaten  away  in  little  dots  all  over ;  and  some- 
times it  is  tuberculated  here  and  there,  nodules  of  new  bone  being  formed,  and 
subsequently  in  their  turn  becoming  ulcerated  and  destroyed.  Occasionally  very 
extensive  absorption  of  bone  takes  place  without  suppuration  (Fig.  185). 

Condensation  and  sclerosis  more  often  affect  the  diploe  and  the  inner  table, 
particularly  in  the  frontal  region.  The  bone  may  become  absolutely  solid  and 
hard  all  through,  so  that  there  is  no  trace  left  of  cancellous  spaces,  and  huge 
masses  of  dense  osseous  tissue  may  be  thrown  out  on  the  inner  surface,  between 
the  inner  table  and  the  dura  mater  (subcranial  nodes).  These  are  usually  sym- 
metrical, arranged  on  either  side  of  the  superior  longitudinal  sinus  (Fig.  186). 
Suppurating  gummata  in  the  diploe  are  more  rare ;  sometimes,  however,  they 
cause  inmiense  expansion,  which  chiefly  affects  the  outer  table  and  reduces  the 
intervenin<r  tissue  to  a  series  of  radiating  bonv  bars. 


466     DISEASES  AND   INJURIES   OE  SPECIAL    STRUCTURES. 


The  long  hones  are  af- 
fected in  the  same  way,  ex- 
cept that,  owing  to  the  osteo- 
plastic function  of  the  perios- 
teum, a  greater  amount  of 
new  tissue  is  formed  upon  the 
surface.  The  early  nodes  are 
acute  and  soon  absorbed  ;  later 
ones,  involving  the  bones  as 
well  as  the  ])eriosteum,  leave 
a  thickening  which  very  often 
persists.  In  some  cases,  in 
which  the  deeper-lying  osseous 
tissue  and  the  medulla  are  es- 
pecially concerned,  the  whole 
bone  becomes  hard  and  dense 
(osteosclerosis)  ;  and  occasion- 
ally the  formation  of  new  tissue 
is  so  extensive  that  the  Haver- 
sian canals  become  obliterated, 
and  the  blood-supply  of  some 
of  the  central  portion  cut  off. 
If  this  occurs,  and  central 
necrosis  is  added  as  a  further 
source  of  irritation,  the  whole 
bone  may  at  length  become  so 
changed  in  shape  and  density, 
and  so  irregular  ui)on  the  sur- 
face, as  to  lose  all  resemblance 
"  ~  to  its  former  self.     This,  how- 

ever, is  more  common  in  con- 

FiG.    185. — Syphilitic  Caries  jt   \  a,;lt   t.t  Skull.     There  was  no  sign  of  .      ,  UT  fl"      *■'  *-V. 

suppuration  or  abscess;  the  bone  was  simply  eaten  away  by  specific   genital    SyphlllS,     atiecting     tlie 

"^"^^^  tibia  especially  (hyperostosis) 

than  in  the  acquired  form. 
In  the  tertiary  stage,  when  the  gummatous  material  is  deposited  in  larger 
quantities  and  has  a  greater  tendency  to  caseation  and  suppuration,  caries  and 
necrosis  are  more  common.  Sometimes  pus  forms  between  the  periosteum  and  the 
bone  ;  the  former  is  destroyed  by  the  syphilitic  exudation  :  no  new  shell  is  formed 
upon  the  outside,  the  skin  gives  way,  and  the  bone  beneath  is  exposed,  rough  and 
soft  upon  the  surface  (caries),  so  that  a  probe  can  be  pushed  into  it.  Very  often 
the  depression  left  appears  deeper  than  it  really  is,  because  of  the  deposit  of  new 
tissue  by  the  periosteum  round  the  edge.  If  the  bone  is  deeply  involved  this  may 
lead  to  spontaneous  fracture.  In  other  cases  the  exudation  is  more  marked  in  the 
central  and  interstitial  medulla  ;  the  whole  bone  is  expanded  and  softened,  so  that 
when  suppuration  occurs  and  the  skin  gives  way  it  seems  as  if  it  would  be  entirely 
destroyed.  This  is  not  uncommon  in  the  upper  extremity,  especially  the  forearm. 
That  part  of  the  limb  is  immensely  swollen  and  thickened  ;  the  skin  is  reddened 
and  undermined  with  sinuses  ;  the  shaft  of  the  radius  or  ulna,  as  the  case  might 
be,  is  enormously  enlarged,  so  that  the  size  of  the  swelling  appears  almost  entirely 
due  to  the  bone  ;  and  a  probe  passed  into  one  of  the  sinuses  can  be  pushed  in 
almost  any  direction.  The  appearance  before  suppuration  sets  in  is  almost  iden- 
tical with  that  of  a  rapidly  growing  sarcoma ;  but  even  in  advanced  cases  resolu- 
tion and  absorption  take  place  readily  under  the  influence  of  iodide  of  potash 
combined  with  tonics  and  good  food.  The  same  thing  is  not  uncommon  in  con- 
nection with  the  phalanges  of  the  fingers  and  toes,  both  in  the  hereditary  and 
acquired  form,  leading  to  a  very  great  enlargement,  of  a  peculiarly  uniform 
shape.      Occasionally  it  ends  in  necrosis. 


SYPHILITIC  DISEASE  OF  BONE. 


467 


The  other  bones  are  not  exempt.  The  cervical  vertebrtne  may  be  affected  and 
cause  disease  of  the  occipito-atloid,  or  atlo-axoid  articulation.  Gummatous  deposit 
may  occur  beneath  the  mucous  membrane  of  the  nose  and  lead  to  necrosis  of  the 
nasal  bones.  Perforation  of  the  hard  palate  (always  exactly  in  the  middle  line) 
and  destruction  of  the  nasal  septum  and  of  the  turbinate  bones  are  not  uncommon. 
The  jaws  may  be  affected,  the  upper  more  often  than  the  lower,  causing  large  por- 
tions of  the  alveolar  margin  to  undergo  necrosis,  and  leading  to  loss  of  teeth  ;  and 
this  may  occur  in  patients  who  have  never  taken  mercury.  In  short,  nearly  every 
bone  in  the  body  may  be  affected  to  a  greater  or  less  extent,  the  changes  being 


4  A 


Fig. if 


. — Symmelrical  Nodes   on  Inner  Surface  of  Frontal  Bone.     Tlie  diploe  is  filled  in,  and  the 
grooves  for  the  meningeal  arteries  are  much  too  deep  and  too  numerous. 


practically  identical  in  them  all,  depending  upon  the  amount  of  the  syphilitic 
exudation,  the  length  of  time  it  is  allowed  to  destroy  the  bone,  and  the 
subsequent  changes  it  undergoes. 


(2)  In    Congenital  Syphilis. 

Bone-lesions  are  very  common  in  congenital  syphilis,  occurring  in  iitero, 
during  the  first  few  months  of  infancy,  and  later  at  puberty,  in  the  same  way  as 
the  other  manifestations.  Those  that  appear  in  early  infancy,  and  some  of  the 
later  ones,  are  peculiar  to  the  congenital  form  and  are  never  met  with  in  the 
acquired  ;  but  gummata,  followed  by  caries  and  necrosis,  occur  as  well,  and  can- 
not be  distinguished  from  ordinary  tertiary  ones,  except  perhaps  that  they  are 
more  intractable  and  yield  less  readily  to  iodide  of  potash. 

(«z)  The  early  changes  are  partly  inflammatory,  attended  with  new  growth  and 
the  formation  of  fresh  bone,  partly  atrophic,  with  wasting  and  degeneration.  Not 
unfrequently,  as  in  some  other  constitutional  affections  of  bone,  the  two  are  found 
together  side  by  side.  As  a  rule  they  appear  within  the  first  year,  often  within 
the  first  three  months. 

I.   The  former  chiefly  occur  under  the  pericranium  and  under  the  periosteum 


468     DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 


Flo.  187. — Parrot's  Nodes  Round  the  Anterior  Fontanelle. 


of  the  shafts  of  the  long  bones.      On  the  skull  they  are  known  as  Parrof  s  nodes, 

and  are  of  themselves  abso- 
lutely characteristic.  They 
form  four  broad  flattened 
bosses,  sometimes  half  an 
inch  in  thickness,  surround- 
ing the  anterior  fontanelle, 
one  on  each  parietal  bone, 
one  on  each  half  of  the 
frontal,  lictween  them  is 
a  deep  crucial  depression, 
corresponding  to  the  su- 
tures, and  a  skull  marked  in 
this  way  is  described  as 
"  natiform."  The  centres 
of  ossification  are  not  in- 
volved ;  the  new  bone  orig- 
inates in  the  deeper  layers 
of  the  periosteum,  and  very 
often  spreads  down  the  su- 
tures until  it  meets  across 
and  bridges  them.  At  first 
it  is  very  vascular  and  por- 
ous, consisting  of  more  or 
less  perfectly  developed 
horizontal  lamellae,  united 
by  trabeculos  running  in  a 
vertical  direction  ;  in  the 
interspaces  is  a  soft  pulpy  medullary  substance,  continuous  through  the  widely 
dilated  Haversian  canals  with  that  in  the  bone  underneath.  At  a  later  period  it 
becomes  more  dense  and  solid. 

The  shafts  of  the  long  bones,  especially  near  the  epiphyses,  are  not  unfre- 
quently  sheathed  in  with  a  similar  deposit  arranged  in  layers  around  them,  some- 
times quite  soft,  and  hardly  ossified  at  all  (the  periosteum  then  separates  more 
easily  than  natural),  sometimes  hard  and  dense.  It  may  be  associated  with  changes 
at  the  growing  ends  of  the  bones,  but  not  necessarily  so  in  any  way.  In  some  of 
these  cases  the  medulla  is  found  to  be  replaced  and  the  central  canal  filled  with  a 
fine  trabeculated,  soft,  spongy  mass. 

2.  The  atrophic  changes  [gclatiniform  degeneration)  are  also  met  with  on  the 
skull  under  the  pericranium  (by  which  they  can  be  distinguished  from  craniotabes, 
which  is  simply  a  wasting  of  the  bone  under  certain  conditions  from  long-con- 
tinued pressure),  but  the  situation  is  not  a  common  one.  The  favorite  place  is 
at  the  ends  of  the  long  bones,  es])ecially  of  the  elbow-joint,  though  none  are 
exempt.  Strictly  speaking  the  epiphysis  is  not  affected,  the  disease  attacks  the 
growing  layer  at  the  end  of  the  shaft  and  the  cartilage  (intermediary)  that  imme- 
diately joins  it.  The  medullary  spaces  in  the  growing  bone  increase  enormously 
in  size  ;  the  new-formed  vertical  lamellne  waste  away,  the  medulla  itself  becomes 
converted  into  a  i)eculiar  gelatinous  mass  ("  like  fluid  jelly,"  whence  the  name 
given  it  by  Parrot),  from  which  the  cells  disappear,  leaving  little  but  a  fibrillar 
network  with  blood-vessels  running  here  and  there.  In  some  cases  there  is  a 
layer  of  this  soft  semi-diflfluent  material,  a  line  in  thickness,  between  the  cartilage 
and  the  bone.  The  cartilage  itself  undergoes  a  different  transformation  ;  the 
matrix  becomes  calcified  to  an  abnormal  extent,  the  cells  are  i)rematurely  enclosed, 
and  the  brittle  vertical  lamella  rest  upon  the  soft  gelatinous  layer  on  the  end  of 
the  shaft. 

In  many  respects  these  changes  closely  resemble  those  that  occur  in  rickets, 
and   the  difficulty  of  distinguishing  them   is  rendered   greater  by  the   fact  that 


SYPHILITIC  DISEASE  OF  BONE.  469 

the    two  (.liseases    not    untVoi|ucntly  coexist.      Parrot's  nodes,   however,  are  dis- 
tinctive. 

The  symj^tonis  to  which  these  changes  give  rise  are  very  characteristic.  A 
soft,  puffy,  tender  swelhng  forms  round  the  end  of  the  bone,  involving  the  joint; 
the  limb  is  perfectly  helpless  (it  has  been  called  syphilitic  pseudo-paralysis  of 
infants),  it  bends  and  yields  with  the  least  pressure,  and  sometimes  a  certain 
amount  of  soft  grating  can  be  felt  as  if  there  was  a  separation  between  the  calcified 
cartilage  and  the  soft  tissue  at  the  end  of  the  shaft.  In  the  worst  cases  this  does 
actually  take  place,  and  the  end  of  the  bone  can  be  felt  free  and  detached.  Later, 
owing  to  the  way  in  which  the  limb  is  constantly  being  hurt,  as  soon  as  the  strength 
of  the  central  support  is  lost,  suppuration  may  set  in,  generally  under  the  perios- 
teum at  the  end,  rarely  between  the  bone  and  the  epiphysis.  Resolution  under 
appropriate  mercurial  treatment  is  the  rule,  but  not  unfrequently  premature  ossifi- 
cation follows,  and  the  growth  and  development  of  the  body  are  arrested  ;  not 
only  does  the  size  remain  small,  but  the  changes  that  normally  occur  at  puberty 
are  delayed.  In  the  worst  necrosis  may  follow,  but  such  cases  rarely  survive 
sufficiently  long. 

(^li)  In  the  period  between  infancy  and  early  puberty  the  bones,  like  the  other 
tissues,  are  rarely  affected.  Gummata  may  occur,  but  they  are  not  usual.  At 
puberty  there  is  a  fresh  outbreak. 

The  form  this  takes  is  in  many  instances  as  characteristic  as  the  one  already 
described.  The  shafts  of  the  long  bones,  especially  the  tibia,  are  the  parts  most 
commonly  attacked.  Ill-defined  periosteal  nodes,  not  so  acute  as  those  met  with 
in  secondary  syphilis,  make  their  appearance  on  the  skin  ;  at  first  they  yield  to 
treatment  fairly  well,  though  a  certain  amount  of  thickening  is  always  left ;  but 
they  return  again  and  again  with  the  greatest  obstinacy,  and  each  time  they  resist 
absorption  more  and  more.  At  first  the  periosteum  only  is  affected,  the  superficial 
lamelliTe  are  a  little  more  vascular,  but  that  is  all  ;  in  a  short  time,  however,  the 
inflammation  shows  itself  in  the  bone,  and  before  long  the  whole  of  the  shaft 
becomes  thickened,  bent  (usually  in  exaggeration  of  the  normal  curve),  lengthened 
perhaps,  and  covered  over  with  great  irregular  bosses.  On  section  the  normal 
compact  tissue  can  hardly  be  distinguished  ;  the  whole  of  the  bone  is  dense  and 
hard,  immensely  thickened  and  altogether  altered  in  shape  (^hyperostosis  or  inter- 
stitial condensing  osteitis) . 

Sometimes,  when  it  occurs  at  an  early  age,  I  believe  this  is  symmetrical, 
though  usually  one  leg  is  much  worse  than  the  other  ;  if  it  breaks  out  for  the  first 
time  later  in  life  (and  it  may  not  appear  until  two  or  three  and  twenty)  this  is  not 
the  case.  In  most  instances  the  tibiae  are  affected,  but  the  bones  of  the  upper 
extremity,  especially  at  the  elbow,  not  unfrequently  suffer  as  well,  and  sometimes 
the  clavicles,  ribs,  scapulae,  and  other  bones  are  attacked,  too.  Generally  it  is 
limited  to  the  shaft,  but  it  may  extend  to  the  epiphyses,  especially  the  upper  one 
on  the  ti-bia,  and  then  it  is  always  accompanied  by  synovitis,  with  effusion  into 
the  joint  and  thickening  of  the  synovial  membrane.  In  the  milder  cases  suppura- 
tion does  not  occur  ;  in  the  more  severe  ones,  after  the  disease  has  lasted  some 
little  time,  the  syphilitic  deposit  under  the  periosteum  perishes,  and  the  bone  is 
exposed  at  the  bottom  of  an  ulcer,  bare,  hard,  and  rough.  The  sequestra  are 
usually  superficial,  but  owing  to  the  dense  character  of  the  bone  beneath  they 
often  do  not  separate  for  years ;  and  by  the  irritation  they  cause,  and  the  assist- 
ance they  get  from  pyogenic  organisms,  they  lead  at  length  to  such  an  amount  of 
solid  oedema,  ulceration,  and  sclerosis,  that  the  limb  resembles  an  old  gnarled 
tree-trunk  more  than  anything  else. 

Besides  these,  many  other  lesions  are  met  with  in  congenital  syphilis  similar  to 
those  of  the  acquired  form.  Necrosis  of  the  nasal  bones  and  of  the  ethmoid  is 
not  uncommon,  leading  to  great  deformity  and  attended  with  a  profuse  and  in- 
tensely offensive  discharge  from  the  nose  ;  the  whole  of  the  frontal  bone  is  some- 
times exposed,  bare,  rough,  and  almost  black  ;  perforation  of  the  hard  palate  in 


470    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  middle  line  is  often  met  with;  inllanimation  of  the  phalanges  of  the  fingers 
occurs  occasionally  ;  and  in  short  there  is  scarcely  a  i)art  of  the  body  in  which 
the  bones  may  not  become  the  seat  of  gummatous  deposit  and  perish,  either  in 
minute  fragments  (caries),  or  in  large  ones  (necrosis). 

Symptoms. — Pain,  heat,  swelling,  and  redness  are  present  as  in  other  forms 
of  inflammation,  varying  very  greatly  in  intensity.  The  first  is  the  most  con- 
stant. In  acute  cases  it  is  very  severe,  and  like  all  bone-i)ain  is  much  worse  at 
night  and  after  exertion  ;  the  skin  over  the  affected  part  is  exquisitely  tender  ;  the 
patient  will  not  allow  a  finger  to  come  near  it,  and  the  whole  bone  when  it  is 
percussed  is  highly  sensitive.  When  the  inflammation  is  more  chronic  this  is 
much  less  marked,  but  a  dull  aching  sensation,  becoming  more  severe  under  the 
same  conditions,  is  rarely  altogether  absent.  The  amount  of  heat  and  redness 
depends  chiefly  upon  the  locality  of  the  inflammation,  whether  it  is  near  the  surface 
or  not,  and  upon  the  presence  of  suppuration.  Like  the  other  signs,  they  are 
much  more  severe  w'hen  the  attack  is  acute.  The  swelling  is  of  great  importance, 
as  the  diagnosis  of  the  cause  depends  very  largely  upon  the  locality  and  the  part 
of  the  bone  involved.  In  the  secondary  stage  the  shafts  of  the  long  bones  and 
the  skull  are  affected,  and  the  swelling  is  tense,  circular,  and  very  small,  limited 
to  one  surface  of  the  bone,  chiefly  periosteal.  In  the  tertiary  it  is  much  larger 
and  more  chronic  ;  the  whole  bone  is  involved  ;  the  swelling  is  uniform  in  shape, 
extending  around,  as  well  as  along  the  shaft ;  and  the  same  is  true  of  the  heredi- 
tary form  when  the  long  bones  are  attacked. 

In  children  syphilitic  nodes  are  very  difficult  to  distinguish  from  the  strumous 
or  tubercular,  especially  when  the  metacarpal  bones  and  the  phalanges  are  con- 
cerned ;  the  swelling  is  the  same  in  shape,  the  other  symptoms  are  the  same,  and 
often  it  is  nece.ssary  to  rely  upon  the  other  signs  that  are  present.  In  adults,  or 
when  the  long  bones  of  the  limbs  are  concerned  {e.  g.,  the  radius  or  ulna),  there  is 
not  the  same  difficulty,  as  tubercle  under  these  conditions  is  rarely  met  with,  and 
does  not,  like  tertiary  syphilis,  attack  the  compact  tissue  of  the  shaft. 

As  the  inflammation  extends,  other  signs  make  their  appearance  :  suppuration 
may  occur  with  caries  or  necrosis ;  an  osseous  node  or  enlargement  of  the  whole 
bone  may  be  left  from  organization  of  the  exudation  ;  neighboring  structures 
may  become  involved,  the  joints  for  example  may  become  inflamed,  the  cortex 
of  the  brain  may  be  irritated  or  compressed,  nerves  and  blood-vessels  may  be 
pressed  upon  ;  and  in  some  cases  the  destruction  is  so  great  as  to  cause  the  most 
serious  deformity. 

Diagnosis. — Strumous  nodes,  as  already  mentioned,  closely  resemble  those 
that  occur  in  tertiary  and  hereditary  syphilis,  especially  when  the  bones  of  the 
hand  or  foot  are  attacked.  In  each  there  is  a  chronic  enlargement  of  the  whole 
bone,  with  a  tendency  to  break  down  and  caseate,  and  in  man)^  instances  it  is  only 
possible  to  distinguish  one  from  the  other  by  the  history  or  the  presence  of  other 
signs.  Ulceration  of  the  scalp  with  caries  of  the  subjacent  bone  in  children  is 
generally  tubercular,  after  puberty  it  is  more  often  syphilitic,  especially  if  it  is 
attended  with  necrosis.  In  the  case  of  the  long  bones  tubercle  nearly  always 
begins  in  the  cancellous  ends,  which  rarely  suffer  in  the  course  of  syphilis. 

Rheumatic  nodes,  leading  to  chronic  osteitis,  are  still  more  difficult  to  distin- 
guish. The  symptoms  in  each  are  due  to  the  condensation  and  sclerosis,  and 
practically  present  no  difference.  Osteocopic  wandering  pains  may  occur  in  rheu- 
matism as  well  as  in  syphilis. 

Tertiary  syphilitic  nodes  can,  in  some  cases,  only  be  distinguished  from  sar- 
comata of  bone  by  a  course  of  iodide  of  potash  ;  and,  as  rapidly  growing  tumors 
are  always  accompanied  by  a  certain  amount  of  inflammation  (periostitis  and 
osteitis),  a  definite  conclusion  must  not  be  drawn  until  there  is  a  very  distinct 
degree  of  improvement.  In  doubtful  cases  it  may  be  necessary  to  make  an  ex- 
ploration with  a  trocar  and  cannula. 

From  rickets  the  difficulty  of  distinguishing  hereditary  syphilis  is  greater  still. 


RHEUMATIC  OSTEITIS.  471 

Craiiiotabes,  enlargement  of  the  eijiphysial  ends  with  thickening  and  bowing  of 
the  shafts,  and  bending  of  the  ribs  are  present  in  both  ;  but  as  a  rule  in  syphilis 
the  course  is  more  acute  and  the  disease  not  so  uniformly  distributed  over  the 
body ;  the  stress  of  the  complaint  seems  to  fall  on  one  or  two  parts.  Separation 
of  epiphyses  and  Parrot's  nodes  may  be  regarded  as  distinctive.  In  the  latter 
stage  the  enlargement  of  the  tibice,  that  is  so  common  in  hereditary  syphilis,  has 
often  been  confounded  with  the  bending  and  the  concavity  that  occur  in  rickets, 
but  the  enormous  overgrowth  in  all  directions,  not  in  one  only,  and  the  irregularity 
of  the  siirtare  are  never  met  with  in  the  latter. 

Treatment. — The  treatment  proper  to  the  stage  of  the  constitutional  disease 
must  be  thoroughly  carried  out.  Secondary  syphilitic  nodes  yield  at  once  to 
small  doses  of  iodide  of  potash,  but  relapses  are  very  common.  Tertiary  ones  are 
less  satisfactory  ;  it  is  often  necessary  to  increase  the  amount  very  largely  before 
any  effect  is  produced,  and  even  then  in  some  instances  it  is  of  very  little  avail  by 
itself.  Rest,  warmth,  tonics,  good  food,  and  fresh  air  are  no  less  essential,  espe- 
cially in  inveterate  cases,  and  not  unfrequently  when  iodide  of  potash  appears 
to  fail  altogether,  it  succeeds  at  once  if  the  patient  is  sent  to  the  seaside  and  made 
to  lay  up  completely.  The  hereditary  nodes  that  occur  at  puberty  are  still  more 
intractable.  The  bone  becomes  sclerosed  and  dense,  and  nothing  seems  to  have 
any  effect  upon  it.  In  some  of  these  cases,  in  which  it  is  evident  that  the  pain  is 
kept  up  rather  by  the  local  condition  than  by  the  constitutional  taint,  linear 
osteotomy  may  be  performed  with  advantage. 

The  inflammation  that  occurs  in  infancy  must  be  treated  with  mercury  in  the 
same  way  as  other  infantile  manifestations.  The  prognosis,  if  only  one  joint  is 
affected,  is  good  ;  if,  however,  there  are  several,  or  if  suppuration  occurs,  recovery 
is  very  doubtful ;  rickets  and  visceral  lesions  are  nearly  always  present  as  well,  and 
even  when  the  specific  symptoms  abate,  the  child  generally  dies  from  wasting  and 
exhaustion,  or  from  some  comparatively  trivial  intercurrent  disorder. 

Rheumatic  Osteitis. 

In  chronic  rheumatoid  arthritis  the  bones  become  inflamed,  as  part  of  the 
joints,  together  with  the  other  tissues.  Atrophy  and  absorption  take  place  to  a 
certain  extent  along  the  line  of  pressure;  and  around  the  margin  osteophytes  are 
thrown  out,  dense  hard  masses  of  new  bone,  sometimes  formed  under  the  perios- 
teum, sometimes  due  to  the  ossification  of  ecchondroses. 

In  addition  to  this,  the  bones  themselves  are  liable  to  a  form  of  osteitis,  which, 
like  rheumatic  inflammation  generally,  tends  to  organization  and  sclerosis.  Sup- 
puration never  occurs.  The  periosteal  surface  is  roughened  and  irregular  with 
outgrowths,  the  compact  tissue  beneath  is  exceedingly  dense  and  hard,  and  the 
medullary  canal  is  contracted.  The  changes,  in  other  words,  are  typically  those 
of  osteosclerosis,  exceedingly  chronic,  progressive,  and  attended  with  a  con- 
siderable degree  of  aching  pain  which  is  worse  at  night  and  when  exposed  to 
damp. 

Very  little  can  be  done  for  this  condition  ;  iodide  of  potash  has  scarcely 
any  effect  upon  it,  although  it  relieves  the  pain  to  a  certain  extent.  Strong  iodine 
liniment  painted  over  the  part,  mercurial  ointment  well  rubbed  in,  flying  blisters 
and  other  forms  of  counter-irritation  are  often  serviceable  in  the  same  way ;  the 
progress  of  the  inflammation  is  stayed,  and  there  is  only  the  inconvenience  arising 
from  the  increased  size  and  weight  of  the  bone.  If  this  does  not  succeed,  and 
the  pain  is  severe,  trephining,  or  linear  osteotomy,  according  to  the  part  of  the 
bone  involved,  should  be  tried.  Very  often  this  gives  perfect  relief,  apparently 
by  diminishing  the  tension  of  the  part,  or  by  the  subsequent  changes  that  take 
place  in  the  bone. 


472    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

TlliKkCLLAk    OsTKITIS. 

This  may  occur  eitlicr  as  part  of  a  general  disorder  (acute  miliary  tubercu- 
losis), or  as  an  affection  that  is  at  first  local  and  invades  the  surrounding  tissues 
slowly,  although  untler  certain  conditions  it  may  becom.e  the  source  of  a  general 
infection.  The  former  has  practically  no  surgical  im])ortance,  and  does  not  admit 
of  recognition  during  life  ;  the  latter  is  the  same  as  what  has  hitherto  been  known 
as  scrofulous  disease  of  bone. 

The  cancellous  tissue  is  the  part  chiefly  affected,  the  ends  of  the  long  bones, 
the  bodies  of  the  vertebra;,  and  the  carpus  and  tarsus  ;  but  it  may  occur  upon  the 
skull,  and  in  children  it  often  attacks  the  phalanges  and  the  metacarpal  bones. 
The  shafts  of  the  long  bones  of  the  limbs,  the  favorite  seat  of  syphilitic  disease, 
are  practically  exempt. 

it  begins,  like  chronic  inflammation  of  cancellous  tissue  generally,  as  rarefy- 
ing osteitis.  The  trabecular  are  softened  and  thinned  at  one  spot ;  the  medulla  is 
replaced  by  reddish  granulation  tissue,  round  the  margins  of  which  typical  mili- 
ary tubercles  may  be  found,  and  this,  in  its  turn,  is  enclosed  by  a  ring  of  hyi^er- 
jemia.  Occasionally  there  are  several  of  these  close  together,  gradually  enlarging 
until  they  coalesce. 

The  subsequent  changes  depend  upon  the  activity  of  the  bacillus  and  the 
power  of  resistance  possessed  by  the  tissues. 

In  some  cases  caries  sicca  sets  in  ;  the  granulations  continue  to  grow  and 
increase  without  caseating  or  suppurating,  and  gradually  the  whole  bone  is  absorbed 
and  rei)laced  by  a  soft,  vascular  mass,  more  or  less  representing  it  in  shape,  accord- 
ing to  the  amount  of  pressure  it  has  to  sustain.  After  a  time  this  may  break  down 
and  caseate,  or  it  may  slowly  disappear,  leaving  a  hard,  shapeless,  irregular  mass 
of  dense  fibrous  tissue  and  bone. 

More  often  the  granulation  tissue  in  the  centre  becomes  soft  and  yellow ; 
caseation,  followed  by  liquefaction,  sets  in,  and  a  tubercular  abscess  (so  called)  is 
formed.  Sometimes  even  then,  if  the  nutrition  of  the  part  improves,  sclerosis  may 
take  place  around  and  enclose  it  ;  much  more  frequently  the  neighboring  can- 
cellous spaces  become  involved  ;  the  trabecuL'e  perish  and  fall  off  in  fragments  of 
various  sizes  (if  they  are  of  any  dimensions  it  is  known  as  caries  nccrotica'),  and 
a  cavity  is  formed,  filled  with  a  caseous  liquid  mi.xed  with  debris  and  minute 
sequestra,  and  enclosed  by  walls  of  soft,  carious  bone,  in  the  medullary  spaces  of 
which  miliary  tubercles  may  be  found  here  and  there.  So  long  as  these  continue 
to  form  the  softening  spreads,  until  at  length  at  some  point  it  reaches  the  limit  of 
the  bone.  If  this  is  under  the  periosteum,  further  progress  is  often  barred  by  thick- 
ening and  condensation  and  the  formation  of  new  layers,  so  that  the  evacuation 
of  the  contents  is  checked.  If  it  is  near  the  articular  surface,  unfortunately  this 
cannot  take  place;  as  the  infection  spreads  the  cartilage  gradually  becomes  under- 
mined, until  it  is  detached  or  perforated  by  the  granulations,  and  the  tubercular 
material  spreads  at  once  over  the  synovial  cavity. 

When  the  compact  tissue  of  the  skull  or  of  the  other  flat  bones  is  involved, 
the  changes  are  essentially  the  same,  only,  as  might  be  expected  from  the  structure 
of  the  part,  necrosis  is  a  more  prominent  feature.  Sometimes  wedge-shaped  seques- 
tra are  found  in  the  articular  ends  of  the  long  bones,  and  it  has  been  suggested  that 
these  are  really  due  to  embolism,  the  bacilli  having  been  suddenly  distributed  over 
all  the  vessels  of  the  affected  region,  and  from  their  number  setting  up  such  an 
acute  attack  of  inflammation  as  to  cause  necrosis.  In  the  phalanges  and  metacarpal 
bones  (rarely  in  the  other  long  bones,  even  in  children)  the  disease  sometimes 
takes  the  form  of  expansion,  giving  rise  to  an  enlargement  a])parently  similar  to 
that  met  with  in  syphilis,  but  without  any  sclerosis ;  there  is  a  deposit  of  tubercle 
in  the  centre  of  the  bone,  spreading  into  the  interstitial  medulla  of  the  shaft,  and 
as  the  interior  becomes  hollowed  out,  layer  after  layer  of  vascular  new  tissue  is 
formed  under  the  periosteum,  until  at  length  the  size  of  the  part  is  more  than 
double  {spina  ventosa')  (Fig.  i88). 


TUBERCULAR   OSTEITIS. 


473 


Symptoms. — In  tubercular  osteitis  these  at  tlie  first  are 
very  vague  and  inclefinite.  If  the  hone  is  deeply  seated,  as,  for 
example,  the  body  of  a  vertebra,  pain  (often  referred  to  the  dis- 
tal end  of  the  spinal  nerves),  a  little  tenderness  on  pressure,  and 
a  peculiar  rigidity  of  the  muscles  around  the  part,  are  the  only 
signs,  until  the  loss  of  the  tissue  cau.ses  deformity.  When  it  is 
superficial,  the  diagnosis  is  more  easy  :  there  is  an  ill-defined  en- 
largement, due  at  first  to  thickening  of  the  soft  tissues  and  the 
periosteum,  later  to  the  expansion  of  the  bone  itself;  but  there 
is  very  little  pain,  even  at  night  ;  tenderness  on  pressure  is  very 
slightly  marked,  and,  unless  the  skin  is  involved,  there  is  no  rise 
of  temperature  i)erceptil)le  to  the  hand,  and  no  redness  or  pitting. 

Later,  as  the  inflammation  extends  to  the  neighboring  struc- 
tures and  the  area  of  softening  enlarges,  it  becomes  more  easy. 
Neighboring  joints  become  involved  ;  at  first  there  is  simply  an 
increa.se  in  the  synovial  effusion,  due  to  the  presence  of  a  focus  of 
inflammation  near,  but  later,  when  the  cartilage  is  perforated  by 
the  granulations,  tubercular  infection  takes  place,  and  thickening 
and  pulpy  degeneration  follow.  Characteristic  deformity,  short- 
ening of  the  phalanges,  for  example,  or  angular  curvature  of  the 
spine  makes  its  appearance,  and,  when  the  abscesses  break  or  are 
opened,  sinuses  are  left,  lined  with  tubercular  granulations  and 
leading  down  to  soft,  carious  bone,  into  which  the  blunt  end  of 
a  probe  sinks  with  ease. 

Diagnosis. — Tubercular  osteitis  is  met  with  in  adults,  and 
exceptionally  in  old  age;  but  it  is  by  far  the  most  common  in 
childhood  and  young  adult  life.  In  a  very  large  proportion  of 
cases  there  is  evidence,  either  of  the  presence  of  tubercle  else- 
where, or  of  a  distinct  constitutional  predisposition,  and  not  un- 
frequently  the  personal  appearance  is  characteristic.  So  far  as 
the  local  symptoms  are  concerned,  the  diagnosis  rests  chiefly  upon 
the  part  of  the  bone  involved  and  the  peculiarly  chronic  and  in- 
sidious character  of  the  inflammation.  The  difficulty  is  greatest 
in  the  strumous  dactylitis  of  children,  which  is  very  closely 
imitated  by  the  syphilitic  form.  In  the  later  stages  the  uniform 
character  of  the  swelling,  the  whiteness  of  the  skin,  except  at  the  actual  point  of 
suppuration,  the  soft,  doughy  sensation  when  it  is  pressed  upon,  the  presence  of 
caries,  and  the  thin,  oily  character  of  the  liquid  discharged  are  distinctive. 

The  prognosis  depends  partly  upon  the  constitutional  predisposition  of  the 
patient,  whether  the  taint  is  very  strongly  marked,  partly  upon  the  seat  and  in- 
tensity of  the  inflammation.  Where,  for  example,  there  is  a  possibility  of  com- 
plete local  removal  before  the  surrounding  structures  are  involved,  or  where  casea- 
tion and  liquefacation  are  delayed,  and  the  granulation-tissue  tends  rather  to 
organization,  there  is  much  better  hope  than  when  the  bodies  of  the  vertebrae  are 
concerned  and  when  the  bone  breaks  down  at  once.  Even  then,  however,  although 
the  destruction  may  be  very  extensive,  the  whole  of  the  tuberculous  mass  may  at 
length  dry  up  and  calcify  or  come  away ;  and,  as  the  patient's  health  improves, 
the  process  of  softening  and  decay  may  come  to  an  end,  and  give  way  to  sclerosis 
and  organization.  Bony  ankylosis,  for  example,  may  occur  in  the  spine,  even 
after  the  bodies  of  several  of  the  vertebrae  have  been  destroyed. 

In  a  very  large  proportion  of  cases,  the  period  of  quiescence  and  organization 
unfortunately  is  only  temporary.  For  the  moment,  under  the  influence  of  treat- 
ment, or  owing  to  the  patient's  vigor  of  resistance,  the  spread  of  the  tubercle  is 
arrested  and  active  repair  sets  in  ;  but,  unhappily,  there  is  always  the  danger  that, 
from  slight  local  injury  or  from  general  failure  of  health,  the  disease  will  beconie 
active  again  and  the  inflammation  commence  afresh. 

Treatment. — The  constitutional  treatment  is  the  same  as  that  required  in 
31 


IG.  188. — Radius  from 
a  Case  of  Tubercular 
Caries,  showing  what 
has  been  called  an 
inflammatory'  expan- 
sion of  bone,  or  spina 
ventosa. 


474    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

other  cases  of  tuberculosis.  Local  measures  must  be  guided  by  the  situation  and 
the  character  of  the  inflammation.  Rest  is  absolutely  essential.  The  amount  of 
blood  flowing  through  the  part  should  be  perfectly  uniform  ;  venous  congestion 
and  transient  hyperajmia  are  equally  injurious.  Cold  is  of  great  service,  not  only 
in  checking  the  inflammation,  but  in  arresting  the  growth  of  the  bacillus;  care, 
however,  must  be  taken  not  to  lower  the  vitality  of  the  tissues  too  much.  In  very 
chronic  cases  counter-irritants  may  be  used,  iodine,  blisters,  and  even  the  actual 
cautery,  but  not  on  the  distal  side  of  the  disease  or  immediately  over  it,  if  it  is 
superficial,  for  fear  of  lighting  up  fresh  mischief. 

If,  however,  the  disease  is  more  active  from  the  first,  or  if,  from  its  situation, 
there  is  reason  to  fear  its  extension  to  a  joint  or  to  some  other  important  structure, 
it  should,  if  accessible,  be  thoroughly  removed,  every  precaution  being  taken  to 
prevent  its  becoming  more  widely  disseminated  by  the  ojjeration.  The  limb  should 
be  raised  ;  Esmarch's  bandage  applied  to  control,  not  only  hemorrhage,  but  ab- 
sorption through  the  veins  ;  the  cavity  freely  opened  (as  far  as  possible  with  cut- 
ting instruments,  so  as  to  avoid  crushing  or  bruising)  and  thoroughly  evacuated. 
The  granulations  lining  it  and  the  soft,  carious  bone  around  it  should  then  be 
freely  cut  away,  and  the  wound  i)lugged  with  iodoform  gauze,  or  washed  out  with 
an  ethereal  solution  of  iodoform.  Afterward  it  must  be  kept  as  dry  as  possible  by 
a  proper  system  of  drainage,  and  every  precaution  taken  to  prevent  decomposition 
and  suppuration.  Carious  bones  in  which  sinuses  are  already  present  may  be 
tr£ated  in  the  same  way  if  they  show  no  inclination  to  get  well  with  milder 
nreasures.  The  os  calcis,  for  example,  may  be  entirely  scooped  out,  merely 
leaving  a  periosteal  shell,  with  an  excellent  result. 

Rickets  (Rhachiiis). 

Rickets  is  a  constitutional  disorder,  occurring  in  early  life,  and  characterized 
by  a  peculiar  condition  of  the  bones,  affecting  especially  their  epii)hysial  ends. 
Other  lesions  are  met  with  in  the  viscera  in  fatal  cases,  but  this  is  the  only  one 
that  is  universal  and  distinrti\e. 

Pathological  Appearances. — The  changes  are  most  marked  in  the  grow- 
ing portion  of  the  bones  ;  the  older  parts,  those  that  are  already  firm  and  well 
ossified,  are  but  little  affected  in  comparison,  although  there  is  in  them  a  diminu- 
tion of  the  earthy  salts  with  enlargement  of  the  medullary  spaces  and  Haversian 
canals. 

The  periosteum  everywhere  is  thickened,  .softened,  and  too  vascular  ;  it  strips 
away  too  easily  from  the  bone  l)eneath  ;  the  line  of  separation  between  the  deeper 
layer  (the  osteoid  tissue)  and  the  surface  of  the  shaft  is  ill  defined,  and  the  exterior 
of  the  latter  is  covered  with  laminje  of  soft,  porous  bone.  In  between  these,  sepa- 
rating them  from  each  other,  is  a  kind  of  fibrillated  medullary  substance  ;  some  of 
the  cavities  perhaps  are  formed  afresh,  but  others  are  due  to  absorption  of  the 
part  already  developed  and  the  enlargement  of  the  interstitial  medullary  spaces 
near  the  surface.  In  other  words,  the  circumference  of  the  bone  continues  to  en- 
large ;  the  quantity  of  soft,  organic  material  increases  (actually,  probably,  as  well 
as  relatively)  ;  the  amount  of  bone  developed  is  very  much  less,  and  what  there 
is,  is  deficient  in  lime  salts. 

Changes  of  a  similar  character  take  place  at  the  epiphysial  ends.  Normally, 
between  the  cartilage  and  bone,  there  is  a  narrow,  gra)ish,  semi-translucent  line, 
visible  to  the  naked  eye,  of  cartilage  that  has  undergone  the  transformation  pre- 
liminary to  the  development  of  bone.  In  rickets  this  layer  is  many  times  too 
thick,  and,  instead  of  being  sharply  and  clearly  defined  from  the  bone  already 
formed,  there  are  most  irregular  prolongations  of  it,  penetrating  deeply  here  and 
therebetween  the  growing  lamelhu  beneath  (Fig.  189).  The  microscoi)ic  anatomy 
shows  a  similar  change.  The  cartilage  cells  multiply  to  an  altogether  unusual 
extent  ;  the  primary  capsules  are  much  larger  than  normal  ;  and  the  calcification 
of  the  matrix  is  excessive.      Meanwhile,  the  soft  medullary  tissue  in  the  growing 


RICKETS. 


475 


bone  beneath  increases  greatly  in  amount  and  btcomes  finely  fibrillatcd.     The 
altered  cartilage  is  invaded  and  absorbed  ;   but  in- 
stead of   the  spaces  so   formed   being    lined    with 

laminae  of  new  bone,  until  the  central   hollow   is  if  li-if'-    '••^'jil^^ 

narrowed  down  to  a  Haversian  canal,  that  which  ■•IvM.U       ■fi^Vi'^' 

has  been  already  deposited   is  removed,  and   the  vl'  M'     ;  ^^ViSllf} 

trabecular  are  weakened  to  such  an  extent  that  the  of/i^l' ''  ''%xv'"^''.^: 

line  of  junction  becomes  soft  and  yielding.  ':'^'*l^/^  *H'>iH'.. 

The  effect  i)roduced  by  these  changes  is  easily  A' '*).'» >ii,i^<'''' 

imagined  ;   the  soft  tissue  at  the  epiphysial  ends  of  .■'*/'r.'Ji)t»  ~'fH!''\t\\' 

the  long  bones  yields  before  the  ]jressure  it  has  to 
sustain,  and  bulges  out  at  the  sides,  forming  the 
peculiar  tender  and  characteristic  enlargement  ; 
the  shafts  of  the  bones,  the  strength  of  which  is 
impaired  by  the  advancing  absorption,  give  way 
and  bend  at  their  weakest  i)art  ;  the  curves  that  are 
normally  present  become  exaggerated  ;  and  in  some 
cases  they  are  so  strongly  marked  that,  when  the 
bones  are  subcutaneous,  like  the  clavicle,  it  maybe  Fig.  i8c)-Section  through  Lower  End  of 

.^^        ,  1-      •  -11  r  •    1      /  Bone  affected  with  Rickets,  showing 

dlmcult    to    distinguish   them    from    greenstick    frac-  the   enormous  thickness  of  the  gelati- 

tures,  especially  as  the  tenderness  on  pressure  is  not  of°\he''iyne  ofossSor  '"'^"'"'"''y 
unfrequently  quite  as  great.- 

As  soon  as  the  morbid  process  comes  to  an  end  and  health  is  regained,  ossifi- 
cation sets  in  and  proceeds  at  an  unusually  rapid  rate.  The  compact  tissue  of  the 
shaft  becomes  peculiarly  dense  and  hard  ;  the  growing  layer  at  the  end,  where  it 
abuts  upon  the  epiphysis,  is  converted  into  bone,  so  that  development  is  stopped 
too  soon  :  and  the  osteoid  tissue  under  the  periosteum  undergoes  the  same  change 
so  far  as  the  concavity  of  the  curve  is  concerned.  On  the  convexity  it  is  absorbed 
and  disappears,  and  the  compact  layer  of  the  shaft  is  left  thinner  than  normal. 
This  change  is  produced  gradually,  and,  like  the  similar  ones  that  occur  in  con- 
nection with  badly  united  fractures,  is  the  result,  not  of  the  rickets,  but  of  the 
alteration  in  the  shape  of  the  bones.  The  concavity  is  strengthened  because  it  has 
to  sustain  the  weight  of  the  part  and  has  more  than  its  normal  share  of  work  ;  the 
convexity  becomes  thinner  for  the  opposite  reason. 

The  extent  to  which  the  various  bones  are  affected  depends  upon  the  age  and 
habits  of  the  child,  whether  it  is  unable  to  stand  or  whether  it  has  commenced  to 
walk.      Every  part  of  the  body  may  be  more  or  less  distorted. 

The  cranium  becomes  peculiarly  square  and  flat  on  the  top;  ossification  is 
delayed  along  the  sutures ;  the  anterior  fontanelle,  instead  of  closing  at  the 
twentieth  month,  remains  open  until  the  third  or  fourth  year  ;  and,  owing  to  their 
being  unable  to  resist  the  internal  pressure,  the  bones  separate  to  a  certain  extent 
from  each  other.  This  is  usually  associated  with  some  degree  of  chronic  hydro- 
cephalus. If  the  child  lies  upon  its  back  (and  very  often  the  same  position  is 
retained  for  hours  together,  owing  to  the  pain  caused  by  muscular  exertion)  the 
occipital  bone  becomes  flattened  and  in  places  absorbed  (cratiiotabes).  The  con- 
stant pressure  of  the  brain  causes  such  wasting  that  opposite  the  convolutions  the 
bone  completely  disappears  ;  the  dura  mater  comes  into  contact  with  the  peri- 
cranium ;  the  wall  of  the  skull  becomes  as  thin  as  parchment ;  and  especially  at 
the  sides  of  the  occipital  bone,  w^here  ossification  is  normally  later  than  elsewhere, 
firm  pressure  wdth  the  finger  makes  it  crackle  and  bend  in.  The  growth  of  the 
face  is  checked  :  in  many  instances  this  is  more  apparent  than  real,  owing  to  the 
way  in  which  it  is  overhung  by  the  forehead  ;  but  later  in  life,  at  puberty,  the 
arrest  of  development  cannot  be  mistaken.  The  temporary  teeth  are  always  cut 
very  late  ;  and  when  at  last  they  do  appear,  they  break  off  and  decay  in  a  very 
short  time.  In  certain  rare  cases  the  bones  of  the  skull,  in  particular  those  devel- 
oped in  membrane,  become  enormously  thickened,  soft,  and  porous ;  the  orbits 
are  partially  blocked  and  the  optic  nerves  atrophy ;   but  this,  though  common  in 


476    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


animals,  is  very  unusual  in  man.  and  is  so  different  that  by  many  it  is  not  consid- 
ered due  to  rickets. 

If  the  child  is  old  enough  to  sit  \\\),  the  vertebral  column  becomes  distorted 
and  bent.  The  head  is  usually  thrown  back,  so  that  the  sjjines  of  the  cervical 
vertebrae  are  deeply  sunken,  and  the  whole  of  the  dorso-lumbar  regions  form  one 
great  curve  with  its  convexity  backward.  As  a  rule,  this  extends  from  the  lower 
cervical  region  to  the  sacrum,  and  is  perfectly  uniform,  so  that  there  is  no  fear  of 
mistaking  it  for  the  angular  curvature  of  caries.  Sometimes,  however,  it  is  very 
shari)Iy  marked,  esi)ecially  in  the  lower  dorsal  region,  and  the  resemblance  then  is 
exceedingly  close,  especially  as,  at  the  same  time,  the  muscles  are  rigidly  con- 
tracted, owing  to  the  pain  that  movement  causes.  In  other  instances,  when  the 
disease  first  begins  at  a  later  period,  the  natural  curves  may  be  simply  exaggerated  ; 
or  lateral  curvature  with  rotation  of  the  bodies  may  come  on  and  end  in  the  most 
extreme  distortion. 

The  deformity  the  thorax  undergoes  {pigeon  breast)  is  characteristic.     The 

sternum  is  thrust  forward  by  the 
ribs,  partly  from  the  increased  cur- 
vature of  the  spine,  partly  from  the 
yielding  and  sinking  in  of  the  w-alls 
of  the  thorax  at  the  costo-chondral 
line.  The  chest  is  flattened  at  the 
sides  (less  so  on  the  right,  owing  to 
the  liver,  than  on  the  left)  ;  there 
is  an  abrupt  bending  inward  of  the 
ribs  near  their  junction  with  the 
cartilages,  leading  to  the  formation 
of  a  groove  on  the  antero-lateral 
wall  of  the  che.st,  from  the  third  rib 
downward  and  slightly  outward, 
and  at  the  lower  border  of  the 
sternum  this  becomes  continuous 
with  a  nearly  horizontal  constriction 
corresponding  to  the  attachment  of 
the  diaphragm.  In  addition,  the 
costochondral  line  is  marked  by  a 
series  of  enlargements  (the  so-called 
beading  of  the  ribs)  analogous  to 
the  thickening  and  softening  of  the 
epiphyses  on  the  ends  of  the  long 
bones.  Very  often  these  nodes  are 
so  distinct  upon  the  inner  surface 
as  to  form  distinct  imi^ressionsupon 
the  lungs  and  even  upon  the  liver. 
The  brim  of  the  pelvis  is  widened 
and  flattened  by  the  jiressure  of 
„  J         r  JTU-  r.  <•  „  jv  T3-  1  .     Tu    the  abdominal  organs  from  above  : 

Fics.  190  and  191. — Femur  and  1  ibia  Deformed  by  Rickets.   The  .  .0  ' 

bones  are  exceedingly  short  (premature  ossification  of  the  epi-  but    the     Cavity    is     verV'  mUCh    COn- 

physes),  the  natural  curves  are  much  exaggerated,  and  the  con-  .  .     j  it  \      \       •  1  1<a 

cavities  are  buttressed  up  with  masses  of  dense,  compact  bone,  traCteO,   and     at     pUuerty   IS     unaDlC 

arranged  along  the  lines  of  pressure.     This  is   best  seen  in  the  4-j-,     asSlUlie     characteristic     develOD- 
tibia,  for  the  linea  aspera  is  to  a  certain  extent  normal.  '    '  '  .  ,.      ^ 

ment.  The  antero-])osterior  diam- 
eter is  lessened  by  the  projection  of  the  sacro-vertebral  angle,  ami  the  acetabula 
and  the  ischial  tuberosities  are  pushed  in  from  the  sides,  until  it  is  forced  into  a 
trefoil  shape.  Occasionally  lamina  of  new,  soft,  porous  bone  are  formed  upon  the 
surface  similar  to  those  under  the  j^eriosteum  of  the  scapulae  and  the  long  bones. 
Of  all  the  long  bones,  the  tibiae  are  the  ones  that  suffer  most  conspicuously. 
The  curve  is  generally  most  marked  at  the  junction  of  the  middle  and  lower  third  ; 
sometimes  it  is  very  sharp  and  strictly  antero-posterior,  the  bone  being  flattened 


RICKETS.  47  7 

from  side  to  side  until  it  is  scarcely  so  wide  across  as  the  fibula  ;  in  other  cases  it 
is  bent  inward  or  outward  as  well,  and  overhangs  the  foot,  the  difference  depend- 
ing, in  all  probability,  upon  the  age  of  the  child,  whether  it  is  old  enough  to  walk 
about  of  itself  or  is  carried  constantly  upon  its  back  (Figs.  190  and  191).  The 
femur  is  always  bent  forward  ;  the  head  is  usually  sunken,  so  that  it  is  much  below 
the  level  of  the  trochanter,  and  the  linea  aspera  is  exaggerated  into  a  great  buttress 
of  bone  toward  which  all  the  pressure  lines  converge.  In  the  upper  extremity, 
the  amount  of  distortion  is  rarely  so  great ;  but  the  clavicles  are  sometimes  very 
sharply  bent,  and  the  humerus  and  radius  may  be  considerably  bowed,  especially 
when  the  child  is  in  the  habit  of  propping  itself  up  upon  its  hands.  In  other  ca.ses 
-there  is  little  deformity  of  the  shaft,  owing  to  the  fact  that  it  carries  no  weight ; 
but  the  lower  ej^iphysis  of  the  radius,  no  matter  how  slight  the  attack,  rarely  fails 
to  show  a  certain  degree  of  thickening. 

The  other  pathological  changes  met  with  in  rickets  are  less  constant,  but  they 
are  much  more  frequently  the  cause  of  death.  Bronchitis  and  broncho-pneumonia 
with  collapse  of  the  lung  are  rarely  altogether  absent  in  fatal  cases.  There  is 
usually  evidence  of  gastro-intestinal  catarrh,  and  the  solitary  glands  and  Peyer's 
patches  are  often  unduly  conspicuous.  The  liver  is  enlarged  and  very  frequently 
fatty,  often  showing  the  marks  caused  by  the  ribs.  The  spleen  is  generally 
increased  in  size  and  is  tougher  and  more  dense  than  natural.  The  muscular 
system  is  ill-developed  ;  the  ligaments,  especially  in  the  latter  stages,  are  lax  and 
yielding,  so  that  not  unfrequently  they  become  much  too  long  ;  and,  in  short,  there 
is  evidence  of  general  malnutrition  affecting  the  whole  body,  though  it  only  pro- 
duces characteristic  changes  in  the  bones. 

Causes. — Rickets  may  be  caused  by  anything  that  impairs  nutrition  ;  it  is 
possible  that  an  excess  of  starchy  food  at  a  period  of  life  when  it  cannot  be  assim- 
ilated is  one  of  the  most  potent  factors  ;  but  it  is  certainly  not  the  only  cause,  and 
in  no  sense  is  it  to  be  regarded  as  a  specific  one. 

Weakly  parents,  in  whatever  station  of  life  they  may  be,  and  whatever  the 
cause,  produce  feeble  children  ;  and  these,  as  they  are  almost  always  exposed  to 
the  same  injurious  conditions,  become  rickety.  Distinct  evidence  of  rickets  (not 
foetal  rickets,  which  is  probably  entirely  different)  has  been  found  in  the  foetus 
and  is  not  uncommon  within  a  few  weeks  of  birth,  at  a  time  when  the  ordinarily 
assigned  causes,  improper  food,  want  of  air  and  light,  etc.,  can  hardly  have  pro- 
duced any  effect.  In  the  lower  clas.ses,  frequent  pregnancies  and  prolonged  lacta- 
tion, combined  with  the  greater  difficulty  of  obtaining  proper  food  for  a  larger 
number,  often  reduce  the  health  of  the  mother,  so  that  the  later  children  show 
definite  evidence  of  rickets,  while  the  earlier  ones  escape. 

Artificial  feeding,  unless  it  is  carried  out  with  the  greatest  care  and  with 
especial  regard  to  a  child's  requirements,  will  always  cause  it ;  and  for  this  reason, 
among  others,  it  is  met  with  in  all  classes  of  life.  It  may,  however,  occur  in 
infants  at  the  breast  when  the  milk  is  insufficient  in  quantity  or  quality  ;  and  it  is 
practically  certain  if  the  child  is  suckled  for  too  long  a  time. 

Bad  ventilation,  want  of  fresh  air  and  .sunlight,  overcrowded  rooms,  and 
neglect  of  ordinary  hygienic  conditions  greatly  favor  its  occurrence,  not  only  by 
the  direct  effect  upon  the  child,  but  by  the  way  in  which  the  health  and  strength 
of  the  patient  become  deteriorated.  For  this  reason,  it  is  much  more  common  in 
towns  where  there  is  overcrowding  than  in  the  country.  Syphilis,  tubercle,  and 
others  disorders  are  very  commonly  associated  with  it ;  and  they  must  be  regarded 
as  predisposing  causes  from  the  influence  they  have  upon  the  health  of  the  parent 
as  well  as  upon  that  of  the  child.  Rickets  is  not,  however,  in  any  sense  of  the 
term,  directly  produced  by  them. 

Symptoms. — Rickets  may  be  present  before  birth  ;  craniotabes  (occurring 
then  on  the  inner  side  of  the  vertex  of  the  skull  owing  to  the  position  of  the 
foetus)  and  acute  bending  of  the  bones  (infractions)  have  been  found  on  many 
occasions  ;  within  the  first  {^w  months  of  life  beading  of  the  ribs  is  quite  common  ; 
after  two  years  old  it  is  rare  for  the  disease  to  begin,  though  exceptional  cases  have 


478     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES, 

been  met  witli  as  late  as  eight  or  ten.  Sometimes,  hut  hy  no  means  always,  the 
chiKlrcn  are  miserable,  wasted,  and  puny  ;  in  many  instances  there  is  nothing 
remarkable  about  their  appearance  ;  and  occasionally  it  occurs  in  those  that  are 
apparently  well  fed,  with  plump,  rounded  limbs,  of  unusual  size  and  weight  for 
their  age. 

Sometimes  it  commences  acutely ;  suddenly,  almost  from  one  day  to 
another,  the  bones  become  tender,  the  contraction  of  the  muscles  exceedingly 
])ainful,  and  the  child  lies  perfectly  still  on  its  back,  afraid  to  move  on  account  of 
the  ])ain,  and  crying  as  soon  as  any  one  comes  near.  Occasionally  the  inability 
is  so  marked  that  such  cases  have  been  mistaken  for  general  infantile  j)aralysis. 
Much  more  commonly  the  onset  is  so  insidious  that  it  is  impossible  to  assign  even 
an  ai)proximate  time.  Profuse  persjjiration  about  the  head,  and  throwing  off  the 
bed-clothes  jjersistently  at  night ;  a  rather  large,  square-shajjed  head  ;  delay  in  den- 
tition or  inclosure  of  the  anterior  fontanelle ;  a  prominent  abdomen,  with  occa- 
sionally diarrhoea  and  very  offensive  motions,  are  all  present  in  the  early  stages  of 
rickets,  and  should  always,  especially  when  they  occur  together,  excite  grave  sus- 
picion ;  but  they  are  not  uncommon  in  perfectly  healthy,  well-fed  children,  who 
neither  then  nor  afterward  show  any  sign  of  the  affection. 

Enlargement  of  the  epiphyses,  especially  of  the  wrist  and  ankle,  beading  of 
the  ribs,  and  craniotabes  may  be  regarded  as  definite  signs.  The  child,  to  use  the 
popular  expression,  is  taken  off  its  legs  ;  it  loses  its  liveliness,  becomes  ])eevish 
and  fretful,  and  is  only  too  happy  if  it  is  left  alone ;  movement  is  attended  with 
pain,  the  muscles  become  soft  and  flabby,  the  ligaments  loose  and  yielding  (double 
jointed),  and  if  the  back  is  involved,  even  the  power  of  sitting  up  may  be  lost. 
Bending  of  the  bones  and  deformity  then  begin  to  make  their  appearance  ;  owing 
to  the  respiratory  movements  the  thorax  always  suffers  and  becomes  i)igeon- 
breasted  ;  and  later,  according  to  the  age  and  habits  of  the  child,  the  long  bones 
of  the  limbs  become  affected. 

Bronchitis,  with  collapse  of  the  lung  and  broncho-pneumonia,  is  of  common 
occurrence  and  may  prove  fatal  ;  gastro-intestinal  catarrh  and  diarrhfjca  are  very 
often  present,  not  unfrequently  assisting  as  a  cause  ;  and  according  to  Parker,  no 
less  than  two-thirds  of  all  the  convulsive  attacks  to  which  children  are  liable 
(laryngismus  stridulus,  carpopedal  contractions,  tetany,  strabismus,  etc.)^redue  to 
or  associated  with  rickets.  Flat-foot,  knock-knee,  and  lateral  curvature  of  the 
spine,  all  of  which  are  the  outcome  of  weakness  of  the  muscles  and  ligaments, 
usually,  when  the  result  of  rickets,  make  their  appearance  at  a  later  date. 

Prognosis. — Except  in  acute  rickets,  which  is  not  unfrequently  fatal,  the 
prognosis  is,  generally  speaking,  good.  Bronchitis,  convulsions,  and  diarrhoea 
must,  however,  always  be  regarded  as  very  serious.  In  the  vast  majority  of  cases, 
although  the  growth  of  the  bones  is  very  liable  to  be  checked,  the  deformity  prac- 
tically disai)i)ears,  e.xcept  so  far  as  the  thorax  and  skull  are  concerned  ;  the  pigeon- 
chest  and  the  peculiar  square-.shaped  cranium,  if  once  thoroughly  developed, 
persist  through  life.  Probably  the  same  is  true,  though  perhaps  not  to  the  same 
extent,  of  the  pelvis.  In  a  few  cases  the  bones  never  regain  their  normal  outline  ; 
the  neck  of  the  femur  is  horizontal,  and  the  shaft  and  that  of  the  tibia  arel)owed  ; 
and  in  these  the  diminution  of  height,  from  premature  ossification  of  the  growing 
line,  is  always  very  distinct. 

Treatment. — In  most  little  more  is  required  than  careful  attention  to  diet 
and  the  general  princijiles  of  hygiene.  In  this  respect  the  mother's  health  is  of 
scarcely  less  imjjortance  than  the  child's.  Cod-liver  oil  acts  as  a  specific,  and 
there  are  very  few  children,  especially  rickety  ones,  who  cannot  l)e  induced  to 
take  it,  or  who  do  not  even  become  fond  of  it.  It  should  be  given  after  food,  and 
in  small  doses  several  times  a  day  ;  large  ones  are  more  liable  to  create  repugnance 
and  may  disagree.  Iron  is  especially  indicated  where  there  is  much  anaemia. 
Lime,  in  the  form  of  lime-water,  is  a  necessary  addition  to  the  milk  of  most  large 
towns,  but  by  itself  it  has  no  power  over  rickets.  The  lactophosphate  of  iron 
and  such  preparations  as  Parrish's  food  are  more  valuable. 


ACUTE  RICKETS.  479 

The  diet  must  be  as  nutritious  as  possible,  l)ut  at  the  same  time  well  diluted, 
or  It  may  create  indi|^^estion  and  do  more  harm  than  good.  For  young  infants, 
cow's  milk,  diluted  according  to  the  age,  with  milk  sugar,  and  perhaps  a  few  drops 
of  some  i)ancreatic  i)reparation  added,  is  most  suitable.  For  older  ones,  some  of 
the  artificial  foods,  the  yolk  of  an  egg.  or,  if  the  symptoms  are  very  severe,  a  little 
raw  jjoumled  meat,  may  be  given  ;  but  even  in  them  the  chief  reliance  must  l)e 
placed  upon  thoroughly  good  milk,  in  sufficient  quantity,  and  cod-liver  oil.  A 
certain  amount  of  fresh  fruit  occasionally  (the  juice  of  an  orange,  baked  apples, 
or  well-cooked  i)otatoes)  is  of  value,  not  only  by  assisting  digestion,  but  by  giving 
variety  and  checking  any  scorbutic  tendency. 

Fresh  air,  light,  friction  at  night  with  oil  and  bathing  (with  sea  salt  if  it  can 
be  procured)  are  almost  as  essential.  The  body  should  be  kept  warm,  without 
being  overclad  ;  and  especial  attention  should  be  paid  to  this  at  night,  for  fear  of 
chills.  Slight  degrees  of  deformity  may  be  trusted  to  get  well  of  themselves;  for 
them  splints  are  of  very  questionable  value  ;  put  on  in  whatever  fashion  they  may 
be,  they  never  can  prevent  an  active  child,  conscious  of  recovering  its  strength, 
crawling  about  and  propping  itself  up.  In  severer  cases  it  is  a  different  matter ; 
in  these  they  may  be  of  service,  not  to  put  pressure  on  the  limbs  (this  is  only 
possible  in  cases  of  lateral  bending,  and  even  then  very  little  can  be  done,  owing 
to  the  delicacy  of  an  infant's  skin),  but  to  keep  the  child  quiet;  and  they  should 
be  suitably  contrived  for  this.  Bad  cases  of  knock-knee,  for  exami)le,  may  be 
placed  in  a  box-splint  with  weight  extension  ;  but  the  apparatus  must  be  removed 
at  frequent  intervals,  that  the  limbs  may  be  thoroughly  rubbed  and  washed  and 
the  circulation  through  them  encouraged.  It  is  extraordinary  the  effect  that  sim- 
ple rest  in  bed,  combined,  of  course,  with  food,  fresh  air,  cod-liver  oil,  rubbing 
and  sea  bathing,  has  upon  the  deformity  of  an  infant's  limbs.  The  health  does 
not  suffer  in  the  lea.st  from  the  confinement  ;  the  muscles  do  not  waste  ;  the 
strength,  instead  of  being  impaired,  seems  to  increase  at  an  unusually  rapid  rate  ; 
and  the  weight  being  taken  off  the  limbs,  the  bones  and  joints  begin  to  straighten 
themselves  out  at  once.  Even  in  advanced  cases,  in  which  the  thickening  of  the 
epiphysis  and  the  beading  of  the  ribs  are  less  prominent  than  they  were,  the  same 
may  be  tried  with  benefit  for  a  time  ;  if,  however,  the  bones  are  definitely  set  and 
the  sclerosing  process  is  complete,  it  is  rarely  possible  to  correct  the  deformity 
without  an  operation. 

Acute  Rickets. 

Under  this  name  a  class  of  cases  has  been  described  by  Barlow  and  others 
differing  from  ordinary  rickets  in  several  particulars,  and  probably  associated  with 
scurvy.  It  only  occurs  in  artifically  fed  children,  generally  in  the  course  of  the 
second  year  ;  and  it  is  characterized  by  the  presence  of  extensive  sub-periosteal 
hemorrhages,  particularly  on  the  femur,  but  involving  other  bones  as  well,  even 
the  beads  upon  the  ribs.  Later,  when  the  acute  stage  is  passed,  the  bones  become 
enormously  thickened,  in  all  probability  from  the  formation  of  a  new  periosteal 
shell  around  the  extravasation.  In  some  cases  purpuric  patches  have  been  noted 
upon  the  skin  ;  in  others  there  were  ecchymoses  under  the  conjunctiva  or  in  the 
eyelids ;  and  in  one  the  whole  intestinal  tract  showed  deep  purple  stains  under  the 
peritoneum,  due  to  extravasation  into  the  solitary  glands  and  the  adenoid  tissue  of 
the  mucous  coat. 

The  symptoms  are  very  much  more  severe  ;  in  some  cases  they  appear  sud- 
denly, in  others  they  supervene  upon  the  ordinary  ones.  The  child  is  completely 
taken  off  its  legs  and  lies  flat  upon  its  back,  with  the  lower  limbs  slightly  flexed 
and  everted,  utterly  unable  to  move  them  (pseudo-paralysis).  The  pain  is  ex- 
treme ;  the  thighs,  which  are  usually  the  most  affected,  are  swollen,  tense,  and 
shining ;  the  skin  is  pale,  but  often  warmer  than  natural,  and  the  tenderness  is  so 
great  that  the  child  begins  to  scream  as  soon  as  any  one  approaches.  The  femur 
feels  immensely  thickened,  and  later,  when  the  surrounding  swelling  has  subsided, 
and  the  muscles  are  wasted,  a  dense  solid  casing  can  be  made  out  around  the  bone, 


48o    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

either  extending  over  its  whole  length  or  chiefly  localized  at  the  junction  of  the 
epiphysis  with  the  shaft.  Soft  crepitus  can  often  be  felt  at  the  same  time,  as  if  the 
epiphysis  was  detached.  The  legs  may  be  affected  as  well,  and  even  the  bones  of 
the  upper  extremity,  but  rarely  so  badly.  Before  the  disease  commences  there  is 
usually  very  great  fretfulness  ;  the  an?emia  is  extreme  ;  the  muscles  waste  ;  the  gums 
are  swollen  and  spongy  in  a  large  proi)ortion  of  cases,  especially  around  any  teeth 
that  are  newly  cut  ;  there  is  a  putritl  odor  about  the  mouth  ;  and  not  unfrequently 
marks  of  bruising  can  be  seen  on  the  body. 

The  prognosis  of  these  cases  is  exceedingly  grave  ;  the  same  treatment  must 
be  carried  out,  the  limits  being  protected  from  pressure  and  injury  as  far  as  possi- 
ble. In  one  instance  an  excellent  result  was  obtained  by  cutting  freely  down  on 
to  the  bone,  removing  the  blood-clot,  and  draining  the  cavity.  It  does  not  appear 
to  have  been  followed  \)\  further  hemorrhage. 


Osteitis  Deptjrmans. 

This  name  was  given  by  Paget  to  an  affection  in  which  certain  of  the  bones  of 
the  skeleton  successively  undergo  a  peculiar  form  of  enlargement.  It  may  com- 
mence in  one,  generally  the  tibia,  or  in  several ;  as  a 
rule,  it  progresses  slowly  but  steadily  until  all  are  more 
or  less  involved,  the  bones  of  the  face  and  the  hands 
and  the  feet  being  the  latest.  It  is  much  more  common 
in  men  than  women  ;  rarely  begins  before  late  in 
adult  life  ;  and  may  be  symmetrical,  though  this  is 
seldom  exact.  Respiration  and  locomotion  are  in- 
terfered with  to  a  certain  extent ;  the  former  by  the 
changes  in  the  spine  and  the  thorax,  the  latter  by  the 
size  and  weight  of  the  bones  ;  so  that  the  health  fre- 


FiG.  192.— Section  through  Frontal  Region  of  Skull  from  a  Case  of  Osteiti; 
Deformans. 


quently  suffers,  and  patients  have  the  aspect  and  atti- 
tude of  extreme  old  age  ;  but  unless  secondary 
complications  occur  it  does  not  appear  in  any  way 
to  shorten  life.  In  three  out  of  the  first  five  cases 
described  by  Paget,  malignant  disease  of  some  type 
set  in ;  and  this  has  been  observed  by  others, 
though  not  to  the  same  extent.  Whether  there  is 
any  connection  is  doubtful  ;  sarcoma  and  carcinoma 
have  both  been  met  with,  sometimes  involving  the 
bones  themselves,  sometimes  attacking  other  parts 
of  the  body  altogether. 


Fig.  193. —  Ketiuir  from  a  Similar 
Case. 


OSTEITIS  DEFORMANS. 


48 1 


The  vault  of  the  skull  becomes  enormously  thickened,  and  at  the  same  time 
uniform  in  character,  the  diploe  disappearing  completely  (Fig.  192).  The 
long  bones  increase  in  all  their  dimensions  (Fig.  193)  ;  they  become  longer, 
thicker,  and  more  irregular  on  the  surface  ;  at  the  same  time  they  bend,  and 
the  curve  involves  the  whole  of  the  shaft,  not  as  in  rickets,  the  weakest  part 
only.  The  spine  sinks  down  in  a  most  peculiar  way,  the  head  falling  forward, 
and  the  back  and  loins  forming  one  long,  uniform  curve,  with  the  convexity  back- 
ward. The  thorax  becomes  rigid  and  distorted,  so  that  the  chest  appears  pecu- 
liarly short  and  narrow  ;  and  the  pelvis  widens  out  from  side  to  side  and  diminishes 
from  above  downward. 

The  structure  of  the  bone  is  at  the  same  time  profoundly  chajiged.  At  first 
there  must  be  a  certain  degree  of  softening  to  account  for  the  alteration  in  shape  ; 
but  this  condition  has  not  yet  been  identified.  The  compact  tissue  of  the  .shaft 
and  at  the  ends  is  especially  affected  and  is  replaced  almost  altogether  by  irregularly 
developed  cancellous  substance.  The  medullary  canal  is  filled  u])  more  or  less, 
and  the  periosteal  surface  is  roughened  and  irregular. 

The  microscopic  appearances  are  practically  the  same  as  in  rarefying  osteitis. 
The  Haversian  canals  are  enlarged  and  their  walls  eaten  out  with  Howship's 
lacunar  ;  the  innermost  layer  is  soft,  staining  readily  with  logwood,  and  the  me- 
dulla inside  resembles  that  found  generally  in  inflamed  bone,  only  it  is  more  fibrillar 
and  less  rich  in  cells.  The  bone-corpuscles  are  irregular  in  their  distribution  ;  the 
lacunae  small,  shrunken,  and  provided  with  but  few  processes;  and  the  concen- 
tric lamellae  exceedingly  uneven  in  their  arrangement ;  but  there  is  nothing  in  any 
way  distinctive  and  there  is  no  change  in  chemical  constitution.  Here  and  there 
evidence  of  formative  osteitis  may  be  found,  in  the  shape  of  greatly  reduced 
Haversian  systems.  Sometimes  it  is  associated  with  rheumatoid  arthritis  round  the 
joint  ends,  but  it  does  not  appear  to  be  connected  with  it.  Bones  in  this  condi- 
tion have  been  known  to  break  and  to  unite  again  without  difficulty.  No  visceral 
lesions  of  any  kind  have  been  found,  and  there  is  no  alteration  in  the  urine. 

Cause. — Nothing  is  known  with  regard  to  the  cause  of  this  complaint.  It 
appears  to  be  much  more  common  in  England,  especially  in  London,  than  else- 
where, but  in  all  probability  this  is  accidental.  Gout  has  been  found  to  exist  in 
some,  but  by  no  means  a  large  proportion.  In  one  or  two  instances  it  has  appar- 
ently originated  from  injury  ;  in  others  it  has  been  associated  with  exposure  to 
cold  and  damp.  Certainly  it  is  more  common  in  infirmaries  than  is  generally 
believed.  It  is  peculiar  that  such  a  large  proportion  of  the  earlier  cases  should 
have  ended  in  malignant  disease; 
but  as  there  was  no  uniformity 
as  to  the  kind  or  even  situation, 
this  must  probably  be  regarded 
as  an  accidental  complication. 

Hutchinson  regards  it  as  an 
infective  osteitis  excited  by  in- 
jury. It  is  distinctly  inflam- 
matory, usually  originates  in 
one  bone,  is  not  exactly  sym- 
metrical, and,  what  is  especially 
important,  becomes  more  rapid 
and  involves  other  bones  more 
extensively  in  proportion  to  its 
duration.  At  first  the  onset  is 
slow,  the  changes  very  gradual, 
and  the  number  of  bones  at- 
tacked few ;  later  it  spreads 
much  more  rapidly.  For  pur- 
poses of  illustration,  Hutchinson 

•  .1        ^1  J-  Fig.  T04. — Attitude  of  a  Man  Suffering  from  Osteitis  Deformans 

compares    it    \\\X\\    the   disease  ^  (Bryant;. 


482    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

known  as  granuloma  fungoides.  'I'his  l)egins  as  one  isolated  patch  ;  progresses 
slowly  at  first ;  after  a  time  leads  to  the  production  of  others,  and  finally  becomes 
malignant.  It  has  been  suggested  on  the  analogy  of  acute  multiple  periostitis,  in 
which  secondary  abscesses  form  one  after  the  other  on  distant  bones,  that 
the  products  of  inflammation  of  any  tissue  are,  when  circulating  in  the  blood, 
infective  to  that  tissue  throughout  the  body  ;  and  the  greater  the  number  of 
centres  for  infection  the  more  rapid  the  spread  and  the  greater  the  risk  of 
contamination. 

Symptoms. — At  first  these  are  very  obscure.  Vague  pains  are  com])lained 
of  in  one  of  the  bones,  not  especially  nocturnal  or  periodic  in  character,  but  some- 
times in  the  eajly  stages  rather  severe.  The  head  is  never  affected  by  them  ;  it 
simply  increases  in  size,  so  that  a  larger  and  larger  hat  becomes  necessary  each 
year,  without  anything  else  being  noticed.  Then  a  certain  degree  of  enlargement, 
generally  a  bowing  forward  of  the  tibia,  is  detected,  and  after  jierhaps  an  interval 
of  years,  one  bone  after  another  becomes  involved,  until  the  whole  skeleton  is 
distorted. 

In  advanced  cases  the  attitude  and  aspect  are  characteristic  (Fig.  194).  The 
skull  is  massive  and  of  enormous  size,  the  head  is  carried  forward  and  lowered 
until  the  chin  is  an  inch  or  more  below  the  top  of  the  sternum.  The  neck  is 
shortened,  rigid,  and  bent  forward,  so  that  it  is  impossible  for  the  patient  to  look 
up.  The  diminution  of  height  is  most  striking  ;  the  whole  spine  is  sunken  and 
bowed,  and  even  six  inches  may  be  lost.  The  shoulders  are  raised  and  very 
round  ;  the  arms  appear  of  immense  and  dispro]}ortionate  length,  so  that  the  hands 
reach  below  the  knees.  The  chest  is  short  and  narrow,  the  abdomen  broad  and 
protuberant ;  and  respiration  entirely  diaphragmatic  ;  or  if  a  deep  breath  is  taken, 
the  whole  of  the  upper  part  of  the  trunk  is  raised.  The  lower  limbs  are  strangely 
thickened,  curved  outward,  and  held  apart,  one  usually  a  little  in  front  of  the 
other ;  the  toes  are  turned  out,  the  ankles  overhung  by  the  legs,  and  the  gait  slow 
and  awkward. 

Diagnosis. — In  the  early  stage  the  symptoms  very  closely  resemble  those  of 
rheumatic  osteitis,  but  the  pain  is  rarely  so  severe  ;  afterward  the  deformity  is  char- 
acteristic. Enlargement  of  the  bones,  sometimes  attended  with  l:)owing  (esi)ecially 
in  the  leg),  is  met  with  under  other  conditions,  but  the  diagnosis  is  rarely  difficult. 
Simple  hypertrophy,  for  example,  without  alteration  in  jirojiortion,  is  not  uncon- 
mon  in  the  young,  arising  from  overuse  or  from  lymphatic  obstruction  ;  and  great 
overgrowth  may  occur  in  inflammation  dependent  upon  necrosis,  syi)hilis,  etc.  ; 
but  the  structural  changes  in  the  bones,  the  conditions  under  which  they  occur, 
and  the  course  they  pursue  are  entirely  different. 

In  osteomalacia  the  skull  sometimes  becomes  increased  in  size,  but  it  is  brittle, 
soft,  and  light,  with  abundance  of  medullary  substance.  A  similar  condition  has 
been  met  with  in  rickets,  very  rarely  in  man,  commonly  in  animals  HJland  Sutton). 
The  bone  is  described  as  l)ecoming  enormously  thickened,  but  it  is  light,  almost 
friable,  and  not  porous  on  the  surface  ;  when  touched  it  feels  like  fine  cloth  or  felt. 
The  membrane  bones  in  particular  are  affected,  and  the  change  is  not  limited  to 
the  skull,  but  extends  to  the  face,  leading  to  closing  of  the  orbits,  filling  up  of  the 
antrum,  and  atrophy  of  the  optic  nerves  from  pressure  in  the  optic  foramina.  In 
leontiasis  ossea,  the  growth,  which  usually  involves  the  jaws  as  much  as  or  more 
than  any  other  bone  in  the  head,  is  more  irregular,  and  partakes  rather  of  the 
character  of  exostosis  than  of  simple  enlargement. 

So  far  as  treatment  is  concerned  nothing  that  is  yet  known  ap])ears  to 
have  the  least  effect.  Iodide  of  potash  is  entirely  useless,  even  for  relieving 
pain  ;  fortunately  this  is  rarely  severe,  and  the  disease  does  not  appear  to 
shorten  life. 


OSTE  OMALA  CIA .  483 

Osteomalacia — Mollitif.s  Ossium. 

This  is  a  disease  of  adult  life,  in  which  the  bones  become  softened  to  such  an 
extent  that  they  may  be  bent  in  almost  any  direction.  It  is  very  much  more  com- 
mon in  women  than  in  men,  and  appears  in  many  instances  to  be  associated  with 
child-bearing,  esi)ecially  with  frequent  pregnancies.  Often  it  commences  during 
the  course  of  one  of  them,  or  shortly  after  childbirth  ;  and  when  it  occurs  under 
these  conditions  it  nearly  always  attacks  the  bones  of  the  pelvis  and  the  lower 
part  of  the  spine.  Ihider  other  circumstances  the  lower  extremities  are  usually 
the  first  to  suffer;  and  occasionally  it  remains  limited  to  them.  In  most  it  in- 
volves one  part  after  another  ;  the  jjatient  becomes  absolutely  helpless  ;  the  cra- 
nium is  thickened  ;  infractions  of  the  ribs  and  the  bones  of  the  extremities  occur  ; 
and  the  walls  of  the  thorax  are  softened  to  such  an  extent  that  respiration  can 
hardly  be  carried  out 

Osteomalacia  is  apparently  an  affection  of  the  medulla  occupying  the  central 
space  and  the  Haversian  canals.  It  seems  at  first  to  be  converted  into  a  small 
round-celled  growth,  so  vascular  that  hemorrhages  take  place  in  it  everywhere. 
The  bone  in  contact  with  it  is  softened  and  removed  ;  the  earthy  matter  disappears  ; 
the  organic  matrix  is  left  with  only  a  faint  indication  of  lacunar  orcanaliculi  ;  and 
this  in  its  turn  undergoes  a  kind  of  gelatinous  transformation  until  there  is  nothing 
but  a  soft,  thin  shell  under  the  periosteum,  filled  with  a  pulpy  substance  incai)able 
of  the  least  resistance.  Sometimes  this  is  so  mixed  with  blood  that  it  forms  a 
reddish-brown  semi-solid  mass,  resembling  the  substance  of  the  spleen  ;  in  the 
later  stages  it  undergoes  fatty  degeneration  and  becomes  converted  into  a  pale 
yellow  gelatinous  material  containing  large  quantities  of  serum. 

Nothing  is  known  with  regard  to  the  cause  ;  it  appears  to  be  endemic  in  cer- 
tain localities,  but  sporadic  cases,  especially  those  affecting  the  pelvis,  occur  every- 
where. Great  general  nervous  depression  is  stated  to  have  been  present  in  a  large 
proportion  before  the  softening  showed  itself.  No  certain  visceral  lesions  have 
been  found,  and  with  the  exception  of  the  urine,  which  at  certain  periods  of  the 
disease  is  loaded  with  lime  salts,  even  forming  calculi,  there  are  no  symptoms  other 
than  those  that  result  from  the  softening  of  the  skeleton  and  the  consequent 
deformity. 

Deep-seated  aching  pains,  not  unlike  those  due  to  rheumatism,  are  usually 
present,  and  as  a  rule  are  worse  at  night  and  after  exercise.  At  the  same  time 
there  is  a  sense  of  weakness  and  of  inability  to  make  any  exertion  ;  standing  par- 
ticularly is  attended  with  pain  ;  but  there  is  nothing  definite  and  no  diagnosis  is 
possible  until  some  alteration  in  shape  is  detected.  The  particular  kind  of  defor- 
mity depends  upon  the  circumstances  of  the  case  ;  the  sides  of  the  pelvis  and  the 
promontory  of  the  sacrum  may  be  crushed  together  until  the  cavity  is  almost 
obliterated  ;  the  spine  may  be  bent  almost  double  ;  the  ribs  and  the  walls  of  the 
thorax  driven,  and  perhaps  broken  in,  until  the  arms  lie  in  two  great  hollows  ;  or 
the  bones  of  the  extremity  softened  to  such  an  extent  that  they  can  be  made  to 
assume  any  direction  with  the  least  pressure. 

The  disease  does  not  appear  to  shorten  life,  except  by  the  complications  it 
causes.  In  a  large  proportion  of  cases  death  has  occurred  in  connection  with 
parturition  ;  occasionally,  when  the  skull  has  been  involved,  cerebral  symptoms 
have  set  in  ;  more  frequently,  owing  to  changes  in  the  spine  and  ribs,  respiration 
has  gradually  become  more  and  more  difficult,  until  at  last  hypostatic  congestion 
and  pneumonia  have  followed,  and  in  a  few  paraplegia  has  occurred.  If  no  com- 
plication of  this  kind  makes  its  appearance  the  health  gradually  becomes  more  and 
more  impaired  from  confinement  and  interference  with  digestion  and  the  other 
functions  of  the  body,  until  at  length  the  patient  sinks  from  exhaustion.  Occa- 
sionally the  disease  remains  stationary  for  a  long  time,  and  some  instances  of 
recovery,  especially  when  it  has  been  limited  to  the  pelvis,  are  known  ;  but  no 
treatment  appears  to  have  any  effect  upon  it.  Recently,  however,  a  case  has  been 
reported  in  which  the  symptoms  disappeared  after  the  ovaries  had  been  removed. 


484    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

A  few  cases  are  recorded  in  which  osteomalacia  has  occurred  in  childhood 
(Davies  Colley)  and  in  infants  (Rehn).  The  diagnosis  from  rickets  is  in  such 
circumstances  exceedingly  difficult  ;  and  this  has  led  some  to  the  opinion  that  the 
two  diseases  are  essentially  the  same,  occurring  under  different  conditions.  In 
osteomalacia,  however,  there  is  no  enlargement  of  the  epiphyses  or  periosteal 
thickening,  as  in  rickets ;  and  the  course  of  the  disease  and  the  effect  of 
treatment  are  entirely  different. 


TUMORS    OF    BONE. 

Tumors  of  bone  are  either  simple  or  malignant,  though  the  degree  of  their 
malignancy  varies  within  very  wide  limits.  The  former  comprises  the  fibromata, 
osteomata,  and  enchondromata,  springing  from  the  substance  of  the  bone  itself  or 
the  tough  tendinous  layer  of  the  periosteum,  and  composed  of  what  might  be 
called  adult  tissues  ;  the  latter  are  all  of  them  sarcomata,  round-celled,  spindle- 
celled,  myeloid,  or  mixed,  without  any  predominant  element,  and  arise  either  in 
the  soft  vascular  medulla  (central  or  interstitial;  or  in  the  corresponding  tissue 
in  the  deejier  layer  of  the  periosteum. 

Osteoma. 

Exostoses  are  of  two  kinds,  ivory  or  cancellous.  The  former,  which  are 
chiefly  developed  in  membrane,  spring  from  the  compact  tissue  of  the  flat  bones, 
especially  those  of  the  skull,  and  are  so  named  because  of  their  density  ;  their 
structure  is  that  of  true  but  exceedingly  compact  bone.  As  a  rule,  they  are  single 
and  limited  in  size  ;  but  occasionally,  especially  when  they  occupy  the  frontal  or 
nasal  sinuses,  they  attain  very  considerable  dimensions  and  cause  the  most  terrible 
deformity  (Figs.  195  and  196).     Even  when  they  are  quite  small  they  may,  from 


J  nat.tia 


Fig.  195. — Exostosis  of  Frontal 
Sinus. 


Fig.  196. 
Ivory  Exostosis  from  Frontal  Sinus. 


their  position,  in  the  external  auditory  meatus,  for  example,  give   rise   to   very 
serious  inconvenience  and  even  death. 

Cancellous  exostoses,  on  the  other  hand,  are  generally  met  with  on  the  long 
bones.  In  many  cases  they  are  multiple  and  symmetrical,  and  then  they  are  not 
unfrequently  hereditary.  As  a  rule,  they  occur  in  childhood,  at  the  junction  of  the 
epiphyses  with  the  shaft,  especially  in  the  neighborhood  of  the  knee  joint,  and 
they  continue  to  grow  until  the  ossification  of  the  bone  upon  which  they  are 
placed  is  complete.  Generally  they  stop  then,  but  occasionally,  when  they  have 
.appeared  rather  later  than  usual,  they  continue  to  increase,  and,  unless  they  are 
dealt  with,  form  tumors  of  very  serious  dimensions.     Unlike  the  ivory  ones,  they 


TUMORS  OF  BONE.  485 

are  developed  from  cartilage  which  gradually  becomes  converted  into  cancellous 
tissue,  continuous  with  that  of  the  bone  beneath.      So  long  as 
they  are  growing  a  thin  layer  persists  upon  the  surface  like  a 
cap  ;  afterward  it  becomes  ossified  and  converted  into  compact 
tissue  continuous  with  that  of  the  shaft. 

Single  exostoses  are  frecpiently  met  with  njjon  the  linea 
aspera  of  the  femur  and  the  supra-condyloid  ridges  of  the 
humerus,  originating  apparently  in  the  fibro-cartilaginous  tissue 
that  marks  the  attachment  of  muscular  aponeuroses.  Very 
often  it  is  difficult  to  distinguish  them  from  osteophytes,  out- 
growths in  the  same  region  caused  either  by  injury  or  by  rheu-  ; 
matic  inflammation.  Another  very  common  situation  is  the 
dorsal  surface  of  the  last  phalanx  of  the  great  toe,  where  they 
give  rise  to  the  greatest  inconvenience,  from  the  way  in  which    ^  ,  ,  ,  - 

the  nail   is  lifted  up,  first  into  a  vertical  position,  and  then 
further  still,  until   it  grows  back  upon  itself.      Curiously,  this  particular  form  is 
much  more  frequently  met  with  in  women  than  in  men  (Fig.  197). 

Symptoms. — An  exostosis,  unless  it  presses  upon  some  adjacent  structure, 
merely  forms  a  hard,  painless  enlargement  of  exceeJingly  slow  growth.  Not 
unfrequently  a  bursa  is  developed  over  it  from  the  constant  friction,  and  this  may 
increase  in  size  until  it  forms  a  communication  with  the  neighboring  joint.  In 
other  cases,  however,  the  growth  may  prove  a  very  serious  matter.  The  eyeball 
may  almost  be  forced  out  of  its  socket  and  the  face  hideously  distorted  by  one 
growing  from  the  frontal  sinus  or  antrum.  The  external  auditory  meatus  may  be 
closed,  so  that  the  secretion  collects  behind  and  sets  up  inflammation.  The 
brachial  }:)lexus  may  be  pressed  upon  by  an  outgrowth  fro .11  the  transverse  process 
of  a  vertebra.  Cerebral  symptoms  may  be  caused  by  one  lying  on  the  inner  sur- 
face of  the  skull.  The  use  of  a  joint  may  be  rendered  impossible.  The  pericar- 
dium may  be  pierced  by  one  growing  from  a  rib,  and,  in  short,  there  is  hardly  any 
structure  near  a  bone  that  may  not  suffer. 

Treatment. — In  one  or  two  instances  an  ivory  exostosis  has  separated  spon- 
taneously ;  probably  the  bone  at  the  neck  became  so  dense  that  the  blood-vessels 
were  gradually  obliterated,  and  it  was  shed  like  the  antler  of  a  stag.  Such  an  oc- 
currence, however,  is  rare.  Whether  it  is  advi.sable  to  attempt  removal  must  de- 
pend entirely  upon  the  symptoms;  if  there  is  no  inconvenience  it  should  certainly 
be  left  alone,  as  the  operation,  even  though  the  neck  of  the  growth  is  often  very 
much  smaller  than  the  body,  is  not  one  to  be  undertaken  lightly. 

Many  are  so  hard  that  it  is  impossible  to  make  any  impression  upon  them  with 
an  ordinary  trephine.  On  several  occasions  they  have  been  removed,  only  after 
the  most  intense  suffering  and  repeated  operations,  by  constantly  applying  acid  to 
the  base,  so  as  gradually  to  cause  necrosis.  Probably  the  most  effective  instrument 
for  the  purpose  is  the  surgical  engine,  with  well-tempered  steel  drills,  made  to  suit 
each  condition.  In  the  case  of  the  external  auditory  meatus,  for  e.xample,  they 
should  be  guarded  so  as  not  to  pass  too  far  down.  It  is  scarcely  possible  for  any 
growth  to  resist  this,  applied  under  an  anaesthetic,  but  it  is  as  well  to  have  a  series 
of  instruments  at  hand. 

Cancellous  exostoses  generally  stop  growing  when  the  skeleton  becomes 
developed,  but  if  an  operation  is  necessary,  the  neck  can,  as  a  rule,  be  divided 
easily  with  a  chisel.  Various  kinds  of  cutting  forceps,  and  occasionally  a  chain 
saw,  may  be  required.  Removal  of  the  cartilaginous  layer  only,  in  most  cases,  is 
sufficient  to  stop  the  growth,  but  if  the  tumor  presses  upon  adjacent  structures  it  is 
better  to  take  it  away  entirely.  Subcutaneous  fracture  or  section  of  the  neck  has 
been  recommended,  and  sometimes  after  this  the  growth  atrophies  and  disappears, 
but  not  infrequently,  in  spite  of  all  precautions,  union  takes  place  again.  In  the 
case  of  the  subungual  exostosis  an  incision  should  be  made  horizontally  round  the 
anterior  end  of  the  projection,  and  the  nail,  with  its  matrix  reflected  ;  the  growth  t 
can  then  be  excised  and  the  nail  replaced  in  its  natural  position. 


486    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


^l 


Fig. 


iM-i 


u — Enchondroma   Springing   from   Surface 
Shaft  of  I'halanx. 


Enchondroma. 

Cartilaginous  tumors  grow  from  the  long  bones  at  the  junction  of  the  epiphy- 
sis with  the  shaft,  from  the  phalanges  and  metacari)al  bones  of  the  hand  (the  foot 
more  rarely),  and  from  some  of  the  fiat  bones,  especially  the  i)elvis  and  .scapula. 

Not  unfrequently  they  are  multiple.     In 

some   cases  they  originate  in   the  centre 

and  cause  the  bones  to  expand  evenly  into 
a  thin  shell,  which  ultimately  disapjjears 
in  places ;  more  often  they  grow  from 
some  point  in  its  substance  or  immediately 
under  the  periosteum  (Fig.  198)  ;  occa- 
sionally there  are  several  separate  foci, 
and  in  some  exceptional  instances  the 
tumor  appears  to  be  diffuse,  involving 
more  or  less  the  whole  structure  of  the 
bone  at  one  point.  In  addition  enchondromata  sometimes  originate  from  the  ex- 
terior of  the  periosteum  and  l)y  their  pressure  cause  absorption  of  the  bone  on 
which  they  lie. 

Some  are  composed  almost  entirely  of  hyaline  cartilage,  with  but  little  fibrous 
tissue,  and  soon  become  ossified  into  cancellous  exostoses.  Others,  especially 
those  on  the  phalanges,  become  calcified  in  parts,  or  converted  into  mucous  tissue, 
or  undergo  cystic  degeneration,  so  that  they  are  filled  with  cavities  containing  a 
thin  glairy  fluid.  Their  growth  is  always  exceedingly  slow.  If,  particularly  in 
the  case  of  a  tumor  attached  to  the  surface  of  a  flat  bone,  progress  is  at  any  time 
rapid — if,  for  example,  it  has  doubled  its  size  within  the  year — it  must  be  regarded 
with  very  grave  suspicion,  as  it  is  very  likely  to  turn  out,  not  a  true  enchondroma, 
but  a  chondrifving  periosteal  sarcoma,  the  prognosis  of  which  is  exceedingly 
bad. 

Enchondromata  are  much  more  common  in  the  young  than  in  the  old  ;  often 
they  have  lasted  for  years  already  before  any  attention  is  paid  to  them,  and  occa- 
sionally, especially  when  they  grow  from  some  inconspicuous  place,  such  as  the 
pelvis,  they  are  allowed  to  attain  an  enormous  size.  They  form  smooth,  rounded, 
or  slightly  lobulated  swellings,  the  outline  of  which,  though  it  may  shade  off  into 
that  of  the  subjacent  bone,  is  always  free  from  the  other  structures  around  ;  the 
skin  and  the  muscles  may  be  made  to  move  over  it  without  difticulty.      Usually  it 

has  the  peculiarly  firm,  elastic  resistance  of  cartilage, 
but  sometimes  bony  jilates  may  be  detected  on  the 
exterior,  and  occasionally  it  is  plainly  cystic.  Cen- 
tral growths  are  fusiform  in  shape  and  no  line  of 
separation  from  the  bone  can  be  made  out  ;  some- 
times parchment  crackling  can  be  felt.  Superficial 
or  i)eripheral  ones  are  more  distinctly  rounded,  pro- 
jecting from  the  bone  beneath,  and  if  there  is  a 
pedicle  are  often  slightly  movable. 

Exce])t  in  the  case  of  intrajjelvic  tumors  the 
diagnosis  rarely  presents  any  difticulty.  The  most  im- 
l^iortant  feature  is  the  extreme  slowness  of  growth  ; 
unless  some  nerve  is  caught  and  compressed  all  the 
surrounding  structures  are  gradually  and  painlessly 
j)ushed  aside.  Syphilitic  or  strumous  enlargement 
occasionally  presents  a  certain  amount  of  resem- 
blance, especially  in  the  case  of  the  fingers;  but 
though  it  may  not  be  very  distinct,  there  is  always 
some  evidence  of  inflammation  in  these  cases. 

The  prognosis,  so  far  as  the  character  of   the 
growth  is  concerned,  is  very  good  ;   there  is  little  doubt  that   the  cases  formerly 


Fig.  199. — Enchondroma  of  Hand. 


TUMORS  OF  BONE.  487 

described,  in  which  secondary  deposits  made  their  appearance  within  a  compara- 
tively short  time,  were  really  sarcomata,  in  which  the  greater  portion  of  the  growth 
had  become  converted  into  cartilage  ;  but  very  great  inconvenience  and  even 
danger  may  arise  from  the  size,  number,  or  situation. 

The  only  treatment  is  the  removal,  if  possible,  of  the  whole  growth,  though 
in  some  cases  portions  have  been  left  behind  without  causing  further  trouble. 
Whether  this  should  be  attempted  or  not  must  depend  upon  the  circumstances  of 
each  case ;  if  the  tumor  is  not  increasing  in  size,  or  is  not  in  such  a  situation  as  to 
cause  inconvenience  or  danger,  it  maybe  left,  provided  the  patient  is  aware  of  the 
necessity  for  careful  watching.  \\'hen  it  is  situated  on  one  of  the  fingers  it  is  often 
possible  to  excise  the  growth,  leaving  the  bone  from  which  it  springs  ;  even  though 
there  is  merely  a  shell,  it  will  become  sufficiently  consolidated  to  act  as  a  support. 
If  this  cannot  be  done,  and  the  growth  is  very  unsightly,  the  finger  must  be  ampu- 
tated. The  same  plan  may  be  followed  with  the  large  single  enchondromata  oc- 
curring in  the  other  parts  of  the  body  ;  either  excision  or  amputation,  according 
to  the  situation  of  the  growth  and  condition  of  the  parts  left  after  its  removal ; 
but  occasionally,  especially  when  it  grows  from  the  pelvis,  this  may  be  a  matter 
of  the  very  greatest  difficulty  ;  in  one  instance,  for  example,  it  became  necessary 
to  place  ligatures  upon  the  common  and  external  iliac  arteries  and  veins  before  the 
tumor  could  be  removed. 

Fibroma. 

Tumors  composed  simply  of  fibrous  tissue  are  rarely  met  with,  except  in  the 
form  of  naso-pharyngeal  polypi,  growing  from  the  under  surface  of  the  base  of 
the  skull,  and  epulis  springing  from  the  alveolar  border  of  the  jaws.  With  a  few 
exceptions  they  are  always  attached  to  the  periosteum,  and  are  more  or  less  pedun- 
culated. The  diagnosis  from  enchondroma  is  rarely  possible  before  removal. 
Fibro-sarcomata  may  be  distinguished  by  their  greater  rapidity  of  growth. 

Sarcoma. 

Probably  all  primary  malignant  tumors  of  bone  belong  to  one  or  other  of  the 
varieties  of  sarcoma.  Carcinoma  never  occurs  except  from  secondary  infection 
or  direct  extension.  Like  other  sarcomata,  they  are  met  with  at  all  ages,  but  are 
much  more  common  in  early  life,  and  they  are  distinguished  from  all  other  tumors 
of  bone  by  the  rapidity  of  their  growth.  In  many  instances  they  originate  after, 
and  possibly  because  of,  local  injuries. 

There  are  two  forms  fairly  well  distinguished  :  one  growing  from  the  deeper 
layer  of  the  periosteum,  the  other  from  the  medulla,  either  of  the  central  canal  or 
of  the  cancellous  ends.  In  addition  periosteal  growths  are  occasionally  met  with, 
originating  from  the  exterior  and  extending  into  the  substance  of  the  bone.  Few 
are  composed  of  only  one  tissue,  nearly  all  are  mixed  ;  but,  as  a  rule,  one  kind 
predominates  sufficiently  to  admit  of  their  being  classified  as  round-celled,  spindle- 
celled,  and  myeloid  or  giant-celled.  Secondary  changes  are  often  present  as  well : 
ossification  and  chondrification,  for  example,  are  not  uncommon,  especially  in 
periosteal  growths  ;  myxomatous  and  Cystic  degeneration  are  of  frequent  occur- 
rence in  the  central  ;  hemorrhages  may  be  caused  by  the  most  trivial  degrees  of 
violence,  owing  to  the  thinness  of  the  walls  of  the  vessel ;  and  the  extravasation 
is  sometimes  so  extensive  that  nothing  but  a  shell  of  solid  tissue  is  left  around  the 
exterior. 

The  bones  of  the  lower  extremity  are  very  much  more  frequently  attacked 
than  those  of  the  upper,  and  the  neighborhood  of  the  knee  joint  is  by  far  the 
favorite  locality  ;  but  they  are  common  upon  the  jaws  (forming  one  variety  of 
epulis),  and  they  may  occur  upon  any  bone  in  the  body. 

Their  malignant  character  is  shown  by  the  way  in  which  they  infiltrate  the 
structures  around,  implicate  lymphatic  glands,  and  occasion  secondary  deposits 
in  other  organs,  especially  the  lungs.      In  this  respect,  however,  they  present  con- 


48 S    DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 

siderable  differences.  Central  ones,  for  examjjle,  confined  within  a  shell  of  bone, 
are  much  less  i)rone  to  extend  than  periosteal  ;  lymphatic  enlargement  is  much 
more  unusual  in  the  spindle-celled  variety  than  in  the  round-celled,  and  it  is  much 
more  likely  to  occur  in  sarcomata  of  the  pelvis  than  in  those  growing  from  any 
other  part  of  the  body. 

Spindle-celled  periosteal  sarcomata  are  the  most  malignant,  giant-celled  cen- 
tral ones  the  least  so. 

I .   Central  Sarcomata. 

These  grow  from  the  articular  ends  of  long  bones  or  the  cancellous  tissue  of 
short  ones.  Sometimes  they  simi)ly  remove  and  replace  the  bone,  keeping  exactly 
to  the  shape  and  size,  so  that  the  first  definite  sign  is  spontaneous  fracture ;  more 
frequently  they  cause  gradual  expansion,  the  compact  ti.ssue  being  absorbed  from 
the  interior,  and  a  new  deposit  being  laid  down  under  the  periosteum,  until  at 
length  a  great  shell  is  formed,  more  or  less  spherical  in  shape,  smooth  on  the  sur- 


:.X. 


S  .%  i- 


Fig.  200. — Ceiitr.il  Myeloid  Sarcoma  of  Upper  End  of  Tibia. 
The  articular  cartilage  on  top  is  intact.  Below  are  many 
cysts. 


Fir..  201. — Myeloid  Sarcoma  of  Upper 
End  of  Fibula,  causing  immense  ex- 
pansion of  bones.  The  interior  con- 
tained apparently  nothing  but  blood 
until  the  wall  was  scraped. 


face,  and  covered  over  with  thinliony  plates,  which  give  a  sensation  of  egg-shell 
crackling  when  pressed  upon.  The  rate  of  growth  is  less  rapid  than  that  of  the 
periosteal  variety,  but  at  length  the  casing  gives  way  and  the  overlying  soft  tissues 
are  invaded.  The  articular  cartilage  resists  to  the  last,  so  that  after  the  bone  is 
removed  it  floats  as  it  were  upon  a  soft,  yielding  bed,  incapable  of  withstanding  the 
least  strain  ;  but  unless  it  is  torn  accidentally  it  very  rarely  gives  way  of  itself. 
Pain  is  often  severe,  especially  at  night  ;  pulsation  has  been  noticed  in  a  large 
proportion,  and  spontaneous  fracture  is  not  unfrequent. 

Giant-celled,  round-celled,  and  spindle-celled,  forms  may  all  occur  ;  but  the 
first  is  the  most  striking  in  appearance.  Dark  red,  brown,  or  maroon-colored 
masses  of  myeloid  cell  are  mixed  here  and  there  with  whiter  parts,  in  which  the 
round  or  spindle  cells  predominate.  Cysts  are  scattered  all  through  the  substance 
of  the  tumor,  some  containing  a  perfectly  clear  fluid,  others  filled  with  a  soft, 
greenish,  jelly-like  material,,  the  product  apparently  of  myxomatous  degeneration 


TUMORS  OF  BONE.  489- 

(Fig.  200),  while  here  and  there  blackened  patches  from  old  hemorrhages,  or 
bright  red  ones  from  those  more  recent,  add  to  the  general  variety.  In  some 
instances,  which  used  to  be  described  as  blood-cysts,  the  hemorrhage  is  so  exten- 
sive that  there  is  merely  a  thin,  bony  shell  filled  with  extravasated  blood  and  lined 
with  a  film  of  sarcomatous  tissue  (Fig.  201). 

The  spindle-celleil  form  has  a  tendency  to  attack  the  shafts  of  the  long  bones 
rather  than  the  cancellous  extremities,  and  assumes  the  shape  of  a  rounded  tumor, 
generally  firm  and  elastic  to  the  touch,  and  grayish-white  and  smooth  in  section. 
From  its  position  it  is  peculiarly  liable  to  lead  to  spontaneous  fracture  ;  local  pain 
is  felt  for  a  week  or  two  in  the  shaft  of  one  of  the  bones,  sometimes  very  severely  ; 
fracture  suddenly  occurs  without  any  adequate  reason  ;  and  a  rapidly  growing 
tumor  forms  at  the  seat  of  injury.  It  is  in  these  cases  that  the  diagnosis  from 
quiet  necrosis  is  so  exceptionally  difficult. 

Round-celled  sarcomata,  when  they  occur  in  the  medulla,  are  only  to  be 
distinguished  from  myeloid  ones  by  their  greater  rapidity  of  growth  ;  consequently 
in  them  the  pain  is  more  severe,  pulsation  more  frequent,  and  the  tendency  to 
hemorrhage  and  invasion  of  surrounding  parts  more  distinctly  marked. 

2.  Periosteal  Sarcomata. 

These  are  either  round-celled  or  spindle-celled  in  varying  proportion  ;  some- 
times almost  pure,  sometimes  evenly  mixed.  Giant-cells  are  generally  present  in 
the  deeper  parts,  but  not  in  sufficient  number  to  form  a  separate  class.  Many  of 
them  are  converted  to  a  greater  or  less  extent  into  cartilage  or  bone;  and  it  is 
probable  that  most,  if  not  all  the  tumors  formerly  described,  from  their  malignancy, 
as  osteoid  cancer,  malignant  enchondroma  and  the  like,  were  really  periosteal 
sarcomata.  They  spring  from  the  deeper,  more  vascular  layer  ;  and  the  tumor  at 
first  is  confined  to  one  side  of  the  bone.  The  fibrous  part  is  stretched  over  it  so 
long  as  the  growth  is  small  ;  but  as  soon  as  it  attains  any  size  it  bursts  through 
this,  invades  the  tissues  around,  and  destroys  everything,  including  the  superficial 
portion  of  the  bone  (Fig.  202).  Sometimes  it  extends  into  and  rapidly  fills  up 
the  central  canal. 

The  consistence  of  the  growth  is  very 
variable.  In  many  instances  it  is  simply 
a  soft,  pulpy  mass  filled  with  broken- 
down  extravasations  ;  in  some  it  is  much 
firmer  and  almost  fibrous  on  section.  The 
base  is  often  partially  converted  into  cartil- 
age or  bone  ;  and  the  whole  of  its  substance 
may  be  traversed  by  delicate  osseous  trabe- 
cul^e  springing  from  the  bone  beneath,  and 
forming  a  most  elaborate  skeleton.  Cystic 
and  gelatinous  degeneration  also  occurs  in 
patches  here  and  there. 

Periosteal  sarcomata  appear  to  be  more 
common  in  the  femur  than  elsewhere,  com- 
mencing either  on  the  shaft  or  the  epiphy- 
sis ;.  but  there  is  no  bone  in  the  body  that 
is  exempt.  They  are  all  of  them  of  the 
most  intensely  malignant  character,  affect- 
ing  not   so    much     the    lymphatic     glands 

(spindle-celled   ones  very  rarely)  but  other      W.  '>      ^^  >f 

distant  organs  ;  so  that  even  if  amputation       ^  ,^J  ^      ^z 

is  performed   as   soon  as  the    diagno.sis    is        ^ 
made,  the  stump  may  remain  healthy  to  the 

ItcI-  hill-  cf>ronrlTr\-  CTrnwfl-iQ  nrp  almnQl"  tjiirf  Fig.  202.— Skeleton  ofa  Periosteal  Sarcoma  Growing 
last,   out    SeCOnaar)    grOWtnS    are  almost    sure       fro^  L^^-er  End  of  Femur;  the  epiohyslsis  not 

to    appear    within    the   twelvemonth.     The     yet  united. 


490    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

liability  to  fracture,  of  course,  is  less  than  in  the  central  variety  ;  hut  the  other 
signs  due  to  the  extension  of  the  growth  into  the  .structures  around  are,  as  a 
rule,  more  distinct. 

Symptoms. — In  the  early  stages  these  are  very  indefinite.  Pain  is  rarely 
absent ;  olten  it  is  very  severe,  especially  at  night.  In  the  periosteal  form  a  dis- 
tinct swelling,  projecting  from  one  side  of  the  bone,  is  one  of  the  earliest  symp- 
toms ;  in  the  central  it  is  rarely  perceptible  until  the  disease  is  far  advanced  ;  and 
when  the  growth  commences  in  the  interstitial  medulla,  at  one  of  the  cancellous 
ends,  it  is  often  entirely  absent  until  the  whole  framework  has  disapi)eared.  The 
outline  of  the  enlargement  is  fusiform,  spreading  along  the  bone  and  ill-defined 
in  the  periosteal ;  in  the  central  it  is  rounded  and  more  distinctly  limited.  Its 
consistence  is  equally  variable  ;  sometimes  it  is  soft  and  fluctuating  ;  sometimes 
hard  and  dense,  according  to  the  character  of  the  predominant  tissue.  Egg-shell 
crackling  is  only  met  with  in  the  central  variety. 

Spontaneous  fracture  may  occur  in  either,  but  it  is  less  common  in  the  perios- 
teal. Occasionally  it  takes  place  without  any  evidence  of  tumor  or  new  growth 
except  pain  ;  but  the  swelling  rarely  fails  to  make  its  appearance  immediately  after, 
and  soon  attains  an  enormous  size. 

Rapid  growth,  enlarged  cutaneous  veins  over  the  tumor,  softness,  and  above 
all  pulsation,  are  most  important.  Any  tumor  attached  to  bone  that  doubles  its 
size  within  six  months  must  be  regarded  with  very  grave  suspicion,  ])articularly  if 
it  occurs  in  a  young  person  and  in  the  neighborhood  of  the  knee  joint.  Pulsation 
is  present  in  a  large  proportion  of  central  sarcomata,  and  in  periosteal  ones,  when 
they  grow  from  the  flat  bones  ;  and  when  it  occurs  it  is  practically  definite.  It 
is  entirely  different  from  the  heaving  impulse  of  an  aneurysm  ;  and  though  it  may 
be  accompanied  l)y  a  distinct  thrill  and  bruit,  these  are  only  present  over  a  small 
portion  of  the  swelling.  The  pulse  in  the  limb  below  is  unaffected  unless  the 
tumor  compresses  the  main  artery  against  the  bone  ;  and  the  swelling  cannot  be 
materially  les.sened  by  pressure. 

If  the  diagnosis  is  uncertain  the  swelling  should  be  explored  without  delay 
with  a  fair-sized  trocar  and  cannula.  In  many  cases  this  penetrates  into  the  bone 
in  such  a  way  that  there  can  be  no  doubt  as  to  the  change  it  has  undergone  ;  in 
others,  myeloid  cells,  or  other  structures  that  can  be  recognized  as  sarcomatous, 
come  away  with  the  blood  and  can  be  recognized  under  the  microscope. 

Diagnosis. — Innocent  tumors  of  bone  are  distinguished  by  the  slowness  of 
their  growth,  and  by  the  al)sence  of  pain  and  increased  vascularity. 

Gummata  occasionally  presents  some  difficulty,  as  the  history  of  syphilis  does 
not  exclude  the  presence  of  sarcoma.  Any  doubt,  however,  can  usually  be  dis- 
pelled in  a  few  days  by  the  administration  of  iodide  of  potash.  It  relieves  the 
pain  of  sarcoma,  so  far  as  this  is  dependent  upon  accompanying  periostitis,  but  it 
has  no  effect  upon  the  size. 

When  the  sarcoma  occupies  the  cancellous  end  of  one  of  the  long  bones  it 
may  be  entirely  concealed  by  the  symptoms  of  inflammation  of  the  neighboring 
joint.  This  chiefly  occurs  at  the  knee  ;  the  position  of  the  limb  is  characteristic 
of  disea.se  of  the  joint  ;  movement  is  painful  and  limited  ;  the  synovial  sac  is 
filled  with  fluid  ;  and  though  the  lower  end  of  the  femur  or  the  upper  end  of  the 
tibia  is  replaced  completely  by  a  new  growth,  there  is  no  enlargement  of  the  bone. 
The  same  mistake  may  easily  occur  in  the  acute  suppurative  arthritis  of  infants, 
especially  as  rapidly-grown ng  sarcomata,  such  as  simulate  abscesses,  are  often  at- 
tended with  a  typically  hectic  temperature. 

Chronic  inflammation  of  bone,  with  the  formation  of  a  sequestrum  (quiet  ne- 
crosis), is  most  deceptive,  especially  when  the  shaft  of  one  of  the  long  bones  is 
concerned.  Even  after  s|)ontaneous  fracture  has  occurred  it  is  sometimes  impossi- 
ble to  make  a  diagnosis  without  free  exploration. 

A  few  instances  have  been  recorded  of  pulsating  tumors  of  bone  without  any 
sarcomatous  growth  (osteo-aneurysm)  ;  such,  howe\er,  are  very  rare.  True 
aneurysm  may  sometimes  cause  a  certain  amount  of  difficulty,  but  in  nearly  every 


TUMORS   OF  BONE. 


491 


case  the  position,  the  relation  it  bears  to  the  artery,  the   fact  that  the  sac  can  be 
emptied  by  pressure,  or  tlie  history,  settles  the  cpiestion  at  once. 

Treatment. —  i.  Central  Sarcomata. — Excision  may  be  practiced  when  the 
structure  of  the  part  allows  it,  and  the  growth  has  not  become  diffused  too  widely. 
Thus,  the  upper  end  of  the  fibula  may  be  completely  removed,  or  part  of  the  ulna  ; 
and  the  upper  end  of  the  humerus  even  has  been  treated  in  the  same  way,  leaving 
a  fairly  useful  limb.  But  all  such  cases  must  be  very  carefully  watched,  for  fear  of 
local  recurrence. 

Where  this  is  not  possible,  am])utation  should  be  ijerformed  sufficiently  far 
above  the  growth  to  make  sure  that  the  tissues  are  healthy,  and  if  the  I)one  is 
divided  the  cut  surface  of  the  medulla  should  be  very  carefully  examined. 

2.  Periosteal  Sarcomata. — For  these,  amputation  is  the  only  resource.  If  the 
growth  is  situated  at  the  distal  end  of  one  of  the  long  bones,  and  the  disease  is 
not  of  long  standing,  the  operation  may  be  performed  through  the  shaft,  at  a  suffi- 
cient distance  above.  Recurrence  is  very  probable,  but  if  the  sawn  section  of  the 
bone  is  healthy,  it  may  not  take  place  in  the  stump.  When  the  disease  is  situated 
higher  up,  disarticulation  should  be  practiced,  except  in  the  case  of  the  hip.  Am- 
putation at  this  joint  for  periosteal  sarcoma  at  or  above  the  middle  of  the  bone  is 
practically  hopeless. 

Portions  of  the  clavicle  have  been  excised  successfully  for  central  sarcoma  ; 
but  when  the  growth  is  periosteal,  or  when  it  has  invaded  neighboring  structures, 
it  must  rest  with  the  patierit  whether  such  an  operation  should  be  undertaken. 
Resection  of  the  inferior  angle  of  the  scapula  is  not  a  serious  or  difficult  matter, 
if  it  is  done  as  soon  as  the  nature  of  the  tumor  is  recognized.  The  whole  bone 
has  been  removed  on  some  twenty  occasions,  with  preservation  of  the  arm  ;  and 
more  than  once  the  whole  of  the  upper  extremity,  with  the  scapula  and  part  of  the 
clavicle,  has  been  taken  away.  Nearly  all  of  these,  however,  have  terminated 
fatally  within  the  twelvemonth,  from  secondary  deposits  in  the  lungs. 


Cysts. 

Hydatid  cysts  are  occasionally  found  in  bones ;  and  chronic  abscesses  some- 
times leave  behind  them  smooth-walled  spaces  with  clear  contents  ;  but  unless  they 
lead  to  great  dilatation  or  to  spontaneous  fracture,  they  are  not  likely  to  be 
diagnosed. 

Cysts,  due  to  softening,  degeneration,  or  hemorrhage,  are  very  common  in 
connection  with  .sarcomata,  especially  central  ones  ;  but,  except  some  occurring  in 
the  jaws,  which,  owing  to  their  special  character,  are  described  by  themselves,  other 
forms  are  almost  unknown. 

Carcinoma. 

It  is  doubtful  whether,  in  the  absence  of  epithelial  elements,  primary  carci- 
noma of  bone  can  occur.  Secondary  deposits,  however,  are  not  unfrequent;  cancer 
of  the  vertebrae,  for  example,  may  occur  in  scirrhus  of  the  breast;  and  especially  in 
the  leg,  over  the  subcutaneous  surface  of  the  tibia,  epithelioma  may  gradually 
extend  down  into  the  substance  of  the  bone. 


492     DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 


SECTION   IV.— INJURIES  OF  JOINTS. 

These,  like  injuries  of  bones,  are  divided  into  two  classes.  In  the  one  there 
is  no  external  wound  ;  the  skin  is  unbroken  ;  the  tissue  changes  that  follow  are 
rarelv  more  than  is  required  for  rei)air,  and  inflammation  is  rarely  severe  unless  there 
is  some  additional  irritant,  such  as  gout  or  scrofula,  to  keep  it  up.  In  the  other 
the  interior  of  the  joint  is  filled  with  fluid  and  exposed  to  the  air  ;  decomposition 
may  set  in  at  any  moment ;  and  if  it  does,  it  is  certain  to  cause  an  attack  of  inflam- 
mation, which  is  very  likely  to  end  in  the  destruction  of  the  joint  or  i)lace  life 
itself  in  danger. 

Wounds  oy  Joints. 

Punctures  and  clean  incised  wounds  are  caused  by  stabs  and  cuts  ;  lacerated 
ones  are  usually  associated  with  compound  fractures  or  gun-shot  injuries  ;  but 
they  may  be  produced  by  any  crushing  or  tearing  force,  and  may  be  of  any  extent, 
from  a  puncture,  the  very  existence  of  which  is  doubtful,  to  a  rent  which  lays  open 
the  joint  from  side  to  side.  In  many  instances  the  diagnosis  is  clear  at  the  first 
glance  ;  the  interior  of  the  joint  can  be  seen  ;  or  there  is  an  escape  of  synovia, 
recognized,  even  when  mixed  with  blood,  by  its  peculiar  glutinous  feel ;  or  the 
joint  in  a  very  few  moments  becomes  distended  with  fluid.  But  in  a  few  it  is  a  matter 
of  some  difficulty,  either  from  the  nature  and  direction  of  the  wound,  or  from  the 
presence  of  neighboring  spaces,  such  as  burs»,  tendon  sheaths  and  cysts,  which 
contain  the  same  kind  of  fluid,  and  which  sometimes  do,  and  sometimes  do  not, 
communicate  with  the  central  cavity.  If  there  is  the  least  ground  for  suspicion, 
the  case  must  be  treated  with  exactly  the  same  precautions  as  if  the  joint  were 
really  opened  ;  and  no  attempt  should  ever  be  made  to  explore  the  wound  with 
the  probe  or  the  finger  merely  for  the  purpose  of  making  certain.  This,  of  course, 
does  not  apply  to  any  case  in  which  the  wound  is  dirty,  or  inflicted  with  a 
dirty  instrument,  or  in  which  there  is  the  least  probability  of  such  a  thing; 
thorough  exi)loration,  then,  is  essential. 

Pathological  Changes.  —  These  are  the  same  as  those  that  follow  other 
injuries  ;  the  danger  arises  from  the  size  and  complexity  of  the  cavity,  its  extent 
of  absorbing  surface,  and  the  difficulty  of  draining  it  effectually.  Suppuration 
rarely  occurs  in  small  joints,  and  extensive  wounds  often  heal  with  the  least  dis- 
turbance, because  the  risk  of  decomposing  material  being  confined  under  high 
tension  is  so  much  less. 

Large  vessels  are  not  often  divided,  but  the  small  ones  bleed  profusely,  and 
often  before  their  orifices  are  closed  the  synovial  cavity  and  the  loose  spaces  around 
are  filled  with  blood.  Then  the  edges  of  the  wound  become  red  and  swollen,  the 
ves.sels  dilate,  lymph  pours  out  through  their  walls,  the  perisynovial  tissues  become 
infiltrated  and  gelatinous,  and  the  cavity  grows  fiiller  and  fuller.  Soon  the  irrita- 
tation  spreads  to  the  lining  of  the  sac,  the  endothelium  falls  away,  the  surface  loses 
its  polish,  the  folds  and  fringes  become  hyperremic  and  swollen,  small  extravasa- 
tions take  place  here  and  there,  especially  along  the  line  of  attachment  of  the 
capsule,  and  the  joint  becomes  distended  with  a  turbid,  blood-stained  mixture  of 
synovia  and  lymph. 

The  subsequent  course  depends  upon  the  kind  and  the  persistence  of  the  irri- 
tant. If  there  is  no  tension  or  decomposition,  if  the  only  injury  is  that  which  was 
inflicted  at  the  moment  of  the  accident  and  no  other  is  added,  the  hypercemia 
soon  begins  to  subside,  the  quantity  of  fluid  diminishes,  the  swelling  of  the  cellu- 
lar tissue  disappears,  the  cells  on  the  surface  of  the  synovial  membrane  gradually 
resume  their  normal  character,  the  edyes  of  the  wound   cohere  together,  and  the 


INJURIES  OF  JOINTS— WOUNDS.  493 

joint  is  left  souiul,  though  weakened  a  little  and  inclined  to  be  irritable  for  a  short 
time. 

If,  on  the  other  hand,  the  original  hurt  is  not  the  only  one,  if  it  is  supple- 
mented by  some  other  acting  jjcrsistently  on  already  damaged  structures,  the  tissue 
changes  become  excessive,  altogether  beyond  what  is  needed  for  repair,  and  inflam- 
mation sets  in. 

The  severity  of  the  attack  dejtends  uj^on  the  nature  of  the  irritant.  Where 
it  is  merely  high  tension  or  want  of  rest,  supi)uration,  though  it  may  occur,  is 
decidedly  rare.  The  nutrition  of  the  tissues  is  impaired,  but  they  are  still  strong 
enough  to  destroy  any  pyogenic  germs  that  may  reach  them.  The  joint  continues 
painful  and  swollen  after  the  wound  has  healed,  the  skin  is  warmer  than  natural, 
and  even  a  little  reddened  ;  a  certain  amount  of  thickening  is  left,  so  that  the 
synovial  membrane  does  not  unfold  itself  smoothly  and  easily  as  the  joint  moves, 
or  the  amount  of  fluid  is  excessive ;  a  certain  degree  of  inflammation,  in  short, 
persists,  but  it  is  rare  for  it  to  be  dangerous  or  severe. 

If  infection  occurs,  the  difference  is  very  marked.  The  fluid  with  which  the 
joint  is  filled  at  once  becomes  the  most  vinilent  poison  ;  the  whole  of  the  synovial 
sac  is  involved  ;  the  hyperasmia  and  exudation  spread  wider  and  wider  ;  stasis  and 
thrombosis  occur  ;  some  of  the  tissues  perish  at  once  ;  others,  less  severely  injured, 
yield  to  the  pyogenic  microbes  that  find  their  way  in  through  the  wound  or 
through  the  blood,  and  break  down  into  pus ;  only  those  at  a  distance  resist,  and 
strive  to  limit  the  area  of  de.struction  by  forming  a  wall  of  vascular  granulations. 
The  ligaments  become  soft  and  yield,  so  that  one  bone  is  displaced  upon  another  ; 
abscesses  form  in  the  cellular  spaces  around  either  independently  or  by  direct  ex- 
tension from  the  joint  ;  the  cartilages  turn  yellow  and  sodden  ;  where  there  is 
pressure  they  fall  off"  in  large  necrosed  flakes,  which  bring  away  with  them  the 
articular  lamella  of  the  bone  ;  at  the  margins  they  grow  thinner  and  thinner  until 
they  look  like  pieces  of  wet  wash-leather ;  the  bones  become  soft  and  carious  upon 
the  surface,  and  the  joint  is  utterly  disorganized. 

Symptoms. — These  depend  upon  the  size  of  the  joint  and  the  consequences 
that  follow.  If  the  wound  heals  at  once,  by  the  first  intention,  there  may  be 
nothing  noticeable ;  but  nearly  always  the  point  is  swollen  and  tender  for  the  first 
few  days  ;  the  skin  is  warmer  than  natural,  the  muscles  are  rigid,  in  order  to  keep 
the  part  at  rest,  and  if  the  synovial  membrane  is  large,  so  that  there  is  rapid 
absorption,  the  patient  is  feverish  and  uncomfortable,  though  the  rise  of  tempera- 
ture is  scarcely  more  than  one  or  two  degrees. 

In  other  cases  the  symptoms  are  more  marked  and  the  injury  is  followed  by 
an  amount  of  synovitis  sufiicient  to  cause  a  certain  degree  of  anxiety.  The  joint 
is  as  full  as  it  can  be,  the  skin  is  red  and  even  oedematous,  the  pain  and  constitu- 
tional disturbance  are  more  severe ;  but  even  then,  if  the  onset  is  gradual — if 
three,  or,  better  still,  four,  days  pass  by  without  the  symptoms  becoming  urgent — 
there  is  reasonable  hope  that  the  inflammation  is  due  to  other  causes  than  decom- 
position, and  that  it  will  subside  without  running  on  to  suppuration. 

If  infection  does  occur  in  the  interior  of  one  of  the  larger  joints,  the  symp- 
toms are  generally  beyond  question.  From  the  first  few  hours  they  are  infinitely 
more  intense,  and  they  grow  worse  and  worse  with  such  rapidity  that  in  the  course 
of  three  or  four  days,  if  the  case  is  left  to  itself,  the  condition  of  the  joint  is  al- 
most hopeless.  Acute  suppurative  arthritis  sets  in  with  the  utmost  virulence.  The 
edges  of  the  wound  are  reddened  and  everted,  and  a  thin,  serous  pus  oozes  out ; 
the  skin  is  dusky  with  enlarged  veins  running  in  it ;  it  is  boggy  and  oedematous, 
pitting  deeply  in  places,  and  it  almost  scorches  the  hand.  The  swelling  is 
no  longer  the  shape  of  the  synovial  sac,  it  is  more  rounded  and  uniform ;  or  it 
extends  a  greater  distance  along  the  limb,  particularly  on  its  inner  side  ;  the  pain 
is  intense,  and  is  no  longer  of  the  same  character  ;  the  joint  burns  or  throbs  as  if  it 
were  bursting ;  it  is  held  rigidly  fixed  in  a  position  of  semi-flexion  ;  the  slightest 
attempt  at  movement  causes  the  utmost  dread  ;  and  the  fever  is  of  the  severest  type, 
the  temperature,  if  it  is  the  knee,  reaching  105°  or  even  106°,  so  that  the  patient 


494    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

becomes  delirious.  When  rii^ors,  or  what  are  known  as  starting-pains,  make  their 
aj)pearance,  the  prognosis  is  even  more  grave.  The  former  may  mean  the  onset 
of  suppuration  or  the  beginning  of  pyaemia;  the  latter  jjoints  to  necrosis  and 
destruction  of  the  cartilages.  Later,  if  the  ))atient  does  not  die  from  .septic  ab- 
.sor))tion,  the  fever  alters  its  character,  and  as  granulations  are  thrown  out,  assumes 
the  hectic  tyjje,  fresh  abscesses,  each  causing  a  new  outbreak,  forming  every  now 
and  then  in  the  cellular  tissue  around.  Finally,  if  the  patient  is  not  attacked  by 
py;v;mia  or  other  comjilications,  and  does  not  sink  from  exhaustion,  the  constitu- 
tional disturbance  gradually  subsides  as  the  wound  becomes  smaller,  and  the  limb 
is  left  stiffened,  wasted,  and  covered  with  scars. 

Treatment. — C"oni])ouivl  (open)  fractures  into  joints,  comjjound  (open) 
dislocations,  and  wounds  of  joints  accompanied  by  injury  to  important  structures 
near,  will  be  dealt  with  by  themselves.  The  age  and  constitution  of  the  patient,  the 
size  and  importance  of  the  joint,  whether  it  is  in  the  upper  or  the  lower  limb,  and 
the  extent  of  the  injury  sustained  by  the  soft  parts  and  the  bones  respectively,  are 
the  chief  factors  in  determining  what  is  to  be  done.  The  choice  lies  in  each  case 
between  preservation,  excision,  and  amputation. 

In  the  case  of  a  wound  the  first  thing  is  to  prevent  infection.  A  simple 
incision,  such  as  that  inflicted  by  a  surgeon  for  the  removal  of  a  foreign  body, 
should  be  closed  at  once.  If  it  is  large  a  catgut  suture  may  be  inserted  ;  if  small, 
the  edges  may  be  brought  together  and  sealed  with  collodion,  or  covered  with 
iodoform,  or  closed  with  lint  dipjied  in  Friar's  balsam.  A  lacerated  or  dirty 
wound,  on  the  other  hand,  or  one  the  condition  of  which  is  even  suspicious,  must 
be  thoroughly  and  perfectly  cleansed.  Whether  the  joint  should  be  washed  out  or 
not,  depends  upon  the  character  of  the  injury  and  the  length  of  time  it  has  been 
inflicted  ;  but  if  there  is  any  doubt  it  should  certainly  be  done,  additional  open- 
ings being  made  if  the  cavity  is  a  large  one.  In  the  case  of  the  ankle,  wrist,  and 
elbow,  it  is  an  excellent  plan  to  immerse  the  limb  bodily  in  a  corrosive  sublimate 
bath  for  an  hour  each  day,  syringing  the  joint  out  thoroughly  through  a  piece  of 
rubber  tubing  inserted  into  the  wound.  I  have  on  several  occasions  treated  com- 
pound fractures  into  the  wrist-joint,  and  they  perhaps  are  the  worst  of  the  three, 
in  this  manner  with  excellent  results.  If  it  is  the  knee,  this  is  hardly  practicable, 
and  infection  must  be  prevented  in  other  ways.  Washing  out  the  joint,  even  with 
the  most  active  antiseptic,  is  rarely  enough  :  it  is  very  difficult  to  make  it  pene- 
trate eiificiently  into  all  the  recesses,  especially  in  the  case  of  a  person  who  is 
somewhat  advanced  in  life  :  in  children  it  may  answer,  as  the  shape  of  the  sac  is 
more  simple.  Constant  irrigation  is  more  likely  to  succeed,  esi)ecially  if  com- 
menced at  once  :  the  products  of  decomjjosition  can  hardly  collect  then  ;  and 
Treves  has  shown  that  if  it  is  thoroughly  carried  out,  and  kept  uj)  night  and  day, 
even  with  simple  water,  a  knee  joint  that  has  already  begun  to  supjnirate  may 
recover  Avith  almost  jierfect  mobility. 

It  is  equally  important  to  prevent  tension  and  to  secure  perfect  rest.  A 
lacerated  or  contused  wound  should  be  left  partially  open  and  covered  with  a 
small  piece  of  non-adhesive  dressing,  so  that  the  exudation  can  escape  at  once  ; 
or  if  the  synovial  lining  is  very  com]jlex  and  ill-adai)ted  for  drainage,  additional 
openings  should  be  made,  and  tubes  inserted  into  every  pocket.  When  the  knee- 
joint  is  concerned,  the  simplest  way  is  to  push  a  i)air  of  dressing-forceps  down 
through  the  wound,  until  it  projects  in  the  po])liteal  space,  when  a  small  incision 
may  be  made  over  the  end,  the  tube  grasped  and  drawn  back  again.  Then  the 
whole  joint  should  be  covered  over  with  an  abundance  of  wood-wool  or  some  other 
thoroughly  absorbent  dressing. 

The  limb  must  be  placed  upon  a  splint  in  the  most  comfortable  position 
(always  provided  it  is  a  suitable  one)  and  fixed  securely  ;  it  should  be  raised  if 
possible,  well  bandaged,  and  kept  cool  by  means  of  an  ice-bag  or  Leiter's  coils. 
The  patient  must  be  placed  on  low  diet,  the  bowels  well  opened,  and  sleep  and 
quiet  ensured  by  opium  or  chloral. 

The  temperature  is  the  best  guide  to  the  subsequent  treatment.     If  there  is 


INJURIES  OF  JOINTS—SPRAINS.  495 

only  a  slight  rise  and  the  pain  a])oiit  the  joint  is  not  severe,  the  wound  should  not 
be  touched  (iniless  drainage-tubes  reiiuire  to  be  taken  away)  until  it  is  sound,  the 
l)art  meantime  being  enveloj^ed  in  cotton-wool  and  well  bandaged  to  prevent  any 
distention  of  the  capsule.  If,  however,  the  temperature  rises  more  than  one  or 
two  degrees,  if  the  joint  becomes  distended  and  [)ainful,  i)articularly  if  it  begins 
to  throb,  the  condition  is  much  more  critical.  Cold  and  compre.ssion  with  layers 
of  cotton-wool  may  still  be  tried  ;  leeches  placed  all  round  the  joint ;  an  ice-bag 
laid  upon  the  main  artery  of  the  limb  (the  femoral  has  been  tied  for  acute  sup- 
]Kiration  in  the  knee  joint)  ;  or  even  the  joint  as]Mrated  to  reduce  the  tension  ;  but 
if  the  skin  is  boggy  and  (jedematous,  and  if  the  swelling  is  diffuse,  no  longer 
confined  to  the  synovial  sac,  it  is  very  doubtful  whether  supjmration  can  be  pre- 
vented. If  there  is  not  speedy  imi)rovement,  the  joint  must  be  laid  open  freely 
on  both  sides  (small  incisions  are  worse  than  useless)  and  irrigated  so  thoroughly 
that  retention  of  decomposing  material  is  impossible.  Then  the  limb  jnust  be 
fixed  to  a  splint  in  such  a  position  that  if  ankylosis  does  occur,  it  may  still  Ije  of 
some  service.  Sometimes  even  after  this  the  articulation  recovers,  especially  in 
children,  with  a  surprising  degree  of  mobility.  More  often  the  severity  of  the 
inflammation  subsides  ;  granulations  spring  up  ;  the  amount  of  pus  diminishes  ; 
organization  sets  in  ;  and  fibrous  or  bony  ankylosis  results.  Occasionally  abscesses 
continue  to  make  their  appearance  along  the  limb  funder  the  quadriceps  in  the 
case  of  the  knee),  and  either  the  patient  sinks  under  the  prolonged  suppuration  or 
amputation  is  performed. 

Subcutaneous  Injuries. 

Sprai7is  and  Contusions. 

Under  this  heading  are  included  almost  all  injuries  of  joints  that  are  not 
attended  by  permanent  displacement  of  the  articular  surfaces.  There  may  be 
merely  a  slight  effusion  into  the  capsule  of  a  joint  with  a  little  stretching  of  some 
of  the  fibres  ;  or  the  synovial  sac  may  be  filled  with  blood,  the  ligaments  torn  or 
wrenched  off  the  bone,  the  muscles  lacerated,  the  tendons  displaced  from  their 
grooves,  and  the  tissues  torn  and  crushed  as  severely  as  if  it  were  a  dislocation.  In 
many  cases  the  sole  difference  between  a  sprain  and  a  dislocation  is  that,  in  the 
one,  the  bones,  which  are  wrenched  asunder  at  the  time  of  the  accident,  resume 
their  normal  relation  as  soon  as  the  force  is  spent  ;  in  the  other,  they  either  remain 
fi.xed  where  they  are  or  slip  a  little  further  aside. 

Contusions  are  the  result  of  direct  violence,  such  as  blows  and  kicks,  and  may 
be  serious  from  the  extent  of  the  bruising  or  from  the  tension  set  up  by  the 
blood  that  pours  into  the  cavity  of  the  joint.  Sprains,  on  the  other  hand,  are 
due  to  violent  and  sudden  twists,  wrenching  the  joint  when  the  muscles  are  either 
tired  out  or  are  caught  unawares ;  probably,  without  this,  they  would  very  rarely 
occur.  Astley  Cooper  said  of  dislocations  that  it  was  only  possible  for  them  to 
take  place  when  the  muscles  were  unprepared  for  resistance,  and  the  same  is  nearly 
as  true  of  sprains. 

The  atnoiitit  of  injiirx  is  very  variable.  In  some  there  is  only  a  spot  or  two 
of  extravasated  blood,  just  at  the  attached  margin  of  the  capsule  ;  in  others  the 
joint,  and  the  loose  cellular  tissue  that  extends  along  the  bone  and  under  the  skin, 
are  filled  with  it.  Sometimes  it  is  uncertain  whether  there  is  a  rent  or  not  ;  or 
the  strongest  ligaments  in  the  body,  such  as  the  internal  lateral  ligament  of  the 
knee  or  ankle,  may  be  torn  in  two.  Nearly  always  when  this  happens  they  drag 
away  with  them  a  thin  scale  from  off  the  bone.  In  severe  cases  the  muscles  always 
suffer,  and  sometimes  they  are  extensively  lacerated,  possibly  in  the  sudden  spas- 
modic effort  at  recovery  :  the  tendon  sheaths  are  bruised  and  filled  with  blood  ; 
the  nerves  are  stretched  and  torn  ;  and  even  the  bones  show  at  times  deep  ecchy- 
moses  in  their  cancellous  substance. 

The  pain  at  the  moment  is  intense  and  of  a  peculiar  sickening  character,  so 


496    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

that  the  patient  may  fall  clown  fainting;  later  the  i)art  becomes  numbed,  with  a 
dull  aching  sensation,  due  to  the  tension  of  the  nerves.  Swelling  generally  sets  in 
at  once,  and  the  synovial  cavity  is  distended  to  its  utmost  in  the  course  of  a  few 
moments  ;  but  sometimes,  when  it  is  due  rather  to  inflammatory  exudation,  it  is 
more  gradual,  and  does  not  attain  its  maximum  for  twelve  or  even  twenty-four 
hours.  The  skin  is  exceedingly  tender,  esjtecially  over  the  spot  where  the  liga- 
ments have  given  way  ;  the  least  attempt  at  movement  is  looked  upon  with  dread  ; 
and  discoloration  soon  begins  to  make  its  appearance.  In  the  case  of  a  sprained 
ankle,  if  there  are  many  small  varicose  veins  round  the  joint,  the  ecchymosis  may 
reach  as  far  as  the  knee  in  a  very  short  time. 

Recovery  is  often  im])erfect.  Inflammation  does  not  occur  unless  there  is 
some  other  irritant  as  well,  but  very  often  the  joint  remains  cold,  stiff,  and  pain- 
ful whenever  an  attempt  is  made  to  use  it.  This  may  be  caused  in  various  ways. 
Adhesions  may  have  formed,  binding  tendons  down  to  their  sheaths,  or  even  unit- 
ing two  articular  surfaces  to  each  other  ;  the  cajjsule  and  the  loose  tissue  around 
may  have  become  dense  and  unyielding  (especially  on  the  inner  side  where  it  is 
soft  and  thrown  into  folds)  ;  the  muscles  may  be  matted  together  ;  or  the  synovial 
sac  may  remain  distended  ;  but  in  many  instances  nothing  can  be  found.  Move- 
ment is  restricted  and  painful,  at  one  spot  in  particular,  but  there  is  nothing  out 
of  place.  There  is  a  sense  of  weakness  about  the  joint,  so  that  it  does  not  feel  as 
if  it  could  be  trusted,  or  it  becomes  swollen  whenever  it  is  used,  but  there  is  no 
inflammation  ;  the  skin  rather  is  unnaturally  cold  ;  it  is  smooth,  glossy,  and  livid, 
showing  that  the  circulation  through  it  is  imperfect ;  the  tissues,  in  short,  are 
starved,  from  prolonged  inactivity  ;  they  are  unable  to  work,  because  they  never 
get  a  proper  supply  of  blood  ;  and  the  only  remedy  lies  in  encouraging  the  circu- 
lation as  much  as  i)Ossible. 

Treatment. — Slight  sprains,  when  the  tissues  are  stretched  rather  than  torn, 
are  treated  most  successfully  by  massage  and  bandaging;  but  it  must  be  carried 
out  carefully  and  thoroughly.  The  limb  must  be  raised,  the  muscles  relaxed,  and 
all  constricting  garments  removed.  At  first  the  movement  must  be  exceedingly 
light,  and  directed  so  as  to  diminish  the  sensitiveness  of  the  skin,  commencing 
above  the  injured  joint,  where  the  swelling  has  not  yet  shown  itself,  and  working 
gradually  nearer  to  it.  The  direction  must  always  be  toward  the  trunk  ;  the 
thumb,  or  the  tips  of  the  fingers,  or  the  palm  of  the  hand,  may  be  used,  accord- 
ing to  the  shape  of  the  surface  ;  and  the  tender  spots  must  be  left  to  the  last.  If 
this  is  properly  carried  out,  the  swelling  begins  to  diminish  in  a  few  minutes,  and, 
as  the  circulation  improves,  absorption  becomes  more  rapid,  and  the  tendency  to 
start  and  the  involuntary  shrinking  disappear.  Then  more  attention  may  be  paid 
to  the  spaces  in  which  the  extravasated  blood  has  collected  ;  the  tii)S  of  the  fingers 
or  the  thumb  may  be  made  to  trace  out  the  irregular  intervals  between  the  bony 
prominences,  moving  round  and  round  in  small  circles  upon  the  skin  ;  and  grad- 
ually firmer  and  firmer  pressure  may  be  used,  as  the  superficial  structures  become 
accustomed  to  it.  This  must  be  kept  up  until  the  effusion  has  almost  disappeared, 
and  slight  passive  movements,  of  such  a  nature  as  not  to  exert  any  traction  on  the 
injured  ligaments,  are  allowed  without  resistance.  Then  the  joint  must  be  cov- 
ered with  several  layers  of  cotton-wool,  and  compressed  as  firmly  as  possible  with 
a  flannel  or  a  domett  bandage.  Generally  speaking,  this  has  to  be  repeated  for 
two  or  three  days,  but  each  time  the  sitting  is  shorter  and  less  irksome. 

In  more  severe  injuries,  where  from  the  tenderness  over  certain  spots  it  is 
clear  that  some  of  the  ligaments  have  given  way,  the  same  plan  may  be  tried  ;  but 
naturally  a  longer  time  is  necessary  for  repair.  Heat  and  cold,  if  used  with  suffi- 
cient energy,  are  of  excellent  service  as  temporary  remedies.  They  help  to  check 
the  effusion  l)y  constricting  the  small  vessels,  but  they  do  not  assist  absorption  ; 
and  the  sooner  methodical  compression  is  applied  the  better.  Care,  of  course,  must 
be  taken  that  the  pressure  really  falls  upon  the  parts  that  need  it — not,  for  ex- 
ample, in  the  ankle,  on  the  heel  and  the  malleoli.  Passive  motion  should  be 
commenced  as  soon  as  the  effusion  is  absorbed,  on  the  second  or  third  day.  Even 


DISL  O  CA  TIONS.  49  7 

if  the  ligaments  are  torn,  the  joints  may  be  moved  gently  through  a  very  wide 
range,  without  throwing  the  least  strain  upon  them.  For  this  reason  a  fixed  ap- 
paratus, such  as  plaster-of- Paris,  should  never  be  employed  in  sprains. 


Dislocations. 

A  dislocation  is  a  sudden  displacement  of  one  of  the  bones  of  a  joint  from 
its  normal  position.  (Gradual  displacements,  which  result  either  from  disease 
(pathological)  or  from  malformation  (congenital),  are  better  dealt  with  by 
themselves. 

Dislocations  are  said  to  be  complete  when  the  articular  surfaces  are  entirely 
separated  from  each  other,  incomplete  when  they  are  still  to  a  certain  extent  in 
contact,  as  usually  happens,  for  example,  in  the  case  of  the  knee.  They  are  sim- 
ple if  the  skin  is  unbroken,  compound  {open)  if  there  is  a  wound  exposing  the 
interior  of  the  joint ;  and  the  distal  segment  of  a  limb  is  always  described  as 
being  displaced  from  the  proximal. 

Causes. — These  are  either  predisposing  or  immediate. 

1.  Predisposing. — Dislocations  are  met  with  at  all  times  of  life,  from  birth  to 
old  age,  but  with  very  different  degrees  of  frequency.  With  the  exception  of  the 
elbow-joint,  they  are  much  more  common  in  adult  life,  because  then  the  bones  are 
at  their  strongest,  and  naturally  they  are  more  often  met  with  among  men  than 
among  women.  But,  independently  of  this,  there  is  a  certain  class  of  persons  in 
whom  they  are  peculiarly  liable  to  occur.  The  muscles  are  poorly  developed,  the 
bony  prominences  feebly  marked,  and  the  ligaments  loose  and  yielding,  so  that 
the  slightest  force,  if  the  muscles  are  caught  unawares,  is  enough  to  cause  displace- 
ment. Fortunately  in  many  of  these  the  capsule  is  not  torn  and  the  injury  is 
really  only  a  subluxation,  but  occasionally  it  gives  way  under  the  strain  and  the 
head  of  the  bone  is  forced  through  the  rent. 

Certain  joints  are  especially  liable  to  dislocation.  In  many  instances  this 
may  be  explained  by  their  situation  or  construction.  The  shoulder,  for  example, 
which  depends  for  its  security  mainly  on  the  muscles  that  surround  it,  not  on  the 
shape  of  its  articular  surfaces  or  on  the  strength  of  the  ligaments,  is  dislocated 
more  frequently  than  all  the  rest  of  the  joints  together.  In  children,  again,  dis- 
location of  the  elbow  is  particularly  common,  owing  to  the  small  size  and  smooth, 
rounded  surface  of  the  coronoid,  which  does  not  offer  so  much  resistance  as  the 
sharply  marked  process  of  adult  life.  In  other  instances  the  tendency  is  acquired  ; 
a  shoulder-joint  that  has  once  been  dislocated  is  more  likely  to  be  dislocated  a 
second  time  ;  and  if  this  happens  often,  the  joint  becomes  so  insecure  that  the 
bone  slips  in  and  out  of  the  socket  whenever  the  arm  is  raised  from  the  side. 

2.  Im/nediate. — These  are  muscular  action  and  external  violence. 

(i)  Muscular  Action. — In  some  instances,  notably  the  lower  jaw  and  the  pa- 
tella, this  acts  entirely  by  itself ;  in  most,  however,  it  is  only  of  secondary  impor- 
tance, fixing  the  segments  of  the  joint  and  rendering  other  articulations  rigid,  so 
that  force  is  transmitted  unbroken  along  the  limb  ;  and  in  dislocations  by  direct 
violence  it  plays  no  part  at  all.  0*1  the  other  hand,  it  is  almost  entirely  responsi- 
ble for  what  is  known  as  consecutive  displacement,  that  is,  the  alteration  in  the 
position  of  the  dislocated  bone  after  it  has  been  driven  through  the  capsule. 

(2)  External  Violence. — This  may  be  either  direct  or  indirect.  The  former 
is  not  common ,  but  it  occasionally  happens  that  the  head  of  the  humerus  is  driven 
directly  through  the  capsule  of  the  joint  by  a  blow  upon  the  shoulder  ;  or,  when 
the  body  is  much  flexed,  the  head  of  the  femur  forced  out  from  the  acetabulum  on 
to  the  dorsum. 

In  dislocations  by  indirect  violence  the  force  is  applied  at  some  distance  from 
the  articulation,  either  to  the  sauie  bone,  or,  as  it  falls  upon  the  hand,  to  the  other 
end  of  the  limb.  The  neck  of  the  bone  is  fixed  and  acts  as  a  fulcrum,  and  the 
head,  which  represent  the  short  arm  of  the  lever,  is  tilted  out  from  its  socket  and 


498     DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 

forced  against  the  capsule  until  it  is  driven  through  it.     The  spasmodic  contrac- 
tion of  the  muscles  and  the  weight  of  the  jjart  drag  it  still  further  aside. 

Pathology. —  ihe  immediate  effects  of  a  dislocation  are  more  extensive  than 
woidd  be  expected  from  the  api)earance  of  the  i)art  and  from  the  ease  with  which 
repair  is  carried  out  when  the  skin  is  unbroken.  (Generally  speaking,  the  tissues  on 
one  side  of  a  limb  are  strained  and  rent,  those  on  the  other  crushed  and  bruised 
by  the  pressure  of  the  displaced  bone.  Ecchymosis,  sometimes  making  its  appear- 
ance a  long  way  off,  and  perhai:)S  days  after  the  injury,  is  always  a  prominent  fea- 
ture. The  capsule  is  usually  torn  at  its  weakest  spot,  sometimes  it  is  stripped  off 
tne  bone,  and  occasionally  it  drags  away  with  it  portions  of  the  articular  margin. 
The  ligaments  suffer  in  the  same  way,  excejit  the  stronger  ones,  such  as  the  ilio- 
femoral band  at  the  hip,  and  the  interosseous  one  between  the  tibia  and  fibula  at 
their  lower  extremity  ;  these  either  resi.st  successfully,  or  only  give  way  after  the 
bones  are  broken.  The  muscles  are  always  more  or  less  cru.shed  and  bruised  ;  in 
many  instances  they  are  extensively  torn,  unless,  as  sometimes  happens,  they  wrench 
away  with  them  the  process  of  bone  to  which  they  are  attached.  Arteries  and 
veins  share  the  same  fate,  but  though  they  are  not  unfrequently  compressed  and 
bruised,  so  that  the  circulation  through  the  limb  is  interfered  with  and  even  inter- 
rupted altogether,  the  larger  ones  are  rarely  torn  across  in  recent  dislocations, 
unless  the  violence  is  extreme.  Nerves  escape  even  better  :  they  are  so  tough 
that  they  rarely  give  way,  but  if  they  are  compressed  there  may  be  most  intense 
jiain.  and  if  it  is  kept  up  for  any  length  of  time  permanent  loss  of  power  may 
follow. 

The  bones  are  frequently  broken  ;  sometimes,  as  already  mentioned,  merely  a 
process  is  torn  off;  sometimes,  as  in  the  case  of  the  fibula,  when  the  ankle  is  dis- 
located, the  shaft  gives  way,  perhaps  at  a  distance  from  the  seat  of  injury.  Occa- 
sionally other  structures  that  lie  near  are  injured  too  ;  the  trachea,  for  example, 
may  be  seriously  compressed  in  dislocations  of  the  clavicle,  and  the  spinal  cord  of 
the  medulla  may  be  crushed  in  displacement  of  the  vertebrae. 

As  soon  as  reduction  is  accomplished  these  effects  begin  to  pass  away;  the 
blood  becomes  absorlied,  the  effusion  into  the  synovial  sac  and  the  spaces  near  it 
disajjpear,  and  the  lymph  thrown  out  by  the  injured  structures  gradually  becomes 
organized.  In  some  instances,  where  the  capsule  is  very  extensively  torn,  the  rent 
is  never  thoroughly  repaired,  and  the  joint  remains  weak  and  untrustworthy.  In 
others  an  excessive  amount  of  lymph  is  thrown  out ;  for  want  of  properly  regulated 
passive  motion,  adhesions  form  between  adjacent  parts,  and  the  joint  becomes  stiff 
and  more  or  less  crippled  and  painful.  The  same  thing  may  happen  from  injury  to 
the  neighboring  muscles.  Occasionally  inflammation  sets  in — suppurative  arthritis 
very  rarely,  so  long  as  the  skin  is  unbroken  ;  but  rheumatoid  arthritis,  or  gout,  or 
strumous  disease,  according  to  the  particular  diathesis,  not  uncommonly. 

If  the  dislocation  is  not  reduced  the  head  of  the  bone  and  the  surrounding 
structures  mutually  adapt  themselves  to  each  other.  The  old  cavity  gradually  be- 
comes contracted  and  shallow  ;  in  many  cases  the  outline  becomes  angular  from  the 
pressure  of  the  displaced  head  resting  on  one  of  its  borders  ;  the  cartilage  at  the 
bottom  grows  thinner  and  thinner,  and  either  disappears  altogether,  or  is  replaced 
by  fibrous  tissue  which  fuses  with  the  shrunken  and  collapsed  remains  of  the  cap- 
sule ;  and,  at  length,  though  some  seml)lance  of  its  original  character  is  always 
preserved,  the  socket  becomes  so  altered  that  even  if  the  head  of  the  bone  were 
replaced  it  could  no  longer  play  its  proper  part.  How  soon  these  changes  take 
jjlace  depends  mainly  upon  the  age  of  the  patient  and  the  presence  or  absence  of 
that  kind  of  inflammation  which  so  often  complicates  joint  injuries.  On  the  one 
hand,  the  glenoid  fossa  has  been  found  so  altered  within  thirteen  weeks  of  the  acci- 
dent that  reduction  could  not  have  been  effected  ;  on  the  other,  the  acetabulum 
has  been  shown  to  be  to  all  intents  and  purposes  intact  after  as  many  years. 

The  changes  in  the  displaced  bone  depend  chiefly  upon  the  character  of  the 
bed  upon  which  it  rests  and  the  extent  to  which  the  limb  is  exercised.  If  the 
articular  surface  is  imbedded  in  muscles,  or  lies  upon  a  soft  ma.ss  of  connective 


DISLOCATIONS. 


499 


.^f>s. 


\ 


tissue,  the  cartilage  slowly  becomes  fibroid  and  disapjiears,  the  ends  of  the  bones 
waste  away,  and  lose  their  characteristic  shape,  and  adhesions  form  between  them 
and  the  structures  around.  Where,  on  the  other  hand,  it  is  directly  in  contact 
with  the  periosteum,  as  in  subcoracoid  dislocation  of  the  humerus,  the  surfaces 
wear  each  other  away  and  become  moulded  together  in  such  a  fashion  that  the 
original  outline  can  hardly  be  traced.  In  most  instances  the  cartilage  disap- 
jiears  and  the  articular  lamella  beneath  becomes  hard  and  eburnated,  as  in  rheu- 
matoid arthritis  (Fig.  203)  ;  sometimes  it 
becomes  fibrous,  and  a  dense  layer  of  simi- 
lar material  forms  on  the  opposing  surface, 
so  that  movement  is  smooth  and  free.  In 
time,  if  the  part  is  sufficiently  used,  a  new 
socket  is  developed,  ])artly  worn  out  by  ab- 
sorption, partly  built  up  by  the  deposit  round 
the  margin  from  the  irritated  periosteum  ; 
and  the  lymph  thrown  out  by  the  surround- 
ing tissues  becomes  modeled  into  a  capsule, 
lined  with  a  membrane  like  that  found  in 
adventitious  bursre,  and  filled  with  a  similar 
kind  of  fluid  (Figs.  204  and  205).  Occa- 
sionally this  is  carried  to  such  an  extent  that 
the  joint  becomes  nearly  as-  useful  as  it  was 
before;  but  as  a  rule,  hinge  joints  do  not 
succeed  so  well  as  ball-and-socket  ones. 

All  the  structures  that  lie  near  are  more 
or  less  affected  ;  the  old  capsule  shrinks  and 
contracts  or  becomes  adherent  to  the  car- 
tilage ;  the  muscles  waste  from  disuse  and 
become  fatty  ;  the  bone  is  hollowed  out  in 
the  interior ;  and  the  tissues  are  matted 
together  l)y  bands  of  organized  lymph. 
Sometimes  the  displaced  bone  is  firmly  fixed  ; 

sometimes  it  is  so    movable    that    it  becomes   Fig.  203— Old   Subcoracoid  Luxation   of  Humerus. 

T  CTrnvp  QniirrP  nf  inr^nnvf^niAno^         Doz-acinn  '^^^   "*^  cavity   is  for  the  most  part  eburnated; 

a  grave  source  01  inconvenience.        occasion-       around  is  a   new  capsule  of    fibrous  tissue,  while 

ally   it   causes    very    serious   consequences    by       someoftheoldisstiUleft  asafringeon  theedgeof 
■'      .  ■'  .  ^  .     •'        the  glenoid  fossa. 

pressing  upon  or  becoming  adherent  to  im- 
portant structures,  such  as  nerves  and  blood-vessels.  In  all  probability  this  is  the 
reason  why  rupture  of  the  axillary  artery  occurs  so  frequently  in  reducing  old  dis- 
locations of  the  humerus.  The  vessel  is  bound  down  to  the  head  of  the  bone  by 
adhesions,  so  that  the  strain  falls  directly  upon  it  as  soon  as  any  traction  is  made 
upon  the  limb. 

Symptoms  and  Diagnosis. — The  only  certain  sign  of  a  dislocation  is  the 
sudden  disappearance  of  the  articular  end  of  a  bone  from  its  normal  situation,  or 
its  sudden  appearance  somewhere  else.  The  account  of  the  accident,  though  it 
should  always  be  carefully  enquired  into,  is  only  of  use  as  confirmation,  and  the 
pain  depends  mainly  upon  accidental  circumstances.  In  most  instances  it  is 
severe  and  long-continued,  but  when  the  dislocation  has  already  occurred  several 
times  it  may  be  comparatively  slight.  Only  in  such  cases  as  when  the  head  of  the 
humerus  presses  upon  the  brachial  plexus  and  causes  intense  neuralgia  down  the 
arm,  can  it  be  looked  upon  as  a  diagnostic  sign. 

The  first  thing,  therefore,  is  to  compare  the  injured  part  with  the  corre- 
sponding joint  on  the  opposite  side  of  the  body.  Sometimes  the  alteration  in 
outline  is  conspicuous  at  the  first  glance,  as  in  the  sterno-clavicular  articulation  ; 
or,  as  in  dislocations  of  the  hip,  the  position  of  the  limb  is  enough  to  prove,  not 
only  that  the  head  of  the  bone  has  been  forced  out  of  its  socket,  but  that  it  has 
been  driven  in  one  definite  direction.  If  inspection  fails,  there  may  be  some 
marked  alteration  in  the  length  of  the  limb ;  or  local  measurements,  especially  in 


v^-" 


5oo    DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

such  joints  as  the  elbow,  where  the  bony  prominences  are  close  beneath  the  skin, 
may  supply  the  necessary  evidence.  If  the  diagnosis  is  still  uncertain,  deep 
pressure  may  reveal  the  altered  position  of  the  bones  ;  natural  {)rominences  may 
have  disappeared,  or  some  depression  may  be  filled  up.  Finally,  before  an  attempt 
is  made  to  move  the  part,  valuable  information  may  sometimes  be  obtained  from 
other  evidence  of  local  pressure  ;  the  arm,  for  example,  may  be  cedematous,  from 
the  head  of  the  humerus  resting  upon  the  axillary  vein,  or  the  pulse  at  the  wrist 
may  be  absent,  from  compression  of  the  artery. 

Inspection,  measurement,  and  palpation  may  prove  the  existence  of  a  disloca- 
tion ;  manipulation  only  can  determine  the  particular  variety  and  exclude  all  other 
injuries.  Owing  to  the  pain  it  causes,  it  should  always  be  postponed  to  the  last ; 
and,  particularly  in  the  case  of  the  hip  and  elbow,  it  is  often  necessary  to  admin- 
ister an  aniEsthetic  ;  the  strength  and  the  size  of  the  muscles  in  the  one,  and  the 
amount  of  swelling  in  the  other,  render  it  a  matter  of  very  great  difficulty  without. 
Voluntary  movements  are  always  restricted  ;  in  many  instances,  as  in  dislocations 
of  the  lower  jaw,  they  are  altogether  impossible  ;  passive  movements  are  more 
variable  ;  sometimes,  when  the  soft  parts  are  very  extensively  torn,  they  are  unnat- 


FiG5.  204  and  205. — New  Sockets  in  Old  Pubic  and  Subspinous  Dislocations  of  Hip. 


urally  free,  especially  when  the  patient  is  under  an  anaesthetic  ;  but  nearly  always 
they  are  restricted  in  at  least  one  direction,  either  by  the  locking  of  the  bones  or 
by  the  tightening  up  of  ligaments  that  have  not  given  way. 

The  diagnosis  has  to  be  made  from  severe  sprains,  fractures  in  the  neighbor- 
hood of  a  joint,  and  the  separation  of  epiphyses.  The  chief  features  are  the 
absence  of  crepitus,  the  character  of  the  deformity,  the  fact  that  when  it  has  once 
been  rectified  it  does  not  return,  and  the  immobility  of  the  part,  both  as  regards 
active  and  passive  movement ;  but  not  one  of  these  by  itself  can  be  regarded  as 
sufficient.  Crepitus  is  absent  in  many  fractures  and  present  in  many  dislocations, 
because  there  is  a  fracture  combined  with  them  ;  moreover,  false  crepitus,  due  to 
the  displaced  bone  rubbing  over  tendons  or  pressing  on  bursx  filled  with  extrava- 
sated  blood,  is  sometimes  very  difficult  to  distinguish  from  real.  Deformity,  too, 
may  return  at  once,  unless  steps  are  taken  to  prevent  it  (as  in  dislocations  of  the 
ankle),  and  immobility,  passive  as  well  as  active,  is  not  by  any  means  a  sure  guide. 
In  each  case  it  is  absolutely  necessary  to  weigh  the  whole  of  the  evidence  before 
coming  to  a  positive  decision. 

A  peculiar  condition  is  occasionally  met  with  in  ball-and-socket  joints  (espe- 


DISL  O  CA  T/ONS.  5  o  i 

cially  the  shoulder),  wliith,  though  not  a  dislocation  in  the  strict  sense  of  the  term, 
yet  resembles  it  in  many  respects.  The  head  of  the  bone  and  the  socket  are  both 
intact,  but  they  are  not  in  apposition.  The  capsule  is  stretched  ;  the  articular 
surfaces  are  separated  ;  there  is  complete  loss  of  power ;  the  position  of  the  limb 
is  that  of  a  real  dislocation,  but  there  is  undue  mobility.  In  the  case  of  the 
humerus  there  is  generally  paralysis  of  the  muscles,  passing  from  the  trunk  to  the  arm, 
and  the  head  of  the  bone  can  be  replaced  at  once  by  raising  the  elbow  ;  in  other 
joints  it  seems  to  be  the  result  of  chronic  distention  of  the  capsule:  the  fluid  in- 
sinuates itself  between  the  articular  surfaces,  and  the  fil)res  become  softened  and 
stretched  until  they  can  no  longer  liold  the  bones  in  jjosition.  It  cannot  be  called 
a  dislocation,  because  the  head  of  the  bone  still  lies  within  the  capsule  ;  but  neither 
can  it  be  compared  with  those  cases  in  which,  as  a  result  of  rheumatoid  arthritis  or 
strumous  inflammation,  the  cartilages  are  eroded,  the  bones  exposed,  and  the  cap- 
sule completely  destroyed. 

Treatment. — Dislocations  should  in  all  cases  be  reduced  as  soon  as  possible. 
The  obstacles  are  of  two  kinds.  One  is  mechanical  ;  the  head  of  the  bone,  for 
example,  no  longer  corresponds  to  the  rent  in  the  capsule  ;  or  it  is  caught  by  some 
ligament  or  tendon,  or  locked  against  some  other  bone.  The  other  is  the  contrac- 
tion of  neighboring  muscles.  Immediately  after  the  accident  they  are  relaxed  and 
offer  but  slight  resistance.  In  a  short  time  they  begin  to  contract  and  drag  the 
dislocated  bone  further  and  further  away.  Soon  they  become  absolutely  rigid,  and 
at  length  they  undergo  a  kind  of  fibroid  degeneration  ;  a  great  deal  of  their  exten- 
sibility is  lost,  and  they  tear  sooner  than  stretch.  In  recent  dislocations  this  source 
of  difficulty  disai)pears  entirely  under  an  anc^sthetic  ;  in  old  ones  it  is  added  to  the 
rest. 

There  are  two  methods  of  effecting  reduction,  manipulation  and  extension. 
In  the  former,  which  is  almost  always  used  for  ball-and-socket  joints,  the  muscles 
are  relaxed,  either  by  placing  the  patient  under  an  anaesthetic  or  by  moving  the 
limb  in  suitable  directions  ;  the  head  of  the  bone  is  disentangled  from  the  structures 
that  hold  it,  and  brought  back  along  the  route  it  has  taken  until  it  is  opposite  the 
rent  in  the  capsule ;  then  it  is  either  lifted  over  the  margin  of  the  socket  or  tilted 
in  by  using  the  untorn  portion  of  the  capsule  as  a  fulcrum  and  making  the  limb 
the  long  arm  of  the  lever.  In  the  latter  the  muscles  are  stretched  until  they  either 
yield  or  tear,  all  obstacles  are  broken  down  or  pushed  aside  by  main  strength,  until 
the  head  of  the  bone  is  free  and  can  be  forced  into  position  again. 

Extension  may  be  made  with,  or  without,  the  aid  of  appliances,  but  in  recent 
dislocations  it  rarely  happens  that  more  than  a  jack-towel  is  required.  The  trunk 
or  the  proximal  segment  of  the  limb  must  be  securely  held  for  counter-extension. 
If  it  is  the  humerus,  the  knee  or  the  foot  may  be  placed  in  the  axilla ;  or  a  well- 
padded  towel  or  leather  belt  passed  round  the  arm  and  fixed  to  a  hook  or  staple 
in  the  opposite  wall ;  but  it  is  of  great  advantage  to  have  an  assistant  who,  besides 
helping  to  fix  the  scapula,  can  manipulate  and  disengage  the  head  of  the  bone  at 
the  same  time.  In  the  case  of  the  femur,  if  manipulation  has  failed  and  extension 
is  being  tried,  this  is  always  one  person's  duty. 

In  recent  dislocations,  simple  manual  extension  is  generally  suificient,  espe- 
cially if  the  muscles  are  relaxed  by  an  anaesthetic  ;  and  the  limb  may  be  grasped 
at  the  most  convenient  situation — the  wrist,  for  example,  in  dislocations  of  the 
humerus.  If  more  than  this  is  required,  a  jack-towel  may  be  made  into  a  clove- 
hitch  and  fastened  round  the  limb  ;  but  the  skin  must  be  perfectly  protected  by 
means  of  a  wet  bandage,  and  extension  must  be  made  from  the  lower  end  of  the 
displaced  bone  without  an  intervening  joint.  If  the  limb  is  grasped  with  the  hands, 
and  the  loop  of  the  towel  is  passed  over  the  shoulder  of  the  operator,  so  that  he 
can  bring  into  play  the  muscles  of  his  back,  sufficient  power  may  be  obtained  to 
overcome  the  resistance  of  any  joint  but  the  hip. 

If  the  dislocation  has  already  lasted  some  length  of  time,  so  that  the  muscles 
have  degenerated  and  the  lymph  has  become  organized,  mechanical  contrivances, 
such  as  multiplying  pulleys,  may  be  required.     The  adhesions  are  first  broken 


502     DISEASES  AND   INJURIES   OF  SPECIAL   SIKUCTUKES. 

clown  hy  inaniptilatiun  and  rotation  ;  then  the  limb  is  carefully  bandaged  with  a  wet 
roller  to  prevent  slipping  and  to  protect  the  skin  ;  counter-extension  arranged  so 
as  to  avoid  bruising,  and  to  leave  the  part  accessible;  and  the  leather  collar  to 
which  the  cord  of  the  pulley  is  attached  buckled  round  the  lower  end  of  the  dis- 
placed bone.  An  anaesthetic  is  indisijensable.  The  other  end  of  the  pulleys  is  then 
made  secure,  and  the  rope  tightened  very  gradually  and  quietly,  avoiding  anything 
like  a  sudden  jerk,  and  making  extension  in  the  axis  of  the  limb.  The  amount  of 
force  must  be  regulated  by  the  case :  the  operator  must  keep  his  hands  upon  the 
head  of  the  bone,  assisting  it  as  far  as  he  can  in  the  right  direction  by  manipula- 
tion and  rotation,  and  watching  carefully  the  progress  tliat  it  makes  and  the  tension 
upon  the  skin.  Very  serious  injuries  have  before  now  been  inflicted  in  cases  of 
this  kind,  and  sometimes  important  structures  have  been  torn  across,  even  when 
the  amount  of  force  used  was  quite  insignificant,  probably  ow-ing  to  the  tissues 
being  bound  together  by  adhesions,  or  softened  and  weakened  by  degeneration. 

When  pulleys  are  not  available,  a  very  efficient  substitute  may  be  manufactured 
out  of  a  simple  piece  of  rope  doubled  once  or  twice  upon  itself.  By  placing  a  ruler 
in  the  middle  and  twisting  it  up,  any  required  degree  of  traction  may  be  obtained, 
slowly  and  evenly.  No  estimate,  it  is  true,  can  be  formed  as  to  the  actual  amount 
of  force  employed  ;  but  it  is  more  than  doubtful  whether  .such  is  really  of  any  use  ; 
each  case  must  be  decided  on  its  own  merits. 

As  soon  as  the  head  of  the  bone  is  brought  down,  an  attempt  must  be  made 
to  carry  it  in  the  direction  of  the  socket.  If  it  is  the  humerus,  the  arm  is  draw^n 
across  the  chest,  making  use  of  the  surgical  neck  as  a  fulcrum,  or  it  is  abducted  as 
far  as  it  can  go  ;  or,  while  the  arm  is  fixed,  the  trunk  is  swayed  slowly  from  side 
to  side.  If  the  femur,  a  broad  band  is  looped  round  the  thigh  to  lift  the  bone  up- 
ward, or  outward,  according  to  the  direction  of  the  displacement.  In  the  case 
of  the  lower  jaw,  again,  firm  pressure  is  made  in  a  backward  direction  upon  the 
coronoid  processes.  In  short,  in  each  dislocation  the  method  of  manipulation, 
when  once  the  head  of  the  bone  has  been  forced  down,  must  be  guided  by  the 
structure  of  the  joint,  the  direction  of  the  misplacement,  and  the  character  of  the 
obstacles  that  stand  in  the  way. 

After  a  certain  period,  varying  for  each  joint,  reduction  becomes  impossible. 
Even  if  it  could  be  effected,  it  is  more  than  doubtful  whether  the  use  of  the  part 
w^ould  in  any  way  be  improved,  owing  to  the  extensive  changes  that  take  place 
about  the  articular  ends.  In  such  cases  all  that  can  be  done  is  to  break  down  the 
adhesions  as  thoroughly  as  possible,  and  by  means  of  massage,  friction,  galvanism, 
and  passive  motion,  improve  the  nutrition  and  freedom  of  the  parts  as  far  as 
may  be. 

In  recent  dislocations,  when  the  patient  is  not  under  the  influence  of  an  anaes- 
thetic, as  soon  as  the  head  of  the  bone  is  brought  opposite  to  the  rent,  it  is  pulled 
into  the  socket,  with  a  sudden,  sometimes  almost  audible,  snap.  In  old  ones,  how- 
ever, or  when  the  muscles  are  relaxed,  and  in  paralyzed  limbs,  rejilacement  is 
gradual,  and  may  even  be  imperceptible,  except  for  the  restoration  of  the  full  range 
of  movement,  and  a  certain  amount  of  alteration  in  shape. 

The  treatment  of  a  dislocation,  after  it  has  been  reduced,  does  not  differ  from 
that  of  a  severe  sprain  :  the  joint  must  l)e  secured,  so  that  there  is  no  danger  of  a 
recurrence  ;  kept  perfectly  quiet,  and  either  liandaged  or  covered  with  some  evap- 
orating lotion,  or  with  Leiter's  coils.  Inflammation  rarely  follows,  j^robably  be- 
cause the  capsule  is  extensively  torn,  and  intra-articular  tension  is  impossible  ;  but, 
for  all  that,  every  precaution  .should  be  taken  to  prevent  its  occurrence. 

The  length  of  time  the  joint  should  be  kept  at  rest  dei)ends  more  upon  its  kind 
and  construction  than  on  the  injury  that  has  been  inflicted.  There  are  dangers  on 
either  side.  On  the  one  hand,  if  the  part  is  kept  at  rest  too  long,  adhesions  may 
form  between  contiguous  surfaces,  or  the  capsules  become  hard  and  rigid.  On  the 
other,  if  movement  is  allowed  too  soon,  there  is  always  the  possibility  of  the  rent 
in  the  capsules  never  being  repaired,  or,  worse  still,  of  inflammation  setting  in.  The 
question  turns  mainly  upon  the  kind  of  movement.     Passive  motion  is  perfectly 


DISLOCATIONS. 


503 


safe,  and,  if  carn'ccl  out  under  proper  sui)ervisi()n,  may  be  commenced  in  the  first 
week  ;  it  stretches  out  tiie  folds  of  the  capsule,  prevents  the  muscles  and  ligaments 
becoming  shortened,  and  checks  the  formation  of  adhesions,  without  entlangering 
the  prospect  of  union  or  giving  the  faintest  reason  for  inflammation.  Active  move- 
ment, on  the  other  hand,  because  it  cannot  be  so  well  controlled,  must  be  postponed 
until  passive  motion  is  free  from  pain,  and  until  all  risk  of  recurrence  has  disap- 
peared. \\\  the  hip  and  elbow,  where  the  security  of  the  joint  is  dependent  upon 
the  shape  of  the  articular  surfaces,  it  may  be  allowed  with  certain  precautions  after 
the  first  few  days;  in  the  lower  jaw,  however,  and  still  more  in  the  shoulder,  free 
movement  without  restriction  cannot  be  permitted  lor  at  least  a  month,  and  certain 
particular  actions  are  especially  to  be  forbidden.  A  variable  amount  of  stiffness  is 
always  present  after  a  dislocation,  and  the  muscles  atrophy  to  some  degree,  particu- 
larly the  extensors  ;  but  this  soon  disappears.  Massage  and  galvanism  are  of  very 
great  service  if  it  shows  the  least  tendency  to  persist.  It  must  not,  however,  be 
forgotten  that  a  rapidly  progressive  form  of  osteo-arthritis  is  not  an  uncommon 
complication  of  joint  injuries,  especially  in  those  who  are  gouty  or  rheumatic,  and 
that  muscular  wasting  is  one  of  its  earliest  signs. 

Coi)ipoit)id{i}peii)  dislocations,  in  which,  in  addition  to  the  displacements  of  the 
bones,  the  skin  is  torn  or  cut  and  the  synovial  cavity  of  the  joint  exposed,  are  ex- 
ceedingly serious,  even  when  they  are  not  complicated  by  the  addition  of  fractures 
or  other  injuries.  The  danger  is  the  occurrence  of  suppurative  arthritis.  If  this 
breaks  out,  the  joint  rarely  recovers  without  some  degree  of  ankylosis  ;  often  the 
cavity  is  entirely  obliterated  and  the  articular  surfaces  are  united  together  by  dense 
fibrous  tissue  or  by  bone.  Even  this  result,  however,  cannot  always  be  obtained. 
If  suppuration  once  develops  it  is  impossible  to  say  when  or  where  it  will  stop, 
and  the  risk,  as  regards  life  as  well  as  limb,  increases  with  the  size  and  complexity 
of  the  synovial  membrane.  Abscesses  may  form  in  the  tissues  near  ;  the  pus  may 
spread  in  the  tendon  sheaths,  or  in  the  loose  tissue  around  them  half-way  along 
a  limb  ;  erysipelas,  cellulitis,  or  pyeemia  may  break  out  at  any  moment ;  the  bones 
may  be  eaten  away  on  the  surface  or  even  perish  completely  ;  and  at  length,  if  the 
patient  does  not  succumb  from  septic  absorption,  and  if  the  limb  does  recover, 
it  may  be  so  stiff  and  oedematous  as  to  be  absolutely  useless,  or  there  may  be  such 
an  amount  of  discharge  that  it  has  to  be  removed  for  fear  of  hectic  or  amyloid 
disease. 

The  treatment  of  open  dislocations  must  be  guided  by  the  same  considera- 
tions as  that  of  open  fractures  into  joints.  The  choice  lies  between  an  attempt 
to  save  the  part,  excision  or  amputation  ;  and  the  decision  must  be  determined  in 
each  case  partly  by  the  age  and  constitution  of  the  patient,  partly  by  the  situation 
of  the  joint  and  the  extent  of  the  injury.  The  first  question  is  whether  it  is  pos- 
sible to  save  the  limb  without  running  too  great  a  risk,  and  whether,  supposing  this 
is  successful,  the  limb  is  likely  to  be  of  any  use  afterward.  In  open  dislocations 
of  the  knee  joint  there  is  rarely  any  hope  unless  the  tissues  at  the  back  are  quite 
intact ;  but  in  other  joints,  especially  in  those  of  the  upper  extremity,  it  can  often 
be  managed,  if  only  the  vessels  are  unhurt  and  the  skin  not  too  much  torn  or 
stripped  up.  Nerves  do  not  seem  to  be  of  so  much  consequence  in  this  matter ; 
they  are  so  tough  that  they  rarely  give  way,  and  even  if  they  do  they  may  often 
be  joined  again  by  means  of  sutures. 

Whether  the  joint  should  be  excised  or  not  depends  upon  the  condition  of  the 
ends  of  the  bones.  If  they  are  comminuted,  and  the  soft  parts  not  seriously  injured, 
this  may  be  done  with  great  success,  especially  in  the  case  of  the  shoulder  and 
elbow ;  but  it  must  always  be  remembered  that  primary  excision  is  not  to  be  com- 
pared, either  in  its  course  or  its  results,  with  the  same  operation  when  performed 
for  disease.  The  smaller  joints,  those  in  the  fingers,  for  example,  sometimes  suc- 
ceed very  well. 

If  it  is  decided  to  try  and  save  the  joint,  the  protruding  bone  and  the  surround- 
ing skin  must  first  be  thoroughly  cleansed  with  some  antiseptic  ;  fragments  that  are 
too  much  bruised  or  ground-in  with  dirt  to  live,  removed  ;  and  reduction  effected 


504    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

as  soon  as  possible.  (lenerally  there  is  no  difticulty  in  this,  owing  to  the  extent  of 
the  laceration  ;  but  sometimes  the  head  of  the  bone  is  so. tightly  embraced  by  the 
skin  that  the  opening  has  to  be  carefully  enlarged. 

Then  the  cavity  of  the  joint  must  be  washed  out  again  and  again,  and  laid 
freely  open,  so  that  there  may  be  thorough  drainage.  The  most  efficient  method 
of  carrying  this  out  is  either  to  immerse  the  part  bodily  for  an  hour  each  day  in  a 
bath  of  corrosive  sublimate  or  carbolic,  with  the  wounds  widely  open,  or  to  use 
continuous  irrigation  with  water  as  already  described  in  speaking  of  penetrating 
wounds.  Merely  i)assing  a  drainage-tube  through  the  synovial  cavity  is  of  little  or 
no  service,  and  small  incisions  are  worse  than  useless  ;  the  discharge  must  be  thor- 
oughly removed.  The  limb  may  then  be  placed  upon  a  splint,  well  bandaged, 
raised  and  kept  at  perfect  rest  in  the  position  that  will  ultimately  be  most  useful. 
An  ice-bag  laid  upon  the  joint,  or  over  the  course  of  the  main  artery  of  the  limb, 
is  of  some  assistance  in  controlling  the  amount  of  blood  flowing  to  the  part ;  but 
care  should  be  taken  that  the  application  is  really  continuous. 

The  further  course  must  be  guided  by  the  temi)erature  and  the  degree  of 
inflammation  that  ensues.  Careful  watch  must  be  kept  that  the  discharge  cannot 
collect  anywhere.  If  suppuration  sets  in  the  freest  possible  incisions  may  still  be 
tried  ;  but  unless  it  is  checked  at  once  the  cartilages  necrose,  the  synovial  lining 
is  destroyed,  the  cavity  is  filled  with  granulation  tissue,  and  abscesses  form  every- 
where in  the  cellular  tissue  around.  At  first  the  constitutional  disturbance  is  ex- 
ceedingly severe,  especially  in  the  case  of  the  larger  joints  ;  gradually,  as  the  tissues 
gain  the  upper  hand,  the  fever  begins  to  drop  of  a  morning,  and  if  no  further  com- 
jjlication  sets  in  assumes  the  hectic  type  ;  and  then  again  it  may  become  a  question 
whether  the  patient's  strength  is  sufficient ;  or  whether  it  may  not  be  advisable  to 
perform  some  secondary  operation,  excision,  or  even  amputation. 

Fractures  and  dislocations  are  not  unfrequently  combined,  and  occasionally, 
a  fracture  is  present  as  a  complication  ;  the  humerus,  for  example,  is  dislocated,  and 
the  surgical  neck  broken  by  the  same  force.  When  this  occurs  it  has  been  recom- 
mended to  allow  the  fracture  to  unite  before  attempting  to  reduce  the  dislocation, 
but  if  it  is  possible  the  head  of  the  bone  should  be  replaced  at  once.  The  patient 
should  be  placed  under  an  anesthetic,  the  fracture  securely  fixed  between  splints, 
and  the  displaced  bone  manipulated  as  far  as  it  can  be  in  the  right  direction.  Ex- 
tension may  be  tried  if  the  fracture  is  at  some  distance,  at  the  other  end  of  a  long 
bone,  or  even  in  the  middle  ;  but  if  the  injury  is  near  the  joint  it  is  rarely  prac- 
ticable. If  this  fails  the  only  course  left  is  either  to  lay  the  part  open,  and 
convert  the  fracture  into  a  compound  one  communicating  with  a  synovial  cavity, 
or  by  passive  motion  to  encourage  as  far  as  possible  the  formation  of  a  false 
joint. 

Dislocations  of  the  Lower  Jaw. 

Dislocation  of  the  lower  jaw  may  be  unilateral  or  bilateral,  but  it  can  only 
take  place  in  one  direction,  forward.  As  the  mouth  opens  the  condyle  and  the 
fibro-cartilage  are  brought  forward  together  upon  the  eminentia  articularis  ;  the 
external  lateral  ligament,  which  normally  runs  downward  and  backward,  becomes 
nearly  vertical ;  the  internal  and  posterior  are  stretched,  and  the  coronoid  pro- 
cess is  lowered  into  a  slanting  direction.  If  at  this  moment  the  external 
pterygoid  contracts,  or  if  a  slight  blow  is  delivered  in  a  downward  direction 
upon  the  incisor  teeth,  the  condyle  slips  forward  on  to  the  front  of  the  eminence 
and  is  carried  up  into  the  temporal  fossa  by  the  combined  action  of  the  temporal, 
masseter,  and  internal  pterygoid.  The  capsule  appears  to  stretch  rather  than 
tear,  though  the  tension  on  some  of  it  must  be  \ery  severe,  and  sometimes  the 
temporal  muscle  is  a  little  torn. 

Causes. — Dislocation  may  be  produced  either  by  muscular  action  alone,  or 
by  indirect  violence,  but  neither  of  these  is  capable  of  effecting  it  unless  the 
mouth  is  widely  open.     If  it  is  the  former  of  the  two,  the  condyle  is  pulled 


DISLOCATION    OF  THE   LOWER  JAW. 


505 


forward ;  if  the  latter,  the  bone  is  converted  into  a  lever,  of  which  the 
coronoid  process,  fixed  by  the  temporal  muscle,  is  the  fulcrum ;  the  force  is 
applied  to  the  symphysis,  and  the  condyle  is  driven  forward.  It  often  happens 
from  yawning  or  shouting,  but  it  may  be 
caused  by  blows  with  the  fist,  by  forcing 
into  the  mouth  anything  that  is  too  large, 
and  even  by  such  operations  as  the  extrac- 
tion of  teeth  and  taking  wax  casts  of  the 
alveolar  arch.  It  is  rare  in  children,  because 
in  them  the  eminence  hardly  exists,  and 
because,  owing  to  the  shape  of  the  jaw,  the 
temporal  muscle  does  not  obtain  such  lever- 
age ;  and  it  appears  to  be  more  common 
in  women  than  in  men. 

If  both  sides  are  dislocated  the  symp- 
toms are  very  characteristic.  The  patient 
supports  the  lower  jaw  with  his  hand,  to 
prevent  further  movement,  the  mouth  is 
widely  open,  the  chin  protrudes,  the  saliva 
dribbles  away,  and  speech  is  exceedingly 
difficult.  Labial  consonants  cannot  be  pro- 
nounced at  all.  In  place  of  the  natural 
projection  in  front  of  the  ear,  caused  by 
the  condyle,  there  is  a  depression  ;    in  front 

of  this,   making  it  more  distinct,   the  skin  is  Fig.  206.— Dislocation  of  the  Lower  jaw. 

raised,   partly  by  the  bone,   partly   by  the 

irregular  contraction  of  the  fibres  of  the  masseter ;  and  movement,  except  to  a 
very  slight  extent  in  a  down\vard  direction,  is  out  of  the  question.  The  first 
time  the  dislocation  happens  the  pain  is  very  severe,  but  in  old  recurring  cases 
it  may  be  so  slight  as  not  to  cause  any  complaint.  If  the  displacement  is  only 
on  one  side,  the  lower  jaw  appears  to  be  pushed  toward  the  other  one ;  the  face 
is  much  less  distorted  ;  and  though  the  general  symptoms  are  the  same,  they  are 
often  so  slight  as  to  lie  in  some  danger  of  being  overlooked. 

Subluxation  or  partial  dislocation  forward,  is  very  common  in  young  people, 
and  sometimes  gives  rise  to  much  inconvenience,  as  it  is  liable  to  occur  whenever 
the  mouth  is  widely  open.  The  jaw  is  caught,  as  it  were,  and  held  until  the 
condyle  is  forced  back  by  pressing  the  chin  upward  ;  formal  reduction  is  rarely 
necessary. 

Treatment. — The  patient  should  be  seated  with  the  mouth  wide  open  ;  the 
head  is  thrown  back  and  supported  from  behind,  the  thumbs  (protected  with  a 
handkerchief  or  some  lint  so  that  they  may  not  be  bitten)  are  placed  on  the  molar 
teeth  as  far  back  as  possible,  the  fingers  brought  round  under  the  chin,  and  pres- 
sure made  downward  and  backward  with  the  one,  while  the  symphysis  is  raised 
by  means  of  the  others.  By  this  the  lower  jaw  is  converted  into  a  lever  of  the 
first  order,  the  thumbs  form  the  fulcrum,  and  ought  therefore  to  be  placed  as  far 
back  as  they  can  ;  the  downward  pressure  helps  to  disengage  the  condyles,  and  as 
soon  as  they  become  free  the  muscles  pull  the  jaw  back  with  a  sudden  snap.  Gen- 
erally the  two  sides  slip  back  together  ;  but  in  old  dislocations,  or  if  there  is  any 
difficulty,  an  attempt  may  be  made  upon  one  first,  only  care  must  be  taken  not  to 
displace  it  again  while  the  other  is  being  reduced.  Sometimes  reduction  is  im- 
peded by  the  coronoid  process  becoming  entangled  in  the  fibres  of  the  temporal 
muscle  ;  and  in  one  case,  at  least,  it  is  certain  that  it  caught  against  the  malar 
process  ;  but  this  can  generally  be  obviated  by  depressing  the  chin  somewhat 
further  before  trying  to  raise  it. 

If  this  plan  fails  other  measures  must  be  adopted  to    obtain  more  pow'er. 
Wedges  of  cork  or  wood  may  be  placed   between  the  molar  teeth  and   the  chin 
drawn  up  by  main  force ;  in  one  case,  four   months  old,  Pollock  made  use  of  a 
35 


5o6    DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

strap  tourniquet,  which  was  passed  round  the  head,  under  the  chin,  and  slowly 
screwed  uj).  The  angle  may  be  dejiressed  by  resting  one  end  of  a  flat  piece  of 
wood  about  a  foot  long  upon  the  molars,  and  pulling  the  other  upward,  the  teeth 
of  the  upper  jaw  serving  as  a  fulcrum  ;  or  a  stout  pair  of  forceps  may  be  intro- 
duced as  far  back  as  possible,  and  the  blades  separated  from  each  other.  Direct 
pressure  backward  upon  the  coronoid  processes  from  the  inside  of  the  mouth  is 
sometimes  successful,  even  in  dislocations  of  long  standing. 

A  four-tailed  bandage  must  be  worn  for  a  week  or  ten  days  after,  and  the 
patient  should  be  warned  that  yawning  or  opening  the  mouth  wide  for  any  other 
purpose  is  exceedingly  likely  to  reproduce  the  displacement  for  months  to  come. 

If  the  dislocation  is  not  reduced,  the  amount  of  movement  gradually  increases 
until  the  patient  is  able  to  close  the  lips  and  to  o]jen  the  mouth  fairly  wide,  but  the 
teeth  can  never  be  brought  properly  into  apposition  with  each  other. 


Dislocation  of  the  Clavicle. 

The  sternal  end  of  the  clavicle  is  rarely  displaced,  although  the  articular  sur- 
faces are  very  little  adapted  to  each  other.  The  shoulder  is  so  freely  movable  that 
no  severe  strain  falls  upon  the  joint,  unless  the  force  is  applied  to  the  clavicle 
directly,  and  the  inter-articular  fibro-cartilage,  and  the  ligaments  that  hold  the 
bones  together,  are  so  strong  and  secured  so  well  by  the  muscles,  that  the  clavicle, 
as  a  rule,  gives  way  before  the  joint.  The  natural  movements  take  place  either  on 
a  vertical  axis  between  the  fibro-cartilage  and  the  sternum,  or  on  an  antero-pos- 
terior  one  between  the  same  structure  and  the  clavicle.  When  they  are  carried  too 
far  the  capsule  gives  way,  and  the  articular  end  of  the  bone  is  forced  through  the 
rent,  either  forward,  backward,  or  upward. 

In  spite  of  the  backward  direction  of  the  articular  facet  on  the  sternum,  and 
the  hook-like  j^rojection  on  the  j)osterior  margin  of  the  clavicle,  dislocation  for- 
ward is  the  most  common  of  these.  The  sternal  end  of  the  bone  is  carried  on  to 
the  front  of  the  manubrium,  and  stands  out  beneath  the  skin  ;  the  clavicular  por- 
tion of  the  sterno-mastoid  is  tense  and  rigid  ;  the  head  is  inclined  downward  and 
forward  ;  the  shoulder  is  approximated  to  the  middle  line,  and  all  the  movements 
of  the  arm,  but  particularly  any  attempt  to  bring  the  shoulders  forward,  are  attended 
by  severe  pain. 

Dislocation  backward  is  equally  plain,  only  in  this  case  there  is  a  well-marked 
depression  by  the  side  of  the  manubrium  instead  of  an  elevation,  and  the  shoulder 
is  brought  forward,  as  well  as  toward  the  middle  line.  Sometimes  the  head  of 
the  bone  presses  upon  the  trachea  or  oesophagus,  causing  extreme  dyspna:a  or 
dysphagia,  and  in  one  instance  coma  is  said  to  have  ensued  from  pressure  upon  the 
innominate  vein. 

Dislocation  upward  is  more  rare,  and  might  almost  be  regarded^ as  a  variety 
of  the  former,  as  the  articular  end  is  always  carried  backward  as  well  to  some 
extent,  sometimes  sufficiently  far  to  press  upon  the  trachea.  It  lies  behind  the 
sternal  portion  of  the  sterno-mastoid,  between  it  and  the  sterno-hyoid,  fdling  up 
the  episternal  notch  ;  the  shoulder  is  carried  far  inward  toward  the  middle  line, 
and  the  neck  is  bent,  as  much  to  relieve  the  respiration  as  to  relax  the  muscles. 

In  all  of  these  the  rent  in  the  capsule  is  very  extensive  ;  the  rhomboid  liga- 
ment either  gives  way,  or  the  cartilage  of  the  first  rib  is  torn  ;  the  fibro-cartilage 
in  the  interior  of  the  joint  is  separated  from  the  clavicle,  or  more  often  from  the 
sternum  ;  and  the  muscles,  especially  the  sterno-mastoid,  are  put  upon  the  stretch, 
and  sometimes  torn. 

Causes. — Dislocation  of  the  sternal  end  of  the  clavicle  may  be  produced 
either  by  direct  or  indirect  violence.  In  the  former  case  the  force  is  ai>j>lied  to 
the  inner  end  of  the  bone,  as  when  a  cart-wheel  passes  over  the  chest ;  the  dis- 
placement must  be  either  backward,  or  backward  and  upward  ;  and  often  the 
surrounding  structures,  such  as  the  ribs  and  sternum,  are  crushed  as  well.      In  the 


DISLOCATION   OF  THE   CLAVICLE. 


507 


latter,  where  the  force  acts  either  on  the  shoulder  or  on  the  outer  end  of  the  bone, 
the  displacement  may  take  any  direction,  except  downward.  A  blow,  for  exam- 
ple, on  the  front  of  the  shoulder,  forcing  it  backward,  causes  the  clavicle  to  rotate 
on  its  centre,  and  throws  the  strain  upon  the  anterior  sterno-clavicular  ligament, 
the  joint  opening  out  in  front.  If  the  force  continues,  the  head  of  the  bone  is  dis- 
placed forward  until  the  ligaments  give  way,  and  it  is  carried  on  to  the  front  of 
the  manubrium.  In  a  similar  manner,  a  force  applied  from  behind,  or  violent 
traction  on  the  arm  from  the  front,  causes  the  clavicle  to  rotate  in  the  opposite 
direction,  and  tends  to  produce  dislocation  backward.  But  while  the  cause  of 
these  dislocations  is  fairly  clear,  the  mechanism  by  which  they  are  produced  is  not 
so  easily  understood.  Owing  to  the  convexity  forward  of  the  inner  part  of  the 
clavicle,  it  is  impossible  for  the  first  rib  to  act  as  the  fulcrum  of  a  lever ;  and  these 
dislocations  cannot  be  produced  in  the  dead  subject,  without  previous  division  of 
some  of  the  ligaments.  They  cannot  therefore  be  the  result  merely  of  traction  or 
pressure  apjjlied  to  the  outer  end  of  the  bone,  regardless  of  everything  else.  The 
contraction  of  the  surrounding  muscles  is  of  some  assistance,  and  rigidity  of  the 
thorax  is  very  likely  essential  (they  have  been  produced  on  several  occasions  by 
pressure  in  crowds,  and  by  wrestling),  but  probably  the  most  important  element  is 
the  position  of  the  vertebral  column  at  the  moment  of  the  receipt  of  the  injury. 
In  some  cases  of  extreme  spinal  curvature,  gradual  displacement  has  resulted  from 
this  alone  without  the  occurrence  of  any  accident. 

Partial  dislocation,  without  tearing  of  the  capsule,  is  common  among  yourg 
people  of  weak  muscular  development  ;  and  is  often  noticed  for  the  first  time  after 
some  sudden  strain  or  unusual  muscular  exertion.  The  bone  projects  on  the  front 
of  the  articulation  forward,  or  forward  and  upward,  but  slips  back  again  into  its 
position  as  soon  as  the  weight  of  the  limb  is  taken  off.  The  chief  inconvenience 
is  the  weakness  of  the  arm  and  the  sense  of  insecurity  ;  sometimes  this  is  so  markecf 
that  the  use  of  the  limb  is  seriously  impaired. 

Treatment. — The  method  of  reduction  is  the  same  for  a]l  of  these.  The 
patient  is  seated  upon  a  low  stool,  with  his  back  to  the  operator.  The  latter  places 
his  knee  against  the  spine,  between  the  scapulae,  and  grasping  the  shoulders, 
draws  them  backward,  the  patient's  elbows  being  kept  in  front  of  the  median- 
lateral  line.  Generally  the  head  of  the  bone  slips  in  either  at  once  or  with  a  little 
manipulation  ;  if  it  resist,  a  stout  pad  may  be  placed  in  the  axilla,  and  the  elbow 
be  drawn  into  the  side,  so  as  to  pry  it  out.  The  difficulty  is  after  reduction  has 
been  effected  ;  there  is  nothing  to  retain  the  bone  in  its  proper  position  ;  the  articu- 
lar surfaces  are  almost  flat ;  all  the  ligaments  are  torn  ;  the  whole  weight  of  the 
arm  rests  upon  it ;  and  every  movement,  even  that  of  respiration,  affects  it. 

In  the  backward,  or  the  backward  and  upward  dislocation,  Velpeau's  plan  is 
the  best.  The  bone  is  held  in  position  ;  the  axilla  carefully  padded  so  as  to  square 
up  as  far  as  possible  the  conical  shape  of  the  thorax  ;  the  elbow  brought  forward  to 
the  middle  line,  and  well  raised  by  strips  of  pla.ster,  and  the  hand  fastened  against 
the  opposite  shoulder.  In  the  forward  dislocation,  which  in  this  respect  is  the 
worst  of  the  three,  a  double  figure-of-eight  succeeds  better.  A  stout  pad  or  a 
thickly  covered  splint  is  placed  between  the  shoulders,  and  the  bandage  is  carried 
round  them  alternately,  to  draw  them  back  as  far  as  possible.  Astley  Cooper 
recommended  that  well-padded  straps  should  be  carried  round  the  axillae,  and 
fastened  back  by  leather  bands  to  a  splint,  fitting  against  the  spine,  and  well  secured 
round  the  body.  In  any  ca.se  it  is  important  to  fix  the  scapulae  against  the  ribs ;  and 
where  there  is  serious  concern  about  the  deformity,  the  best  plan  is  to  keep  the 
patient  in  bed,  in  the  supine  position,  as  long  as  he  can  be  induced  to  stand  it.  If 
the  dislocation  is  forward,  a  well-fitting  pad  over  the  projection,  firmly  strapped 
down,  is  often  of  great  a.ssistance. 

Whichever  method  is  adopted,  the  arm  must  be  kept  rigidly  fixed  for  at  least 
three  weeks  ;  if  plaster  is  not  used,  the  bandages  must  be  secured  with  starch  or 
dextrin,  as  Velpeau  recommends;  after  that  the  confinement  may  be  relaxed  to 
some  extent,  but  no  movement  should  be  allowed  for  at  least  as  long  again  ;  and 


5oS    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

some  protection,  either  a  pad  or  a  properly  made  truss,  must  be  worn  until  it  is 
certain  that  repair  is  perfect.  In  some  instances  it  is  impossible  to  retain  the  l)one 
in  position.  If  the  displacement  is  forward  this  is  not  so  serious,  though  the  de- 
formity is  very  unsightly,  as  a  new  joint  soon  forms,  and  the  arm  regains  a  great 
deal  of  its  power  and  freedom  of  movement ;  but  when  the  bone  lies  wedged 
between  the  posterior  surface  of  the  sternum  and  the  trachea,  and  either  cannot  be 
dislodged,  or  cannot  be  prevented  from  slipping  back,  it  has  been  found  necessary 
to  divide  the  shaft  and  remove  the  inner  extremity. 

[Gunn's  rule  in  all  dislocations  :  Place  the  dislocated  bone  on  the  position  which 
characterized  it  at  the  moment  of  its  escape  from  the  articular  cavity ,  and  then  reduce 
by  appropriate  manipulation.^ 

Dislocation  of  the  Scapula. 

The  acromion  may  be  dislocated  from  the  clavicle  in  two  directions,  upward 
or  downward.  The  former  is  exceedingly  rare  ;  the  latter,  in  spite  of  the  shape  of 
the  articular  surfaces,  is  not  so  common  as  might  be  expected,  owing  to  the 
strength  of  the  conoid  and  trapezoid  ligaments,  which  form  the  main  bond  of 
union  between  the  bones. 

The  cause  is  nearly  always  a  fall  or  a  blow  upon  the  shoulder  delivered  from 
behind  and  above,  so  as  to  drive  the  point  of  the  acromion  downward  and  for- 
ward. Partial  displacement,  however,  is  met  with  now  and  then  in  rai)idly  grow- 
ing girls,  merely  from  carrying  heavy  weights  upon  the  arm.  Proljably  in  these 
cases  the  fibres  of  the  capsule  do  not  give  way  completely. 

Complete  dislocation  can  hardly  be  mistaken.  The  head  is  inclined  to  the 
injured  side ;  the  margin  of  the  trapezius  stands  out  distinctly ;  the  outer  end  of 
the  clavicle  is  rai.sed  and  forms  a  great  projection  upon  the  acromion,  and  the 
scapula  is  depressed  and  rotated.  There  is  tenderness  on  j^ressure  over  the  cora- 
coid,  the  movements  of  the  arm  are  painful  and  very  limited,  and  raising  it  even 
to  the  level  of  the  shoulder  is  impossible. 

Like  the  preceding,  this  dislocation  is  very  easy  to  reduce  and  very  difficult 
to  keep  in  position  ;  all  that  is  necessary  is  to  draw  the  shoulder  back,  press  the 
clavicle  down,  and  the  scapula  slips  out  from  underneath  at  once  ;  but  as  soon  as 
the  pressure  is  relaxed  the  displacement  appears  again.  Very  often  the  bones  can- 
not be  made  secure,  and  then  a  new  joint  is  gradually  developed  in  the  upper  sur- 
face of  the  acromion,  and,  though  the  projection  is  very  unsightly,  the  arm  regains 
nearly  the  whole  of  its  power,  except  for  overhand  movements. 

The  most  successful  method  of  treating  this  dislocation  is  by  means  of 
Velpeau's  dextrin  bandage,  only  substituting  Holland  plaster,  which  never 
stretches.  Great  care  must  be  taken  to  prevent  sloughing  of  the  skin.  If  this 
fails  a  pad  may  be  placed  over  the  acromial  end  of  the  clavicle  and  strapped  firmly 
down  by  means  of  a  broad  webbing  band  carried  over  it  and  under  the  point  of 
the  elbow.  In  such  a  case  the  axilla  must  be  well  padded  and  the  scapula  fixed  as 
far  as  possible  against  the  wall  of  the  thorax.  Where  deformity  is  the  first  con- 
sideration, the  patient  must  be  kept  lying  flat  on  the  back  in  bed  for  a  week  or 
ten  days  ;  the  scapula  is  fixed  perfectly  ;  the  weight  of  the  limb  is  taken  off ;  the 
trapezius  is  relaxed  ;  and  the  clavicle  can  easily  be  prevented  from  riding  up. 

Dislocations  of  the  Humerus. 

The  shoulder  is  dislocated  more  frequently  than  all  the  other  joints  in  the 
body  together.  This  is  due  to  its  anatomical  construction  ;  its  security  is  de- 
pendent almost  entirely  on  the  muscles  and  tendons  that  surround  it ;  the  glenoid 
fossa  is  so  flat  and  shallow  that  it  can  afford  no  protection  for  the  head  ;  the  cap- 
sule, wnth  the  exception  of  one  jart,  is  exceedingly  loose  and  weak  ;  the  move- 
ments are  unusually  free  in  all  directions  ;  and  the  length  of  the  arm  gives  such  enor- 
mous leverage  that  when  the  head  of  the  bone  is  driven  against  the  capsule  it 
tears  it  with  the  greatest  ease. 

The  cause  is  nearly  always  indirect  violence — a  fall  upon  the  elbow  or  the 


DISLOCATIONS   OF  THE  HUMERUS.  509 

outstretched  hand  ;  occasionally  direct — a  blow,  for  instance,  upon  tlie  back  of 
the  shoulder  while  the  arm  is  abducted  ;  in  a  few  rare  instances,  muscular  action 
by  itself,  without  outside  assistance. 

1.  Dislocation  by  Indirect  Violence. — This  is  always  the  result  of  abduction. 
As  the  arm  is  lifted  away  from  the  side,  the  great  tuberosity  comes  into  contact 
with  the  upper  margin  of  the  glenoid  fossa  and  the  surgical  neck  with  the  acromio- 
clavicular arch  ;  if  the  scapula  is  fixed  and  the  force  continues,  the  head  projects 
against  the  under  and  inner  part  of  the  capsule  until  it  tears  it  across,  leaving  the 
strong  upper  part  tensely  stretched  by  the  strain  that  falls  upon  it ;  then  as  soon  as 
the  force  is  expended  the  weight  of  the  arm  and  the  contraction  of  the  muscles 
carry  the  head  of  the  bone  along  the  margin  of  the  glenoid  fossa,  until  it  either 
reaches  the  base  of  the  coracoid  or  is  buried  in  the  substance  of  the  subscapularis. 
In  the  first  part  of  the  act,  the  great  tuberosity  or  the  surgical  neck  forms  the  t"ul- 
crum  of  the  lever  ;  as  soon  as  the  dislocation  is  effected,  the  upper  untorn  i)ortion 
of  the  capsule  (the  coraco-humerai  ligament  included)  becomes  the  fixed  point, 
and  the  head  of  the  bone  glides  upward  as  the  hand  sinks.  In  a  few  instances, 
owing  to  the  head  of  the  bone  in  some  way  being  caught  immediately  after  burst- 
ing through  the  capsule,  this  consecutive  displacement  does  not  take  place,  and  the 
arm  remains  in  the  i)osition  of  extreme  abduction  (liixatio  erecta). 

Complete  abduction,  however,  is  not  absolutely  necessary.  If  the  arm  is  held 
only  a  moderate  distance  from  the  side,  a  blow  upon  the  inner  condyle  of  the 
humerus,  or  an  outward  pull- upon  the  arm,  may  dislocate  the  head  of  the  bone. 
One  part  of  the  humerus  is  fixed  by  the  coraco-humeral  ligament ;  another  a  little 
lower  down,  by  the  muscles,  especially  the  deltoid  ;  some  point  between  the  two 
serves  as  a  fulcrum,  and  the  force  applied  to  the  inner  side  of  the  elbow  levers  the 
head  of  the  humerus  out. 

2.  /;/  dislocations  by  muscular  action,  which  are  much  more  rare,  the  mechan- 
ism is  somewhat  the  same,  only  the  force  in  this  case  is  the  momentum  of  the  arm. 
When  it  is  moderately  abducted,  the  upper  part  of  the  shaft  of  the  humerus  is  fixed 
between  the  abductors  (the  deltoid)  and  the  adductors  (the  pectoralis  major  and 
the  latissimus  dorsi),  so  that  a  kind  of  fulcrum  forms,  upon  which  the  arm  swings.  If 
at  the  moment  this  takes  place  the  lower  part  of  the  arm  is  moving  vigorously  in 
the  direction  of  abduction,  the  head  of  the  bone  is  driven  to  the  opposite  side, 
against  the  front  and  inner  part  of  the  capsule,  and  may  be  forced  through  into 
the  subscapular  fossa. 

3.  Dislocation  from  direct  violence  is  not  very  uncommon.  It  can  easily  be 
produced  by  a  blow  upon  the  shoulder  when  the  arm  is  abducted  and  held  in  a 
horizontal  position.  The  scapula  yields  a  little,  the  head  is  driven  against  a  weak 
part  of  the  capsule,  and  the  bone  is  dislocated  either  backward  or  forward,  accord- 
ing to  the  position  of  the  arm  and  the  direction  of  the  blow. 

Varieties. 

With  the  exception  of  some  of  those  that  are  produced  by  direct  violence,  all 
dislocations  of  the  humerus  are  primarily  downward  into  the  axilla,  but  it  is  only 
in  the  rare  cases  of  what  is  known  as  luxatio  erecta  that  the  bone  retains  that  posi- 
tion. Nearly  always  it  is  carried,  partly  by  the  weight  of  the  limb,  partly  by  the 
contraction  of  the  muscles,  either  in  a  forward  or  backward  direction,  upward 
along  the  margin  of  the  glenoid  fossa. 

There  are  four  well-marked  varieties  of  this  consecutive  displacement  :  three 
forward — subglenoid,  subcoracoid,  and  subclavicular  ;  and  one  backward — sub- 
spinous. Besides  these,  minor  varieties  have  been  described — subacromial,  for 
instance,  and  supra-coracoid  ;  but  they  are  very  uncommon,  and  the  latter  at  least 
cannot  take  place  without  the  presence  of  fracture  as  well. 

I.  Subcoracoid  Dislocation. — This  is  by  far  the  most  common  ;  indeed,  it  is 
the  only  dislocation  that  is  usually  met  with,  the  others  are  all  exceptional.  The 
rent  in  the  capsule  lies  on  the  inner  and  lower  border  of  the  glenoid  fossa,  often 


5IO     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

commencing  at  the  opening  for  the  bursa ;  the  head  of  the  humerus  is  pushed 
between  the  bone  and  the  subscapularis  muscle  up  to  the  root  of  the  coracoid,  until 
the  anatomical  neck  rests  upon  the  anterior  margin  of  the  glenoid  cavity ;  the 
muscle  is  bruised  and  stripped  uj)  from  its  attachment,  the  upper  and  back  part  of 
the  capsule  is  strained  across  the  glenoid  cavity,  the  tendon  of  the  biceps  is  lifted 
out  of  the  groove  as  far  as  the  capsule  will  allow  it,  and  the  external  rotators 
attached  to  the  great  tuberosity  are  stretched  or  torn.  If,  as  sometimes  happens, 
they  give  way  completely  or  wrench  the  tuberosity  away  from  the  shaft,  the  bone 
is  drawn  more  toward  the  middle  line  and  is  less  rotated.  Sometimes  the  axillary 
vessels  and  the  brachial  plexus  are  compressed,  but  this  is  not  so  common  or  so 
well  marked  as  in  the  subglenoid  form. 

2.  Subglenoid  Dislocation. — In  this,  which  is  the  next  most  frequent,  the  head 
of  the  bone  either  escapes  below  the  subscapularis,  between  it  and  the  teres  muscles, 
or  is  driven  through  its  substance  and  pulled  up  until  it  rests  upon  it  opposite  the 
lower  margin  of  the  glenoid  fossa.  The  rent  in«the  capsule  may  be  the  same  as  in 
the  subcoracoid  variety,  or  the  fibres  may  be  torn  away  from  the  under  and  inner 
l)art  of  the  humerus,  but  the  difference  does  not  appear  to  be  material.  The  ex- 
ternal rotators  and  the  other  muscles  suffer  to  much  the  same  extent,  but  the  vessels 
and  nerves  are  more  likely  to  be  compressed. 

3.  Subclavicular  Dislocation. — This  is  the  rarest  of  the  four  ordinary  forms  : 
in  it  the  head  of  the  bone  is  carried  under  the  pectoral  muscles  to  the  inner  side  of 
the  coracoid  process,  so  that  it  projects  underneath  the  skin  and  can  no  longer  be 


7 


Fig.  207. — Old  Dislocaiion  of  Humerus,  seen  from  above,  showing  the  way  in 
which  the  head  of  the  bone  and  the  glenoid  edge  mutually  wear  each  other 
away  and  simulate  a  partial  dislocation. 

felt  in  the  axilla.  It  can  only  be  produced  by  extreme  violence,  rupturing  the  ex- 
ternal rotators,  or  tearing  the  tuberosity  away  from  the  shaft  ;  and  the  amount  of 
damage  inflicted  on  the  surrounding  structures  is  proportionately  great. 

4.  Subspinous  Dislocation. — Under  this  may  be  included  all  the  forms  of  back- 
ward displacement  in  which  the  head  of  the  bone  rests  upon  the  dorsal  surface  of 
the  scapula  beneath  the  infraspinatus.  The  rent  in  the  capsule  must  involve  the 
lower  part,  but  probably  in  the  majority  of  instances  it  extends  nearly  round  the 
whole,  the  upper  part  only  being  left  strained  across  the  glenoid  cavity.  The 
subscapularis  may  be  merely  stretched,  or  it  may  be  torn  away  from  the  humerus. 

5.  In  the  supracoracoid  variety  the  head  of  the  bone  is  dri\  en  ujjward  between 
the  coracoid  and  acromion,  fracturing  one  or  other  until  it  rests  upon  the  coraco- 
acromial  ligament  and  projects  through  the  substance  of  the  deltoid.  Only  three 
cases  are  on  record. 

Partial  dislocations  have  often  been  described,  but  probably,  in  most  in- 
stances, they  have  really  been  either  old  unreduced  complete  ones  or  the  result  of 
chronic  rheumatoid  arthritis.  In  the  former  case,  when  the  head  of  the  bone  has 
been  resting  for  many  years  on  the  front  margin  of  the  glenoid  cavity,  it  gradually 
wears  it  away  until  it  seems  as  if  it  were  lying  partly  in  the  fossa  itself,  partly  on 
the  bone  in  front  of  it ;  in  the  latter,  when  the  biceps  tendon  has  been  absorbed  or 
torn  across,  the  head  of  the  bone  is  pulled  upward  and  forward  under  the 
acromio-clavicular  arch,  and  forms  there  a  new  socket  for  itself,  with  a  capsule 


DISLOCATIONS   OF  THE   HUMERUS. 


5" 


partly  adapted  from  the  old  one,  partly  formed  afresh  (Fig.  244).  Genuine  cases, 
however,  are  occasionally  met  with  ;  in  one  under  my  care,  the  patient,  a  tall 
overgrown  girl  of  seventeen,  was  unable  to  place  her  hand  at  the  back  of  her  head, 
as,  owing  to  the  feeble  develoi)ment  of  the  short  muscles,  the  bone  always  slii)ped 
forward  on  to  the  anterior  margin  of  the  glenoid  fossa,  stretching  the  capsule  more 
and  more  each  time.  In  other  cases,  the  same  result  is  stated  to  have  been  due 
to  the  unusual  development  of  the  Inirsa  under  the  subscapularis,  and  in  one  in- 
stance it  was  proved  by  dissection  that  the  capsule  had  been  torn  in  a  way  that 
would  allow  the  head  to  be  partially  displaced. 

Recurrent  Dislocatio7is. — A  similar  condition  of  things  is  sometimes  met  with 
after  the  reduction  of  an  ordinary  dislocation  :  the  arm,  when  an  attempt  is  made 
to  use  it,  feels  too  insecure ;  if  it  is  raised  in  the  least,  the  head  of  the  bone  slips 
forward,  and  though  it  generally  falls  back  again  into  the  fossa  as  soon  as  it  is  lowered, 
sometimes  it  is  caught  and  requires  to  be  released  by  manipulation.  This  is 
probably  caused  by  loss  of  power  over  the  short  external  rotators,  which  are  often 
damaged  or  torn  in  dislocations  ;  but  it  may  be  due  to  part  of  the  lip  of  the 
glenoid  cavity  having  been  pulled  off  by  the  capsule. 

Symptoms. — The  appearance  presented  by  a  patient  with  a  dislocated 
shoulder  is  very  characteristic  ;  the  head  is  bent  toward  the  affected  side  ;  the  fore- 
arm is  supported  by  the  other  hand ;  the  elbow  is  flexed  owing  to  the  tension  on 
the  biceps,  and  the  shoulder  has  completely  lost  its  rounded  shape ;  the  point  of 
the  acromion  stands  out  beneath  the  skin  ;  instead  of  the  normal  curve,  the  line 
falls  almost  vertically  ;  the  infra-clavicular  fossa  is  obliterated  ;  and  sometimes  the 
head  of  the  bone  projects  through  the  substance  of  the  muscles.  The  arm  is 
abducted  from  the  side,  especially  in  the  subglenoid  variety;  in  the  subcoracoid  it 
may  still  almost  touch,  in  spite  of  the  convexity  of  the  thorax  :  its  axis  does  not 
run  in  the  normal  direction  toward  the  glenoid  fossa,  but  too  much  inward  ;  the 
elbow,  except  in  the  subspinous  form,  has  an  inclination  backward,  though  it  does 
not  pass  the  mid-lateral  line  of  the  body,  and  there  is  a  general  look  of  helpless- 
ness about  the  part.  Sometimes  the  arm  is  swollen  from  pressure  upon  the  axillary 
vein  ;  or  the  radial  pulse  cannot  be  felt ;  or  again  there  is  intense  pain  down  some 
of  the  branches  of  the  brachial  plexus. 

If,  in  order  to  compare  the  two  sides  together  more  accurately,  measurements 
are  taken,  the  results  vary  according  to  the  kind  of  dislocation  :  in  the  subglenoid, 
owing  to  the  head  of  the  bone  lying 
below  its  normal  level,  there  is  length- 
ening with  marked  abduction  (mainly 
due  to  the  coraco-humeral  band,  but 
partly  perhaps  to  the  muscles)  ;  in 
the  subcoracoid  the  abduction  is  less 
and  there  is  no  certain  alteration  in 
length  ;  and  in  the  subclavicular, 
in  which  the  head  of  the  bone  is 
carried  far  inward,  the  arm  points 
outward  and  is  greatly  shortened. 
One  measurement,  however,  that  is 
always  increased  is  the  vertical  cir- 
cumference of  the  shoulder,  taken 
round  the  acromion  and  the  axilla. 

These  results  are  next  to  be  con- 
firmed by  palpation.  Under  the 
acromion  there  is  a  great  depression  ; 
the  finger  cannot  be  made  to  touch 
the  glenoid  fossa,  owing  to  the 
deltoid  and  the  external  rotator  mus- 
cles that  cover  it,  but  it  seems  to 
sink  right  in.     In  the  subclavicular  form  the  head  of  the  humerus  projects  in  such 


■i 


I// 


i 


1 


Bi^i 


Fig.  208. — Subcoracoid  Dislocation  of  Humerus. 


512    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

a  way  as  to  strike  the  eye  at  once  ;  in  the  subcoracoid  it  is  not  so  prominent  as 
this,  but  it  always  obliterates  the  natural  hollow  beneath  the  clavicle,  and  in 
addition  can  easily  be  felt  by  pressing  the  fingers  ui)ward  into  the  axilla.  In  the 
subglenoid  this  is  plainer  still ;  the  head  of  the  bone  lies  lower  down  ;  there  is  a 
hollow  between  it  and  the  coracoid  ;  and  the  anterior  fold  of  the  axilla  is  less 
prominent,  owing  to  the  drawing  downward  of  the  pectoralis  major.  I  have  only 
seen  two  examples  of  dislocation  backward,  but  in  neither  was  there  any  difficulty 
in  making  out  the  exact  position  of  the  head. 

Finally,  any  doubt  may  be  set  at  rest  at  once  by  manipulation.  Voluntary 
movement  is  almost  out  of  the  question  ;  pa.ssive  movement,  though  more  free,  is 
very  painful,  and  definitely  limited.  The  head  of  the  bone  rotates  easily  in  its 
new  situation,  though  not  so  freely  as  when  in  the  glenoid  fo.ssa  ;  abduction  to  a 
certain  extent  is  possible  still  ;  but  adduction,  so  as  to  make  the  elbow  touch  the 
side,  especially  when  the  fingers  are  laid  upon  the  oj)posite  shoulder,  is  absolutely 
impossible  in  all  forms  of  dislocation — the  shape  of  the  thorax  is  such  that  it  can- 


FiG.  209. — Subcoracoid  Dislocation,  with  the  Capsule  Laid  Open  and  Turned  Back. 


not  be  done.     This  and  the  vertical  measurement  round  the  axilla  are  almost  con- 
clusive. 

The  diagnosis  of  dislocation  has  to  be  made  from  : — 

1.  Fracture  of  the  neck  of  the  scapula,  in  which  the  glenoid  fossa  and  the 
coracoid  process  are  separated  from  the  rest  of  the  bone,  carrying  the  arm  with 
them. 

2.  Fracture  of  the  anatomical  neck  of  the  humerus. 

3.  Fracture  of  the  surgical  neck. 

4.  Separation  of  the  great  tuberosity,  in  which  the  head  of  the  bone  is  always 
dragged  forward  by  the  other  muscles,  until  it  rests  upon  the  anterior  margin  of 
the  glenoid  cavity,  but  within  the  capsule. 

5.  Paralysis  of  the  mu.scles  passing  from  the  trunk  to  the  arm,  with  conse- 
quent dropping  of  the  head  of  the  bone,  until  a  great  hollow  makes  its  appearance 
beneath  the  acromion.  This  may  occur  in  adults,  but  is  more  common  in  new- 
born infants,  from  the  pressure  of  forceps  in  delivery. 

In  all  of  these,  however,  instead  of  rigidity  and  immobility,  pa.ssive  motion  is 


DISLOCATIONS  OF   THE  HUMERUS. 


513 


unduly  free,  and  the  ell)o\v  can  be  made  to  touch  the  side  with  ease ;  indeed,  it 
generally  is  already  in  contact  with  it.  This  is  especially  true  of  separation  of  the 
great  tuberosity,  where  the  difficulty  is  often  a  very  real  one.      In  all  the  other 


J¥     /! 


Fig.  210.— a  similar  Dislocation,  showing  the  effecu  of  Rotation  Outward,  Abduction  and  Traction  Backward. 
The  head  is  just  passing  over  the  anterior  edge  of  the  glenoid. 


Fig.  211 — Rotation  Outward,  10  be  followed  by  Abduction. 


fractures  crepitus  can  easily  be  made  out,  unless  they  are  either  impacted  or  already 
in  part  united. 

Treatment. — Immediately  after  the  accident,  or  in  a  moderately  recent 


5t4    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

case,  when  the  muscles  are  relaxed  by  an  ana.^sthetic,  the  only  difficulty  is  the 
mechanical  one.  The  head,  for  example,  no  longer  corresponds  to  the  rent  in  the 
capsule,  or  it  is  fixed  by  the  tension  of  some  of  the  ligaments.  After  a  few  hours, 
however,  others  are  added  ;  the  muscles  contract  and  become  rigid  ;  later  still  they 
undergo  fibroid  degeneration  ;  adhesions  form  between  surrounding  structures  ; 
the  lymph  that  has  been  thrown  out  becomes  organized  ;  the  rei\t  in  the  capsule  is 
repaired,  and  sometimes  even  the  glenoid  fossa  is  filled  in. 

Reduction  is  effected  partly  by  the  aid  of  the  coraco-humeral  band,  which 
now  runs  downward  and  inward  from  the  l)ase  of  the  coracoid  to  the  tul)erosities, 
partly  by  the  tension  of  the  short  external  rotator  muscles  and  the  posterior  portion 
of  the  capsule,  which  are  tightly  strained  across  the  glenoid  fossa.  The  first  thing 
is  to  fix  the  scapula,  which  may  be  done  by  an  assistant  standing  behind  and  press- 
ing it  down  upon  the  thorax,  while  his  fingers  help  to  manipulate  the  head  of  the 
bone.     This  lies  underneath  the  subscapularis  or  in  its  substance,  suspended  as  it 


Fig.  212. — Circumduction  of  Elbow,  after  Rotation. 

were  by  the  muscles  and  ligaments  attached  to  the  great  tuberosity,  and  fixed  firmly 
against  the  projecting  anterior  lip  of  the  glenoid  fossa  (Fig.  209). 

In  many  cases  it  may  be  released  at  once  by  rotation  outward,  or  rotation 
combined  with  traction.  If  the  elbow  (which  is  already  flexed  owing  to  tension 
on  the  biceps)  is  pressed  firmly  into  the  side,  and  then  the  forearm  rotated  out- 
ward as  far  as  it  can  go,  the  outer  and  posterior  portions  of  the  capsule,  which 
are  strained  tightly  against  the  glenoid  fossa,  are  lifted  away  from  it  by  the  great 
tuberosity  ;  the  edges  of  the  rent  are  held  apart ;  and,  if  the  opening  is  high  up, 
as  in  most  cases  of  subcoracoid  dislocation,  the  head  of  the  bone  is  fixed  between 
the  upper  and  lower  parts  of  the  capsule  (both  of  which  are  still  tense)  on  the 
anterior  lip  of  the  glenoid  fossa,  close  to  the  spot  at  which  it  burst  through  (Fig. 
210).  Sometimes  then  a  little  outward  pressure  from  the  axilla  or  backward 
traction  from  the  elbow  is  sufficient  to  make  it  describe  the  arc  of  a  circle,  of 
which  the  upper  untorn  portion  of  the  capsule  is  the  radius,  and  it  slips  at  once 
over  the  edge  into  its  socket.     A  greater  amount  of  force  may  be  obtained  by 


DISLOCATIONS   OF  THE  HUMERUS. 


515 


pulling  the  upper  jjart  of  tlic  humerus  outward,  while  the  elbow  is  drawn  across 
the  front  of  the  chest. 

I(  this  does  not  succeed,  further  manipulation  must  be  tried  ;  the  forearm 
must  still  be  kept  flexed  and  rotated  out  as  far  as  it  will  go,  but  the  elbow  must 
now  be  brought  forward  until  the  arm  is  horizontal  (Fig.  211).  By  this  the 
ui)per  part  of  the  capsule  is  relaxed,  as  well  as  the  external  rotator  muscles,  and 
the  only  portion  left  tense  is  the  lower  and  posterior ;  this  fixes  the  neck  of  the 
humerus  and  prevents  the  head  from  moving  further  forward.  If  now  the  forearm 
is  circimiducted  inward,  so  that  the  fingers  touch  the  other  shoulder,  the  head  of 
the  bone  is  forced  to  move  in 
the  opposite  direction  and  can 
hardly  fail  to  be  carried  into  its 
socket  (Fig.  212).  It  is  essen- 
tial, however,  that  the  move- 
ments should  be  carried  out 
slowly  and  deliberately  and  to 
their  full  extent. 

Inward  rotation  from  the 
first  is  simpler  still,  and  is  more 
successfiil  when  the  rent  in  the 
capsule  is  low  down,  as  in  the 
subglenoid  form.  The  position 
of  the  patient  is  the  same  ;  the 
same  precaution  must  be  taken 
with  regard  to  the  elbow  and 
the  shoulder ;  then  the  arm  is  a 
little  abducted,  drawn  down  to 
release  the  head  from  the  fibres 
of  the  muscle  that  surround  it, 
and  rotated  in  (Fig.  213).  The 
coraco-humeral  band  and  the 
short  external  rotators  are 
stretched  as  tightly  as  they  can  p,j.  ^13 
be,  and  the  head  of  the  bone 
travels  round  the  inner  margin 
of  the  glenoid   fossa  until  it  is  compelled   to  rise  over  the  edge 


f 


/ 


Forced  Rotation  Inward,  tightening  up  the  short  external 
rotators  and  the  iintorn  parts  of  the  capsule. 


Drawing  the 


Fig.  214. — Reduction  of  Dislocation  by  Heel  in  the  Axilla. 


lower  end  of  the  humerus  across  the  body,  while  the  upper  part  is  either  being 
pulled  or  pressed  outward  at  the  same  time,  is  of  great  assistance. 


5i6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

If  manipulation  and  rotation  l)oth  fail  (and  even  when  the  patient  is  under 
an  anaesthetic  they  will  do  so  sometimes,  either  because  of  the  peculiar  position  of 
the  rent  in  the  capsule,  or  from  the  changes  that  occur  when  the  case  is  left  to 
itself)  extension  must  be  tried.  The  most  successful  of  all  methods  is  by  means 
of  the  heel  in  the  axilla.  The  patient  is  directed  to  lie  down  upon  a  low  couch, 
close  to  the  edge  ;  the  surgeon  (having  first  removed  his  boot)  seats  himself  on 
the  edge  on  the  same  side  as  the  dislocated  arm,  facing  the  jjatient ;  he  then  takes 
hold  of  the  limb  by  the  wrist,  and  placing  his  heel  (not  the  sole)  well  up  in  the 
axilla,  so  that  it  comes  in  contact  with  the  axillary  border  of  the  .scaimla,  proceeds 
to  make  traction  upon  the  limb  in  its  abnormal  direction,  slightly  abducted,  that 
is  to  say  (Fig.  214).  The  foot  acts  as  a  counter-extending  force;  the  heel  and 
the  traction  combined  fix  the  scapula ;  and  if  the  arm  is  rotated  a  little  or  gently 
swayed  from  side  to  side,  or  if  the  head  of  the  bone  can  be  manipulated  from 
above  by  an  assistant,  it  slips  out  at  once,  and  is  carried  up  by  the  muscles  into 

the  fossa  with  a  sudden  snap.  In  older  cases,  or 
when  the  muscles  are  relaxed  by  an  anaesthetic, 
the  foot  has  to  act  the  part  of  a  fulcrum  as  well  ; 
the  head  of  the  bone  is  gradually  drawn  down 
until  it  is  disengaged  ;  then  the  hand  is  brought 
across  the  chest,  and  the  upper  end  of  the  humerus 
is  levered  outward  in  the  direction  of  its  socket. 

A  greater  amount  of  force  may  be  obtained 
by  means  of  a  jack-towel  made  into  a  clove-hitch. 
-A  wet  bandage  must  first  be  placed  round  the  arm 
to  protect  the  skin  as  well  as  to  prevent  the  towel 
slipping  ;  the  clove-hitch  is  adjusted  above  the 
Fig.  213— ciove-hiich.  elbow  ;  and  the  loop  of  the  towel  passed  over  one 

shoulder  of  the  operator  and  under  the  other  arm  ; 
by  this  means  he  can  bring  into  play  the  extensor  muscles  of  the  back  and  at  the 
same  time  leave  his  hands  free  to  grasp  the  wrist  and  aid  in  reduction  by  rotating 
and  abducting  the  arm.  In  cases  of  still  longer  standing,  in  which  rotation  has 
failed  and  it  is  considered  advisable  to  make  further  trial,  the  pulleys  may  be 
adjusted  to  the  arm  above  the  elbow  in  the  manner  already  described. 

The  same  result  is  aimed  at  by  means  of  the  knee  in  the  axilla  (Astley 
Cooper's  method),  but  it  is  not  so  successful ;  the  patient  is  seated  on  a  low 
chair;  the  surgeon  stands  behind,  and  resting  his  foot  upon  the  edge  of  the  chair, 
places  his  knee  in  the  axilla;  then,  grasping  the  arm  above  the  ell)ow  with  one 
hand,  and  pressing  down  upon  the  acromion  with  the  other,  he  makes  traction 
downward,  and  at  the  same  time,  by  raising  his  foot  upon  his  toes,  forces  the 
neck  of  the  humerus  outward,  thus  combining  traction  and  abduction  with 
leverage. 

One  other  method,  that  of  hyper-abduction,  must  be  mentioned,  as  the  prin- 
ciple upon  which  it  is  conducted  is  rather  different,  and  it  sometimes  succeeds 
when  others  fail.  The  arm  is  raised  from  the  side,  and  abducted  until  it  is  in  a 
line  with  the  patient's  body  ;  the  deltoid  and  the  untorn  part  of  the  capsule  are  re- 
laxed ;  the  acromio-clavicular  arch  is  made  use  of  as  a  fulcrum,  and  the  head  of  the 
bone  is  first  of  all  pulled  downward,  and  then,  as  the  scai)ula  shifts,  pulled  out  at 
right  angles  to  the  glenoid  fossa,  until  it  is  sufficiently  released  to  ride  over  its 
edge.  It  may  be  carried  out  in  various  ways.  The  patient  may  be  seated  on  the 
floor,  and  the  surgeon  stand  on  a  chair  over  him  ;  or  he  may  be  lying  down  on  a 
sofa,  near  the  edge,  so  that  nothing  can  impede  the  upward  movement  of  the  arm 
(Fig.  216)  ;  and  counter-extension  may  be  effected,  either  by  making  a  slit  in  a 
towel,  passing  the  arm  through  it,  and  then  giving  it  to  some  one  else  to  hold  on 
the  opposite  side  of  the  patient,  so  that  the  scapula  is  i)ulled  down  upon  the  thorax 
— or  by  the  surgeon  himself  pressing  his  foot  or  his  hand  (fowu  upon  the  shoulder 
from  above  and  behind  while  making  extension  upon  the  arm.  It  is  scarcely  ad- 
visable for  dislocations  of  long  standing  until  other  measures  have  been  tried  and 


DISLOCATIONS  OF  THE  HUMERUS. 


517 


failed,  as,  owing  to  the  extent    of  movement  of  tlie  head  of  the  bone,  it  must 
expose  the  axillary  vessels  to  a  certain  amount  of  risk. 

After  reduction  has  been  effected  the  axilla  must  be  dusted  over  with  oxide  of 
zinc  powder  and  carefully  padded  with  cotton  wool,  partly  to  prevent  any  forward 
displacement  of  the  arm,  which  might  occur  from  the  injury  sustained  by  the 
muscles  attached  to  the  great  tuberosity,  partly  to  assist  by  its  pressure  i'l  the  ab- 
sorjjtion  of  the  exudation  that  is  thrown  out.  Then  the  arm  must  be  bandaged  to 
the  side.  Passive  motion  should  be  commenced  not  later  than  the  end  of  the  first 
week  ;  if  carefully  carried  out  there  is  no  ri.sk  of  causing  re-dislocation  ;  and  it  is 
the  best  method  for  checking  the  stiffness  that  is  liable  to  occur  from  confinement 
of  the  joint.  Whether  the  limb  after  that  period  should  be  merely  carried  in  a 
sling,  or  should  each  time  be  secured  by  bandages  again,  mu.st  depend  upon  the 
patient  and  the  amount  of  care  he  will  take  of  himself.  Active  movement  should 
certainly  not  be  allowed  for  three  weeks,  and  no  overhand  movement  for  a  much 
longer  period. 

Unreduced  Dislocations. 

Dislocations  of  the  humerus  are  very  frequently  neglected  or  overlooked,  and 
it  is  by  no  means  uncommon  for  the  patient  to  apply  for  treatment  for  the  first  time 


Fig.  216. — Reduction  of  Dislocation  by  Upward  Traction. 


months  after  the  accident.  The  question  then  arises  whether  an  attempt  should  be 
made  to  effect  reduction,  or  whether  it  would  not  be  better  merely  to  break  down 
the  adhesions,  and,  by  means  of  exercise  and  passive  motion,  encourage  as  far  as 
possible  the  formation  of  a  new  joint.  The  time  that  has  elapsed  is  of  course  the 
most  important  element,  but  it  is  not  the  only  one — the  age  of  the  patient  and  the 
usefulness  of  the  arm  have  to  be  considered.  Up  to  four  months  success  is  com- 
mon, and  may  be  looked  for,  and  the  arm  generally  recovers  ;  but  many  instances 
of  failure,  more  or  less  complete,  after  much  shorter  periods  than  that,  have  been 
recorded.  After  four  months  it  becomes  more  and  more  doubtful  each  day, 
although  cases  have  succeeded  after  as  long  as  two  years.  The  best  guide  probably 
is  the  amount  of  pain  the  patient  suffers ;  if  it  is  severe — and  sometimes  it  is  so  bad 
as  to  justify  excision  of  the  head  of  the  humerus — the  limb  is  sure  to  be  kept  at 
rest,  and  will  become  completely  stiff;  if,  on  the  other  hand,  movement  is  already 
free  and  painless,  and  the  part  is  fairly  useful,  it  is  certainly  not  advisable  to  try  too 
much.  The  patient  may  be  placed  under  an  anaesthetic,  the  head  of  the  humerus 
rotated  from  side  to  side,  and  the  various  methods  of  manipulation  practiced,  with 
the  prospect,  even  if  reduction  is  not  effected,  of  materially  improving  the  use  of 
the  part ;  but  if,  after  this  has  had  a  fair  trial,  the  head  of  the    bone  shows   no 


5iS     DISEASES  AND  INJURIES   OE  SPECIAL   STRUCTURES. 

inclination  to  return,  it  is  doubtful  whether   much  improvement  is  likely  to  result 
from  the  use  of  tlie  pulleys. 

Complications. — Dislocations  of  the  shoulder  are  always  attended  by  bruis- 
ing and  laceration  of  the  surrounding  structures ;  but,  unless  the  injury  is  very 
extensive  or  involves  some  i)art  that  usually  escapes,  it  ought  not  to  rank  as  a  com- 
plication. ^Extravasation  of  blood  into  the  axilla,  for  example,  rarely  deserves  to 
be  counted  as  one,  though  sometimes,  owing  to  the  number  of  small  vessels  torn 
across  and  the  loose  spaces  in  the  cellular  tissue,  it  is  very  considerable  in  amount ; 
but  occasionally  the  axillary  artery  gives  way,  or,  what  is  ecpially  grave,  one  of  its 
large  branches  is  torn  off  from  it,  and  an  arterial  h?ematoma  of  the  most  serious 
description  forms  at  once.  The  axilla  becomes  distended  to  its  utmost ;  the  pulse 
at  the  wrist  cea.ses  ;  the  arm  becomes  ocdematous  and  cold  ;  and  the  patient  falls 
into  a  -state  of  collapse.  In  such  a  case  there  is  no  alternative  ;  the  subclavian 
must  be  compressed  ;  the  axilla  opened  ;  the  blood  turned  out ;  and  the  artery 
tied  above  and  below  the  seat  of  injury.  Only  when  the  swelling  cea.ses  to  increase, 
while  the  arm  still  retains  its  warmth  and  feeling,  it  is  admissible  to  wait.  Pos- 
sibly, when  this  is  the  case,  the  swelling  has  become  accidentally  circumscribed, 
and  an  aneurysm  will  form,  which  can  be  dealt  with  later  on  ;  or  the  opening  in 
the  artery  has  become  temporarily  blocked  by  a  coagulum,  which  may  not  give 
way  again,  although  it  nearly  always  does.  At  any  rate,  in  such  circumstances 
there  is  no  need  to  proceed  at  once  to  such  a  serious  operation,  although  the  ca.se 
must  be  very  carefully  watched.  Ligature  of  the  subclavian,  if  the  swelling  is  dif- 
fuse, will  not  check  the  hemorrhage  and  may  cause  gangrene. 

It  is  more  common  for  the  artery  to  be  bruised  by  the  head  of  the  bone,  but 
this  rarely  leads  to  anything  more  serious  than  a  temporary  cessation  of  the  pulse. 
Sometimes,  however,  a  thrombus  forms,  probably  from  the  injury  to  the  inner  coat, 
and  the  artery  is  permanently  closed  ;  and  occasionally  an  aneurysm  develops  later 
on.      In  a  few  instances //?^?w>z  has  been  ruptured  as  well.  , 

The  brachial  plexus,  owing  to  its  strength,  nearly  always  escapes  ;  but  there  is 
very  often  intense  pain  down  some  of  the  nerves,  from  the  pressure  of  the  head  of 
the  humerus  ;  and  sometimes,  probably  from  the  same  cause,  this  is  followed  by  loss 
of  power.  It  rarely,  however,  persists  for  any  length  of  time.  The  circinnflex 
nerve  is  not  so  fortunate.  Atrophy  of  the  deltoid  is  not  uncommon  after  disloca- 
tions, and  though  in  many  instances  it  is  the  result  of  rheumatoid  arthritis,  setting 
in  after  the  accident,  sometimes  at  least  it  is  due  to  the  bruising  or  tearing  this 
nerve  has  sustained. 

The  effect  on  the  muscles  has  been  already  mentioned  ;  the  short  external 
rotators  suffer  the  most ;  .sometimes  they  are  completely  torn  across,  or  what  is 
equally  serious,  drag  away  with  them  the  great  tuberosity.  The  others  may  be 
badly  bruised,  but  there  is  seldom  any  graver  injury  ;  even  the  long  tendon  of  the 
biceps,  though  it  is  subjected  to  a  considerable  strain,  is  very  rarely  torn  or  dis- 
placed. 

Fracture  of  the  surgical  neck,  whether  it  is  the  result  of  the  original  accident 
(the  force  continuing  to  act  after  the  dislocation  has  been  produced)  or  is  due  to 
attempts  at  reduction,  is  a  most  serious  complication.  In  the  former  case  the 
patient  must  be  placed  under  an  anaesthetic,  and  every  effort  made  to  manipulate 
the  bone  back  into  its  socket ;  in  the  latter,  it  is  probably  best  to  push  the  uj^per 
end  of  the  shaft  into  the  glenoid  fo.ssa,  and  try  to  establish  a  false  joint.  Eracture 
of  the  lip  of  the  glenoid  cavity  sometimes  occurs,  and,  like  separation  of  the  greater 
tuberosity,  is  important,  as  it  tends  to  impair  the  security  of  the  joint  after 
reduction. 

These  complications  occur  much  more  frecpiently  from  trying  to  reduce  dis- 
locations of  long  standing.  Even  when  the  attempt  succeeds  without  much  man- 
ipulation, the  cellular  tissue  is  bruised  and  torn,  the  adhesions  broken  down,  and 
the  muscles  lacerated  to  such  an  extent  that,  especially  if  pulleys  have  been  used, 
it  is  not  uncommon  to  find  the  side  of  the  chest  and  the  axilla  black  and  blue  for 
weeks  afterward.      But  worse  consequences  than  these  have  often  happened.     The 


DJSL  O  CA  TIONS  A  T  THE  ELBOW.  519 

bone,  for  example,  has  been  ])roken  many  times,  especially  at  the  surgical  neck  ; 
it  becomes  atroi)hied  to  a  certain  extent  from  disuse,  and  as  soon  as  any  leverage 
is  put  upon  it,  it  gives  way  at  its  weakest  part.  The  artery  has  been  torn,  and 
though  on  a  few  occasions  this  has  been  the  result  of  excessive  violence,  it  has 
happened  to  the  most  careful  surgeons  from  mere  manipulation.  It  is  probably 
due  to  adhesions  having  formed  between  it  and  the  head  of  the  bone,  so  that, 
when  the  latter  is  moved  to  a  very  slight  degree,  the  whole  of  the  tension  falls  on 
a  limited  portion  of  the  wall  of  the  vessel.  The  same  thing  has  happened  to  the 
vein  :  the  brachial  plexus  has  been  torn  out  from  the  spinal  cord  ;  the  ribs  have 
been  broken  ;  the  soft  parts  hopelessly  damaged  j  and  even  the  arm  itself  has  been 
torn  off. 

Compound  dislocations  are  very  rare,  and  the  treatment  must  be  guided  by 
the  amount  of  injury  sustained  by  the  soft  structures  round  the  joint ;  unless  these 
are  verv  extensively  hurt,  the  dislocation  should  be  reduced  and  an  attempt  made 
to  save  the  limb. 

Dislocations  at  the  Elbow^  Joint. 

Under  this  are  included  dislocations  of  the  ulna  and  radius  together,  of 
either  of  the  two  by  itself,  and  of  the  two  separately,  the  one  being  driven  forward 
and  the  other  backward.  Of  these  the  first  named  and  dislocation  of  the  radius 
by  itself  are  common,  the  others  are  very  rare.  They  may  occur  at  all  ages,  but, 
owing  to  the  smooth  and  rounded  shape  of  the  articular  surfaces  in  childhood, 
they  are  much  more  frequently  met  with  at  this  period  than  in  any  other.  All 
the  processes,  especially  the  coronoid,  at  that  time  of  life  are  low  and  cartilagi- 
nous ;  the  depressions  are  not  deep  or  well-defined  ;  and  the  head  of  the  radius  is 
not  only  smaller  in  proportion  to  the  shaft,  but  is  not  marked  off  from  it  so  dis- 
tinctly as  it  is  in  later  years. 

Dislocation  of  Radius  and  Ulna  together. 

This  may  be  complete  or  incomplete,  that  is  to  say,  the  two  bones  may 
either  have  lost  all  relation  to  the  lower  end  of  the  humerus,  or  they  may  still  be 
to  a  certain  extent  in  contact  with  it,  and  it 
may  take  place  in  any  one  of  the  four 
directions,  backward  (Fig.  217),  forward, 
outward,  or  inward  ;  or  it  may  be  diagonal, 
backward  and  outward,  or  backward  and 
inward.  Of  these  the  dislocations  back- 
ward, and  backward  and  outward,  are  the 
two  most  common  ;  the  others  are  very  rare, 
the  prominence  of  the  olecranon  prevents 
one,  the  direction  and  shape  of  the  trochlear 
surface   of   the    humerus  prevents   another, 

and    complete    lateral     dislocation    in    either  Fig.  217— Dislocation  of  Bones  of  Forearm 

direction  can  hardly  take  place  without   the  (Back), 

injury  becoming  compound. 

Causes. — These  injuries  are  nearly  always  the  result  of  a  fall  upon  the 
hand,  with  or  without  violence  applied  to  the  elbow  itself,  but  the  way  in  which 
they  are  produced  is  not  always  the  same.  In  many  cases  they  are  due  to  over- 
extension :  the  tip  of  the  olecranon  is  pressed  against  the  posterior  surface  of  the 
humerus,  and  forms  the  fixed  point ;  then,  if  the  force  continues,  the  strain  falls 
upon  the  anterior  ligament,  the  biceps  and  brachialis  anticus  being  either  over- 
come or  taken  unawares  ;  the  sigmoid  cavity  of  the  ulna  is  separated  from  the 
trochlea,  and  the  two  bones  are  carried  together,  behind  the  humerus,  until  the 
coronoid  process  passes  the  centre  of  the  articular  surface.  If  it  is  carried  right  up 
to  the  olecranon  fossa  (it  cannot  lodge  in  it  so  long  as  the  radio-ulnar  ligaments 
are  intact),  the  dislocation  is  complete  ;    if  it  falls  short  of  this  it  is  incomplete. 


520     DISEASES  AND  INJURIES   OE  SPECIAL   STRUCTURES. 

Dislocation  backward  and  outward  (which  corresponds  very  nearly  to  that 
described  by  Malgaigne  as  "incomplete  backward  ")  can  also  be  produced  by 
over-extension.  In  a  fall  upon  the  hand  the  arm  forms  a  rigid  bar  between  the 
resistance  in  front  and  the  momentum  of  the  body  behind;  if,  at  the  moment 
that  the  bones  are  separating  and  the  ulna  slipping  behind  the  humerus,  the 
elbow  bends  a  little  to  one  side,  the  strain  falls  ujjon  one  of  the  lateral  ligaments 
more  than  on  the  other,  and  the  displacement  becomes  diagonal,  nearly  always 
backward  and  outward. 

In  many  instances,  however,  leaving  dislocation  forward  and  directly  outward 
altogether  on  one  side,  over-extension  never  takes  place.  The  primary  displace- 
ment is  due  either  to  lateral  bending  or  to  rotation  inward,  and  when  the  coronoid 
process  has  in  this  way  been  shifted  from  its  position  in  front  of  the  trochlea,  the 
bones  are  carried  upward  and  backward  by  the  muscles.  This  is  easily  accom- 
plished in  children.  The  hand  is  fixed  by  the  momentum  of  the  fall,  the  inner 
side  of  the  forearm  or  elbow  comes  into  contact  with  the  ground,  the  internal 
lateral  ligament  tears  across,  or  the  internal  epicondyle  gives  way,  either  from 
direct  violence  or  because  it  is  unequal  to  the  strain,  the  sigmoid  cavity  is  separ- 
ated slightly  from  the  trochlea,  and  the  ulna  is  dragged  upward  and  backward. 
The  amount  of  lateral  displacement  depends  upon  the  degree  of  force  applied  to 
the  side  of  the  elbow  ;  I  have  known  pure  outward  dislocation  ^incomplete) 
caused  in  this  way  even  in  an  adult ;  more  often  it  is  backward  and  outward,  and 
occasionally  it  is  directly  backward. 

Dislocation  inward  and  complete  dislocation  outward  (in  which  the  ulna  as 
well  as  the  radius  is  carried  to  the  outer  side  of  the  capitellum)  can  only  be  pro- 
duced by  a  very  great  degree  of  violence  applied  directly  to  the  joint.  Disloca- 
tion of  both  bones  forward,  so  that  the  olecranon  rests  against  the  anterior  surface 
of  the  humerus,  has  been  caused  on  several  occasions  by  a  blow  on  the  back  of 
the  joint  when  in  a  position  of  extreme  flexion. 

Symptoms  and  Diagnosis. — In  adults  it  is  generally  easy  to  say  whether 
there  is  dislocation,  though  it  may  be  very  difficult  to  determine  the  exact  extent 
of  the  injury  ;  in  children,  on  the  other  hand,  it  is  often  impossible  to  come  to  a 
conclusion  without  a  prolonged  examination  under  an  anaesthetic.  The  injury  is 
frequently  complicated  by  Iracture  or  by  separation  of  the  epiphyses  ;  the  bony 
prominences  are  not  well  defined  or  easily  felt,  and  the  j^art  becomes  so  swollen 
in  the  course  of  a  i^w  minutes  that  accurate  measurements  are  almost  out  of  the 
question. 

Dislocation  backward  is  the  most  characteristic  :  the  forearm  is  flexed  almost 
to  a  right  angle  and  shortened,  the  hand  is  generally  supinated  (it  may  be  pro- 
nated),  the  tip  of  the  olecranon  stands  out  behind,  and  the  triceps  runs  down 
toward  it,  leaving  a  well-marked  hollow  on  either  side  ;  while  in  front,  especially 
if  the  arm  is  slightly  extended,  the  lower  end  of  the  humerus  projects  beneath  the 
skin,  filling  up  the  hollow  of  the  elbow.  Active  movement  is  out  of  the  question, 
passive  is  very  much  restricted,  and  any  attempt  causes  severe  pain.  But  the 
most  important  test  is  the  relative  position  of  the  bony  prominences :  when  the 
elbow  is  at  a  right  angle  a  line  drawn  horizontally  from  one  epicondyle  to  the 
other  lies  above  the  tip  of  the  olecranon  ;  the  head  of  the  radius  can  be  felt  and 
can  be  made  to  rotate  about  half  an  inch  in  front  of  the  external  condyle,  and  the 
olecranon  fossa  can  be  clearly  made  out.  In  dislocation — not  only  in  dislocation 
backward — this  is  all  changed,  the  relations  are  no  longer  the  same,  and  they  are 
altered  to  such  an  extent  that  even  when  the  swelling  around  the  joint  is  extreme 
some  essential  difference  can  always  be  made  out. 

Dislocation  backward  and  outward  is  more  difficult,  as  all  the  signs  are  much 
less  distinct.  The  position  of  the  forearm  is  the  same,  but  there  is  not  so  much 
shortening  ;  the  deformity  is  less  ;  the  head  of  the  radius,  instead  of  being  clearly 
felt  behind  the  external  condyle,  is  partly  concealed  by  it ;  the  olecranon  is 
scarcely  more  prominent  than  natural,  as  the  sigmoid  cavity  embraces  the  capi- 
tellum to  some  extent,  and  it  is  hardly  raised  at  all ;  passive  motion  is  much  more 


DISLOCATIONS  AT   THE   ELBOW.  521 

free  ;  ev(*n  a  certain  aniouiU  of  active  extension  is  jjossible  ;  the  external  condyle 
and  the  external  lateral  lii^ament  are  unhurt,  though  the  hollow  behind  is  filled  up, 
and  the  internal  epicondyle  is  very  often  not  so  [)rominent  as  might  l)e  expected, 
as  it  is  fretpiently  either  torn  away  or  knocketl  off,  antl  is  partly  buried  behind 
the  trochlea,  partly  concealed  by  the  extravasation. 

In  the  other  forms  of  dislocation  the  deformity  is  so  conspicuous  that  it  can 
scarcely  fail  to  be  recognized  at  once. 

The  diagnosis  has  to  be  made  from  supra-condyloid  and  condyloid  fracture, 
separation  of  the  lower  epiphysis  of  the  humerus,  wholly  or  in  part,  displacement 
backward  with  fracture  of  the  coronoid  process,  and  effusion  into  the  bursa  behind 
the  olecranon,  which  occasionally  causes  a  deformity  something  like  that  of  a 
dislocation. 

The  first  named  presents  but  little  difficulty.  It  is  true  there  is  a  prqminence 
in  front  of  the  bend  of  the  elbow,  caused  by  the  lower  end  of  the  upper  fragment, 
and  another  behind,  from  the  olecranon  being  carried  backward  ;  but  the  former 
is  always  sharp  and  angular,  not  rounded  like  the  articular  surface  of  the  humerus, 
and  they  can  both  be  made  to  disappear  and  reappear  by  making  or  relaxing  exten- 
sion. Moreover,  instead  of  the  joint  being  rigid,  there  is  undue  mobility,  the 
weight  of  the  forearm  causing  it  to  drop  at  once  ;  crepitus  can  usually  be  made  out, 
and  what  is  most  important  of  all,  the  head  of  the  radius  and  the  olecranon  preserve 
strictly  their  normal  relation  to  the  two  condyles.  The  same  may  be  said,  with 
slight  modification,  of  separation  of  either  condyle  ;  but  in  children,  if  the  outer 
part  of  the  lower  epiphysis  of  the  humerus  is  detached  from  the  shaft,  leaving  the 
internal  condyle  unhurt,  the  difficulty  of  diagnosis  is  often  very  serious.  Crepitus  is 
absent,  or  there  is  only  that  soft  variety  which  may  be  easily  imitated  in  a  disloca- 
tion ;  the  swelling  may  be  so  great  as  to  keep  the  joint  rigid  ;  the  bony  prominences 
are  almost  obscured  ;  and  unless  great  care  is  taken  it  is  very  easy  to  be  deceived 
by  the  position  of  the  olecranon,  as,  owing  to  its  retaining  its  connection  with  the 
external  part  of  the  joint,  it  does  not  materially  alter  its  relation  to  the  line  joining 
the  two  epicondyles.  Both  kinds  of  accident  are  of  frequent  occurrence,  and  as  it 
is  absolutely  essential  to  form  an  accurate  diagnosis,  there  should  be  no  hesitation 
in  giving  an  anaesthetic  in  order  to  make  the  examination  as  thorough  as  possible. 
If  the  displacement  is  not  corrected,  or  if  the  olecranon  fossa  becomes  partly  filled 
up,  the  range  of  movement  is  seriously  interfered  with.  I  have  known  the  same 
difficulty  occur  in  adults  when  the  external  condyle  of  the  humerus  was  detached 
from  the  shaft,  carrying  the  bones  of  the  forearm  with  it. 

Fracture  of  the  coronoid  process  is  a  very  rare  complication,  but  may  be  sus- 
pected if,  when  the  dislocation  has  been  reduced,  it  returns  again  at  once. 

Treatment. — The  chief  obstacles  are  the  tension  of  the  muscles  and  the 
position  of  the  coronoid  process  which  catches  behind  the  humerus.  The  former 
may  of  course  be  relaxed  at  once  by  an  anaesthetic,  but  this  is  seldom  necessary. 
In  many  instances,  all  that  is  required  is  to  fix  the  humerus,  pressing  it  somewhat 
backward,  and  make  slight  traction  upon  the  forearm  in  the  extended  position  ; 
the  coronoid  readily  slips  over  the  smooth  cartilaginous  surface,  and  the  bones  re- 
turn at  once  with  a  jerk.  If  this  does  not  succeed,  a  slight  degree  of  over-exten- 
sion will  probably  disengage  it.  Dislocation  outward,  and  outward  and  backw-ard, 
may  be  reduced  in  the  same  way  ;  the  obstacles  are  the  same.  The  lateral  displace- 
ment, however,  if  strongly  marked,  should  be  corrected  first ;  in  one  instance  it  is 
recorded  that,  owing  to  the  soft  structures  catching  behind  the  condyle,  reduction 
was  impossible. 

The  plan  ordinarily  described  as  Sir  Astley  Cooper's  hardly  ever  fails,  but  it 
is  open  to  some  objections.  According  to  his  description  the  patient  is  seated  on 
a  low  chair,  and  the  surgeon,  placing  his  knee  on  the  inner  side  of  the  elbow  joint, 
in  the  bend,  takes  hold  of  the  wrist  and  flexes  the  arm.  At  the  same  time  he  presses 
upon  the  radius  and  ulna  with  his  knee,  so  as  to  separate  them  from  the  humerus 
and  disengage  the  coronoid  process;  while  this  pressure  is  sustained  by  the  knee, 
the  arm  is  to  be  forcibly  but  slowly  bent,  and  the  reduction  is  soon  e.Tected.  The 
34 


522     niSEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

\\  rist  is  at  the  end  of  the  long  arm  of  a  lever  ;  the  knee  is  the  fulrnini  ;•  and  the 
olecranon  the  short  arm.  The  resistance  to  be  overcome  is  made  up  of  the  miis- 
(des  (on  both  sides  of  the  joint),  the  lateral  ligaments  and  the  fascia  ;  all  of  these 
structures  nnist  l)e  torn  or  stretched  sufficiently  to  allow  the  coronoid  to  slip  under 
the  humerus  while  the  arm  and  forearm  are  at  right  angles  to  each  other.  The 
method  is  very  successful  ;  but  if  these  structures  are  not  already  torn,  they  must 
give  way,  owing  to  the  force  that  is  used. 

The  after-treatment  is  very  simple. 
There  is  no  fear  of  recurrence,  as  in  the 
case  of  the  humerus,  unless  the  coronoid 
has  been  broken  off ;  but  the  amount  of  ex- 
travasation and  swelling  is  sometimes  very 
considerable  ;  and  especially  in  children — 
there  is  some  risk  of  inflammation  setting 
in.  The  limb  should  be  placed  on  an  in- 
side angular  splint,  and  cold  and  compres- 
sion applied  until  the  swelling  has  gone 
down  and  the  fear  of  inflammation  is  passed. 
Passive  motion  may  in  ordinary  cases  be 
commenced  at  the  end  of  a  week  ;  after 
that,  unless  there  is  something  unusual,  it 
is  sufficient  if  the  forearm  is  sui)i)orted  in 

Fig.  218. — Unreduced  Dislocation  of  Elbow.  ,.  T^      /-  •  11 

a  slmg.  Perfect  movement  is  generally 
regained,  unless  there  has  been  a  fracture  through  the  lower  end  of  the  humerus. 

Old  dislocations  may  be  reduced  up  to  the  end  of  three  weeks  or  a  month 
without  much  difficulty  ;  after  that  it  becomes  doubtful,  and  though  reduction  has 
been  accomplished  as  late  as  four  months,  this  is  cjuite  the  exception  (Fig.  218). 
In  one  or  two  cases  in  which  all  attempts  have  failed,  and  the  position  of  the  arm 
has  been  such  that  it  was  almost  useless,  the  olecranon  has  been  sawn  through 
transversely  from  behind,  the  joint  opened  up,  all  obstructions  divided,  the  muscles 
separated  from  the  condyles,  the  olecranon  fossa  and  the  sigmoid  cavity  cleaned 
out,  and  the  bone  replaced.  The  olecranon  must  be  wired  together  and  the  limb 
treated  as  after  excision  of  the  elbow.  In  some  cases  there  has  been  distinct  im- 
provement, but  in  others,  especially  those  in  which  there  was  at  the  same  time  a 
fracture  through  the  lower  end  of  the  humerus,  the  gain  was  not  great  ;  if  sup- 
puration sets  in  bony  ankylosis  is  almost  sure  to  follow. 

Compound  dislocations  must  be  treated  in  the  same  way  as  compound  frac- 
tures into  the  elbow  joint.  The  question  turns  first  on  the  age  and  condition  of 
the  patient,  then  upon  the  extent  of  injury  to  the  soft  structures  ;  and  the  choice 
lies  between  reduction,  with  an  attempt  to  secure  primary  union  of  the  wounds  ; 
reduction  with  free  incision,  and  thorough  (very  thorough)  drainage  ;  excision,  or 
ami)utation. 

Dislocation  of  the  Ulna  by  itself 

is  a  very  unusual  occurrence,  and  is  generally  accompanied  by  partial  displace- 
ment of  the  radius.  Sometimes  the  separation  is  carried  so  far  that  the  ligaments 
connecting  the  two  bones  are  torn  completely  across,  and  one  is  displaced  forward 
and  the  other  backward.  This  can  only  be  produced  by  extreme  pronation  ;  the 
ulna  must  be  twisted  on  its  axis  until  the  internal  lateral  ligament  gives  way  and 
the  bone  is  forced  behind  the  internal  condyle.  The  forearm  is  held  semi-flexed, 
but  completely  pronated. 

Dislocation  of  the  Radius 

may  be  either  forward,  backward,  or  outward  ;  the  first  is  the  most  common, 
thelast  very  rare.  In  adults  it  seldom  occurs  unless  there  is  fracture  of  the  ulna; 
the  force  first  breaks  this  bone,  and  then  wrenches  the  radius  from  its  socket.  In 
children  it  is  tolerably  frequent,  owing  to  the  small  size  of  the  head,  the  absence  of 


DISLOCATIONS  AT  THE  ELBOW.  523 

distinction  between  it  and  the  shaft,  and  the  comparative  looseness  of  the  orbicular 
ligament.  The  rent  in  the  capsule  is  not  always  the  same  ;  in  adults  the  ligament 
appears  generally  to  be  torn  away  from  one  or  other  end  of  the  lesser  sigmoid 
cavity  ;  in  infants  and  children  the  head  of  the  bone  either  slips  out  from  under 
it  or  is  forced  through  it,  just  where  it  is  joined  by  the  fd)res  of  the  external  lateral 
ligament.  Probably  this  serves  to  explain  the  serious  difficulty  that  is  occasionally 
met  with  in  reduction. 

Causes. — Dislocation  of  the  radius  by  itself  is  nearly  always  the  result  of  in- 
direct violence — a  fall  upon  the  palm  of  the  hand;  but  sometimes  it  is  produced 
by  pulling  upon  the  forearm  (swinging  a  child  by  the  hand,  for  instance),  and 
there  are  a  few  cases  on  record  in  which  it  has  resulted  from  force  applied  directly 
to  the  elbow,  the  external  condyle  of  the  humerus  or  the  capitellum  being  cru.shed 
first. 

It  is  very  doubtful  if  it  can  be  produced  by  mere  pronation  ;  if  this  is  carried 
to  its  fullest  extent  it  makes  the  head  of  bone  project  against  the  front  of  the  cap- 
sule ;  but  before  this  gives  way,  either  the  internal  lateral  ligament  tears  across 
and  both  bones  are  dislocated  backward,  or  the  radius  itself  breaks.  The  ulna  in 
the  living  subject  cannot  act  as  a  lever  for  the  radius.  It  is  possible  that  it  may 
be  effected  by  supination  ;  but  probably  not  as  a  rule,  for,  if  the  hand  is  violently 
supinated,  the  inferior  radio-ulnar  articulation  gives  way  first,  and  then  either  the 
radius,  or,  in  children,  the  lower  epiphysis  of  the  humerus.  If,  however,  forcible 
lateral  bending  of  the  joint  (adduction  or  abduction)  is  combined  with  pronation 
or  supination,  the  orbicular  ligament  gives  way  readily,  and  the  head  of  the  bone 
is  carried  either  forward  or  backward,  according  to  the  position  of  the  elbow  at 
the  moment  and  the  direction  of  the  force.  In  a  fall  upon  the  hand  the  limb  is 
nearly  or  quite  extended  ;  its  lower  extremity  is  fixed  against  the  ground  ;  then 
the  momentum  of  the  body  drives  the  elbow  joint  to  one  side  or  the  other,  and  at 
the  same  time  violently  pronates  or  supinates  the  forearm. 

Symptoms. — The  signs  of  this  injury  are  usually  distinct;  the  head  of  the 
radius  projects,  either  in  front  of  the  joint  under  the  supinators,  or  behind  in  the 
hollow  below  the  external  condyle  ;  and  its  peculiar  shape  can  be  recognized  at 
once  on  rotating  the  hand.  The  elbow  is  flexed  ;  the  radial  side  of  the  forearm 
appears  shortened  ;  generally  it  is  moderately  pronated,  and  sometimes  this  is  ex- 
treme ;  voluntary  movement  is  very  much  restricted,  and  passive  motion,  espe- 
cially when  the  displacement  is  forward,  is  limited  by  the  head  of  the  bone  coming 
into  contact  with  the  anterior  surface  of  the  humerus.  In  older  cases,  when  the 
articular  end  has  become  wasted  and  has  worn  a  cavity  for  itself,  this  is  more  free  ; 
and  sometimes,  when  it  can  slip  to  one  side,  a  considerable  degree  of  flexion  is 
possible,  but  this  is  not  common.  The  depression  left  by  the  displacement  of  the 
bone  can  always  be  felt  below  the  external  condyle. 

Treatment. — Reduction  may,  as  a  rule,  be  readily  accomplished  by  fixing 
the  humerus,  making  extension  from  the  hand,  and  pressing  the  head  of  the  bone 
into  position  ;  but  every  now  and  then  great  difficulty  is  experienced,  probably 
owing  to  the  intervention  of  a  portion  of  the  capsule  ;  and  sometimes,  in  spite  of 
manipulation  in  all  directions,  and  pronation  and  supination,  reduction  remains 
impossible.  If  the  orbicular  ligament  has  given  way,  the  difficulty  of  retaining 
the  head  of  the  bone  in  position  is  equally  great  ;  an  anterior  rectangular  splint 
may  be  tried,  or  the  limb  may  be  put  up  in  a  position  of  complete  extension  with 
a  pad  over  the  head  of  the  bone.  If  this  fails,  complL-te  flexion  sometimes  an- 
swers, having  regard  to  the  circulation  ;  but  the  condition  is  not  unlikely  to 
become  permanent.  Unreduced  dislocations  of  the  radius  are  not  uncommon. 
If  the  head  of  the  bone  gives  rise  to  serious  inconvenience,  if,  for  example,  it  pre- 
vents flexion  of  the  elbow,  or,  from  pressing  upon  the  posterior  interosseous  nerve, 
interferes  with  the  extensor  muscles,  it  must  be  excised.  Generally  the  arm  re- 
gains a  good  deal  of  its  power,  partly  no  doubt  because  of  the  age  at  wiiich  the 
injury  usually  occurs;  but  pronation  and  supination  are  never  very  satisfactory. 


524    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


Su/'/t/xa/ion  of  the   Radius. 
This  accident,  which  was  first  correctly  described  by  Duverney,  is  common 
in  children  under  three  years  old,  but  is  hardly  ever  met   with  after  six.      It  is 
always  produced  in  the  same  way  :   traction  with  adduction  and  possibly  prona- 
tion.    A  young  child  is  lifted  up  or  swung  round  by  the  hand  ;  there  is  a  sudden 
cry  of  pain,  and  when  the  arm  is  released  it  either  hangs  hcli^lessly  down  by  the 
side  or  is  supported  across  the  chest  in  the  flexed  i)osition.      Nor  is  the  child  able 
to  use  it.      In  most  cases  no  displacement  can  be  found  ;  sometimes  the  head  of 
the  radius  appears  slightly  ])rominent  in  front,  or  is  a  very  little  separated  from 
the  capitellum  ;  and  sometimes  there  is  a  certain  amount  of  swelling  at  the  back 
of  the  wrist.      Passive  motion  is  perfectly  free,  and  almost 
painless — in    all    directions   except   supination ;    that   stops 
rather  abruptly  ;  and  there  is  distinct  tenderness  and  pain  at 
the  outer  side  of  the  elbow  when  it  is  attempted.      In  a  few 
instances  the  wrist  has  been   painful  too. 

From  experiments  on  dead  subjects  (there  are  no  post- 
mortem records)  it  is  tolerably  clear  that  the  symptoms  are 
caused  by  the  head  of  the  radius  being  drawn  out  from  inside 
the  orbicular  ligament  until  its  anterior  edge  catches  and  is 
held  below  the  lower  border  of  the  ring,  thus  slightly  separ- 
ating it  from  the  capitellum  (Fig.  219).  If  in  addition 
there  is  forced  pronation,  the  head  of  the  bone  projects 
slightly  in  front  (Pingaud).  Possibly  in  those  cases  in  which 
extreme  pronation  is  the  prominent  cause,  the  displacement 
is  made  worse  by  the  posterior  portion  of  the  head  of  the 
bone  separating  sufficiently  from  the  capitellum  to  allow  a 
portion  of  the  cajisule  to  be  scpieezed  in  between  the  two 
bones  by  atmospheric  pressure.  In  either  case  reduction  is 
usually  effected  at  once  by  sudden  extension  combined  with 
supination  (J.  Hutchinson,  junior,  recommends  pronation 
with  flexion)  ;  probably  in  many  instances  it  takes  place 
spontaneously  ;  but,  as  Stimson  remarks,  there  is  reason  to 
think  that  some  cases  of  forward  dislocation  of  the  radius 
found  in  adults,  i)ersisting  from  childhood,  were  originally 
of  this  kind,  the  head  of  the  bone  gradually  being  displaced 
further  and  further. 

Where  the  pain  and  swelling  are  confined  to  the  back 
of  the  wrist  joint,  without  the  elbow  showing  any  sign,  or 
where  both  parts  are  affected  together,  it  is  jjossible,  as  sug- 
gested by  Goyraud,  that  the  injury  really  consists  in  a  dis- 
location of  the  triangular  fibro-cartilage  from  the  lower 
surface  of  the  ulna. 


Fig.  2JQ — Subluxation  of 
Radius  in  an  Infant. 
Shows  supinator bievis 
and  orbicular  ligament 
turned  aside,  showing 
head  of  radius.  Exter- 
nally is  seen  the  mus- 
culo-spiral  nerve  and 
its  two  branches,  the 
radial  and  interosseus 
nerves. 


Dislocation  at  the   Wrist  Joint 

is  a  rare  form  of  accident,  which  formerly  was  often  confiised  with  Colles'  frac- 
ture. The  carjMis  and  hand  are  detached  from  the  radius  and  fibro-cartilage  and 
carried  either  toward  the  dorsum  or  the  palm,  according  to  the  direction  of  the 
force.  The  projection  on  the  back  of  the  wrist,  in  the  one  case  corresponding  to 
the  articular  surface  of  the  carpus,  in  the  other  to  the  lower  end  of  the  radius  and 
ulna,  can  be  recognized  from  its  shape  ;  but  the  most  important  sign  is  the  posi- 
tion of  the  styloid  processes  ;  in  dislocations  their  relation  is  normal ;  in  fracture 
the  radial  one  is  separated  and  follows  the  hand.  Reduction  is  ea.sy,  but,  in  spite 
of  pa.ssive  motion,  is  liable  to  be  followed  by  stiffness. 

Dislocation  of  the  lower  end   of  the  radius,  with  rupture  of   the  triangular 
fibro-cartilage,  may  occur  from  extreme  pronation  or  supination. 


DISLOCATIONS  OF   THE   THUMB.  525 

In  the  transverse  carpal  dislocation  the  distal  row  of  bones  is  separated  from 
the  proximal,  and  is  driven  either  toward  the  j)alm  or  the  dorsum;  in  the  meta- 
carpal the  bones  of  the  hand  are  displaced  ;  but  though  this  is  not  unfrequent  in  the 
case  of  the  metacarpal  bone  of  the  thumb  by  itself,  and  occasionally  happens  to  the 
others,  there  does  not  appear  to  be  any  instance  in  which  it  has  involved  all  at 
once. 

Dislocation  of  the  os  magnum  by  itself  is  not  uncommon,  the  head  of  the 
bone  being  tilted  out  from  the  concavity  of  the  semilunar  by  a  fall  upon  the 
back  of  the  hand.  The  projection  can  be  recognized  at  once  and  is  easy  to 
reduce,  but  it  is  very  apt  to  recur,  even  though  the  hand  is  kept  extended  for  two 
or  three  weeks.  It  is  stated  to  be  more  common  among  women  than  men,  and  it 
has  been  produced  by  violent  muscular  contraction  during  parturition. 

The  pisiform  bone,  with  the  tendon  of  the  flexor  carpi  ulnaris,  is  occasionally 
dislocated  to  one  side,  but  this  rarely  happens  to  any  of  the  others.  They  may 
be  crushed  and  displaced  in  severe  accidents,  but  then  the  injury  is  nearly  always 
compound  and  must  be  treated  as  a  compound  fracture  into  the  wrist  joint. 


Dislocation  of  the  Metacarpal  Boxe  of  the  Thumb 

is  nearly  always  dorsal,  and  may  be  easily  recognized  by  the  prominence  on  the 
trapezium  and  the  shortening  of  the  thumb,  which  is  usually  flexed.  It  may  be 
the  result  of  direct  violence,  as  in  the  bursting  of  a  gun,  or  of  forced  flexion  into  the 
palm  of  the  hand.  Usually  there  is  no  difficulty  in  the  reduction,  but  sometimes 
it  is  almost  impossible  to  keep  the  bone  in  position,  probably  because,  in  some  of 
these  instances  at  any  rate,  there  is  an  oblique  fracture  running  through  the  bone, 
detaching  the  palmar  portion  of  its  base. 


Dislocation  of  the  Proximal  Phalanx  of  the  Thumb. 

This,  too,  is  usually  dorsal  (Fig.  221),  palmar  displacement  being  prevented 
by  the  contact  of  the  soft  parts  in  flexion.  The  cause  is  forced  extension  ;  the 
palmar  ligament  is  torn  from  the  metacarpal  bone  close  to  its  attachment,  and  the 
phalanx  is  carried  backward  over  the  articular  surface,  until  in  complete  cases  it 
rests  upon  the  neck,  projecting  almost  at  a  right  angle.  One  lateral  ligament  is 
generally  torn,  but  both  have  been  found  intact ;  the  tendons  of  the  flexor  brevis 
with  the  sesamoids  lie  on  either  side  of  the  neck,  and  the  distal  phalanx  is  bent 
down  by  the  tension  of  the  long  flexor,  which  usually  lies  to  the  inner  side  of 
the  head  of  the  metacarpal. 

Reduction  is  sometimes 
quite  easy  ;  more  often  it  is 
a  matter  of  very  great  diffi- 
culty, and,  occasionally,  it 
cannot  be  effected  at  all. 
Chloroform  is  of  very  little 
help,  and  the  numerous  for-  Fig.  22c.-Thumb  Forceps. 

ceps  that  have  been  invented 

are  not  much  more,  for  if  the  attempt  succeeds  it  generally  does  so  at  once,  and 
the  hold  on  the  thumb  is  quite  sufficient  (Fig.  220). 

The  head  of  the  metacarpal  bone  is  prolonged  inward  on  its  palmar  aspect, 
so  as  to  form  a  rounded  eminence  for  articulation  with  the  sesamoid  bones. 
These  are  firmly  united  to  the  phalanx  and  to  the  palmar  glenoid  ligament  which 
separates  the  long  flexor  tendon  from  the  joint,  and  extends  up  on  either  side  of 
the  head,  forming  a  large  share  of  the  socket.  On  the  other  hand  the  fibro- 
cartilaginous pad  is  very  loosely  attached  to  the  metacarpal  bone  ;  and  when 
dorsal  extension  is  carried  too  far,  tears  off  at  once,  and  with  the  sesamoids  follows 
all  the  movements  of  the  phalanx. 


526     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 


n-y 


Three  forms  of  this  dislocation  have  been  described  by  Faraboeuf,  differing  in 
degree. 

1.  Incomplete. — This  can  be  produced  in  many  young  i)eoi)le  vohmtarily. 
The  articular  surfaces  are  not  com])letely  separated,  and  the  ]:)halanx  is  held  by 
the  tension  of  the  muscles  attached  to  its  base,  rigidly  fixed  on  the  dorsal  edge 
of  the  articulation,  from  which  it  slips  off  with  a  jerk. 

2.  Complete. — The  articular  surfaces  completely  separated  ;  the  base  of  the 
phalanx  rests  upon  the  dorsum  of  the  metacarpal,  dragging  with  it  the  glenoid 
ligament  (which  has  been  torn  off)  and  the  sesamoid  bones  ;  the  tendon  of  the 
long  flexor  lies  to  the  inner  side  (generally)  and  the  head  of  the  metacarpal  pro- 
jects through  the  rent  in  the  capsule  embraced  by  the 
muscles    attached     to    the    phalanx.       The    jjroximal 
])halanx  ])rojects  at  right  angles,  the  terminal  one  is 
flexed  strongly,  and  the  head  of  the  metacarpal  stands 
out  under  the  skin  (Fig.  222). 

3.  Complex. — If,  in  a  complete  dislocation,'  the 
phalanx  is  brought  into  a  straight  line  with  the  meta- 
carpal, the  tension  of  the  muscles  on  the  sesamoid 
bones  may  pull  them  (and  the  glenoid  ligament  with 
them)  backward  over  the  dorsal  surface  of  the  meta- 
carpal until  they  lie  flat  upon  it.  If,  now,  reduction 
is  attempted  the  ligament  is  dragged  over  the  head  of 
the  metacarpal  by  the  phalanx  until  it  is  interposed 
between  the  two  bones  and  effectually  prevents  proper 
apposition  (Fig.  223).  This  has  been  found  by  dissec- 
tion on  several  occasions  ;  in  another  a  sesamoid  bone 
was  in  the  way,  and  in  three,  at  least,  the  long  flexor 
tendon  had  followed  the  ligament  round  the  head  of 
the  bone,  so  that  reduction  was  impossible  until  it  was 
divided.  Exactly  the  same  occurs  sometimes  in  the 
case  of  the  fingers. 

According  to  Faraboeuf,  complete  dislocations  are 
rendered  complex  by  ill-advised  manipulation,  especially  by  premature  attempts 
at  flexion.  The  metacarpal  bone  must  be  pressed  well  down  into  the  palm  to 
relax  the  short  muscles  as  far  as  possible ;  then  the  phalanx  must  be  over-extended 


l^^ 


Fic 


221. —  Dislocation  of  Proximal 
Phalanx  of  Thumb. 


/ 


-^i^ 


'-Vi-" 


Fig.  222. —  Complete  Dislocation  of  ph.ilanx 
of  Thumb.  The  glenoid  ligament  torn  from 
the  metacarp.il  but  preserving  its  normal 
relation. 


Fig.  223. — Complex  Dislocation.  The  glenoid 
ligament  displaced  on  to  the  dorsal  surface  of 
the  phalanx. 


until  its  back  nearly  touches  that  of  the  metacarpal,  and  pushed  forward  along  it 
until  its  edge  slips  on  to  the  articular  surface ;  then  it  suddenly  becomes  flexed. 
The  position  of  the  long  flexor  tendon,  whether  it  lies  to  the  inner  or  the  outer 
side,  should,  if  possible^  be  made  out,  as  this  is  sometimes  material.     The  former 


DISLOCATIONS  OF  THE  HIP  JOINT. 


527 


is  the  more  coamion,  and  then  as  the  phalanx  is  being  brought  up  it  should  be 
slightly  rotated,  so  as  to  bring  its  inner  edge  into  position  before  the  outer,  and, 
if  "possible,  push  the  tendon  over  the  head  of  the  bone  in  front  of  it. 

In  the  com])lex  form,  when  the  sesamoids  and  the  glenoid  ligament  are 
turned  up  behind  the  head  of  the  metacarpal,  the  only  hope  lies  in  extreme 
extension  of  the  phalanx,  so  that  its  dorsal  surface  shall  touch  that  of  the  meta- 
carpal before  it  is  pushed  on.  In  this  way  they  can  sometimes  be  lifted  sufficiently 
to  lall  into  their  position  again. 

If  this  fails  it  is  better  to  abandon  the  attempt  for  a  time  and  to  keep  the 
joint  perfectly  cool  and  (piiet  for  a  week  or  ten  days ;  then  a  free  incision  may  be 
made  down  one  side,  the  cause  of  the  difficulty  ascertained  and  removed.  Ten- 
otomy of  the  flexor  brevis  has  been  recommended,  but  if  the  cause  is  the  inter- 
position of  some  extraneous  substance  it  would  hardly  meet  the  case.  Division 
of  the  long  flexor  has  been  successful,  and  probably  it  would  have  succeeded  in 
the  three  cases  in  which  the  tendon  was  found  between  the  surfaces.  No  operation, 
however,  may  be  attempted  at  once,  or,  owing  to  the  bruising  of  the  tissues, 
suppuration  is  almost  certain  to  set  in.  As  a  last  resort  the  joint  must  be 
excised. 

Old  unreduced  dislocations  are  not  uncommon  ;  the  phalanx  can  be  bent 
back  almost  on  to  the  metacarpal,  but  cannot  be  brought  quite  into  the  same 
straight  line,  or  flexed  into 
the  palm.  The  deformity 
is  very  unsightly,  but  the  use 
of  the  part  is,  singularly,  lit- 
tle affected.  «i-iiimiiiv  t^^^w  mm  mw     '       m^^  -» 

Similar     displacements      jLM\l^^^*^'i»ifcw,i     w^    X        --"^i^        ^\ 

occur    in    connection    with  ^^,     ^     ^^^                 .  ^.^ 

the      metacarpo    phalangeal  ^Xi^        ««<^;          .-y-    Mi'i'"'. 

and  the  inter-phalangeal  W/*''''^-6 
joints    of    the    fingers  ;    the 

deformity  is  not   so    great    as  Fig.  224.— Dislocation  of  Finger.        * 

that   of  a   real    dislocation, 

and  it  cannot  be  rectified.  In  some  instances  the  fibro-cartilaginous  palmar  liga- 
ment has  been  found  between  the  bones,  and  has  been  removed  ;  in  one  under 
my  care  the  first  attempt  proved  successful  after  division  of  the  flexor  tendon. 

Besides  this,  true  dislocations,  both  palmar  and  dorsal  (Fig.  224),  are  met 
with,  but  much  more  rarely. 


i\ 1\ 


DISLOCATIONS  OF  THE  HIP-JOINT. 

In  spite  of  the  shape  and  depth  of  the  acetabulum  and  of  the  strength  of  the 
muscles  and  ligaments  that  surround  it,  this  accident  is  not  so  uncommon  as  might 
have  been  expected.  This  is  due  partly  to  the  enormous  leverage  afforded  by  the 
lower  limb,  partly  to  the  fact  that  in  certain  positions  the  head  of  the  bone  sinks 
to  a  great  extent  out  of  the  cavity  and  rests  against  the  weakest  portion  of  the 
capsule.  It  may  occur  at  any  age,  but  naturally  is  much  more  common  during 
adult  life  ;  in  children  it  has  occasionally  been  produced  by  direct  traction  upon 
the  limb  ;  as  a  rule  it  only  results  from  extreme  violence,  when,  for  example,  a  man 
is  crushed  to  the  ground  by  a  heavy  weight  falling  on  his  back  as  he  is  stooping 
forward. 

Varieties. 

The  head  of  the  bone  may  come  to  rest  at  any  point  round  the  socket ;  but 
so  long  as  the  anterior  portion  of  the  capsule  is  untorn,  its  range  is  limited  and  it 
practically  occupies  one  of  three  positions.  These  are  known  as  regular  disloca- 
tions, each  having  many  sub-varieties,  in   contradistinction  to  the  irregular  or 


52S     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

anomalous  ones,  in  which,  owing  to  this  part  of  the  capsule  having  given  way,  the 
neck  of  the  femur  is  no  longer  fixed  and  the  head  may  travel  anywhere. 

I.  Displacement  Backward. — The  head  of  the  bone  rests  on  the  dorsum  of 
the  ilium  (Fig.  225),  or  on  the  i)Osterior  surface  of  the  ischium  (Fig.  226),  some- 
where between  the  edge  of  the  acetabulum  and  the  margin  of  the  great  sacro-sciatic 
foramen  ;  possibly  on  the  spine  of  the  ischium,  but  never  in  the  foramen. 

2  Displacenu'tif  Dcnvinvard. — The  head  of  the  bone  rests  on  the  thyroid 
foramen  (Fig.  227),  hardly  having  moved  after  its  immediate  exit  from  the  aceta- 
bulum ;  or  it  is  carried  further  still  into  the  perineum. 

3.  Displacement  Inward  on  to  the  pubes,  at  the  spot  where  the  horizontal 
ramus  joins  the  ilium  (Fig.  2 28). 

In  none  of  these  is  the  anterior  part  of  the  capsule,  the  so-called  Y  ligament 
torn  ;  the  rent  lies  behind,  generally  along  the  inner  margin  of  the  acetabulum 
and  the  posterior  surface  of  the  neck  of  the  femur  ;  the  ligamentum  teres  is  pulled 
in  two,  or  more  frequently  separated  from  its  pit  on  the  femur,  bringing  away  with 
it  some  of  the  articular  cartilage  ;  and  the  muscles  round  the  joint,  especially  the 
short  external  rotators,  are  badly  lacerated. 

The  Mechanism  of  Dislocation. — Except  perhaps  in  pubic  dislocation  (which 
may  be  produced  in  extension)  the  limb  is  always  flexed.  If  it  is  flexed  and 
addiicted,  the  head  of  the  bone  is  driven  directly  through  a  tolerably  strong  part 
of  the  capsule  on  to  the  ilium  or  ischium  ;  if  it  is  flexed  and  abducted,  the  edge 
of  the  acetabulum  acts  as  the  fulcrum  of  a  lever,  the  head  is  tilted  out  from  its 
socket  and  slips  through  where  the  fibres  are  thinnest,  at  the  lower  and  inner 
margin.  Then  it  becomes  displaced  secondarily,  either  backward  or  forward,  by 
the  weight  of  the  limb  and  the  contraction  of  the  muscles.  It  is  still  a  matter  of 
question  which  of  these  two  (the  direct  or  indirect)  is  the  more  common. 

The  shape  of  the  acetabulum  certainly  favors  the  latter ;  the  ui)per  and  back 
part  of  the  cavity  is  of  immense  strength  and  very  deep  ;  the  inner,  on  the  other 
hand,  is  low  and  interrupted  for  nearly  an  inch  by  the  cotyloid  notch.  In  abduc- 
tion the  head  of  the  bone  rolls  more  and  more  toward  this  side  until  it  projects 
above  the  edge,  half  resting  against  the  weakest  portion  of  the  capsule.  In  this 
position  a  very  slight  push  is  sufficient  to  tear  the  thin  membrane  across,  and,  the 
round  ligament  being  relaxed,  to  dislocate  the  head  of  the  bone.  Its  ultimate 
resting-place  is  regulated  by  the  degree  of  flexion  and  rotation.  Sometimes  it 
moves  slightly  inward  and  remains  on  the  thyroid  foramen.  Very  rarely,  only 
indeed  when  the  limb  is  everted  and  extended,  it  ascends  on  to  the  pubes.  Much 
more  often,  owing  to  the  inversion  of  the  head,  it  forces  its  way  backward,  below 
the  tendon  of  the  obturator  internus,  and  either  remains  upon  some  part  of  the 
ischium,  or,  if  the  capsule  and  the  short  external  rotator  muscles  are  badly  torn, 
makes  its  way  higher  up  until  it  lies  upon  the  dorsum  (Fig.  230).  According  to 
this  view%  which  is  strongly  advocated  by  Morris,  all  dislocations  are  primarily 
downward,  the  head  of  the  bone  emerging  somewhere  between  the  ischial  tuber- 
osity and  the  thyroid  foramen  ;  the  other  varieties  are  merely  consecutive  displace- 
ments, due  partly  to  the  weight  of  the  limb  as  it  becomes  extended,  partly  to 
muscular  contraction  ;  and  the  i)articular  variety  is  dependent  upon  the  position 
of  the  limb  at  the  moment  that  the  head  is  leaving  the  socket. 

Now  it  is  certainly  true  that  sometimes  during  manipulation  under  an  anaes- 
thetic instead  of  the  head  of  the  bone  rising  up  into  its  socket,  it  rolls  along  the 
lower  margin  of  the  acetabulum,  passing  from  the  thyroid  foramen  to  the  ischium 
and  back  again,  according  to  the  position  of  the  limb  ;  and  there  is  no  doubt  that 
all  the  four  regular  dislocations  can  be  produced  in  this  way  in  the  dead  subject  ; 
but  it  is  no  less  true  that  this  explanation  will  not  serve  in  all  cases.  In  many 
instances  (probably  in  most)  the  limb,  instead  of  being  abducted,  is  strongly 
adducted  at  the  moment  of  the  accident  ;  further,  the  rent  in  the  cap.suledoes  not 
always  run  along  the  thinnest  ])art,  by  the  margin  of  the  acetabulum  and  the  pos- 
terior surface  of  the  femur.  The  pubo-femoral  portion  of  the  capsule  may  be 
intact;  and,  as  Humphry  has  shown,  there  may  be  at  the  back  a  tri-radiate  rent, 


DISLOCATIONS  OF  THE  HIP  JOINT. 


529 


Fig.  225. — Dorsal  Dislocation. 


Fig.  226. — Sciatic  Dislocation. 


Fig.  227. — Thyroid  Dislocation. 


Fig.  228.— Pubic  Dislocation. 


530    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


forming  a  kind  of  valve,  with  its  apex  opposite  the  lower  part  of  the  tuberosity. 
Such  an  injury  can  only  be  produced  by  the  head  of  the  femur  being  driven  directly 
backward,  in  the  flexed  position.  If  the  joint  is  nearly  straight  at  the  moment  the 
limb  receives  the  shock,  the  lip  of  the  acetabulum  may  be  chipped  off;  if  moder- 
ately flexed,  the  head  of  the  bone  is  driven  out,  above  the  oljturator  internus,  or 
through  its  substance,  tearing  the  capsule  away  from  its  attachment,  or  dragging  off 
part  of  the  bone  (Fig.  229)  ;  when  the  flexion  is  extreme  (as  it  nearly  always  is 
in  these  accidents)  the  head  passes  out  beneath  tlie  tendon  (Fig.  230),  and  either 
comes  to  rest  upon  the  ischium,  or,  if  the  force  continues  to  act  after  the  disloca- 
tion is  produced,  tears  its  way  further  through  the  muscles  until  it  reaches  the 
dorsum. 

Dislocation  Baclrivard. 

This  is  hy  far  the  most  common,  and  includes  Ix^tli  the  dorsal  and  the  sciatic 
varieties  ;  they  are  produced  by  the  same  kind  of  accident ;  the  attitude  of  the 
limb  is  the  same,  although  it  varies  in  degree  ;  and  the  method  of  reduction  is  the 


y  - 


Fig.  229. — Dislocation  on  to  Dorsum  above 
the  Tendon. 


Fig.  230. — Dislocation  on  to  Sciatic  Notch 
below  the  Tendon.  Secondary  displace- 
ment brings  the  two  almost  into  the 
same  position. 


same.  The  difference  depends  upon  the  position  of  the  rent  in  the  capsule  and 
the  extent  of  the  injury  to  the  muscles.  If  the  opening  is  high  up,  the  displace- 
ment is  dorsal  from  the  first ;  if  the  lower  part  is  torn,  it  is  sciatic  ;  but,  if  the 
rent  is  large  and  the  short  external  rotators  are  much  lacerated,  the  head  of  the 
bone  plows  its  way  up  subsequently,  and  the  sciatic  dislocation  becomes  dorsal 
by  secondary  displacement. 

Causes. — The  most  common  is  a  violent  l)low  ujjon  the  back,  while  the  body 
is  bent  forward  in  a  stooping  position.  The  hip  is  always  flexed  ;  if  the  limb  is 
adducted  and  inverted,  the  pelvis  is  driven  down  on  to  the  femur  until  the  head  of 
the  bone  is  forced  through  the  capsule;  if  it  is  abducted  and  inverted,  the  pelvis 
is  twisted,  the  head  of  the  bone  tilted  out  of  the  lowest  part  of  the  socket,  and 
then  forced  below  the  tendon  of  the  ol)turator  internus.  The  ultimate  position  is 
the  same,  because  that  is  dependent  upon  the  untorn  portion  of  the  capsule  and 
the  muscles.     Other  causes  are  falling  with  the  legs  wide  apart;  sudden  abduction 


DISLOCATIONS   OF  THE  HIP  JOINT.  531 

of  one  limb  when  the  other  slips  down  a  hole  ;  or  a  wheel  passing  over  the  hip. 
One  case  of  double  dislocation  is  especially  important :  a  man  was  standing  on  an 
incline  with  his  feet  wide  apart,  the  right  leg  being  lower  down  and  therefore 
straighter  than  the  left ;  suddenly  he  was  crushed  to  the  ground  by  a  heavy  weight 
falling  uijon  his  back;  both  hips  were  dislocated  at  the  same  instant;  the 
right,  which  was  least  flexed,  was  driven  on  to  the  dorsum  ;  the  left  on  to  the  sciatic 
notch. 

Pathology. — The  round  ligament  is  almost  always  broken  ;  sometimes  it  is 
pulled  away  from  the  bone  ;  the  inner  or  posterior  part  of  the  capsule  is  torn,  as 
described  already;  or  the  back  part  of  the  acetabulum  is  dragged  off;  the  short 
external  rotators  always  suffer  ;  in  some  cases  they  are  completely  ruptured,  and  the 
head  of  the  bone  lies  in  the  substance  of  the  glutei ;  in  others  the  ([uadratus 
femoris  and  the  inferior  gemellus  only  are  lacerated,  though  the  rest  are  bruised  by 
the  pressure  of  the  bone;  the  pectineus  usually  gives  way,  and  the  psoas  and 
iliacus  are  very  much  stretched.  Occasionally  the  great  sciatic  nerve  is  seriously 
injured,  either  from  the  accident  itself  or  from  the  efforts  at  reduction.  The 
anterior  part  of  the  capsule  is  always  intact ;  generally  it  is  very  tense,  but  this  is 
not  invariable. 

Symptoms  and  Diagnosis. — Dislocation  on  the  dorsum  can  be  recog- 
nized at  once  by  the  position  of  the  limb.  The  thigh  is  flexed,  adducted,  and  in- 
verted until  the  axis  of  the  femur  crosses  the  lower  third  of  the  opposite  one  ;  the 
knee  is  semi-flexed,  and  the  ball  of  the  great  toe  rests  upon  the  instep  of  the  other 
foot.  In  the  sciatic  this  is  le.ss  conspicuous  :  the  limb  is  nearly  straight,  and  almost 
extended,  although  immediately  after  the  accident  the  inversion  is  sometimes 
even  greater.  The  contour  of  the  hip  is  altered,  the  extent  varying  with  the  con- 
dition of  the  patient.  The  buttock  is  flattened,  and  broader  than  the  other;  the 
gluteal  fold  is  raised,  and  the  trochanter  more  prominent ;  it  rises  above  Nelaton's 
line,  and  approaches  the  anterior  superior  spine  ;  but  in  this  respect  again  sciatic 
dislocation  is  much  less  distinct  than  dorsal. 

The  next  thing  is  to  confirm  this  by  measurement.  The  limb  is  always 
shortened,  in  the  dorsal  dislocation  as  much  as  two  and  even  three  inches  ;  in  the 
sciatic  rarely  more  than  one;  and  as  this  takes  place  entirely  at  the  hip-joint,  it 
may  be  appreciated  best  by  Bryant's  triangle,  the  three  sides  of  which  all  measure 
less  than  normal.  It  is  noteworthy  that  in  sciatic  dislocation,  owing  to  the  head 
of  the  bone  lying  behind  the  acetabulum,  though  the  amount  of  shortening  is 
slight  when  the  limb  is  extended,  it  becomes  very  conspicuous  as  soon  as  it  is 
flexed  to  a  right  angle  (Fig.  231). 

The  head  of  the  bone  can  be  generally  felt  by  deep  pressure  where  the  disloca- 
tion is  on  the  dorsum,  unless  the  patient  is  very  stout ;  but  this  is  rarely  possible 
in  the  sciatic  form,  even  when  the  limb  is  rotated  from  side  to  side.  There  is 
often,  it  is  true,  a  sense  of  resistance  ;  but  that  is  all.  .  In  one  or  two  instances  the 
head  of  the  bone  has  been  felt  per  vaginam.  In  front,  the  hollow  left  can  be 
readily  appreciated,  even  in  a  moderately  stout  person,  the  femoral  vessels  seeming 
to  dip  back  suddenly  after  passing  under  Poupart's  ligament.  In  thin  people  the 
finger  seems  to  sink  almost  into  the  acetabulum. 

Passive  motion,  which  should  always  be  left  to  the  last,  is  conclusive.  If  the 
knee  and  hip  are  flexed,  so  that  the  .sole  of  the  foot  rests  on  the  bed  by  the  side  of 
the  other  knee,  it  is  impossible  to  evert  the  limb ;  the  opposite  side  of  the  pelvis 
rises  at  once.  In  any  case  of  fracture  (except  in  that  very  rare  accident  in  which 
the  head  of  the  bone  is  driven  through  the  floor  of  the  acetabulum),  if  the  limb  is 
not  already  in  this  position,  it  can  be  made  to  assume  it  so  easily  that  it  appears  to 
fall  out  almost  of  its  own  weight. 

Voluntary  movements  are  very  much  restricted  ;  of  passive  ones  flexion  is  the 
least  affected  ;  the  limb  cannot  be  completely  extended,  and  abduction,  adduction, 
and  rotation  are  all  limited.  Sometimes,  however,  in  a  sciatic  dislocation  a  few 
days  old  the  range  of  passive  motion  is  nearly  as  wide  and  as  easy  as  in  the  unin- 


532    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

jured  limb,  with  the  exception  of  abduction  and  eversion  when  the  hi])  is  flexed, 
and  the  power  of  vohintary  action  is  to  a  great  extent  regained. 

Pain,  of  course,  is  always  present  ;  in  many  instances  it  is  very  severe,  and  it 
may  extend  down  the  course  of  the  sciatic  nerve  ;  the  back  is  arched,  especially  if 
any  attempt  is  made  to  extend  the  limb,  and  spurious  crepitus  can  nearly  always  be 
felt  on  manipulation.  Sometimes,  if  the  lip  of  the  acetabulum  has  been  broken, 
true  crepitus  can  be  felt  as  well,  but  only  by  direct  pressure  above  and  behind  the 
trochanter  while  traction  is  being  made  upon  the  limb. 

In  no  case  is  it  wise  to  come  to  a  conclusion  without  examining  the  patient 
under  an  anaesthetic,  not  only  on  account  of  pain,  but  because,  unless  the  disloca- 
tion is  very  recent,  it  is  impossible  to  manipulate  the  limb  sufficiently  freely.  Im- 
pacted fracture  of  the  neck  of  the  femur  with  inversion  of  the  limb  is  the  most 
difficult  to  distinguish,  especially  if  a  portion  of  the  trochanter  has  been  broken 
off;  for  this,  if  pulled  up  on  to  the  dorsum,  may  easily  be  mistaken  for  the  head 
of  the  bone  ;  but  the  range  of  passive  motion  is  totally  different.  Fracture  of  the 
lij)  of  the  acetabulum,  if  the  portion  broken  off  is  small,  will  probably  escape  notice 
altogether  ;   but  if  the  cup  is  much  injured,  the  head  of  the  femur  slips  out  on  to 


Fig.  231.— View  of  Pelvis  from  below,  with   Hips  Flexed  to  a  Right  Angle,  showing  the  Difference  in  Position  and 
the  Amount  of  Shortening  in  a  case  of  Sciatic  Dislocation. 


the  ilium,  and  the  limb  assumes  the  position  of  a  dislocation.  Reduction  is  easy, 
but  as  soon  as  the  limb  is  left  to  itself  it  resumes  its  former  attitude. 

Treatment. — Dislocation  backward  is  always  caused  by  flexion,  and  unless 
everything  that  resists  is  torn  across,  can  only  be  reduced  by  flexion.  The  thigh 
is  bent  at  the  moment  of  the  accident,  generally  to  its  fullest  extent,  whatever  atti- 
tude it  assumes  afterward,  and  the  first  thing  to  do  is  to  restore  it  to  this  position, 
so  as  to  bring  the  head  of  the  bone  opposite  the  rent  through  which  it  escaped. 

The  knee  must  be  bent  to  relax  the  hamstrings  and  the  sciatic  nerve ;  and 
then  the  hip,  until  the  front  of  the  thigh  is  pressed  against  the  abdomen.  The 
ilio-femoral  band  is  relaxed  by  this,  the  femur  is  brought  into  its  proper  line,  the 
inversion  ceases,  because  now  there  is  no  tension  on  the  external  limb  of  the  Y- 
ligament,  and  the  head  of  the  bone  is  lifted  out  from  between  the  rotator  muscles 
until  it  rests  under  the  margin  of  the  acetabulum.  Sometimes  a  little  adduction 
or  rotation  inward  helps  to  push  the  tendons  aside.  If  now  the  pelvis  is  held  down 
by  pressure  upon  the  ilia,  and  the  knee  is  lifted  vertically  upward,  in  many  cases 
the  head  of  the  bone  slips  at  once  over  the  rim  into  its  socket.  The  amount  of 
force  required  is  very  slight,  especially  if  the  patient  is  under  an  anaesthetic. 


DISLOCATIONS  OF   THE  HIP  JOINT.  533 

If  this  does  not  answer,  there  must  Ijc  some  mechanical  reason  for  it.  The 
neck  of  the  bone  may  be  entangled  in  the  obturator  internus  tendon  ;  or  the  sci- 
atic nerve,  or  the  tendon  of  the  obturator  externus,  may  be  twisted  around  it ;  the 
rent  in  the  capsule  may  be  more  on  one  side  ;  or  a  portion  of  muscle  or  of  the 
capsule  may  constantly  get  in  the  way  and  partly  fill  the  cavity.  \Vhatever  it  is, 
an  attempt  must  be  made  by  rotating  the  limb  from  side  to  side,  and  by  abducting 
and  adducting  it,  to  stretch  the  o|)ening  and  disengage  the  head. 

The  next  jjroceeding,  if  the  heatl  of  the  bone  cannot  be  lifted  directly  into 
its  socket,  is  to  try  and  tilt  it  in  l)y  turning  the  femur  into  a  lever.  The  base  of 
the  neck  is  fixed  by  the  Y-shaped  ligament,  and  forms  the  fulcrum  ;  the  limb  is  the 
long  arm,  and  the  head  the  short  one,  so  that  the  power  is  enormous.  The  thigh 
is  flexed  as  before,  but  slightly  abducted  ;  this  brings  the  head  a  litde  toward  the 
inner  side  of  the  cup,  where  the  rim  is  lowest,  and  helps  also  to  stretch  the  open- 
ing in  the  capsule.  Then,  if  it  is  rotated  outward  and  extended,  the  ilio-femoral 
band  is  tightened  up  and  the  head  is  forced  to  travel  round  the  cavity  until  it 
reaches  the  lowest  part  of  the  rim,  over  which  it  rolls  at  once.  During  the  first 
part  of  the  manipulation  the  thigh  should  be  forced  down  upon  the  abdomen,  as 
the  object  is  to  raise  the  head  from  among  the  muscles  ;  but  when  the  limb  is  being 
rotated,  as  a  preliminary  to  extension,  it. should  be  held  at  right  angles  to  the 
body ;  if  it  is  more  flexed  than  this,  or  if  it  is  much  abducted,  the  head  of  the 
bone,  when  the  limb  descends,  slips  to  the  inner  side  of  the  acetabulum,  instead 
of  rising  over  the  edge,  and  the  dislocation  becomes  thyroid. 

These  two  methods  have  practically  superseded  extension  ;  even  for  old  dis- 
locations it  is  never  used  now,  unless  they  have  failed.  Sometimes  the  ilio-femoral 
ligament  is  partly  torn,  so  that  the  fulcrum  is  not  held  firm,  or  a  fold  of  the  cap- 
sule gets  in  the  way,  or  the  head  is  so  surrounded  and  button-holed  that  it  cannot 
be  released,  and  then  extension  is  the  only  thing  left ;  but,  as  a  rule,  in  these 
circumstances  the  parts  are  so  torn  (to  some  extent  by  the  manipulation)  that  it 
can  be  done  by  the  hands  at  once,  or  a  jack-towel  and  pulleys  are  not  required. 

Thyroid  Dislocation. 

Thyroid  dislocation  (dislocation  downward  or  downward  and  forward  into 
the  obturator  foramen)  is  much  more  rare.  It  can  only  be  caused  by  abduction, 
combined  with  slight  eversion,  and  of  the  four  regular  dislocations  is  the  one  that 
undergoes  the  least  degree  of  consecutive  displacement  Jumping  from  a  height 
with  the  feet  wide  apart,  or  the  sudden  movement  of  a  carriage  while  a  person  is 
in  the  act  of  mounting,  may  be  regarded  as  typical.  The  head  of  the  bone  lies  upon 
the  thyroid  foramen,  in  the  substance  of  the  obturator  externus,  below  and  a  little 
to  the  inner  side  of  the  acetabulum  ;  the  rent  in  the  capsule  runs  through  the  thin- 
nest part,  but  the  pubo-femoral  band  may  be  torn  as  well ;  the  ligamentum  teres 
is  ruptured,  the  pectineus  and  the  adductors  very  much  stretched  and  generally 
torn,  and  the  anterior  part  of  the  capsule  and  the  ilio-psoas  as  tense  as  they  can 
be. 

The  position  is  unmistakable  ;  the  patient  lies  with  the  body  bent  toward  the 
injured  side,  and  the  pelvis  tilted  in  such  a  way  that  the  limb  appears  much  longer 
than  its  fellow  ;  the  knee  is  bent,  the  foot  everted,  and  the  thigh  abducted  and 
flexed.  The  degree  to  which  this  takes  place  depends  upon  the  ilio-femoral  band 
and  the  psoas  ;  the  further  the  head  is  from  the  acetabulum,  the  greater  the  amount 
of  distortion.  Actual  measurement  shows  that  the  limb  is  really  shortened.  The 
trochanter  is  sunken  inward,  the  gluteal  fold  is  lowered,  the  abductors  stand  out 
rigidly  on  the  inner  side  of  the  thigh,  and  the  head  of  the  bone  can  generally  be 
felt.  Voluntary  movement  is  out  of  the  question  ;  passive  flexion  is  fairly  easy  ; 
but  so  long  as  it  is  extended  the  limb  cannot  be  inverted  or  brought  to  the  middle 
line.  If  the  dislocation  is  unreduced,  the  limb  gradually  becomes  straighter  and 
may  acquire  a  considerable  range  of  movement,  but  not  so  much  as  in  the  case  of 
the  sciatic. 


534    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Reduction  may  be  effected  either  by  vertical  extension  or  leverage,  as  in  the 
dorsal  form,  only  adduction  and  inversion  must  be  used  instead  of  abduction  and 
eversion.  The  patient  should  be  placed  under  an  anaesthetic,  the  limb  flexed 
right  on  to  the  alDdomen,  bringing  it  gradually  into  its  normal  line,  and  then  an 
attempt  made  to  lift  it  vertically  upward  into  its  socket.  If  this  does  not  succeed, 
in  spite  of  lateral  movements  to  release  the  head  and  stretch  the  capsule  out, 
rotation  must  be  tried.  The  limb  is  flexed  to  a  right  angle,  adducted,  rotated 
inward  and  extended.  The  mechanism  is  the  same  as  in  the  dorsal  form,  and  if 
the  degree  of  flexion  or  adduction  is  too  great,  the  head  of  the  bone  sli]js  round 
the  lower  margin  of  the  acetabulum  in  a  similar  way  (but  in  the  opposite  direc- 
tion), instead  of  rising  over  the  edge. 

Pubic  Dislocation. 

Dislocation  on  to  the  body  of  the  pubes,  not  merely  on  to  the  front  of  the 
bone,  is  still  more  rare.  It  can  only  occur  when  the  limb  is  extended  and  ab- 
ducted, and  it  may  be  caused  either  indirectly  by  this  movement  being  carried  too 
far,  or  directly  by  violence  applied  to  the  back  of  the  hip.  The  head  of  the  bone 
rests  upon  the  point  of  junction  of  the  ilium  with  the  pubes,  outside  the  femoral 
vessels,  and  under  Poupart's  ligament.  The  rent  in  the  capsule  is  a  little  higher 
up  than  usual  ;  the  round  ligament,  the  pectineus,  and  the  abductors  are  always 
more  or  less  torn,  and  sometimes  Poupart's  ligament ;  and  the  short  external 
rotators,  especially  the  obturator  internus,  are  forcibly  stretched  and  hold  the  limb 
down. 

The  limb  is  everted,  abducted,  and  nearly  straight.  The  trochanter  is. more 
sunken  than  in  the  thyroid  form,  the  head  of  the  bone  can  be  felt  distinctly  in 
its  new  situation,  and  in  most  cases  can  be  seen.  There  is  shortening,  generally 
to  the  extent  of  an  inch.  Flexion,  without  drawing  the  head  of  the  bone  down 
or  abducting  the  limb  first,  is  only  allowed  to  a  slight  extent ;  abduction  is  fairly 
free. 

The  mechanism  of  reduction  is  the  same  as  for  thyroid  dislocation  ;  only, 
because  of  the  position  of  the  head  of  the  bone,  the  limb  must  be  abducted  while 
it  is  being  flexed  so  as  to  bring  it  round  the  acetabulum.  Vertical  extension  may 
fail,  owing  to  the  capsule  being  torn  more  on  the  inner  side  than  below  ;  but  rota- 
tion is  nearly  sure  to  succeed  ;  if  it  does  not,  extension,  with  direct  pre.ssure  upon 
the  head  and  the  upper  part  of  the  thigh,  must  be  tried. 


Anomalous   Dislocations. 

Besides  these  dislocations  there  are  others,  either  intermediate  in  their  char- 
acter or  exaggerated,  owing  to  the  amount  of  laceration  and  to  the  distance  that 
the  head  of  the  bone  has  been  carried.  Generally  speaking,  they  may  be  grouped 
round  the  regular  forms  and  classified,  either  by  the  attitude  of  the  limb  or  the 
method  of  reduction.  The  head  of  the  bone,  for  example,  may  rest  upon  the 
ischium  immediately  below  the  acetabulum,  opposite  the  point  from  which  it  has 
escaped,  without  passing  either  forward  or  backward.  Secondary  displacement 
has  been  in  some  way  prevented,  and  the  limb  is  inverted  and  strongly  flexed. 
(This  maybe  compared  with  the  luxatio  erecta  of  the  humerus.)  From  this  point 
the  head  of  the  bone  may  be  carried  toward  the  tuberosity,  or  on  to  some  part  of 
the  margin  of  the  great  sacro-sciatic  foramen,  until  it  is  fixed  in  one  of  the  ordi- 
nary positions. 

In  other  cases  the  head  of  the  bone  is  forced  so  far  inward  that  it  passes  from 
the  obturator  foramen  into  the  perineum,  and  the  abduction,  flexion,  and  eversion 
become  extreme.  I  have  seen,  in  a  case  of  this  kind,  the  thigh  laid  completely  on 
its  outer  side  and  flexed  to  less  than  a  right  angle. 

Most  of  these  irregular  forms,  however,  belong  to  the  pubic  group  ;  the  head 
of  the  bone  may  lie  just  internal  to  the  anterior  inferior  spine,  or  it  may  be  carried 


DISLOCATIONS  OF  THE  HIP  JOINT. 


535 


beyond  it  or  even  above  it,  until  it  rests  in  the  notch  between  the  two  spines  (the 
supraspinous  variety).  The  attitude  of  the  limb  and  the  other  symptoms  are  the 
same  as  in  the  pubic  form,  only  much  exaggerated,  and  reduction  must  be 
carried  out  in  the  same  way,  by  abduction  and  flexion  first,  and  then  inversion, 
adduction,  and  extension. 

After-treatment. — It  occasionally  happens  that,  after  reduction  has  been 
accomplished,  the  head  of  the  bone  slips  out  again  as  soon  as  the  effects  of  the 
anaesthetic  pass  off.  In  old  dislocations  this  may  be  due  to  the  cotyloid  cavity 
being  partly  filled  up;  in  recent  ones  it  is  the  result  either  of  some  portion  of  the 
capsule  having  fallen  into  the  acetalnilum  in  front  of  the  head  of  the  bone,  or  to 
part  of  the  rim  being  dragged  away.  In  either  case  reduction  must  be  effected 
again,  and  a  long  splint  and  weight  extension  applied  before  consciousness  returns, 
in  order  to  ensure  the  position  being  maintained.  The  limb  should  be  kept  quiet 
in  such  a  case  for  at  least  four  weeks. 

Under  ordinary  circumstances,  where  there  is  no  tendency  to  redisplace- 
ment,  it  is  sufficient  to  confine  the  limb  between  sand-bags,  and  passive  motion 
may  be  commenced  at  the  end  of  a  week. 

Old  Dislocations. 

If  not  of  more  than  two  months'  standing,  there  is  a  fair  prospect  of  success  ; 
in  one  ca.se  reduction  was  .accomplished  at  the  end  of  a  twelvemonth,  but   this 


Fig.  232.— Showing  the  Fashion  of  Applying  Pulleys.     (N  B  —The  leg  and  thigh  should  be  bandaged.) 

must  be  regarded  as  quite  exceptional.  Manipulation  under  an  anesthetic  affords 
a  much  better  chance  than  extension,  even  with  the  aid  of  pulleys  (Fig.  232). 
If  the  head  of  the  bone  is  not  reduced,  the  adhesions  are  broken  down,  the  range 
of  movement  is  much  improved,  and,  especially  in  the  sciatic  form,  the  limb 
regains  a  great  deal  of  its  strength  and  activity,  a  new  cavity  gradually  being 
developed  for  the  head.  Care,  however,  must  be  taken  not  to  fracture  the  femur, 
which  is  very  often  atrophied  from  disuse,  or  to  injure  the  sciatic  nerve,  which 
sometimes  is  wound  around  the  neck  of  the  bone.  Both  of  these  accidents  have 
been  met  with  in  recent  dislocations,  but  they  are  much  more  likely  to  happen  in 
old  ones. 

Excision  of  the  head  of  the  bone  has  been  performed  in  several  cases  with  a 
very  satisfactory  result,  though  the  operation  is  a  serious  one.  If  the  head  is  fairly 
movable,  but  the  position  of  the  limb  faulty,  subtrochanteric  osteotomy  may  be 
tried  instead. 


DISLOCATION  OF  THE  PATELLA. 

This  maybe  dislocated  to  either  side,  or  it  may  be  twisted  on  its  vertical  axis 
so  far  that  the  articular  and  cutaneous  surfaces  are  almost  reversed.  Displacement 
upward  can  only  be  regarded  as  a  part  of  rupture  of  the  ligamentum  patellae. 


536     DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 

Outward  dislocation  is  the  most  common,  esi)ecially  if  there  is  any  genu  val- 
gum. It  can  only  occur  in  extension;  the  patella  then  is  so  loosely  held  that  it 
can  be  pushed  from  side  to  side,  and  can  be  dislocated  either  by  muscular  action, 
or  by  a  sudden  blow  from  its  inner  border,  tilting  it  out  over  the  external  condyle  ; 
in  flexion  it  sinks  in  between  the  condyles  and  is  held  strapped  down  by  the  tension 
of  the  muscles.  If  the  dislocation  is  complete,  the  articular  surface  rests  against 
the  outer. side  of  the  external  condyle  ;  if  it  is  only  jjartial,  the  bone  is  not  carried 
so  far  and  the  margin  looks  forward.  Laceration  of  the  capsule  is  very  general, 
but  ai)ijarently  not  absolutely  essential.  Dislocation  inward  and  rotation  are  both 
very  rare;  the  latter  has  Ijeen  produced  by  a  violent  l)low  upon  the  inner  side  of 
the  bone  when  the  knee  was  bent  to  an  acute  angle. 

The  deformity  can  usually  be  recognized  at  once  ;  the  limb  is  extended  or 
very  slightly  flexed  ;  the  knee  is  flattened  in  front  and  broader  than  natural ;  a 
hollow  can  be  felt  between  the  condyles;  and  the  shajjc  of  the  patella,  with  the 
ligamentum  patellae  and  the  tendon  of  the  ciuadricei)s,  both  of  which  are 
very  tense,  can  be  seen  standing  out  beneath  the  skin.  Movement  is  very 
limited. 

Treatment. — Generally,  if  the  hip  is  flexed,  the  knee  extended,  and  direct 
pressure  made  ui)on  the  prominent  border  of  the  bone,  it  slii)s  back  into  its  posi- 
tion at  once  ;  or,  if  this  fails,  the  hip  and  the  knee  may  be  bent  (under  an  anjes- 
thetic)  and  pre.ssure  and  extension  tried  together ;  sometimes  rotation  of  the  leg 
has  been  found  of  assistance.  But,  while  one  or  other  of  these  nearly  always  suc- 
ceeds at  once,  instances  are  occasionally  met  with  in  which  reduction  is  impossible 
in  spite  of  every  attempt.  Nor  is  the  cause  clear.  It  may  be  due  to  the  patella 
catching  in  the  intercondyloid  notch,  or  to  its  being  in  some  way  entangled  in  the 
capsule  ;  but,  whatever  it  is,  in  a  i^^  cases  it  has  resisted  everything,  and  the  dis- 
location has  remained  unreduced  in  spite  of  section  of  the  ligaments  and  the 
tendon  of  the  quadriceps.  In  such  circumstances  it  would  be  wiser  to  open  the 
joint  freely,  with  every  antise])tic  precaution,  and  divide  the  structures  that  retain 
the  bone,  than  to  trust  to  force  and  subcutaneous  section,  which  on  several  occa- 
sions have  ended  in  suppuration. 

As  in  all  injuries  involving  the  knee,  the  joint  becomes  filled  with  fluid  even 
before  the  dislocation  is  reduced  ;  and  partly  for  this  reason,  the  capsule  becoming 
stretched  and  softened  by  the  effusion,  partly  because  the  dislocation  is  due  in  great 
measure  to  the  shape  of  the  bones,  recurrence  is  very  common.  The  limb  must 
be  placed  upon  a  splint,  in  a  position  of  moderate  extension,  carefully  packed  in 
cotton-wool,  and  firmly  bandaged  until  the  effusion  is  absori)ed.  Afterward  an 
apparatus  must  be  worn  to  prevent  any  lateral  movement  of  the  patella.  The 
simplest,  perhaps,  is  a  piece  of  chamois  leather  spread  with  lead  plaster  strained 
round  the  limb ;  it  should  be  large  enough,  when  the  knee  is  laid  upon  it,  to  over- 
lap well  in  front,  and  should  extend  a  few  inches  above  and  below  the  joint.  This 
answers  better  than  ordinary  strapping,  unless  it  is  applied  exceedingly  well.  If, 
however,  there  is  much  laceration,  or  if  the  bone  has  been  displaced  more  than 
once,  some  apparatus  similar  to  that  used  to  retain  a  displaced  fibro-cartilage  is 
advisable. 

In  young  people  of  rapid  growth,  when  the  bony  prominences  are  poorly 
marked  and  the  ligaments  yielding,  the  i)atellacan  be  moved  freely  from  one  con- 
dyle to  the  other,  and  sometimes  it  gets  caught  upon  the  outer  one.  The  capsule, 
however,  is  not  torn  ;  the  bone  is  easily  replaced  ;  and  there  is  a  very  slight 
amount  of  effusion  afterward. 


DISLOCATIONS  OF  THE  KNEE. 

The  leg  may  be  dislocated  backward,  forward,  or  to  either  side  ;  and  a  few 
cases  are  recorded  in  which  the  tibia  has  l)een  displaced  so  far  by  rotation  that  the 
inner  tuberosity  was  directed  forward  and  the  tubercle  outward. 


DISLOCATION  OF  THE  KNEE.  537 

Lateral  dislocations  are  the  most  common  and  are  always  incomplete,  the  tibia 
never  being  displaced  entirely  from  the  femur.  This  may  be  caused  by  a  fall  with 
the  leg  bent  under  the  body,  by  sudden  forcible  twisting,  or  by  extreme  violence 
applied  to  one  side  of  the  limb  ;  and  are  always  attended  by  very  serious  injury  to 
the  lateral  and  crucial  ligaments  and  to  the  tendinous  expansion  of  the  vasti.  The 
deformity  is  sufticiently  conspicuous  to  be  recognized  at  once,  the  internal  condyle 
of  the  femur  resting  on  the  outer  tuberosity  of  the  tibia  (or  vice  versa)  and  forming 
a  distinct  and  easily  recognized  projection  on  the  side.  Reduction,  owing  to  the 
extentof  the  injury,  is  easily  accomplished  by  flexion  and  extension  combined  with 
lateral  pressure.  Afterward  the  knee  must  be  placed  upon  a  splint,  raised,  very 
carefully  bandaged  and  covered  with  ice.  Passive  motion  may  be  commenced  in 
a  fortnight  or  three  weeks,  but  through  a  very  small  angle,  so  as  not  to  throw  any 
strain  upon  the  ruptured  parts  ;  and  the  patient  should  not  be  allowed  to  bend  the 
joint  himself  for  at  least  a  month  more.  Afterward  an  apparatus  must  be  worn 
restricting  the  movement  of  the  joint,  for  fear  of  any  sudden  twist  displacing  the 
bones  again. 

Aiitero-posterior  Dislocation. — Dislocation  of  the  knee  forward  may  take  place 
either  by  over-extension  or  by  direct  violence  :  dislocation  backward,  which  is 
much  more  rare,  only  by  the  latter.  The  luxation  may  be  complete,  the  tibia  being 
carried  altogether  in  front  or  behind  the  femur,  and  forced  some  distance  up  the 
thigh  ;  or  more  often  incomplete,  and  the  bones  still  to  a  great  extent  in  contact. 
The  ligaments  are  always  torn,  or  wrench  away  portions  of  the  bones  ;  the  neigh- 
.boring  tendons  and  muscles,  such  as  the  hamstrings  and  the  gastrocnemius,  are 
lacerated  or  stretched  ;  and  the  vessels  either  compressed,  so  that  the  circulation 
is  stopped  or  actually  torn  across.  The  shape  of  the  bones  is  easily  made  out,  and 
the  nature  of  the  injury  can  hardly  be  mistaken.  In  the  forward  dislocation  the 
limb  is  usually  extended,  and  if  it  is  complete,  much  shortened.  The  patella  is 
freely  movable  ;  sometimes  the  joint  is  fixed  ;  sometimes,  owing  to  the  extent  of 
the  laceration  and  the  position  of  the  bones,  there  is  a  wide  range  of  passive  move- 
ment. In  the  backward  form  the  displacement  is  more  variable  ;  generally  the 
limb  is  in  a  position  of  extreme  extension,  but  it  may  be  completely  flexed. 

Reduction,  especially  under  an  anaesthetic,  is  easy,  and  maybe  accomplished 
either  by  traction  in  the  axis  of  the  limb,  or  by  flexion  and  extension,  according  to 
the  position  of  the  bones.  The  condition  of  the  vessels  below  should  be  ascertained 
at  once  ;  even  if  the  artery  has  only  been  compressed  or  stretched,  a  thrombus 
may  form,  and  gangrene  set  in  ;  or  later  an  aneurysm  may  develop  ;  if  it  has  given 
way,  immediate  amputation  should  be  performed.  Usually  this  is  required  in  com- 
pound dislocations  ;  only,  perhaps,  sometimes,  when  the  skin  is  not  so  much  torn, 
and  the  vessels  are  intact,  and  the  patient  is  young  and  healthy,  an  attempt  may 
be  made  to  save  the  limb,  either  by  washing  the  joint  out  and  draining  it  thor- 
oughly, or  by  performing  a  primary  excision. 


Dislocation  of    the  Semilunar  Cartilages. 

In  this  accident,  which  was  first  described  by  Hey  under  the  name  oi  internal 
derangement  of  the  knee  joint,  one  of  the  semilunar  cartilages  is  displaced  and 
caught  between  the  bones,  so  that  the  joint  is  locked  and,  so  far  as  the  patient  is 
concerned,  is  entirely  out  of  control. 

The  external  cartilage  glides  backward  and  forward  freely  over  the  upper 
surface  of  the  tuberosity  ;  the  internal  is  more  fixed  and  follows  the  movements  of 
the  tibia  ;  but  the  latter  appears  to  be  the  more  frequently  displaced.  The  nature 
of  the  injury  probably  differs  a  good  deal.  Sometimes  the  margin  of  the  cartilage 
is  detached,  and  the  disc  is  rolled  inward  toward  the  centre  of  the  joint  ;  the  ex- 
ternal has  been  found  by  Godlee  rolled  up  in  the  inter-condyloid  notch.  More 
often  one  of  the  ends  is  torn  away  from  the  bone,  and  the  disc  is  squeezed  out 
under  the  skin,  either  in  front  or  to  one  side.  The  anterior  part  of  the  internal  is 
35 


538    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  part  that  gives  way  the  most  freriuently  ;  and  it  has  been  found,  as  the  result 
of  football,  so  completely  detached  that  it  had  to  be  removed  as  a  foreign  body. 
In  many  instances  it  is  probable  that  the  actual  laceration  is  insignificant,  the 
fibrous  tissue  by  which  they  are  attached  being  stretched,  rather  than  torn,  so 
that  in  certain  positions  of  the  joint  the  cartilages  can  be  pushed  backward  or 
forward  until  they  are  caught  between  the  bones.  Such  an  accident  may  occur 
even  in  a  healthy  joint ;  but  it  is  much  more  likely  to  happen  when  the  ligaments 
are  already  relaxed  by  chronic  synovitis  or  rheumatoid  arthritis;  and,  for  this 
reason,  recurrence  of  the  displacement,  when  once  it  has  occurred,  is  the  rule 
rather  than  the  exception.  The  joint  always  becomes  filled  with  fluid  after  this 
accident ;  the  ends  of  the  cartilage,  if  it  is  torn,  are  forced  apart  from  each  other, 
so  that  repair  can  only  be  carried  out  imperfectly,  and  all  the  ligaments  are 
stretched  and  softened.  For  the  same  reason  internal  derangement  is  not  uncom- 
mon in  young,  rapidly-growing  subjects,  in  whom,  owing  to  the  weakness  of  the 
muscles  and  the  poor  development  of  the  articular  ends,  the  bones  can  often  be 
made  to  assume  abnormal  jwsitions;  but  it  may  happen  to  the  strongest  and  most 
athletic. 

The  cause  is  always  a  trivial  one  ;  crossing  the  legs,  for  example,  while  .seated  ; 
catching  the  inner  side  of  the  great  toe  in  walking;  twisting  round  to  take  a  ball 
at  lawn-tennis  ;  or  even  suddenly  turning  over  in  bed.  Nearly  always  it  is  caused 
by  rotation  while  the  leg  is  semi-flexed  ;  in  eversion  the  internal  one  suffers  ;  in 
inversion,  the  external  ;  it  may  occur,  how-ever,  at  the  end  of  extension,  if  there  is 
no  weight  on  the  limb  to  hold  the  bones  together.  Thus  it  is  common  at  football 
when  a  kick  is  missed  ;  the  posterior  end  of  the  internal  cartilage  is  carried  for- 
ward until  it  slips  under  the  condyle  ;  if  it  slips  back  again,  there  is  merely  a  sharp 
stab  of  pain,  often  followed  by  a  slight  amount  of  effusion  ;  but,  if  it  is  caught, 
there  is  genuine  displacement  and  the  limb  becomes  locked.  Knott's  and  some 
of  Hey's  cases  were  probably  similar.  In  Lucas's  the  external  was  displaced,  the 
posterior  end  being  carried  forward  in  the  same  way  until  it  was  caught  under  the 
condyle  ;  there  was  a  sudden  jerk  when  the  joint  was  flexed  ;  a  projection  made  its 
appearance  on  the  outer  side  of  the  patella  and  the  limb  became  inverted  ;  in  ex- 
tension this  was  reversed,  the  limb  becoming  straight  and  the  projection  vanish- 
ing.     Several  similar  instances  have  been  recorded  by  Marsh. 

It  is  not  uncommon  to  find,  after  repeated  accidents  of  this  kind,  that  there 
is  a  certain  amount  of  permanent  thickening,  generally  on  the  inner  side  of  the 
limb;  and  in  one  or  two  cases  the  disc  appears  to  have  become  hypertrophied, 
from  the  effect  of  constant  irritation.  According  to  Kocher  it  may  become  con- 
verted into  a  mass  of  granulation  tissue,  and,  unless  it  is  excised,  lead  to  suppura- 
tion in  the  joint. 

Symptoms. — In  all  the  cases  there  is  a  strong  family  likeness,  though  there 
are  many  small  points  of  difference,  depending  in  all  probability  on  the  character 
and  the  direction  of  the  disi)lacement.  There  is  a  sudden  attack  of  the  most  in- 
tense pain  ;  the  patient  falls  down  almost  in  a  fainting  condition  with  the  knee 
slightly  bent ;  and  in  severe  ca.ses  he  is  quite  unable  to  stand.  Voluntary  move- 
ment is  out  of  the  question,  but  passive  motion  is  free  and  almost  painless  ;  if  the 
patient  sits  on  a  table  he  can  swing  the  leg  backward  and  forward,  but  not  to  its 
full  extent  in  either  direction.  In  a  few  minutes  the  joint  becomes  filled  with 
fluid  ;  by  degrees  the  severity  of  the  pain  abates,  and  very  slowly  power  returns 
until  the  patient  can  limp  about  ;  but  so  long  as  the  displacement  persists,  full 
flexion  and  extension  are  imjwssible.  Sometimes  a  projection  can  be  seen  on  the 
outer  or  the  inner  side  of  the  limlj,  corres])onding  to  one  of  the  cartilages  ;  occa- 
sionally the  skin  is  puckered  in  when  the  displacement  is  toward  the  interior;  in 
most  instances  the  only  change  visible  is  a  slight  relaxation  of  the  ligamentum 
patellae  when  compared  with  the  opposite  side.  Synovitis  is  invariable  and  as  a 
rule  very  rapid. 

Slighter  cases,  in  which  the  cartilage  probably  slips  back  of  itself,  are  not 
uncommon.     The  patient  generally  complains  of  the  joints  locking  or  catching, 


DISLOCATION  OF   THE   KNEE.  539 

of  a  moment's  sudden  pain,  and  then,  after  a  sensation  of  something   slipping 
away,  of  l)eing  able  to  move  again,  but  with  a  certain  degree  of  uneasiness. 

Diagnosis. — The  history  and  symptoms  closely  resemble  those  of  loose  car- 
tilages in  a  joint,  but  the  |)resence  of  a  projection  or  a  depression  on  a  level  with 
the  head  of  the  tibia,  and  the  continual  locking  of  the  joint,  generally  make  the 
diagnosis  certain.  If,  however,  before  the  case  is  seen  the  synovial  cavity  has 
alread)'  become  distended,  the  difficulty  may  be  very  considerable,  and  in  all 
cases  in  which  tlie  history  or  symptoms  suggest  either  of  these  conditions,  it  is 
advisable  to  make  the  most  thorough  examination,  not  only  at  once,  but  afterward 
when  the  effusion  has  in  great  measure  subsided.  Much  discredit  has  arisen  on 
more  than  one  occasion,  from  the  fact  that  this  displacement  has  never  been  re- 
cognized. 

Treatment. — The  first  thing  is  to  release  the  cartilage.  In  the  slighter 
cases  it  often  slips  back  of  itself  before  the  patient  is  seen,  or  is  reduced  by  some 
almost  involuntary  action.  Knott,  for  example,  relates  how,  on  the  first  occasion 
on  which  it  happened  to  himself,  he  instinctively  applied  his  hands  upon  each  side 
of  the  joint  and  j^rcssed  as  firmly  as  he  could  to  relieve  the  pain  ;  suddenly  he  felt 
something  slip  and  the  limb  could  be  moved  again  at  once.  Where  the  displace- 
ment has  repeatedly  occurred  this  is  frequently  the  case  and  the  patients  learn 
either  to  do  it  for  themselves  or  to  direct  others  in  the  manipulation  required. 
An  anaesthetic  is  not  absolutely  needed,  but  in  most  cases  it  is  advisable;  the 
manipulation  is  so  much  more  easy,  and  the  condition  of  the  joint  can  be  exam- 
ined so  much  more   thoroughly. 

Hey  recommended  that  the  patient  should  be  seated  on  a  high  chair  facing 
the  surgeon,  who  should  grasp  the  limb  firmly,  extend  it,  until  it  was  as  straight 
as  circumstances  would  allow,  and  then  rapidly  flex  it.  Modern  surgeons  have 
reversed  this  proceeding  with  advantage,  as  preliminary  extension  is  much  more 
painful  than  flexion,  and  in  the  second  step  rapid  flexion  is  somewhat  difficult  to 
carry  out.  Whichever  plan  is  adopted,  firm  pressure  must  be  made  with  the  thumb 
over  any  projection  that  can  be  felt.  If  this  fails  the  limb  may  be  flexed  to  its 
full  extent,  rotated  inward  or  outward  as  far  as  it  can  be,  and  then  rapidly  ex- 
tended, or  abduction  and  adduction  may  be  tried  in  the  same  way.  Sometimes  it 
suddenly  slips  into  position  almost  of  itself;  in  a  few  cases  it  has  never  been 
reduced  at  all,  although  repeated  attempts  have  been  made,  not  only  at  -first,  but 
afterward,  when  the  effusion  into  the  joint  had  been  absorbed.  In  such  cases,  or 
if  the  displacement  takes  place  so  frequently  that  the  joint  is  practically  useless, 
and  is  in  serious  danger  of  becoming  disorganized  from  repeated  attacks  of  syno- 
vitis, there  is  no  doubt  the  cartilage  should  either  be  removed,  or  be  reduced  and 
stitched  into  position  with  catgut. 

As  soon  as  reduction  has  been  accomplished,  means  must  be  taken  to  get  rid 
of  the  effusion.  Recurrence  cannot  always  be  prevented,  especially  if  one  end  of 
the  cartilage  has  been  torn  off  the  bone  ;  but  there  is  no  doubt  the  tendency  to  it 
is  greatly  increased  by  the  amount  and  persistence  of  the  effusion.  The  limb 
must  be  carefully  packed  in  cotton-wool  and  bandaged  as  firmly  as  possible  ;  and 
if  the  pain  and  tension  are  very  severe,  it  should  be  placed  upon  a  splint  and  the 
patient  kept  in  the  recumbent  position  for  a  few  days.  Passive  motion  may  be 
commenced  after  forty-eight  hours,  so  that  there  may  be  no  after-stiffness  or 
wasting  of  the  muscles  ;  but  the  extremes  of  flexion  and  extension  should  be 
avoided,  and  care  should  be  taken  to  keep  the  foot  perfectly  straight. 

After  the  effusion  has  been  absorbed  an  apparatus  must  be  worn  for  some 
months,  especially  when  indulging  in  any  exertion  which,  like  lawn-tennis,  has  a 
particular  tendency  to  produce  this  displacement.  If  it  has  happened  only  once, 
an  elastic  knee-cap,  strengthened  and  padded  opposite  the  cartilage,  whichever  it 
is,  may  suffice,  but  this  must  only  be  worn  during  exercise,  never  at  night ;  and 
the  knee,  every  time  it  is  removed,  must  be  thoroughly  rubbed  and  shampooed, 
or  more  harm  than  good  may  result.  In  older  cases  this  is  not  enough,  and  a 
metal  apparatus  must  be  fitted  on.     A  very  good  arrangement  consists  of  two 


540    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

\vc'll-])a(l(led  metal  plates,  accurately  fitted  roiiml  the  knee-cap,  one  on  either  side, 
and  held  together  above  and  below  by  short  strajjs.  These  plates  are  connected 
together  by  a  steel  spring  passing  horizontally  across  l)ehind  the  joint,  so  that 
when  the  splint  is  in  position  they  press  firmly  upon  the  unprotected  })ortion  of 
the  capsule  where  the  displacement  is  most  likely  to  take  place.  If  this  does  not 
answer,  or  if,  as  not  unfrequently  happens  when  the  internal  lateral  ligament  of 
the  knee  joint  has  been  injured,  rotation  of  the  tibia  is  a  marked  feature  in  the 
displacement,  the  best  kind  of  apparatus  is  formed  on  the  principle  of  two  lateral 
bars,  jointed  opposite  the  knee  and  connected  together  above  and  below  by  a 
circle  round  the  limb,  formed  partly  of  metal,  ])artly  of  leather.  An  additional 
strap  across  the  joint  above  and  below  the  i)atella  is  of  service.  This  is  heavier 
and  more  cumbersome,  but  much  more  efficient  than  the  former  in  checking 
irregular  movements  of  rotation.  In  any  case  the  patient  should  learn  to  keep 
the  foot  as  constantly  as  possible  turned  in  the  direction  of  the  displacement — 
inverted,  that  is  to  say,  when  the  internal  cartilage  is  affected,  and  vice  versd. 


DISLOCATION  OF  THE  ANKLE. 

The  foot  may  be  detached  from  the  tibia  and  fibula,  and  driven  either  back- 
ward, forward,  inward,  or  outward  ;  but  the  displacement  is  rarely  complete.  A 
few  cases  are  recorded  in  which  the  bones  of  the  leg  have  been  separated  from 
each  other,  and  the  astragalus  driven  up  between  them. 

Lateral  Dislocation. 

This  is  caused  by  the  foot  being  forcibly  twisted  on  an  antero-posterior  axis, 
and  it  can  scarcely  take  place  without  fracture  of  one  or  both  malleoli. 

Dislocation  outward,  with  frac- 
ture of  the  fibula,  is  the  more  com- 
mon, and  is  known  as  Pott's  fracture 
(Fig.  233)  :  the  foot  is  forcibly 
everted,  the  strain  falls  upon  the  in- 
ternal lateral  ligament  or  the  in- 
ternal malleolus ;  one  or  other  of 
them  gives  way,  the  fibula  breaks 
inward  toward  the  tibia  a  short 
distance  above  the  joint,  and,  if  the 
force  continues,  the  astragalus  is 
twisted  round  in  its  socket,  carrying 
with  it  the  bones  of  the  foot.  When 
the  violence  is  very  great,  there  is,  in 
addition,  a  vertical  fracture  through 

F.c;.    233.-Potfs    Fracture.  the     tibia,    a     portion      of     the      bOHC 

being  dragged  away  by  the  interosse- 
ous ligament.  If  the  separation  is  only  slight,  the  deformity  is  not  serious,  though, 
unless  care  is  taken  to  prevent  it,  the  socket  in  which  the  astragalus  is  fixed  may 
be  widened,  and  the  security  of  the  joint  permanently  impaired;  but,  if  it  is  ex- 
tensive, the  whole  of  the  foot  and  the  external  malleolus  may  be  carried  upward 
on  to  the  outer  side  of  the  leg,  until  the  articular  surfaces  are  completely  dis- 
placed. This,  which  is  known  as  Dupuytren's  fracture,  is  very  rare  but  very 
serious. 

It  sometimes  happens,  when  both  malleoli  have  given  way,  that  the  astra- 
galus, with  the  foot,  is  carried  boldly  outward  or  inward  on  the  leg  without  any 
twisting. 

Dislocation  inward  is  not  so  often  met  with.  It  can  only  be  produced  by 
extreme  inversion  ;    the  internal  malleolus  or  the  portion  of  the  tibia  carrying  it 


DISLOCATION  OF  THE   ANKLE. 


541 


is  prized  off  by  the  rotation  of  the  foot,  and  either  the  external  lateral  ligament  is 
torn,  or,  more  commonly,  tlie  fibula  is  broken  outward,  from  the  traction  upon  its 
inferior  extremity.      Sometimes  the  astragalus  itself  is  crushed  as  well. 


Fig.  234. — Dislocation  of  Foot, 
Backward. 


Antero-posterior  Dislocation. 

In  spite  of  the  width  of  the  astragalus  in  front,  and  the  strength  of  the 
lateral  ligaments,  the  foot  is  occasionally  displaced  backward ;  displacement 
forward  is  very  rare.  In  either  case  the  lateral  ligaments  give  way  ;  or  the  fibula, 
or  the  internal  malleolus,  is  broken  off  instead,  and 
carried  forward  or  backward  with  the  bones  of  the 
foot. 

Dislocation  backward  may  be  either  complete  or 
incomplete  (Fig.  234).  It  is  caused  by  forced  plantar 
flexion,  the  point  of  the  foot  being  depressed  until 
either  the  bones  or  the  anterior  part  of  the  lateral 
ligaments  give  way ;  then  if  any  force  is  applied  to 
the  leg  from  behind  (such,  for  example,  as  the  im- 
petus of  the  body  in  falling  from  a  carriage  in 
motion)  the  tibia  and  fibula  are  driven  over  the  front 
of  the  astragalus.  As  soon  as  the  force  is  spent,  the 
foot  is  straightened  by  the  action  of  the  muscles. 

Forward  displacement  may  be  produced  by  ex- 
treme dorsal  flexion  :  if,  for  example,  while  the  foot 
is  fixed  and  the  knee  and  ankle  are  completely  bent, 
a  violent  blow  is  delivered  on  the  front  of  the  thigh, 
driving  the  bones  of  the  leg  backward  ;  but  only  six 
cases  are  on  record. 

In  dislocation  nptuard  the  fibula  is  wrenched  off  from  the  tibia,  the  inter- 
osseous ligament  either  giving  way  or  tearing  off  a  portion  of  the  bone  ;  the 
lateral  ligaments  are  torn,  and  the  astragalus  is  forced  vertically  upward  into  the 
inter-space.  This  can  only  arise  from  an  extreme  degree  of  violence  applied  to 
the  sole  of  the  foot,  the  bones  first  being  separated  and  then  the  astragalus  driven 
upward  by  a  continuance  of  the  force.  In  one  case  it  was  bilateral,  caused  by 
jumping  down  from  some  great  height. 

Diagnosis. — Immediately  after  the  accident,  there  is  rarely  any  difficulty, 
owing  to  the  way  in  which  the  bony  prominences  stand  out  beneath  the  skin  ;  but 
the  outlines  soon  become  fainter  as  the  depressions  are  filled  up  by  the  extrava- 
sation and  swelling,  and,  in  a  little  while,  nothing  can  be  seen  but  general  dis- 
tortion. The  position  of  the  foot  with  regard  to  the  rest  of  the  limb,  whether  it 
is  inverted  or  everted,  shortened  or  lengthened,  always  gives  a  clue  to  the  nature 
of  the  injury  ;  and  then  deep  pressure  may  be  used  to  determine  the  particular 
character  of  the  displacement  and  the  amount  of  damage  done  to  the  bones  and 
ligaments,  every  bony  projection  being  compared,  one  by  one,  with  the  corres- 
ponding ones  in  the  opposite  foot.  Finally,  passive  motion  must  be  tried,  not 
only  to  assist  in  identifying  the  bones  by  the  way  in  which  they  move,  but  to 
ascertain  the  presence  of  abnormal  mobility  (lateral  flexion,  for  example),  or  of 
crepitus. 

Treatment. — The  method  of  reduction  is  essentially  the  same  in  them  all. 
The  patient  must  be  placed  under  an  anaesthetic,  to  relax  the  muscles ;  the  knee 
must  be  flexed,  and  then  the  foot  must  be  slowly  but  firmly  brought  round  to  its 
right  position.  If  the  displacement  is  lateral,  this  is  generally  easy ;  when  it  is 
backward,  it  may  usually  be  managed  by  extreme  plantar  flexion,  drawing  the 
foot  downward,  away  from  the  leg,  at  the  same  time,  and  rocking  it  from  side  to 
side  so  as  to  disentangle  it ;  but  in  dislocation  of  the  foot  forward  the  difficulty  is 
very  great.      Dorsal  flexion  appears  to  offer  the  best  prospect,  and    the   tendo- 


542     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES, 

Achillis  or  any  other  that  gets  in  the  way  between  the  bones,  may  be  divided  ; 
but  even  then  the  attempt  has  not  always  been  successful. 

Upward  dislocation,  the  diagnosis  of  which  is  easy,  from  the  enormous 
breadth  of  the  lower  part  of  the  leg  and  the  approximation  of  the  sole  of  the 
malleoli,  can  only  be  reduced  by  extension  on  the  foot.  If  the  attempt  fails,  the 
liml)  ultimately  becomes  very  useful,  although  the  joint  itself  always  remains  stiff. 

In  all  dislocations  of  the  ankle,  some  form  of  apparatus  is  re(]uired  after  re- 
duction has  been  accomplished,  to  prevent  the  surfaces  being  displaced  again. 
In  the  slighter  cases,  in  which  the  tendency  to  return  is  not  very  marked,  and  the 
injury  is  seen  a  short  time  after  the  accident,  so  that  the  extravasation  is  not  ex- 
treme or  the  skin  in  danger  of  giving  way,  a  fixed  apparatus  may  be  apjjlied  at 
once,  only  it  must  be  formed  in  two  parts,  laced,  or  fastened  together  in  some 
other  way;  and  it  must  be  thickly  padded  with  cotton-wool  opijosite  the  seat  of 
injury.  Afterward  the  limb  must  be  raised  for  twenty-four  hours,  and  the  knee 
joint  kept  flexed  until  the  tendency  to  spasmodic  contraction  on  the  part  of  the 
muscles  has  disappeared.  Passive  motion  and  ma.ssage  may  be  commenced  at  the 
end  of  ten  days,  but  the  limb  in  the  meantime  must  be  incased  in  a  starch 
bandage,  and  the  patient  must  not  be  allowed  to  rest  any  weight  upon  it  for  at 
least  six  weeks.  The  greatest  care  is  necessary  during  the  whole  course  of  treat- 
ment to  prevent  any  drooping  of  the  toes  or  version  of  the  foot.  If  either  of 
these  is  present,  the  limb  becomes  almost  useless. 

When  the  injury  is  more  severe,  and  in  all  cases  of  antero-posterior  displace- 
ment, it  is  better  to  make  use  feither  of  back  and  side  splints,  swinging  the  leg 
from  a  cradle  (as  already  described  in  speaking  of  fractures),  or  of  a  single  side 
splint  with  a  foot  and  sole  piece,  the  limb  resting  upon  its  outer  surface.  In 
either  case  the  knee  must  be  kept  well  bent,  the  foot  must  be  exactly  at  right 
angles  to  the  leg,  and  the  pads  must  be  so  arranged  on  the  splints  as  to  correct  as 
far  as  possible  any  tendency  to  eversion  or  inversion.  If  a  side  splint  is  used,  it  is 
of  great  advantage  to  pack  the  ankle  well  with  several  layers  of  cotton-wool  and 
bandage  it  firmly  over  all.  Very  often,  unless  this  is  done,  it  is  difficult  to  be 
certain  whether  the  displacement  is  rectified  or  not,  owing  to  the  amount  and 
the  persistence  of  the  oedema  and  extravasation.  The  limb  may  be  placed  in  a 
fixed  apparatus  at  the  end  of  a  fortnight,  but  this  must  be  so  arranged  that  it  can 
be  removed  for  the  purpose  of  carrying  out  j^assive  exercise  every  two  or  three 
days.  If  this  is  neglected,  the  joint  is  liable  to  become  exceedingly  stiff  and 
painful. 

Covipound  {opeii)  dislocation  of  the  anklc-Joinf  is  a  most  serious  injury,  and, 
especially  if  the  patient  is  broken  down  in  health,  may  require  immediate 
amputation.  Age  is  not  of  so  much  importance  in  this  respect  as  the  condition 
of  the  kidneys,  though  of  course  the  risk  increases  with  advancing  years.  Much 
depends  upon  the  way  in  which  the  accident  happens.  If  it  is  the  result  of  in- 
direct violence,  so  that  the  skin  on  one  side  of  the  joint  is  torn,  and  the 
interior  exposed,  without  the  bones  being  crushed  or  the  soft  parts  bruised,  the 
limb  may  be  saved,  though  it  can  only  be  done  by  the  most  perfect  drainage. 
Even  if  suppuration  and  ankylosis  occur,  it  may  prove  exceedingly  usefiil,  the 
mid-tarsal  joint  replacing  the  one  that  is  lost.  The  bleeding  must  be  stopped  ; 
detached  fragments  of  bone  or  cartilage  removed  ;  the  wound  thoroughly  wa.shed 
out  (it  is  a  very  good  plan  to  immerse  the  part  bodily  in  a  corrosive  sublimate 
bath  for  some  hours)  and  so  arranged  that  it  can  drain  perfectly,  counter-open- 
ings being  made,  if  need  be,  to  ensure  this.  If  the  wound  is  very  small,  it  may 
be  sealed  and  closed  at  once ;  as  a  rule,  it  is  better  to  leave  it  open,  so  that  the 
cavity  can  be  constantly  washed  out  and  there  may  be  no  accumulation  in  the 
interior.  Then  the  ankle  must  be  covered  with  a  thoroughly  absorbent  dressing 
and  fixed  upon  a  splint,  interrupted  so  that  the  wound  may  be  exposed  without 
disturbing  the  bandages.      Parafiin  is  very  usefiil  for  this,  as  it  is  waterproof. 

In  man V  cases  the  wound   heals  up  at  once;   sometimes   there   is  a  certain 


DISLOCATION    OF   THE   ASTRAGALUS.  543 

amount  of  dischari^'c  ;  granulations  spring  \\\)  round  the  orifice,  the  synovial  lining 
becomes  unduly  thickened  and  vascular,  and  the  joint  is  stiffened  from  the  forma- 
tion of  extra-articular  adhesions  ;  but  the  cartilages  remain  intact  and  the  cavity 
is  preserved.  If,  however,  the  drainage  is  not  perfect,  or  if  the  discharge  is 
allowed  to  decompose  inside,  acute  suppurative  arthritis  is  sure  to  set  in  ;  the  car- 
tilages necrose  ;  the  ligaments  are  destroyed  ;  the  surface  of  the  bones  becomes 
carious  ;  and  abscesses  form  in  the  loose  cellular  tissue  around.  Even  then,  if  free 
exit  is  provided,  and  the  cavity  is  kept  constantly  clear,  granulations  may  spring 
up  and  fill  the  cavity,  until  the  oi)posite  surfaces  fuse  together  ;  but  secondary 
amputation  may  at  any  moment  become  necessary.  The  patient's  health  and 
strength  may  fail  from  the  intensity  of  the  fever  and  the  profuse  supi)uration  ;  or 
the  inflammation  may  spread  along  the  tendon-sheaths  or  the  planes  of  cellular 
tissue  ;  or  the  bones  may  become  extensively  necrosed  ;  and  finally,  even  when 
ankylosis  has  set  in,  it  may  be  required,  owing  to  the  useless  condition  of  the 
limb. 

When  the  injury  is  more  severe,  the  same  general  plan  of  treatment  may  be 
followed  ;  but  if  it  is  the  result  of  direct  violence  the  prospect  of  success  is  very 
small.  The  tendons  may  be  sutured  ;  the  ends  of  the  bones  resected  (removal  of 
one  malleolus  has  some  advantage,  as  it  gives  more  room  for  drainage),  and  even 
the  posterior  tibial  has  been  divided  and  tied,  with  a  good  result ;  but  if  the  skin 
is  badly  bruised  and  strii)ped  off  the  adjacent  tissues,  or  if  it  is  torn  a  considerable 
way  round  the  limb,  recovery  with  a  useful  foot  is  almost  hopeless. 


Dislocation  of  the  Astragalus. 

This  must  be  distinguished,  on  the  one  hand,  from  dislocation  at  the  ankle- 
joint,  in  which  the  whole  foot  is  detached  from  the  leg;  and,  on  the  other,  from 
the  subastragalar  form,  in  which  the  rest  of  the  tarsus  is  separated  from  the  astrag- 
alus. In  this  injury  the  astragalus  is  dislocated  both  from  the  foot  and  from  the 
leg ;  and  is  thrown  out  from  its  socket,  sometimes  so  thoroughly  that  it  has  been 
shot  out  of  the  foot  altogether. 

The  displacement  may  be  either  forward  or  backward,  the  bone  generally 
being  forced  to  one  side  or  the  other  at  the  same  time.  True  lateral  displace- 
ment without  fracture  of  the  malleoli  is  scarcely  possible  ;  most  of  the  instances, 
in  all  probability,  having  been  really  dislocations  forward  first.  In  a  few  very 
rare  cases  the  astragalus  has  undergone  a  process  of  version  without  leaving  its 
bed  ;  the  bone  has  been  twisted  round  in  its  socket  by  some  violent  wrench,  so 
that  the  lateral  surfaces  look  upward  or  downward,  or  its  head  faces  one  of  the 
malleoli. 

Dislocation  forward  is  produced  by  over-extension  ;  the  foot  is  first  detached 
from  the  astragalus  ;  the  head  of  this  bone  is  twisted  out  from  the  scaphoid  ;  and 
then,  if  the  force  continues,  the  lateral  ligaments  give  way,  and  it  is  shot  out  from 
underneath  the  tibia.  As  soon  as  the  force  is  spent  the  muscles  pull  the  foot  into 
position  again.  The  dislocation  may  be  either  complete  or  incomplete;  the  as- 
tragalus, that  is  to  say,  may  be  forced  altogether  out  of  its  socket,  until  it  rests 
either  on  the  cuboid,  or  on  the  scaphoid  and  cuneiform  bones,  according  to  the 
side,  while  the  tibia  rests  upon  the  os  calcis  ;  or  it  may  be  merely  detached  from 
its  connection,  and  lie  still  partly  under  the  bones  of  the  leg  (Fig.  235).  In 
either  case  the  neck  of  the  bone  is  not  unfrequently  broken. 

The  prominence  caused  by  the  peculiar  shape  of  the  bone  can  be  recognized 
at  once  ;  the  foot  is  turned  inward  or  outward,  in  the  opposite  direction  to  the 
displacement ;  the  sole,  especially  in  the  complete  form,  is  brought  nearer  to  the 
leg ;  one  malleolus  stands  out  while  the  other  is  deeply  sunken  ;  and  all  move- 
ment is  abolished. 

Dislocation  backward  is  much  more  rare,  and,  owing  to  the  space  in  front  of 
the  tendo-Achillis,-is  not  so  conspicuous.      It  can  only  be  produced  by  extreme 


544    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

flexion  ;  in  one  instance,  for  example,  the  foot  was  fixed,  the  heel  driven  down 
into  a  depression,  and  the  leg  crushed  down  upon  the  foot.  In  most  it  is  incom- 
plete, and  generally  it  is  rather  to  one  side,  but  it  may  be  nearly  straight.  The 
foot  is  neither  inverted  nor  everted  :  in  front  there  is  a  dei)ression  over  which  the 
edge  of  the  tibia  can  be  felt,  and  the  great  toe  is  strongly  flexed,  owing  to  the 
tension  on  the  tendon  of  the  flexor  longus  pollicis  ;  behind,  the  tendo-Achillis  is 
forced  back,  a  hardness  can  be  felt  in  front  of  it,  and  in  some  cases,  where  the 
displacement  is  lateral,  the  shape  of  the  bone  can  be  made  out  to  one  side  or  the 
other. 

Treatment. — In  the  incomplete  form  of  dislocation  forward  (which  is  the 
most  common)  reduction  may  be  accomplished  by  placing  the  patient  under  an 
anaesthetic,  bending  the  knee,  and  making  traction  on  the  foot  away  from  the  leg 
while  in  the  position  of  plantar  flexion,  direct  pressure  meantime  being  exerted 
on  the  anterior  surface  of  the  bone.  If  this  fails  the  tendo-Achillis  may  be 
divided,  and  any  other  bands  that  are  plainly  in  the  way  ;  but,  especially  if  the 
dislocation  is  complete,  the  attempt  is  very  likely  to  fail.     The  space  between  the 

\ 


\* 


V 


9ii;o 


ii^ic? 


KiG.  235. — Subastragalar  Dislocation,  with  Partial  Luxation  of  Astragalus  from  Leg. 

bones  is  so  much  reduced  ;  the  astragalus  it.self  is  often  twisted  ;  there  is  very 
little  hold  ;  and  sometimes  the  bone  is  so  caught  and  entangled  that  it  cannot  be 
released. 

If  it  does  fail,  the  astragalus  should  be  left  in  situ  ;  the  foot,  especially  when 
the  dislocation  is  backward,  regains  a  wonderful  amount  of  power.  Subsequently, 
if  the  skin  over  it  sloughs,  or  if  it  is  seriously  in  the  way,  it  may  be  excised. 
The  operation  should  not  be  performed  at  once,  as  the  parts  are  so  badly  bruised 
that  suppuration  would  almost  certainly  occur. 

In  compound  dislocations,  if  the  skin  and  the  vessels  are  not  much  injured, 
the  astragalus  may  be  freed  from  its  remaining  attachments  and  excised  ;  but  in 
many  cases  amputation  is  necessary. 


Subastragalar  Dislocation. 

This  is  produced  in  the  same  way  as  the  former,  but  by  a  less  degree  of 
force ;  the  bones  of  the  tarsus  only  are  separated  from  the  astragalus  ;  this  is 
often  partially  displaced  from  under  the  tibial  arch,  but  is  not  dislocated  from  it 
(Fig.  235). 


DISEASES  OF  JOINTS.  545 

Dislocations  forward,  and  to  one  side,  have  Ijcen  descril)ed,  hut  the  displace- 
ment is  nearly  always  backward,  with  a  certain  amount  of  lateral  deviation.  It  is 
generally  complete  so  far  as  the  scaphoid  is  concerned,  but  it  is  seldom  that  the 
astragalus  is  entirely  detached  from  the  os  calcis.  The  foot  is  in  the  position  of 
plantar  flexion,  everted  or  inverted,  in  the  direction  of  the  displacement,  and 
carried  backward.  The  head  of  the  astragalus  forms  a  rounded  projection  on  the 
dorsum  under  the  skin  ;  one  malleolus  is  prominent,  the  other  buried  ;  but  they 
still  retain  their  relation  to  the  astragalus  ;  there  is  no  shortening,  as  in  the  former 
dislocation,  antl  a  certain  amount  of  movement  is  permitted  at  the  ankle-joint 
itself. 

Reduction  may  be  accomplished  by  drawing  the  foot  forward,  while  in 
extreme  plantar  flexion,  and  pre.ssing  from  behind  upon  the  heel.  If  this  does 
not  succeed,  any  tendon  that  is  clearly  in  the  way  may  be  divided,  and  a  further 
attempt  made  ;  but  not  unfrequently  it  fails,  either  because  the  under  surface  of 
the  astragalus  is  caught  against  the  groove  of  the  os  calcis  or  the  dorsum  of  the 
scaphoid,  or  because  the  neck  of  the  bone  is  entangled  in  the  tibial  tendons. 

Dislocations  of  the  other  tarsal  bones  are  very  rare  ;  the  internal  cuneiform 
and  the  scaphoid  have  been  displaced  separately,  and  the  scaphoid  and  cuboid, 
carrying  with  them  the  anterior  part  of  the  foot,  together.  There  are  more 
instances  known  in  which  the  metatarsus  has  been  dislocated  from  the  tarsus  ; 
sometimes  all  the  bones  together  (in  one  case  carrying  with  them  the  internal 
cuneiform)  ;  more  often  separately  or  in  groups  of  two  or  three. 

Dislocation  of  the  toes,  both  at  the  metatarsal  and  phalangeal  articulations, 
are  not  uncommon  ;  in  the  case  of  the  great  toe  the  same  difficulty  occurs  as  that 
already  described  in  the  thumb,  probably  for  the  same  reason. 


SECTION  v.— DISEASES   OF   JOINTS. 

Inflammation  of  a  joint  nearly  always  begins  in  the  most  vascular  part,  that  is 
to  say,  either  the  synovial  membrane  or  the  growing  portion  of  the  bone,  and 
spreads  from  there  to  the  rest  of  the  tissues.  Osteo-arthritis  is  an  exception  ; 
whether  it  is  acute  or  chronic,  inflammatory  or  degenerative,  it  is  general  from 
the  first,  and  affects  all  the  structures,  though  not  always  to  the  same  extent. 

Pathology. 

I.  The  Synovial  Meinbrane  and  the  Capsule. — The  immediate  effect  is  the 
same,  whether  the  inflammation  begins  in  the  cavity  or  extends  into  it  from  the 
bones  or  other  structures  near. 

The  vessels  dilate  ;  the  amount  of  blood  flowing  through  the  part  increases  ; 
lymph  is  poured  out  in  excess  ;  the  cellular  tissue  becomes  soft  and  spongy  ;  the 
interstitial  spaces  are  enlarged  and  filled  with  exudation  ;  the  endothelium  is 
detached  ;  and  the  interior  loses  its  polished  appearance,  and  becomes  rough, 
velvety,  and  granular.  In  severe  cases  stasis  and  extravasations  of  blood  occur 
as  well.  This  is  most  marked  where  the  tissues  are  soft  and  vascular  ;  the  fibrous 
capsule  at  first  is  scarcely  affected  ;  on  the  other  hand,  the  folds  at  the  margins 
of  the  joint,  and  the  pads  of  loose  cellular  tissue  and  fat  which  fill  up  the 
inequalities  between  the  bones  as  the  position  of  the  limb  changes,  become  more 
and  more  swollen,  until  the  whole  available  space  is  occupied. 

The  exudation  collects  in  the  synovial  cavity  even  more  freely  than  it  does 


546    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

in  the  tissues.  'Hie  amount  of  fluid  is  increased  ;  the  peculiar  character  of  the 
synovia  is  lost ;  and  the  joint  is  filled  with  a  turbid  and  blood-stained  fluid,  mixed 
with  detached  endothelial  cells,  flakes  of  fibrin,  small  blood-clots,  and  masses  of 
lymph-corpuscles. 

The  ligaments  and  the  capsule,  owing  to  the  density  of  their  structure  and 
the  scanty  distribution  of  vessels,  for  a  long  time  show  but  little  change.  If, 
however,  the  inflammation  continues,  at  length  they  share  the  same  fate ; 
hyi)ernemia  begins  to  show  itself;  the  fibres  soften;  the  interfibrillar  substance 
becomes  more  abundant  and  more  fluid  ;  the  exudation  increases  in  amount ; 
new  vessels  grow  in  from  around  ;  and  by  degrees  the  natural  structure  is  replaced 
by  a  mass  of  soft  vascular  granulation  tissue,  in  which  a  few  traces  of  the  old 
bundles  of  fibres  can  be  found  here  and  there,  more  or  less  softened. 

The  subsequent  changes  dei^end  ui)on  the  nature  and  persistence  of  the  cause. 

If  it  cea.ses  to  act,  resolution  begins,  the  hyperemia  disappears,  the  exudation 
is  absorbed,  and  the  fibrous  tissue  becomes  firm  again. 

If  it  continues,  the  effect  depends  whether  it  is  {a)  merely  a  mechanical  or 
chemical  irritant  or  {b)  a  living  organism. 

{a)  In  the  first  case  the  synovial  membrane  may  continue  to  pour  out  an 
enormous  quantity  of  a  clear  watery  fluid  (Jiydrops  articu/i)  ;  or  a  kind  of  false 
membrane  may  form  upon  the  inner  surface  {fibrinous  synovitis)  ;  or  the  secretion 
may  grow  thicker  and  thicker  until,  without  there  being  any  destruction  of  the 
cartilages,  or  suppuration  outside  the  joint,  the  interior  is  filled  with  a  fluid  appar- 
ently similar  to  pus  (^purulent  synovitis')  ;  or  (especially  when  it  is  due  to  rheuma- 
tism) organization  may  be  the  prominent  feature,  the  synovial  lining  becoming 
thickened  and  opaque,  the  .soft  tissues  condensed  and  hard,  and  the  interior 
covered  with  outgrowths,  synovial  folds,  and  fringes,  sometimes  uniform  in  shape 
and  size,  and  springing  from  every  part  of  the  sac  {papillary  synovitis)  (Fig.  243), 
sometimes  few  in  number  and  very  large. 

{b)  In  the  second,  when  the  irritant  is  a  living  organism,  the  effect  depends 
upon  its  mode  of  action.  In  tubercle,  for  example,  the  synovial  membrane  and 
the  structures  around  are  converted  into  a  mass  of  granulation  tissue,  which  slowly 
undergoes  caseation  and  liquefaction  ;  in  syphilis,  gummata  form  ;  and  when  the 
micrococci  of  suppuration  enter,  all  the  tissues  melt  away  and  form  pus  ;  the  whole 
joint  is  converted  into  an  abscess,  and,  unless  the  tension  is  relieved  at  once,  even 
the  cartilage  and  the  bone  perish.     • 

2.  The  Bone  and  Cartilage. — {a)  If  the  irritant  is  a  very  intense  one,  the 
bone  and  cartilage,  like  other  dense  and  almost  non-vascular  structures,  simply 
undergo  necrosis.  Sometimes  the  sequestra  are  wedge-shaped  (Fig.  252),  with 
their  base  toward  the  joint  and  covered  with  cartilage,  as  if  caused  by  embolism. 
A  mass  of  some  material  (caseous  and  full  of  bacilli  if  it  is  tubercular  ;  broken- 
down  blood-clot  with  micrococci  in  pyaemia)  is  carried  along  by  the  blood-stream 
until  it  is  impacted  in  one  of  the  small  arteries  at  the  cancellous  end  of  a  long 
bone  ;  and  the  corresponding  area  of  tissue  perishes,  partly  from  the  blood-supply 
being  cut  off,  partly  from  the  inflammation  caused  by  the  embolus.  Sometimes, 
on  the  other  hand,  when  the  attack  starts  from  the  synovial  cavity,  the  surface  is 
the  first  part  to  feel  the  effect,  and  either  the  whole  of  the  cartilage  is  separated 
from  the  bone  beneath  (Fig.  238),  or,  more  frcfjuently,  only  those  parts  upon 
which  the  pressure  falls,  where,  for  example,  the  patella  and  the  upper  surface  of 
the  tibia  are  in  contact  with  the  condyles  of  the  femur.  When  this  occurs  the 
articular  lamella  of  the  bone  usually  comes  away  as  well,  leaving  the  cancellous 
tissue  beneath  exposed  and  carious. 

(b)  If  the  exciting  cause  is  not  sufficiently  intense  to  cause  necrosis,  the  bone 
and  cartilage  undergo  the  same  changes  as  the  other  tissues,  only  more  slowly  and 
with  certain  peculiarities  of  their  own. 

In  the  bone  the  inflammation  begins  as  rarefying  osteitis  ;  the  cancellous  tissue 
becomes  softer  and  more  vascular  ;  the  trabecule  are  absorbed  ;  and  the  cancelli 
filled  with  inflammatory  exudation.     What  happens  next  depends  upon  the  excit- 


DISEASES  OE  JOINTS.  547 

ing  cause.  Resolution  takes  place  in  a  large  proportion  of  cases.  Of  the  rest, 
in  some  the  e.xiitiation  simply  continues  to  spread  (fungating  caries),  without 
undergoing  any  further  change,  until  it  invades  the  articular  lamella  (Fig.  251), 
and  either  detaches  the  cartilage  from  beneath  or  perforates  it ;  in  others  it  breaks 
down  into  pus,  and  bursts  through  everything  into  the  synovial  cavity  ;  and  in 
others  again  it  undergoes  organization  and  leads  to  sclerosis  and  condensation 
(Fig.  242). 

The  effect  on  the  cartilage  is  very  similar.     The  matrix  becomes  softened  (in 
osteo-arthritis  it  splits  up  into  fibrils  arranged  vertically  to  the  surface  (Fig.  239), 
the  plasmatic  canals  dilate  so  as  to  allow  the  entry  of  a  larger  (juantity  of  lymph, 
and  the  corpuscles  increase  in  number.      In  the  centre,  where  there  is  pressure,  the 
inflamed  cartilage  becomes  absorbed  ;  around  the  margins  it  becomes  vascular,  the 
blood-vessels  growing  into  it  from  the  synovial  membrane,  so  that  it  is  either 
gradually  replaced  by  granulation  tissue,  as  in  tubercu- 
lar disease,  or  is  heaped  up  into  thickened  and  hyper-  ,,. 
trophied  lips,  as  in  osteo-arthritis.     So  slowly,  however,             ^V             ' '^ 
does  this  take  place  that,  in   many  forms  of  joint  dis-             ■■;f- 
ease,  the  cartilage   is   removed   by  simple  atrophy  and              ^• 
fatty  degeneration,   or  by  the  erosion  of  granulations              -r 
that  spring  from  the  opposite  bone  or  the  surrounding             j|,  V. 
tissues.      In  the  former  case  the  whole  covering  of  car-            p               ■.  V. 
tilage  is  thinned,  the  surface  is  smooth  and  rounded  for 
the  most  part,  but  marked   here  and  there  with  broad 
flat  depressions,  where  the  pressure  of  the  opposing  sur- 
face has  caused   absorption  to   progress  more  rapidly,       f 
and  the  microscopic  character  is  unaltered   except  for      -■ 
the  presence  of  fatty  molecules  in  some  of  the  corpus- 
cles.     In  the  latter  it   is  eaten   out  all  over  into  little     > 
circular  pits,  some  quite  superficial,  others  so  deep  that 
the  bone  beneath  is  exposed  (Fig.  236). 

Fig.  236. — Lower  End  of  Femur  of 

an  Infant,  from  a  case  of  suppur- 

F'rTnTr>r\-  ative  arthritis,  showing  the  way 

JLxlULUU\.  in  w'hich   the   cartilage   is   eaten 

_     _  .  r  •     •  •  ...  out  in   little   circular  pits,   some 

Inflammation  of  joints  may  be  primary,  originating      penetrating  down  to  the  bone, 
in  the  synovial  lining  or  some  other  component  part ;  or 
consecutive,  due  to  extension  from  a  focus  of  disease  in  other  structures  near. 

I.  Fri/nary  inflammaflon\s  duQ  either  to  the  persistent  action  of  a  mechanical 
or  chemical  irritant,  or  to  a  living  organism. 

(a)  Mechanical  Injury. — A  single  strain  merely  causes  a  certain  degree  of 
damage,  which,  if  the  tissues  are  healthy,  is  repaired  forthwith.  If,  however,  it 
is  repeated,  or  if  before  its  effects  have  died  away  a  second  irritation  of  any 
description  makes  its  appearance,  nutrition  is  impaired  and  inflammation  follows. 
Thus  a  neglected  loose  cartilage  gives  rise  to  synovitis  and  ultimately  arthritis ; 
and  want  of  rest  or  undue  tension  may  cause  an  acute  attack  after  a  simple  sprain. 

{h)  Chemical  Irritants. — In  gouty  synovitis  urate  of  soda  is  always  present  in 
the  fluid  and  sometimes  in  the  tissues.  It  may  be  itself  the  exciting  cause;  but, 
as  it  is  not  unusual  to  find  a  considerable  deposit  in  joints  that  have  never  shown 
a  sign  of  inflammation,  it  may,  on  the  other  hand,  merely  be  an  evidence  that  the 
vitality  of  the  tissues  is  impaired,  so  that  they  are  unable  to  withstand  the  slightest 
irritation.  Of  all  chemical  poisons  the  most  intense  is  that  produced  by  septic 
decomposition,  breaking  out  in  a  foul  and  ill-drained  wound. 

{/)  living  Organisms. — These  may  be  pyogenic  or  specific.  In  either  case 
the  irritated  tissues  around  strive  to  protect  themselves  and  repair  the  injury  by 
throwing  out  masses  of  lymph  ;  in  the  former  (acute  suppurative  arthritis)  this 
melts  away  as  pus,  the  fully  developed  tissues  perishing,  too,  so  long  as  the  germs 
are  the  stronger  ;  in  the  latter  either  caseation  and  liquefaction  set  in  (tubercle) 
or  absorption  and  organization  (syphilis). 


54S    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

In  addition  to  these  there  are,  as  in  the  case  of  osteitis,  other  agencies  which, 
perhaps,  should  rather  be  regarded  as  predis])osing  than  exciting  causes.  Of  these 
the  most  important  are  the  action  of  cold  and  damj)  and  the  influence  of  the  cen- 
tral nervous  system. 

{a)  Exposure  to  cold  and  damp  may  be  followed  either  by  acute  inflammation 
(the  resisting  power  of  the  tissues  is  so  depressed  that  the  least  irritation  is  suffi- 
cient to  cause  a  very  severe  attack)  ;  or  when,  without  being  intense  at  any  one 
time,  they  exercise  their  influence  for  years  together,  by  a  kind  of  degeneration  or 
very  chronic  inflammation,  characterized  by  changes  similar  to  those  that  occur  in 
old  age  after  prolonged  disuse,  but  more  severe. 

{b)  Diseases  of  the  Nervous  System. — It  is  believed  by  many  that  certain  very 
rapid  forms  of  degeneration,  attended  with  more  or  less  inflammation,  may  be 
caused  by  diseases  of  the  central  nervous  system  or  the  peripheral  nerves.  The 
pathological  changes  belong  to  the  same  class  as  those  that  follow  prolonged 
exposure  to  cold  and  damp  and  other  depressing  agencies,  though  they  present 
certain  differences  in  degree  ;  the  clinical  symptoms,  however,  in  most  cases  enable 
a  distinction  to  be  drawn  at  once. 

How  causes  of  this  kind  act  is  uncertain.  It  must  be  admitted,  if  they  are 
merely  predisposing  ones,  their  influence  is  so  strong  that  an  almost  imperceptible 
irritant  is  able  to  produce  an  entirely  disproportionate  result.  All  that  can  be  said 
is  that  the  impairment  of  nutrition,  known  as  inflammation,  may  be  induced  either 
by  continued  irritation  (mechanical  or  otherwise)  ;  or  by  a  depressed  condition  of 
vital  energy,  general  or  local  (exposure  to  cold  and  wet,  and  certain  affections  of 
the  nervous  system)  ;  or  with  much  greater  effect  by  both  together. 

2.  Consecutive  inflammation  may  extend  into  the  joint  from  any  of  the  tissues 
near  ;  the  bones  the  most  frequently,  the  bursae,  tendon  sheaths,  and  cellular  tissue 
less  often.  So  long  as  the  original  focus  of  disease  is  at  some  distance,  whatever 
its  character  may  be,  whether  it  is  traumatic,  tubercular,  or  suppurative,  only  the 
synovial  membrane  shows  any  effect,  and  the  inflammation  is  not  specific.  A 
tubercular  focus,  for  example,  in  the  end  of  one  of  the  long  bones  merely  causes 
synovitis  so  long  as  the  bacilli  are  limited  to  the  bone  ;  and  after  evacuation  of 
the  caseous  focus  (if  it  can  be  cleared  out  without  involving  the  joint),  the 
secondary  affection  disappears  of  itself;  but,  if  left,  the  micro-organisms  are 
almost  sure  to  work  their  way  in  at  last,  and  then  the  inflammation  of  the  joint 
becomes  tubercular  and  specific.  The  same  is  true  of  the  pyogenic  and  probably 
of  all  other  organisms;  simple  inflammation  precedes  the  specific  and  prepares  the 
way  for  it. 

Mode  of  Examination. 

Examination  in  a  case  of  suspected  joint  disease  must  be  systematic  and 
thorough,  conducted  with  a  definite  object,  taking  care  not  to  alarm  the  patient, 
and  putting  off  to  the  last  everything  that  might  give  pain.  Children  in  particular 
are  nervous  and  often  exceedingly  afraid  of  being  hurt,  and  an  incautious  move- 
ment at  the  first  may  throw  all  the  muscles  around  the  articulation  into  a  state  of 
perfect  rigidity,  and  obscure  some  of  the  most  valuable  signs.  Unless  it  is  wished 
to  explore  sinuses  with  a  probe,  or  to  ascertain  the  existence  or  the  extent  of  fibrous 
adhesions,  an  anaesthetic  is  inadmissible,  as  many  of  the  most  important  symj)toms 
depend  upon  contraction  of  the  muscles,  which,  of  course,  disappears  at  once. 

The  history,  family  as  well  as  personal,  and  any  evidence  of  a  constitutional 
diathesis  that  may  be  present,  must  be  carefully  noted,  and  then  the  patient's  own 
account  of  the  commencement  of  the  disease,  the  supposed  cause,  the  time  of  its 
first  appearance,  the  progress  it  has  made,  the  kind,  severity,  and  locality  of  the 
pain,  and  whether  it  is  made  worse  by  any  particular  movement.  In  the  case  of 
the  lower  extremity,  if  the  inflammation  is  not  acute,  the  amount  of  impairment 
can  be  fairly  well  estimated  by  seeing  the  patient  walk. 

It  is  an  absolute  rule  that  the  two  sides  of  the  body  must  be  compared 
together  under  the  same  conditions. 


DISEASES  OE  JO/NTS- SYNOVITIS.  549 

Inspection  and  measuremeiit  come  first.  If  it  is  the  hip  joint,  the  patient 
should  lie  upon  a  firm  couch  with  the  legs  parallel  and  the  knees  extended  ;  for 
the  shoulders  he  should  be  seated  facing  the  light.  The  condition  of  the  skin, 
whether  it  is  reddened  or  not,  the  shape  of  the  joint,  the  j^resence  of  any  enlarge- 
ment, the  wasting  of  the  limb,  or  of  one  particular  muscle,  and  any  malposition — 
abduction  or  adduction,  flexion  or  displacement — can  be  detected  at  once.  The 
difficulty  is  greatest  in  the  case  of  the  hip,  as  by  arching  the  back  and  tilting  the 
])elvis  an  appearance  of  parallelism  and  extension  is  produced,  while  the  reality 
is  very  different.  These  results  can  then  be  verified  by  measurement.  The  rod 
should  be  used  to  ascertain  any  alteration  in  length,  a  tape  to  take  the  circumfer- 
ence, and  callipers,  or  the  hand,  which  after  a  little  practice  can  appreciate  the 
most  minute  change,  to  make  certain  as  to  the  difference  in  shape. 

Further  information  may  be  obtained  by  touch,  proceeding  very  carefully  at 
first,  as  sometimes  there  is  great  tenderness  on  pressure.  The  enlargement  may  be 
hard  and  firm,  like  the  bone  upon  which  it  rests  ;  or  soft  and  fluctuating  if  it  is 
due  to  an  effusion  of  fluid  ;  or  it  may  have  a  peculiar  elastic  resistance,  as  when 
the  synovial  membrane  and  the  tissues  around  are  converted  into  a  pulpy  gela- 
tinous mass ;  or  it  may  vary  very  greatly  in  consistence,  especially  if  suppuration 
has  occurred  and  the  pus  is  working  its  way  near  the  surface.  The  tejnperature 
may  be  ascertained  in  the  same  way  with  great  exactness,  taking  care  always  to 
compare  identical  spots  on  the  two  limbs  ;  the  loss  of  muscular  tone  can  be  felt, 
even  when  no  wasting  can  be  detected  with  the  eye  ;  and  the  finger  often  finds  out 
that  some  parts  of  the  skin  are  usually  tender  or  cedematous. 

Finally,  when  all  this  is  clear,  an  attempt  maybe  made  to  ascertain  the  range 
of  movement,  whether  it  is  limited  in  any  direction  or  attended  with  pain  ;  if  there 
is  any  grating,  as  of  two  bony  surfaces  rubbing  against  each  other,  or  crepitation, 
as  when  the  cartilages  have  lost  their  polish  and  the  synovial  fringes  are  enlarged 
and  hardened  ;  and  whether  there  is  any  abnormal  mobility  and  displacement  or 
dislocation  of  the  ends  of  the  bones.  Greater  care  than  ever  must  be  taken  in 
investigating  this,  as  the  least  rough  movement,  or  even  sometimes  the  approach 
of  the  hand,  scares  the  muscles  into  activity,  so  that  the  joint  is  held  perfectly 
rigid. 

Such  tests  as  jarring  the  heel  or  the  knee  in  hip  disease,  which  depend  solely 
upon  the  pain  they  cause,  should  never  be  employed,  unless  from  other  evidence 
it  is  practically  certain  that  the  joint  is  not  inflamed. 


INFLAMMATION  OF  THE  SYNOVIAL  LINING. 

I.  Simple  Acute  Synovitis. 

In  most  cases  synovitis  is  merely  a  symptom  of  arthritis  :  and  whatever  the 
cause,  unless  the  attack  subsides  at  once,  the  inflammation  is  never  really  restricted 
to  the  lining  membrane.  Still,  for  the  sake  of  convenience,  and  because  the 
changes,  although  they  are  not  absolutely  confined  to  that  structure,  are  very  much 
more  extensively  shown  by  it  than  they  are  by  the  rest,  it  is  usual  to  describe  some 
forms  at  least  as  if  the  affection  were  a  distinct  one. 

Causes. — These  maybe  local  or  constitutional.  Injury,  extension  from  the 
bone  or  from  some  other  structure  near,  or  cold  and  wet,  may  cause  it ;  or,  on  the 
other  hand,  it  may  be  merely  a  sign  of  some  constitutional  ailment,  such  as  gout 
or  rheumatism.  These  varieties,  however,  as  they  are  specific,  must  be  described 
by  themselves. 

T\\&  pathological  appearances  oi  ?,\vi\vi\q  synovitis  have  been  described  already. 
The  joint  is  distended  with  fluid,  the  endothelial  lining  is  detached,  the  interior  is 
roughened  and  has  lost  its  polish,  all  the  folds  are  bright  red  or  purple  with  extrava- 
sations, and  so  swollen  that  they  overlap  the  margins  of  the  cartilages  ;  and  all 
the  loose  tissues  round  are  softened,  thickened,  and  filled  with  lymph.     The  fluid 


550    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

varies  much  in  character.  In  cases  of  injury  in  which  the  hemorrhage  is  often 
considerable  and  the  swelling  immediate,  it  may  be  almost  jnire  blood  {hnnar- 
throsis)  ;  more  often  it  is  a  mixture  of  synovia,  blood,  and  lymph  in  varying  pro- 
portions. It  many  cases  it  is  thin  and  watery,  as  if  it  were  mixed  \sith  serum  ; 
not  unfrequently,  when  the  inflammation  is  severe  and  the  tension  high,  the  number 
of  leucocytes  and  the  amount  of  fibrin  increase  to  such  an  extent  that  it  becomes 
milky  and  even  purulent.  This  is  known  as  catarrhal  suppuration  ;  it  may  occur 
after  injury,  but  it  is  much  more  common  when,  as  in  urethral  rheumatism,  the 
irritant  is  of  greater  intensity  without  being  so  .severe  as  to  cause  suppuration. 
The  distinguishing  feature  between  it  and  true  sujjpurative  synovitis  is  the  jjreser- 
vation  of  the  synovial  membrane ;  the  secretion  comes  merely  from  the  surface 
and  does  not  involve  the  deeper  strata. 

Symptoms. — The /^.f///^«  of  the  limb  is  characteristic.  The  affected  joint 
is  fixed  rigidly  by  the  muscles  in  the  position  of  greatest  ease.  The  hip  is  flexed, 
abducted,  and  everted,  the  knee  held  at  an  angle  of  140°,  the  ankle  slightly 
extended,  the  arm  hangs  by  the  side,  and  the  elbow  and  wrist  are  somewhat  bent. 
As  a  rule,  the  patient  can  flex  the  limb  further  still,  but  complete  extension  is  out 
of  the  question.  Not  only  does  it  diminish  the  capacity  of  the  sac  and  increase 
the  pressure  upon  its  inner  surface,  but,  by  the  traction  it  exerts  upon  some  parts  of 
the  inflamed  and  tender  capsule,  it  makes  the  pain  tenfold  worse.  Later,  when 
arthritis  sets  in,  and  the  bone  and  cartilage  are  involved,  this  position  is  exagger- 
ated, and  more  serious  displacement  caused  by  the  persistent  contraction  of  the 
flexor  muscles. 

The  shape  assumed  by  the  distended  synovial  sac  is  equally  important.  In 
acute  traumatic  synovitis  it  is  often  filled  to  its  utmost,  but  the  general  outline  is 
scarcely  altered  ;  there  is  little  or  no  oedema  of  the  cellular  tissue  around,  as  in 
some  forms  of  inflammation,  and  the  weaker  parts  have  not  had  time  to  yield  and 
stretch,  as  when  the  attack  is  more  chronic. 

In  the  knee  the  patella  is  pushed  forward  ;  the  depressions  on  either  side  of  it, 
extending  down  by  the  ligamentum  patellce,  are  filled  ujj,  so  that  the  front  of  the 
joint  is  evenly  convex  ;  and  the  pouch  under  the  quadriceps  is  distended,  though 
it  is  not  stretched  ui)ward  as  in  chronic  synovitis.  Fluctuation  can  be  distinctly 
felt  on  either  side  of  the  knee-cap,  the  hands  being  placed  across  the  joint,  one 
above  and  one  below,  so  that  the  synovial  pouch  is  grasped  between  the  fingers 
and  the  thumbs  ;  and  the  patella  itself  can  be  made  to  float.  This  is  the  most 
valuable  sign  of  all.  If  the  synovial  sac  is  full  there  is  no  difficulty  ;  the  limb 
must  be  gently  extended  and  supported  so  as  to  relax  the  quadriceps,  and  then  the 
bone  can  be  pressed  back  at  once  against  the  articular  surface  of  the  femur. 
More  care  is  required  if  the  distention  is  only  moderate  ;  the  upper  ]jart  of  the  sac 
above  the  patella  must  be  emptied  by  scjueezing  the  fluid  out  of  it  into  the  lower 
s])ace  ;  and  the  pressure  must  be  made  directly  upon  the  centre  of  the  bone,  not 
upon  its  lower  end.  If  the  quadriceps  is  relaxed  and  the  patella  drawn  down,  the 
lower  end  rests  upon  a  soft  cellular  pad  of  fat,  and  even  when  there  is  only  the 
normal  amount  of  fluid  in  the  joint  the  sensation  of  floating  is  easily  produced  if 
pressure  is  made  on  the  apex. 

In  the  ankle  the  chief  swelling  is  behind,  on  either  side,  between  the  malleoli 
and  the  tendo-.'Vchillis,  and  in  front  lifting  up  the  extensor  tendons.  In  the  elbow 
it  lies  on  either  side  of  the  tendon  of  the  triceps  and  over  the  head  of  the  radius. 
In  the  hip  and  shoulder  there  is,  on  the  other  hand,  only  an  ill-defined  fullness — 
most  marked  in  the  former  beneath  Poupart's  ligament,  in  Scarpa's  triangle,  and 
shown  particularly  when  the  limb  is  abducted,  flexed,  and  everted  ;  in  the  latter, 
raising  the  whole  of  the  deltoid. 

Fain  is  always  present ;  sometimes  it  is  very  severe  and  of  a  tense  throbbing 
character  ;  often  it  is  worse  at  night,  and  always  if  an  attempt  is  made  to  use  the 
part  or  press  the  two  bones  together.  The  skin  is  freely  movable  over  the  deeper 
structures  ;  there  is  no  redness  or  oedema,  but  it  is  excessively  tender,  and  at  times 
even  the  weight  of  the  bed-clothes  can  scarcely  be  borne.      Usually  there  are  cer- 


DISEASES    OF   THE  JO/NTS— SYNOVITIS.  551 

tain  spots,  i)eculiar  to  each  joint,  much  worse  than  the  rest.  On  the  inner  side  of 
the  knee,  for  example,  there  is  one  on  a  level  with  the  upper  border  of  the  artic- 
ular surtice  of  the  tibia  ;  in  the  hip  it  lies  behind  the  trochanter,  and  in  the 
ankle  in  front  of  the  external  malleolus.  The  flexor  muscles  are  in  a  state  of  to7tic 
contraction,  so  as  to  limit  the  amount  of  movement  as  much  as  possible  ;  the  exten- 
sors, on  the  other  hand,  waste,  and,  especially  in  the  case  of  purulent  synovitis 
and  that  form  which  ultimately  merges  into  osteoarthritis,  distinct  flabbiness  and 
loss  of  tone  may  be  present  by  the  end  of  a  week.  When  the  joint  is  superficial 
the  temperature  of  the  skin  is  distinctly  raised ;  and,  if  it  is  large,  or  if  several  are 
involved  together,  slight  chills  are  not  uncommon  with  a  certain  degree  of  fever. 
In  some  of  the  constitutional  forms  of  synovitis  it  may  be  very  severe. 

Course  and  Termination.— The  subseciuent  course  depends  partly  upon 
the  exciting  cause,  partly  upon  the  condition  of  the  patient. 

In  simple  traumatic  synovitis,  the  extravasated  blood,  if  there  is  any  (juantity, 
coagulates  in  the  interior ;  the  hyperjemia  and  exudation  continue  to  increase  for 
a  few  hours,  or  perhaps  two  or  three  days,  according  to  the  severity  of  the  injury 
and  the  success  of  the  treatment,  and  then,  if  the  part  is  kept  at  rest,  resolution 
sets  in.  The  coagula  break  down  and  liquefy  ;  the  blood-vessels  contract  again  ; 
the  endothelial  lining  is  restored  ;  and  the  synovial  fluid,  though  it  remains  col- 
ored for  some  little  ttme,  gradually  resumes  its  normal  consistence.  Occasionally, 
when  there  is  a  high  degree  of  tension,  or  when  the  injury  is  repeated  time  after 
time,  the  inflammation  becomes  chronic,  and  either  the  synovial  cavity  remains 
distended  or  the  walls  become  thick  and  rigid  and  covered  over  with  fringes. 
Very  rarely  (unless  there  is  an  open  wound)  suppuration  follows. 

The  same  may  be  said  of  that  form  of  acute  synovitis  which  results  from  ex- 
posure to  cold  and  wet  ;  only,  as  the  attack  is  rarely  an  isolated  one,  the  tendency 
for  the  inflammation  to  become  chronic  is  much  greater.  When,  on  the  other 
hand,  it  is  due  to  extension  from  neighboring  structures,  or  when  it  is  a  symptom 
of  some  constitutional  disorder,  whether  it  is  tubercle,  gonorrhoea,  or  one  of  the 
acute  exanthemata,  the  termination  is  naturally  dependent  upon  the  exciting 
cause  ;  it  may  subside  without  any  further  evidence  of  arthritis  ;  or  it  may  extend 
from  one  part  to  another  until  the  whole  joint  is  inflamed. 

Treatment. — If  there  is  an  external  wound,  this  must  be  dealt  with  first, 
according  to  its  condition.  Either  it  should  be  closed  at  once,  sutures  being  used 
if  required  to  draw  the  deeper  parts  together  ;  or  enlarged,  explored,  washed  out 
and  drained.  The  chief  treatment  must  be  local ;  the  bowels  should  be  well 
opened,  and  the  diet  light  and  unstimulating,  especially  if  there  is  any  tendency 
to  gout  or  rheumatism  ;  but,  unless  there  is  a  high  degree  of  fever  or  a  well-marked 
diathesis,  internal  remedies  are  of  little  avail. 

Rest  is  of  the  first  importance.  Every  movement  causes  pam  and  makes  the 
inflammation  worse  by  increasing  the  amount  of  blood  flowing  through.  Unless 
the  attack  is  very  slight,  and  aff"ects  one  of  the  smaller  joints  only,  the  limb  should 
be  placed  upon  a  splint,  or  fixed  by  means  of  a  sling  or  a  triangular  bandage  and 
raised.  The  position  varies  with  each  joint,  and  is  not  by  any  means  that  which 
the  patient  assumes  of  himself.  The  elbow  should  be  flexed  to  a  little  less  than  a 
right  angle  ;  the  hip  should  be  straight,  the  knee  bent  ever  so  little,  and  the  foot. 
in  the  case  of  the  ankle,  exactly  perpendicular  to  the  leg. 

Heat,  cold,  and  pressure  are  the  most  eff'ectual  means  for  checking  the  exuda- 
tion and  preventing  tension.  Of  these  the  first  is  limited  in  its  application,  and 
is  chiefly  of  service  in  traumatic  synovitis,  when  the  joint,  like  the  ankle,  is  super- 
ficial, and  the  limb  can  be  plunged  for  a  moment  immediately  after  the  accident 
into  water  as  hot  as  can  be  borne.  Cold  is  of  more  general  use,  and  can  be  kept 
up  for  a  longer  time  ;  but  after  the  first  few  hours  its  utility  diminishes  very  rapidly. 
The  immediate  eff"ect  is  a  contraction  of  the  arterioles  ;  but  if  it  is  continued,  the 
walls  of  the  vessels  lose  their  tone  and  passive  congestion  follows.  A  rubber  bag, 
filled  with  ice,  or  Leiter's  tubing  with  ice-cold  water,  is  easily  arranged  in  the 
case  of  most  joints  ;  or,  if  it  is  the  lower  limb,  and  the  patient  is  confined  to  bed, 


552     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

lead  and  spirit  may  be  allowed  to  drip  from  a  vessel  over  the  joint.  Pressure,  if 
it  is  properly  applied,  is  by  far  the  best.  It  must  be  perfectly  uniform,  falling  on 
the  soft  parts  as  well  as  on  the  bones,  gentle,  and  elastic,  so  that  it  does  not 
slacken  off  as  the  blood-vessels  become  empty  and  the  part  diminishes  in  size. 
Absorbent  cotton-wool  answers  all  requirements.  All  the  hollows  of  the  limb 
should  be  packed  with  ixids  until  the  bones  appear  buried  ;  then  several  thick- 
nesses should  be  placed  round  the  whole,  and  over  all  a  moderately  tight  bandage. 
In  the  course  of  a  few  hours  the  extreme  tension  disappears  and  the  bandage  can 
be  replaced  by  a  firmer  one.  Nothing  is  equal  to  this  for  checking  hyperoemia 
and  exudation,  causing  the  absorption  of  extravasated  blood,  and  preventing  the 
distention  of  the  capsule,  which  is  not  only  the  chief  cause  of  the  pain  (after  the 
immediate  effects  of  the  accident  have  subsided),  but,  from  the  weakness  it  leaves 
behind  it,  a  source  of  very  grave  inconvenience  afterward. 

Pain,  if  it  is  very  severe,  may  be  relieved  by  placing  a  few  leeches  over  the 
joint,  or  by  giving  a  hypodermic  injection  of  morphia.  Aspiration  is  seldom 
recjuired  in  cases  of  simple  acute  synovitis,  though  it  may  be  advisal)le  when  there 
is  a  large  extravasation  into  the  synovial  cavity,  as  in  fracture  of  the  patella,  and 
it  is  of  importance  to  empty  the  joint  at  once,  or  when,  from  the  persistence  of 
the  swelling  and  the  continued  heat,  there  is  reason  to  fear  that  the  exudation  is 
becoming  purulent.  Great  care  of  course  is  necessary  ;  the  cannula  should  be 
cleaned  by  boiling  in  liquid  potassce,  so  as  to  make  sure  that  no  greasy  substance 
is  retained  inside ;  [it  should  also  be  made  aseptic  by  passing  through  a  flame,  or 
l)lunging  in  absolute  alcohol  just  previous  to  its  use,]  and  the  opening  should  be 
valvular  and  well  secured.  Very  often  marked  relief  is  ol^tained,  even  if  only  a 
few  drachms  are  withdrawn  ;  the  tension  is  lowered  ;  the  pain  and  hyperemia 
diminish,  and  absorption  commences  at  once. 

Passive  motion  should  not  be  delayed  too  long.  As  a  general  rule,  it  should 
be  commenced  as  soon  as  the  temperature  of  the  part  is  normal.  Moving  the 
joint  once  each  day,  through  its  whole  range,  quietly  and  steadily,  cannot  excite 
inflammation  or  cause  severe  pain,  while  it  effectually  prevents  the  formation  of 
adhesions  and  contractions  in  the  synovial  wall. 

2.   Chronic  Synovitis. 

Chronic  synovitis  occurs  either  by  itself  or  as  part  of  a  general  arthritis  ; 
but  even  when  it  is  local  at  the  first,  the  inflammation  always  involves  the  other 
tissues  sooner  or  later.  Sometimes  it  begins  as  such,  quietly  and  insidiously  ;  in 
most  instances,  however,  it  follows  an  acute  attack,  which,  from  want  of  rest  or 
other  causes,  gradually  becomes  chronic. 

The  pathological  appearances  are  very  variable.  The  fluid  is  usually  increased 
in  quantity  ;  sometimes  there  is  an  immense  excess.  Generally  it  is  thinner  and 
more  watery  than  normal  ;  sometimes  it  is  almost  serous,  and  straw-yellow  in 
color,  and  occasionally  it  is  turbid  ;  but  it  usually  retains  its  lubricating  feeling. 
The  surface  of  the  lining  membrane  is  dull  and  opaque.  In  places  it  is  rough 
and  velvety ;  and  around  the  margins  where  it  is  thrown  into  folds  it  may 
be  covered  with  fringes  and  villous  processes  as  thickly  as  in  chronic  osteo- 
arthritis. The  fibrous  capsule  is  softened  and  weakened  at  some  parts  ;  thickened 
and  rigid  from  the  organization  of  the  exudation  at  others.  In  some  cases  the 
weaker  portions  are  stretched  to  such  an  extent  that  the  shape  of  the  sac  is  com- 
pletely altered  ;  hernial  pouches  form  between  the  fasciculi,  owing  to  the  continued 
I)ressure  ;  or  the  walls  are  gradually  absorbed  until  a  communication  is  established 
with  neighboring  burs?e.  In  others  the  flexibility  is  lost  ;  the  soft  cellular  pads, 
which  should  yield  at  once  to  the  pressure  of  the  bones,  are  hard  and  dense  ;  the 
delicate  peri-synovial  tissue  is  thickened  and  contracted  ;  and  the  folds  of  the 
synovial  membrane,  especially  where  they  are  pressed  together  and  kept  at  rest 
for  any  length  of  time,  as  on  the  inner  side  of  the  shoulder  joint,  become 
adherent  to  each  other,  so  that  they  cannot  open  out  as  the  bones  sejjarate.    In  rarer 


DISEASES  OF  JOINTS— SYNOVITIS.  553 

cases  the  exudation  in  the  interior  becomes  organized,  and  long  slender  adhesions 
are  left,  i)assing  from  one  surface  to  another.  They  form  during  the  acute  stage 
of  the  inflammation,  while  the  endothelium  is  detached  and  the  walls  are  covered 
with  lymj)h  ;  and  while  still  soft  they  are  gradually  stretched  by  some  change  in 
the  position  of  the  joint. 

Symptoms. — The  signs  of  inflammation  are  much  less  marked  than  in  the 
acute  form  ;  the  temperature  of  the  part,  for  example,  is  scarcely  raised,  the  pain 
is  not  so  severe,  and  there  is  no  constitutional  disturbance  ;  but  there  is  evidence 
of  much  greater  changes  in  the  tissues  ;  the  muscles,  especially  the  extensors,  are 
atrophied  ;  the  outline  of  the  joint  is  altered  ;  sometimes  the  bones  stand  out  too 
prominently,  from  the  wasting  of  all  the  tissues  over  them,  more  often  they  are 
concealed  by  the  distention  of  the  synovial  cavity.  The  shape  of  the  synovial  sac 
is  not  the  same  ;  the  weaker  parts  of  the  capsule  yield  more  than  the  rest ;  the 
pouch  under  the  quadriceps,  for  instance,  in  the  case  of  the  knee  is  enormously 
increased  in  size,  while  the  tough  fibrous  capsule  on  either  side  of  the  patella  is 
scarcely  affected.  The  joint  is  stiff  and  weak,  with  a  feeling  of  insecurity  and 
helplessness  ;  the  range  of  movement  is  limited,  full  extension  in  particular  being 
impossible.  There  is  crackling  or  grating,  as  one  surface  moves  upon  the  other; 
sometimes  it  is  the  soft  silken  crepitus  of  cartilage  that  has  lost  its  polish,  more 
frequently  the  rough  sensation  produced  by  the  synovial  fringes  as  they  are 
squeezed  between  the  capsule  and  the  bone ;  and  there  is  always  tenderness  on 
pressure,  not  only  at  the  usual  points,  but  at  others  where  the  capsule  is  thickened 
from  the  organization  of  lymph,  or  where  it  has  grown  out  into  little  pedunculated 
masses  which  are  caught  between  the  finger  and  the  bone. 

Prognosis. — In  most  instances,  tubercular  disease  for  example,  the  syno- 
vitis is  merely  part  of  a  general  arthritis,  or  is  associated  with  some  diathesis, 
and  requires  special  description.  Sometimes,  however,  it  is  local  and  exists  by 
itself. 

In  the  early  stages,  while  the  exudation  is  still  cellular  and  to  a  great  extent 
fluid,  resolution  is  usually  complete  if  the  cause  is  removed.  Later,  when  organi- 
zation has  set  in  and  the  wall  has  undergone  a  definite  alteration  in  structure,  the 
prospect  is  not  so  favorable.  When  part  of  the  capsule  is  hard  and  rigid,  or 
incorporated  with  the  tissues  around,  or  when  the  folds  are  hypertrophied  and 
covered  over  with  fringes,  recovery  is  rarely  perfect ;  the  joint  never  moves  easily, 
it  remains  weak  and  insecure ;  one  spot  in  particular  is  painful,  or  one  special 
action  ;  the  amount  of  fluid  is  too  great,  though  it  varies  from  time  to  time,  and 
there  is  always  the  chance  that  a  sudden  strain,  or  the  slipping  of  one  of  the 
pedunculated  outgrowths  between  the  bones,  may  give  rise  to  an  acute  attack. 

Treatment. — The  sooner  the  exudation  is  absorbed  the  less  the  risk.  If  it 
is  left  for  any  time  the  capsule  becomes  stretched,  and  for  want  of  proper  tension 
the  fluid  collects  again  as  soon  as  it  is  removed.  Gentle  uniform  pressure — an 
elastic  bandage,  for  example,  over  properly  arranged  pads — is  most  successful, 
especially  in  the  early  period,  while  there  is  still  a  certain  degree  of  hyperaemia. 
As  this  disappears,  friction  and  massage  may  be  used  for  a  few  minutes  each 
day  to  prevent  the  wasting  of  the  tissues  and  increase  the  flow  of  lymph  in 
the  vessels.  Then,  as  the  fluid  disappears  and  only  thickened  bands  and  fringes 
are  left,  douching  with  a  jet  of  warm  water  under  moderate  pressure,  steaming, 
shampooing,  and  other  more  vigorous  remedies  may  be  tried.  Very  great  relief 
is  often  obtained  by  the  use  of  counter-irritants  :  oleate  of  mercury  of  various 
degrees  of  strength,  Avith  morphia,  painted  on  the  skin  ;  iodine  applied  every  day 
until  there  is  very  distinct  tenderness  ;  or,  especially  where  there  is  an  unusually 
sensitive  spot,  light  flying  blisters  repeated  at  frequent  intervals.  Scott's  dressing 
is  invaluable  when  the  fluid  persistently  re-collects.  The  joint  is  covered  over 
with  strips  of  lint,  on  which  is  spread  camphorated  mercurial  ointment  (an  ounce 
of  strong  mercurial  ointment  to  a  drachm  of  camphor)  ;  over  this  are  placed  two 
or  three  layers  of  firm  adhesive  plaster  ;  and  then  the  whole  is  fixed  and  rendered 
secure  by  means  of  a  starch  bandage.  This  should  be  removed  at  the  end  of  a 
36 


554    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

week  at  the  latest ;  by  that  time  the  strapping  is  too  loose  to  exert  any  pressure, 
and  very  often  a  sufficient  effect  has  been  produced  upon  the  skin.  Not  unfre- 
quently  it  is  advisable  to  vary  the  treatment,  i)rotecting  the  joint  in  the  mean- 
while from  cold  and  overwork,  without,  unless  the  temperature  is  distinctly 
raised,  laying  it  up  completely. 

In  some  cases,  in  which  the  effusion  persistently  returns  again  and  again  with- 
out any  other  sign  of  inllammation,  aspiration  and  injection  with  a  stinuilating 
fluid  may  be  tried.  A  one  per  cent,  watery  solution  of  carbolic  acid  or  tincture  of 
iodine  and  water  (one  part  in  ten)  is  usually  employed.  The  fluid  is  injected  into 
the  joint,  brought  into  contact  as  far  as  possible  with  all  parts  of  the  synovial 
cavity,  and  then  allowed  to  escape  again,  the  aperture  being  closed  at  once.  The 
limb  should  be  thoroughly  packed  with  cotton-wool  and  kejit  upon  a  splint  until 
the  reaction  that  follows  has  subsided.  Afterward  a  certain  amount  of  sujjport 
(an  elastic  bandage  for  example)  must  be  worn  to  prevent  any  further  accumu- 
lation. This  treatment,  however,  is  by  no  means  devoid  of  risk  :  the  reaction 
may  be  very  much  greater  than  is  wished,  and  it  must  not  be  forgotten  that  this 
passive  collection  of  fluid  {liydrops  articuli  or  hydrarthrosis)  is  in  many  cases 
rather  a  sign  of  incipient  osteoarthritis,  or  of  that  form  of  arthropathy  associated 
with  locomotor  ataxy,  than  of  simple  chronic  synovitis.  [The  injection  of  iodo- 
form emulsion  is  very  valuable,  and  is  seldom  attended  by  any  troublesome 
complication.] 

In  others  again  the  joint  continues  stiff  and  painful  without  any  increase  in 
the  amount  of  fluid,  and  without  any  rise  of  temjjerature,  every  attempt  at  using 
it  bringing  back  an  acute  attack,  although  the  skin  in  the  intervals  is  cold,  blue, 
and  congested.  This  may  be  due  to  the  presence  of  bands  or  adhesions  in  the 
interior  of  the  joint  or  in  the  loose  tissue  around  the  capsule;  but  much  more 
frequently  it  arises  from  simple  disuse  and  defective  circulation.  The  appearance 
of  the  part  is  characteristic ;  it  has  a  helpless,  withered  look  about  it,  the  skin 
does  not  fall  into  its  natural  folds,  or  move  easily  and  freely  over  the  prominences 
beneath ;  it  seems  as  if  it  were  shrunken  on,  and  it  is  always  cold,  though  the 
patient  may  complain  of  a  constant  burning  pain.  Movement  is  generally 
exceedingly  limited  and  very  painful,  especially  at  one  particular  spot,  and  in 
many  cases  the  least  attempt  at  carrying  it  beyond  a  certain  point  is  followed  by 
a  return  of  the  acute  symptoms.  Such  cases  as  these  may  generally  be  cured  at 
once  by  massage,  douching,  and  friction ;  the  circulation  improves,  the  skin 
becomes  warm  again,  and  the  synovial  folds,  which  are,  as  it  were,  glued  together 
from  having  been  kept  at  rest  too  long  while  softened  by  inflammation,  gradually 
open  out  and  allow  the  proper  movements  to  take  place  freely.  Sometimes,  how- 
ever, this  fails ;  instead  of  recovering,  the  joint  continues  tender,  i)articularly  at 
one  spot ;  or,  while  other  movements  can  be  performed  with  ease,  one  remains  ■ 
impossible,  from  the  pain  it  causes.  In  this  case  it  is  probable  that  the  synovitis  is 
kept  up  by  the  stretching  of  an  adhesion,  and  it  may  be  brought  to  an  end  at 
once  by  suddenly  rupturing  it.  The  action  and  the  spot  must  be  noted  carefully, 
the  muscles  thoroughly  relaxed,  preferably  by  an  anaesthetic,  the  i)roximal  segment 
fixed,  and  then  the  band  torn  across  once  for  all  by  suitable  manipulation.  This 
condition,  however,  is  much  more  rare  than  the  former. 


ARTHRITIS. 

Simple  Inflammation. 

This  may  either  begin  in  the  synovial  cavity  and  spread  to  the  rest  of  the 
joint  (primary),  or  follow  disease  of  the  articular  ends  of  tlie  bones  or  other 
adjacent  structures  (consecutive).  It  may  be  acute  or  chronic,  and  according  to 
the  nature  and  persistence  of  the  cause  it  may  subside  or  end  in  disorganization. 
Suppuration   is  a  complication  and  does  not  occur  unless  the  vitality  of  the 


DISEASES  OF  JOINTS-ARTHRITIS.  555 

tissues  is  impaired  and  the  pyogenic  organisms  gain  entrance  in  sufficient 
numbers. 

Causes. — Traumatic  inllammation  of  the  synovial  Hning  is  of  common 
occurrence  ;  but,  except  in  the  case  of  a  neglected  loose  cartilage  or  frequently 
repeated  sprains,  it  seldom  happens  that  mere  mechanical  injury  is  sufficiently 
intense  or  prolonged  to  affect  the  other  tissues  of  the  joint.  Chemical  irritants 
either  give  rise  to  a  specific  form  (gouty  arthritis,  for  instance),  or,  as  in  the  case 
of  septic  decomposition,  are  so  severe  that  suppuration  follows  almost  as  a  matter 
of  course.  A  typical  example  of  simple  inflammation  is  sometimes  met  with 
when  there  is  a  neighboring  focus  of  inflammation  (consecutive  arthritis)  ;  the 
knee-joint,  for  instance,  may  be  more  slowly  disorganized,  as  a  result  of  chronic 
osteitis  of  the  lower  end  of  the  femur,  without  pus  ever  making  its  appearance 
in  the  articulation. 

Pathological  Appearances. — The  earliest  changes  take  place  in  the  most 
vascular  parts.  The  synovial  meml)rane  is  swollen,  softened,  and  reddened  with 
extravasations  ;  the  cavity  filled  with  a  turbid  blood-stained  fluid,  and  the  articular 
ends  of  the  bones  and  the  soft  structures  around  deeply  congested.  The  cartilages, 
as  they  contain  no  vessels,  undergo  no  active  change,  and  the  same  is  true,  although 
to  a  less  extent,  of  the  ligaments  and  capsule. 

If  the  irritant  continues,  this  becomes  more  marked.  The  amount  of  exuda- 
tion increases,  the  fluid  in  the  interior  becomes  thick,  the  ligaments  soften,  their 
fibres  separate  from  each  other,  and  all  the  interstices  are  filled  with  lymph. 

The  synovial  membrane  and  the  capsule  are  so  swollen  and  thickened  that  they 
can  scarcely  be  recognized.  The  cartilages  lose  their  lustre  and  become  opaque  ; 
they  melt  away  on  the  surface  and  grow  thinner  and  thinner,  while  around  at  the 
edges  they  are  eaten  out  in  little  pits  by  the  granulations  that  spring  from  the  vas- 
cular circle  around  the  bone ;  the  periosteum  is  thicker  than  natural ;  it  can  be 
stripped  off"  with  ease  from  the  surface  beneath,  and  the  bones  themselves  are 
deeply  congested  and  so  soft  that  they  can  be  cut  with  a  knife. 

These  extreme  changes  are  only  seen  when  the  irritant  is  an  intense  one  and 
suppuration  impending.  When  the  cause  is  a  loose  cartilage  or  a  neighboring  focus 
of  inflammation,  they  are  much  less  marked  ;  and  as  in  these  cases  there  is  rather  a 
succession  of  slight  attacks  at  frequent  intervals,  than  a  single  very  severe  one,  at 
one  time  all  the  tissues  may  be  swollen,  softened,  and  filled  with  exudation,  at 
another  they  may  be  dense  and  hard  from  organization  and  repair  ;  but,  inevitably, 
if  the  irritant  is  continued  sufficiently  long,  all  the  tissues  of  the  joint  lose  their 
natural  texture  and  it  becomes  more  or  less  crippled  and  ankylosed. 

Repair. — The  destruction  may  be  arrested  at  any  point ;  the  irritant  ceases  to 
act,  the  hyperemia  subsides,  and  the  exudation  partly  becomes  absorbed,  partly 
organized. 

In  most  traumatic  cases  this  takes  place  before  the  synovial  membrane  is 
destroyed  or  any  very  serious  changes  are  produced  in  the  ligaments  or  cartilages  ; 
and  then,  although  the  capsule  is  left  thickened  and  somewhat  rigid,  a  very  fair 
range  of  movement  is  regained.  Even  when  the  surface  of  the  cartilage  has  been 
eaten  away  and  the  ligaments  softened  this  is  still  possible,  especially  in  children, 
so  long  as  there  is  no  displacement.  The  fibrous  tissue  that  fills  up  the  deficiency 
presents  a  sufficiently  smooth  and  even  surface,  and  the  ligaments  soon  become  firm 
again.  If,  however,  the  irritant  persists  (as  in  chronic  osteomyelitis  of  the  lower 
end  of  the  femur  when  the  sequestrum  is  locked  in),  the  joint  may  become  so 
rigid  and  painful  that  the  patient  is  driven  at  last  to  seek  relief  in  operation. 

Symptoms  and  Course. — Acute  arthritis  presents  the  same  class  of  symp- 
toms as  acute  synovitis,  but  they  are  very  different  in  degree.  The  pain  is  more 
severe.  The  limb  is  flexed  and  held  perfectly  rigid.  The  skin  feels  burning  hot, 
and,  though  it  may  be  white  at  first  and  in  the  more  chronic  cases,  reddened 
patches  may  show  themselves  over  the  part  where  the  capsule  is  thin  and  superficial. 
The  whole  of  the  joint  is  swollen,  not  the  synovial  sac  only  ;  the  shape  is  different ; 
it  is  more  rounded  and  uniform,  spreading  upward  and  downward  over  the  bones. 


556     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

and  not  following  the  outline  of  the  cavity.  The  consistence  of  the  swelling  is 
firmer  ;  the  tenderness  on  pressure  is  greater,  and,  though  one  or  two  spots  may  be 
worse  than  the  rest,  it  is  not  confined  to  any  part  in  jjarticular.  The  extensor 
muscles  waste  even  more  quickly;  the  flexor  ones  maintain  a  state  of  rigid  con- 
traction, broken  only  by  sharp  spasms,  especially  at  night,  and  the  constitutional 
disturbance  is  much  more  severe. 

These  symptoms  are  followed  by  the  others  which  do  not  occur  in  synovitis. 
As  the  ligaments  become  soft  and  yield,  undue  mobility  is  allowed.  Displacement 
of  the  articular  ends  and  even  dislocation  may  follow,  the  weight  of  the  lower  seg- 
ment of  the  limb  and  the  persistent  spasm  of  the  flexor  muscles  drawing  the  bones 
away  from  each  other.  Friction  is  felt  when  the  joint  is  moved,  owing  to  the  car- 
tilages having  lost  their  smoothness  of  surface.  At  the  same  time,  or  even  before 
this,  peculiar  starting-pains  make  their  appearance.  These  rarely  hapi)en  in  the 
daytime  or  at  night,  when  the  patient  is  sound  asleep  ;  but  as  he  is  losing  con- 
sciousness and  the  muscles  are  relaxing  their  vigilance  there  is  a  sudden  violent 
jerk  of  the  limb  and  the  two  bones  are  driven  together  with  the  most  excruciating 
pain.  This  may  happen  time  after  time  and  night  after  night,  until  the  patient 
dreads  going  to  sleep,  and  keeps  himself  awake  as  long  as  he  possibly  can.  It 
always  means  that  the  bones  are  inflamed,  and  often  that  the  cartilages  are  eroded. 
The  start  is  due  to  the  sudden  reflex  contraction  of  the  muscles.  As  they  relax  in 
sleep,  one  part  of  the  joint  moves  ever  so  little  upon  the  other,  the  stimulus  is  car- 
ried up  to  the  nerve-centres,  there  is  a  sudden  sj^asm  in  response,  and  the  two  bones 
are  brought  forcibly  into  contact.  It  is  not  uncommon  for  them  to  be  present 
when  no  grating  can  be  detected,  either  because  the  surface  of  the  bones  is  covered 
with  granulations,  or  because  the  cartilage  is  not  yet  removed. 

If  the  irritant  is  very  intense  (such  as  the  poison  of  septic  decomposition)  and 
the  inflammation  continues  to  spread,  the  periarticular  ti-ssues  become  involved, 
the  skin  becomes  red  and  oedematous,  especially  along  the  inner  side  of  the  limb  ; 
the  swelling  increases  rapidly  in  size  and  becomes  more  diffuse;  the  pain  grows 
more  severe  and  continuous  ;  the  constitutional  disturbance  becomes  worse  and 
worse,  and  at  length  the  pyogenic  organisms  gain  the  ui)per  hand  and  suppuration 
sets  in,  sometimes  in  the  joint  itself,  sometimes  in  the  tissue  around. 

Diagnosis. — Occasionally  there  is  some  difiiculty  in  determining  whether 
the  inflammation  involves  the  joint  or  some  of  the  structures  around  it.  This 
usually  occurs  in  connection  with  bnrs?e  (under  the  deltoid  in  the  case  of  the 
shoulders,  between  the  iliopsoas  and  the  front  part  of  the  capsule  in  the  hip  ;  and 
in  children  under  the  crureus,  between  the  quadriceps  and  the  femur)  ;  but  a  careful 
examination  nearly  always  settles  the  point  at  once.  The  shape  of  this  swelling  is 
different  ;  movement  in  some  directions  is  much  more  free  than  when  the  joint  is 
involved,  pain  is  less  severe,  and  the  constitutional  symptoms  are  much  less 
marked. 

Treatment. —  i.  Primary  Arthritis. — {a)  Acute.  In  this,  as  in  synovitis, 
local  treatment  is  the  most  important.  If  the  fever  is  high  and  the  constitutional 
symptoms  severe,  small  doses  of  aconite  (one  minim  of  the  tincture),  or  of  anti- 
mony, may  be  given  at  frequent  intervals  ;  the  bowels  must  be  kept  ojjen,  the  diet 
strictly  limited,  and  antipyrin  or  quinine  may  be  tried  ;  but  unless  there  is  evidence 
of  some  definite  diathesis,  such  as  gout  or  rheumatism,  constitutional  remedies  by 
themselves  are  of  little  avail. 

Rest  is  the  first  consitleration.  Every  movement  of  the  joint  not  only  causes 
intolerable  pain,  but  makes  the  inflammation  worse.  At  the  very  earliest  sign, 
whether  it  is  due  to  a  wound  or  not,  the  limb  should  be  placed  upon  a  suitable 
splint.  This  varies,  of  course,  with  the  nature  and  situation  of  the  joint  ;  it  must 
fix  both  segments,  the  one  al)ove  and  the  one  below  ;  it  must  hold  the  limb  in  the 
most  convenient  position,  supposing  it  should  become  stiff;  it  must  enable  con- 
tinuous extension  to  be  made  if  it  is  required,  and  it  must  be  arranged  so  that  the 
cold,  compression,  or  counter-irritation  may  be  applied  without  its  being  necessary 
to  move  it.     For  the  hip,  either  Bryant's  or  Thomas's  splint  maybe  used,  accord- 


DISEASES  OF  JO/NTS -ARTHRITIS.  557 

ing  to  the  position  of  the  joint,  which  is  certain  to  l)e  flexed,  and  which  may  not 
come  straight  for  days;  in  the  case  of  the  knee,  either  Thomas's  or  Mclntyre's. 
The  anterior  ones  do  not  give  sufficient  immobility,  or  prevent  the  eversion 
which  always  takes  place  if  the  ligaments  are  softened  and  the  limb  is  left  to  itself; 
but,  both  for  this,  the  foot,  and  the  joints  of  the  upper  extremity,  nothing  answers 
better  than  one  of  the  various  forms  of  plaster  splints  (especially  Gamgee's  absorb- 
ent cotton-wool  dipped  in  i)laster  cream)  or  poroplastic  felt. 

Extt-itsion  is  part  of  rest,  and,  especially  in  the  case  of  the  hip  and  knee,  is 
almost  intlispensable.  It  i)revents  muscular  spasm  and  stops  the  starting-pains  at 
once  and  in  a  fashion  which  nothing  else  can  ;  it  prevents  the  two  bones  being 
jammed  against  each  other,  and  saves  the  articular  cartilage  from  absorption  ;  it 
helps  to  steady  the  limb  and  bring  it  into  the  right  line,  and  it  checks  the  tend- 
ency to  displacement.  It  is  managed  most  easily  by  means  of  a  weight  attached 
to  a  stirrup,  the  amount  being  proportioned  to  the  size  of  the  limb. 

Elevation,  cold,  and  compression  are  invaluable  for  checking  the  hyperemia 
and  reducing  the  tension  of  the  part.  With  regard  to  the  first,  Lister  has  shown 
that  not  only  does  the  venous  blood  return  more  freely  when  a  limb  is  raised,  but 
that  there  is  as  well  a  contraction  of  the  artery  under  the  influence  of  the  vasomo- 
tor nerves.  Of  cold  it  is  unnecessary  to  say  anything,  the  only  point  is  that  it  must 
be  continuous  and  not  intermittent.  Ice-bags  may  be  placed  over  the  joint,  or 
Letter's  coils  wound  around  it ;  or,  what  is  perhaps  more  effectual  when  the  affected 
joint  is  covered  thickly  up,  an  ice-bag  may  be  laid  along  the  main  artery  supplying 
the  limb.  It  has  been  proved  that  this  has  a  very  decided  influence  upon  the 
temperature  of  the  parts  below.  Compression  is  even  more  important,  but  it 
must  be  carried  out  thoroughly  and  carefully,  or  it  may  make  the  congestion  worse. 
The  whole  limb,  from  its  extremity  to  well  above  the  affected  joint,  must  be  evenly 
packed  with  layer  upon  layer  of  absorbent  cotton-wool.  On  the  outside  of  this 
longitudinal  strips  of  torn  mill-board  soaked  in  plaster  cream  are  placed  to  give 
firmness  and  resistance  ;  and  then  over  all  a  bandage  carried  evenly  upward, 
diminishing  the  pressure  ever  so  little  toward  the  end. 

Other  remedies  are  occasionally  of  service.  If  the  inflammation  is  very  acute, 
ten  or  a  dozen  leeches  may  be  placed  over  the  joint.  The  skin  may  be  covered 
over  with  a  mixture  of  equal  parts  of  extract  of  belladonna  and  glycerine.  Morphia 
may  be  given  hypodermically  to  relieve  the  pain  and  restlessness  and  procure 
sleep  ;  and  if  the  joint  is  very  much  distended,  aspiration  may  be  used  to  draw  off 
some  of  the  fluid. 

(J))  Chronic. — If  this  treatment  is  successful,  the  severity  of  the  symptoms 
diminishes,  the  fever  subsides,  the  hyperaemia  disappears,  and  the  exudation  is  in 
great  measure  absorbed.  Very  often,  however,  more  or  less  organization  takes 
place,  repair  is  incomplete,  and  a  certain  amount  of  chronic  inflammation  persists. 
The  muscles  are  wasted;  the  joint  is  swollen  and  stiff;  movement  is  painful; 
the  temperature  of  the  part  continues  higher  than  normal ;  there  is  tenderness  on 
pressure  ;  and  every  attempt  at  using  the  limb  threatens  to  bring  back  an  acute 
attack. 

When  this  occurs  rest  is  still  essential  ;  it  must  be  rigidly  enforced  so  long  as 
the  temperature  is  raised,  although  it  may  not  be  necessary  to  confine  the  patient 
absolutely  to  bed.  With  the  aid  of  Thomas's  splints  and  a  patten  under  the  oppo- 
site foot  in  the  case  of  the  hip  and  knee,  and  gum  and  chalk,  leather,  or  poro- 
plastic, for  other  joints,  patients  may  be  allowed  to  get  about  to  a  certain  extent 
upon  crutches  as  soon  as  the  acute  period  is  passed,  very  often  with  great  benefit  to 
their  general  health.  Compression  is  not  of  so  much  service  unless  there  is  a 
large  amount  of  exudation  still ;  but  a  great  deal  of  good  may  follow  the  judicious 
use  of  counter-irritants.  Blisters,  iodine,  and  the  oleate  of  mercury  are  of  Service 
in  the  slighter  cases  only  ;  Scott's  dressing  is  of  greater  use,  as  it  may  be  applied 
as  a  splint  as  well  ;  but  when  there  is  evidence,  from  the  shape  of  the  swelling  and 
the  severity  of  the  pain  at  night,  that  the  bone  is  in  a  state  of  chronic  inflamma- 
tion, and  even  in  some  cases  of  starting  pains,  nothing  succeeds  like  the  actual 


55 S    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

cautery.  The  broad,  flat  platinum  jjoint  of  Paquelin's  cautery  answers  best.  It 
should  be  of  a  black-red  heat,  and  should  be  drawn  slowly  over  the  skin  in  parallel 
lines,  not  destroying  the  whole  thickness,  l^ven  in  disea.se  of  the  spine  I  have 
known  great  benefit  follow  from  this  :  the  i)ain  is  not  great ;  if  the  patient  is  under 
an  anresthetic,  and  the  part  is  covered  up  from  the  air  before  consciousness  returns, 
it  is  scarcely  felt ;  very  slight  suppuration,  only  of  a  superficial  character,  may 
follow;  but  the  tension,  and  the  constant  gnawing  pain  in  the  deeper  structures, 
are  materially  relieved  ;  and  a  great  deal  of  the  exudation  disappears.  In  Pott's 
disease,  with  paraple'gia  of  not  too  long  standing,  the  spinal  cord  sometimes 
recovers  its  power  within  a  short  time  of  the  application. 

Later,  when  the  inflammation  has  subsided,  and  stiffness  or  ankylosis  only  is 
left,  proper  means  must  be  taken  to  restore  the  power  of  the  muscles  and  the 
mobility  of  the  joint. 

2.  Consecutive  Arthritis. — The  diagnosis  of  consecutive  inflammation  from 
primary  arthritis  is  of  especial  importance.  If,  for  example,  it  starts  from  an 
abscess  in  the  bone,  and  this  can  be  opened  so  that  the  pus  has  free  exit  before 
the  joint  is  too  seriously  involved,  complete  recovery  may  be  hoped  for  ;  and  even 
when  there  is  a  sequestrum,  and  it  involves  the  articular  surface,  it  is  sometimes 
possible  to  remove  it  and  leave  a  comparatively  useful  joint.  Where  this  cannot 
be  done,  as  in  many  cases  of  chronic  osetitis  of  the  lower  end  of  the  femur,  either 
the  joint  gradually  becomes  stiff  and  almost  useless  from  the  repeated  attacks  of 
inflammation,  or,  worse  still,  the  abscess  finds  its  way  into  the  interior  and  sets 
up  acute  suppurative  arthritis. 

The  shape  of  the  swelling  is  entirely  different  from  that  of  a  primary  inflam- 
mation of  the  joint,  at  least  in  chronic  cases  ;  acute  ones  run  their  course  too 
quickly.  In  the  knee,  for  instance,  instead  of  its  following  uniformly  the  outline 
of  the  synovial  sac,  it  is  very  much  larger  on  one  side  than  on  the  other  (Figs.  270 
and  271),  and  it  begins  upon  the  bone,  caused  by  the  swelling  and  infiltration 
into  the  periosteum  and  the  soft  tissues  lying  over  it.  Tenderness  is  much  greater, 
particularly  over  the  swelling  ;  sometimes  it  is  definitely  limited  to  one  spot,  the 
skin  over  which  is  slightly  puffy  and  oedematous.  The  pain  is  more  severe  and  of 
a  different  character  ;  there  is  a  constant,  deep-seated  aching  in  one  of  the  bones, 
worse  at  night  and  after  any  evcertion,  and  severe  in  proportion  to  the  acuteness 
of  the  inflammation.  In  traumatic  cases  this  is  usually  very  distinct  ;  in  tubercular 
ones,  on  the  other  hand,  owing  to  the  peculiarly  slow  and  insidious  manner  in 
which  the  affection  advances,  it  is  much  less  clear.  Starting  pains  occur  more 
early  ;  in  synovial  arthritis  they  do  not  begin  until  the  cartilage  is  detached  and 
the  soft,  cancellous  tissue  at  the  end  of  the  bone  exposed  ;  in  the  consecutive  form 
they  commence  as  soon  as  the  inflammation  approaches  the  articular  lamella.  For 
the  same  reason  intra-articular  pressure,  as  when  one  bone  is  driven  smartly  against 
the  other,  is  a  great  deal  more  painful.  Finally,  muscular  wasting  is  a  more  prom- 
inent feature. 

The  first  object  is  to  check  the  progress  of.  the  inflammation  in  the  bone. 
For  this  appropriate  constitutional  and  local  measures  must  be  adopted,  as  already 
described  under  osteitis.  In  tubercular  disease  an  attempt  must  be  made  to 
strengthen  the  resisting  power  of  the  tissues  by  good  food,  fresh  air,  especially  at 
the  seaside,  iron,  cod-liver  oil,  and  other  tonics.  If  it  is  syphilitic,  iodide  of 
potash  and  mercury  in  small  doses  should  be  tried.  The  liml)  should  be  placed 
upon  a  splint,  and  so  long  as  the  inflammation  is  acute  the  patient  should  be  con- 
fined to  bed.  Cold  may  be  aj^plied,  partly  to  check  the  hyper.-emia  and  diminish 
the  amount  of  exudation,  partly,  in  the  tubercular  form  at  least,  because  there  is 
some  evidence  that  it  possesses  the  power  of  checking  the  growth  of  the  bacilli ; 
but  care  must  be  taken  not  to  lower  the  vitality  of  the  tissues  too  much.  Leeches 
are  of  use  when  the  pain  is  very  severe  ;  in  other  cases  more  benefit  follows  the 
use  of  counter-irritants  :  the  actual  cautery,  if  there  are  starting-pains,  iodine, 
blisters  frequently  repeated,  or,  particularly  in  the  case  of  syphilis,  the  oleate  of 
mercury  with  morphia. 


^  UPP  URA  TIVE  A  R  THRl  TIS. 


559 


In  many  instances,  however,  in  spite  of  transient  improvement,  the  pain 
persists,  the  swelling  refuses  to  clisai)i)ear,  the  effusion  in  the  joint  continues,  and 
the  local  tenderness  becomes  more  and  more  distinct.  When  this  occurs  there 
must  be  no  further  delay,  an  attempt  must  be  made  to 
reach  the  seat  of  the  disease  by  incision  in  the  bone,  with- 
out, if  it  can  jjossibly  be  avoided,  implicating  the  joint. 
Even  if  no  pus  is  found,  the  operation  gives  relief  by  dimin- 
ishing the  hyperemia,  with,  so  long  as  the  synovial  cavity 
is  not  opened,  the  least  amount  of  risk.  Sometimes  the 
periosteum  is  thickened  or  detached  from  the  surface  of  the 
compact  tissue  beneath  ;  occasionally  a  small  sinus  can  be 
found,  or  the  bone  is  altered  in  texture.  In  other  cases 
everything  appears  to  be  normal ;  but  even  then,  so  great 
is  the  risk  of  leaving  a  caseous  or  suppurating  focus  in  the 
centre  of  one  of  the  articular  ends,  that  if,  before  the  ope- 
ration, one  spot  w^as  definitely  tender  or  oedematous,  a  circle 
of  bone  should  be  removed  with  the  trephine  and  the  inte- 
rior explored  with  a  small  gouge,  or,  what  answers  better, 
a  steel  director  set  in  a  rounded  wooden  handle.  With  this 
the  difference  in  the  resistance  offered  by  healthy  bone  and 
by  that  which  is  inflamed  and  softened  can  be  api)reciated 
at  once,  even  when  there  is  ho  actual  cavity. 

If  an  abscess  is  found  it  should  be  opened  freely,  any 
loose  fragments  of  bone  that  lie  in  it  removed,  and  the 
cavity  thoroughly  scraped  so  as  to  destroy  all  the  soft 
granulation  tissue,  washed  out  with  a  solution  of  perchloride 
of  mercury  (one  part  in  looo),  and  plugged  with  iodoform  gauze.  This  may  be 
removed  at  the  end  of  twenty-four  or  forty-eight  hours,  and  a  large  drainage- 
tube  inserted. 

If  the  disease  has  not  yet  broken  through  the  articular  cartilage  an  excellent 
result  may  be  obtained  by  this  ;  the  whole  of  the  os  calcis,  for  example,  may  be 
erased,  leaving  merely  a  periosteal  shell,  without  the  neighboring  synovial  mem- 
branes being  lost.  If,  unhappily,  the  disease  has  spread  too  far,  and  suppurative 
arthritis  or  pulpy  degeneration  of  the  synovial  membrane  has  occurred  already, 
further  measures,  drainage,  arthrectomy,  or  excision  will  be  necessary,  according 
to  the  condition  of  the  parts. 


Fig.  237, —  Osteitis  of  Upper 
End  of  Diaphysis  of  Tibia, 
ending  in  suppuration.  Pro- 
bably it  was  tuljercular  in 
origin  ;  on  tbe  outside  is  a 
layer  of  sub-periosteal  new 
bone,  but  notwithstanding 
this  it  made  its  way  as  well 
outside  as  into  the  joint. 


Suppurative  Arthritis. 

This,  like  the  former,  may  either  begin  in  the  joint  or  spread  to  it  from  the 
adjacent  structures.  It  never  arises  without  the  presence  of  pyogenic  organisms, 
acting  on  tissues  the  vitality  of  which  is  already  impaired  by  other  irritants.  If 
these  are  of  but  slight  intensity  and  the  general  nutrition  is  good,  the  destruction 
is  limited  ;  if,  on  the  other  hand,  they  are  severe  (as  in  septic  decomposition),  or 
if  the  tissues  are  badly  nourished  (whether  from  prolonged  intemperance, 
excesses,  kidney  disease,  or  other  causes),  the  destruction  is  widespread  and 
complete. 

Causes. — The  primary  form  very  seldom  originates  without  a  wound  ;  excep- 
tionally in  those  whose  health  is  impaired  by  intemperance  and  renal  disease,  a 
simple  synovitis  steadily  progresses  from  bad  to  worse,  until  at  length  the  tissues 
yield  and  give  way  and  suppuration  sets  in. 

The  consecutive  one  is  nearly  always  the  result  of  suppurative  osteitis.  In 
acute  necrosis  the  inflammation  may  spread  along  the  periosteum  until  it  gains  the 
capsule,  or  work  its  way  between  the  epiphysis  and  the  shaft,  and  then  turn  upward 
through  the  soft  tissue  of  the  former  until  it  reaches  and  undermines  the  articular 
lamella.  Acute  epiphysitis  of  infants  is  sometimes  known  as  suppurative  arthritis, 
from  the  certainty  with  which  the  articulation  is  destroyed.     In  chronic  osteitis. 


56o     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 


whether  tubercular,  syphilitic,  or  traumatic  in  origin,  the  joint,  if  one  is  near,  is 
always  involved  :  at  first,  while  the  focus  of  disease  is  still  some  distance  off,  the 
inflammation  is  simple  in  character  ;  then,  at  least  in  the  tubercular  form,  as  the 
bacilli  gain  the  synovial  membrane,  it  becomes  specific  ;  and  finally,  when  either  an 
external  opening  forms  or  the  pyogenic  organisms  gain  the  upj^r  hand,  suppuration 
sets  in.  In  other  cases  the  starting-point  of  the  disease  is  in  some  neighboring 
bursa  or  tendon -sheath,  or  even  in  the  cellular  tissue. 

Pathological  Appearances. —  The  earlier  changes  are  those  of  acute 
arthritis  ;  then,  as  the  tissues  melt  away  l)efore  the  pyogenic  micrococci,  the  destruc- 
tion becomes  more  rapid.  The  synovial  membrane  grows  thicker  and  thicker, 
until  it  simply  becomes  a  mass  of  inflammatory  e.xudation  with  scarcely  a  trace  of 
its  original  texture  left  ;  the  loose  cellular  tissue  around  swells  up  and  becomes 
gelatinous  ;  and  the  interior  of  the  joint  is  covered  with  flakes  of  fibrin  and 
sloughing  shreds  of  tissue  and  filled  with  a  turbid  mixture  of  pus,  synovia,  and 
debris  from  its  walls.  Soon  the  cartilages  lose  their  pearly-white  color  and  become 
opaque.  Sometimes,  when  the  tension  is  not  very  high,  they  gradually  melt  away  ; 
more  often  the  central  portions,  which  are  pressed  together  when  the  bones  are  in 
contact,  and  which  are  furthest  from  the  vascular  circle,  perish  and  drop  off  as 
sloughs,  bringing  with  them  the  articular  lamella  on  which  they  rest  (Fig.  238), 

while  around  the  margin  and  where  the 
inflammation  is  less  acute,  they  are  gradually 
eaten  out  by  the  granulations  in  the  form  of 
little  circular  pits  (Fig.  236).  The  den.se 
fibrous  capsule  and  the  ligaments  resist  the 
longest  ;  but  in  a  little  while  the  inflamma- 
tory exudation  works  its  way  into  the  inter- 
jr  .j:_  ^"'^^  'W     t      slices;    the   fibres  soften  and   melt  away; 

*-■  f^'  '  vi      yellow  foci  of  suppuration  appear  in  the  tis- 

sues outside  the  joint  ;  and  the  bones  become 
so  movable  that  displacement  and  even  dis- 
location occur.  Finally  the  muscles  waste 
away  and  undergo  fibroid  degeneration  ;  the 
periosteum  is  destroyed  ;  the  capsule  disap- 
pears;  the  pus  spreads  far  and  wide  in  the 
softened  structures  around  ;  the  skin  be- 
comes undermined  ;  and  nothing  is  left  but 
l''r::^%^:!:i':^\'io^^^^^^  the  articular  ends  of  the  bones,  roughened, 

softened,  and  carious,  loathed  in  pus  and 
surrounded  by  suppurating  tissues. 
In  the  most  acute  form  of  suppurative  arthritis  (that  which  follows  a 
poisoned  wound  or  complicates  acute  necrosis)  the  joint  may  be  completely 
destroyed  within  a  few  days  :  if  the  irritant  is  less  intense,  the  changes  take  place 
more  slowly  ;  and  they  may  be  arrested  at  any  stage ;  but  they  are  always  the 
same.  The  difference  in  appearance  arises  from  the  size  of  the  fragments  that 
perish  :  in  the  most  acute  form  necrosis  is  the  prominent  feature,  and  the  cartil- 
ages and  the  ends  of  the  bones  are  thrown  off  in  great  flakes  ;  in  the  less  acute 
these  are  much  smaller,  and  only  come  from  the  s])Ots  where  there  is  pressure  ;  and 
in  those  that  are  less  so  still,  they  are  only  molecular,  the  surface  imperceptibly 
melting  away. 

Repair. — The  extent  to  which  this  is  pos.sible  depends  upon  the  amount  of 
destruction.  So  long  as  only  the  synovial  and  perisynovial  tissues  are  involved, 
and  the  cartilages  are  fairly  intact,  recovery  is  possible,  though  with  a  considerable 
degree  of  rigidity  ;  the  joint-cavity  is  preserved,  although  the  bones  are  tied 
together  by  bands  of  organized  lymph  lying  in  the  substance  of  the  capsule  and 
springing  from  the  summits  of  the  osteophytes  formed  round  the  articular  ends. 
But  if,  as  is  usually  the  case,  the  cartilages  have  sloughed,  bringing  away  with 
them  the  articular  lamella,  and  the  granulations  spring  from  the  ends  of  the  bones 


Fig.  238.- 
tive  Arthr 
cartilage,  except  at  the  margin. 


SUPPURATIVE  ARTHRITIS.  561 

as  well  as  from  the  tissues  around,  when  the  discharge  of  pus  ceases  and  organiza- 
tion begins,  the  opposing  surfaces  grow  together,  the  cavity  is  ol)literated,  and 
eitlier  dense  bands  of  cicatricial  tissue  form  between  the  ends,  or  osseous  union, 
true  boiiv  ankylosis,  takes  place. 

Symptoms.— 'I'hese  are  the  same,  both  constitutional  and  local,  as  those  ot 
acute  arthritis,  but  infinitely  more  severe.  When  the  joint  is  a  large  one  and  the 
attack  acute,  death  may  follow  from  septic  absorption  within  the  first  few  days. 
There  is  a  rigor  or  a  succession  of  chills  ;  the  temperature  rises  rapidly  to  105°  or 
even  106°  F.  ;  the  pulse  at  first  is  full  and  bounding,  but  in  a  very  short  time  it 
becomes  weak  and  feeble  ;  the  tongue  is  dry  and  brown  ;  sordes  appears  upon  the 
lips  and  teeth  ;  delirium  sets  in  ;  and  the  patient  sinks  from  acute  blood-poisoning 
without  the  symptoms  abating  in  the  least. 

In  other  cases  the  constitutional  symptoms  are  less  severe  ;  the  temi>erature  is 
exceedingly  high,  with  occasional  rigors  ;  at  first  it  is  continuous  ;  after  a  time  it 
falls  of  a  morning,  until,  when  suppuration  has  become  free,  it  assumes  the  hectic 
type.  The  pulse  is  soft  and  compressible  without  losing  its  frequency  ;  the  appe- 
tite is  comjjletely  lost ;  the  tongue  continues  dry  and  brown  ;  the  emaciation  is 
extreme,  the  cheeks  become  hollow,  the  eyes  dark  and  sunken,  and  if  the  patient 
escapes  pyaemia  and  other  acute  infectious  disorders,  amputation  is  frequently 
re(iuired,  either  because  the  joint  is  hopelessly  disorganized  and  the  limb  useless, 
or  to  prevent  the  patient  sinking  from  exhaustion. 

In  others  again,  wheir  the  suppuration  is  not  assisted  by  decomposition,  or 
when  the  joint  is  a  small  one— in  one  of  the  fingers,  for  example— the  effect  is 
very  much  less,  but  in  acute  suppurative  arthritis  it  is  always  severe. 

The  local  signs  are  equally  grave.  If  the  joint  is  a  large  one  the  whole  limb 
is  swollen  ;  the  outline  of  the  synovial  cavity  disappears  ;  the  skin  is  burning  hot 
and  duskv'red,  either  in  patches  or  all  over  ;  and  the  inflammatory  cfidema  spreads 
up  the  whole  of  the  inner  side.  The  pain  is  most  intense,  the  patient  screaming 
out  if  the  bed  is  touched,  and  the  limb  is  flexed  and  held  perfectly  rigid,  often 
grasped  with  both  hands  so  as  to  prevent  the  slightest  movement.  Displacement, 
if  it  has  not  occurred  already,  very  soon  follows.  The  ends  of  the  bones  grate 
upon  each  other,  owing  to  the  cartilages  having  sloughed.  The  startmg-pams  at 
night  become  simply  agonizing  ;  and  then,  if  the  patient  survives,  the  skin  becomes 
thinned  at  some  spot,  fluctuation  makes  its  appearance,  and  the  pus  discharges 

itself  externally.  1        >.i,- 

In  acute  suppurative  arthritis  of  the  knee,  it  occasionally  happens,  when  this 
stage  is  reached,  that  there  is  a  sudden  and  most  deceptive  appearance  of  improve- 
ment ;  the  capsule  of  the  joint  gives  way  at  its  weakest  part,  under  the  tendon  of 
the  (piadriceps  ;  the  pus  escapes  and  spreads  along  the  femur,  until  it  is  turned 
aside  by  an  aponeurosis  ;  the  joint  diminishes  in  size  ;  the  tension  becomes  less  ; 
and  the  constitutional  symptoms  are  decidedly  improved.  Unhappily  this  does 
not  last  long  ;  the  swelling  soon  shows  itself  high  upon  the  outer  side  of  the  thigh, 
and  if  the  abscess  is  not  opened  and  drained  at  once,  the  symptoms  become  even 
worse  than  they  were  before. 

Diagnosis.— In  the  acute  form,  especially  that  which  follows  a  wound  ot 
the  joint,  there  is  seldom  any  difficulty;  sometimes,  however,  when  suppurative 
arthritis  sets  in  as  a  result  of  constitutional  infection,  and  it  is  a  question  between 
this  and  purulent  synovitis,  the  signs  are  at  first  far  from  obvious.  The  occurrence 
of  a  rigor ;  a  rapid  rise  of  temperature  ;  the  shape  of  the  swelling,  which  is  no 
longer  that  of  the  synovial  sac  ;  the  presence  of  cedema  and  of  a  peculiar  dusky 
redness  of  the  skin,  and  the  intense  character  of  the  pain,  are  most  significant 
In  any  case  of  doubt  there  should  be  no  hesitation  in  using  the  aspirator  and 
withdrawing  some  of  the  fluid  from  the  interior,  with  the  precautions  already 
described.  If  the  contents  are  still  thin  and  serous,  the  product  of  catarrhal  sup- 
puration, removing  a  certain  quantity  relieves  the  tension  and  the  hypersemia, 
and  then  absorption  may  commence  of  itself.      If,  on  the  other   hand,  they  are 


562     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

thick  and  curdy,  the  sooner  the  contents  are  evacuated  and  the  tension  lowered 
the  better  the  prospect  of  preserving  the  cartilages  and  saving  the  joint. 

Treatment.— Suppurative  arthritis  must  he  dealt  with  at  once.  The  syno- 
vial cavity  must  be  thoroughly  drained  ;  the  poison  that  clings  to  its  walls  destroyed 
or  washed  away  ;  and  all  further  source  of  irritation,  whether  it  is  septic  decom- 
position, tension,  movement,  or  pain,  absolutely  prevented. 

If  there  is  any  doubt  as  to  the  presence  of  pus;  or  if,  as  in  some  cases  of 
constitutional  infection,  there  is  a  suspicion  that  it  is  really  a  purulent  catarrh,  kept 
up  to  a  great  e.xtent  by  tension,  without  the  cartilages  or  the  surrounding  tissues 
being  seriously  concerned,  aspiration  may  be  tried.  On  the  other  hand,  if  the 
skin  is  red  and  oedematous,  if  the  shape  of  the  swelling  is  no  longer  that  of  the 
synovial  sac,  or  if  the  arthritis  is  due  to  a  wound,  or  an  abscess  that  has  formed 
in  connection  with  the  bone  or  one  of  the  surrounding  structures  and  has  burst 
into  the  joint,  the  only  \\o\>q  lies  in  free  incision  and  thorough  drainage.  The 
earlier  this  is  accomplished  the  better.  If  the  patient  is  not  already  jjoisoned  by 
septic  absorption,  and  the  synovial  membrane  is  not  yet  destroyed,  a  fair  amount 
of  movement  may  be  regained  ;  if  it  is  not  done  in  time,  either  the  patient  will 
sink  from  acute  septicaemia  or  exhaustion,  or  if  he  recovers  the  joint  will  be  hope- 
lessly disorganized. 

The  limb  must  be  fixed  upon  a  splint,  protected  with  waterproof  pads,  so 
that  there  can  be  no  displacement  or  spasm,  and  every  part  of  the  joint  laid  open  ; 
the  difficulty  of  accomplishing  this,  in  the  larger  and  more  complicated  ones,  is 
chiefly  responsible  for  the  ill  results  that  follow. 

In  the  case  of  the  knee  a  free  incision  must  be  made  down  each  side  of  the 
patella,  slanting  rather  backward;  and  a  pair  of  dressing-forceps  pushed  through 
the  back  of  the  joint  into  the  popliteal  space  on  the  outer  side  of  the  middle  line, 
until  the  point  is  felt  beneath  the  skin.  Then  a  small  cut  must  be  made,  the 
forceps  driven  through,  and  a  drainage-tube  drawn  back.  Even  with  these  three 
openings,  however,  drainage  is  not  sufficiently  thorough,  and  the  joint  must  be 
kept  free  from  any  accumulation  by  some  other  means.  In  the  early  stages  con- 
tinuous irrigation  answers  admirably,  pure  water  being  allowed  to  flow  into  the 
joint  at  one  side,  and  out  again  at  the  other,  carrying  aw^ay  with  it  all  the  secre- 
tion ;  decomposition  cannot  occur,  as  none  of  the  pus  is  left.  But  when  the 
smooth  synovial  surface  is  destroyed,  and  abscesses  are  forming,  it  is  very  difficult 
to  make  the  fluid  (which  will  follow  the  line  of  least  resistance)  circulate  suffi- 
ciently to  wash  out  all  the  recesses.  More  may  be  done  in  this  case  by  the  intro- 
duction of  large  and  firm-walled  drainage-tubes  at  every  available  spot,  syringing 
out  thoroughly  with  a  solution  of  bichloride  of  mercury  (one  part  in  2000),  and 
then  covering  the  whole  with  a  thick  layer  of  absorbent  moss  or  wood-wool.  The 
poison  is  partly  washed  away — partly,  so  far  as  it  lies  upon  the  surface,  destroyed 
by  the  action  of  the  antiseptic;  tension  is  impossible;  decomjjosition  cannot 
occur  without  fluid  ;  absolute  rest  is  ensured  ;  and  the  gentle,  elastic  compression 
effectually  prevents  hyperaemia  and  limits  the  amount  of  exudation. 

In  the  case  of  the  ankle,  elbow,  wrist,  and  the  smaller  joints,  the  same  plan 
may  be  followed,  varied  slightly  in  its  details.  Thus  it  is  more  effectual  to 
immerse  the  part  bodily  in  a  solution  of  bichloride  (one  part  in  10,000)  for  two  or 
three  hours  after  the  incisions  have  been  made ;  and  iodoform  may  be  freely 
dusted  in  as  soon  as  the  fluid  has  drained  away  ;  owing  to  the  smaller  absorbing 
surface,  there  is  less  risk  of  poisoning.  P3ven  when  the  joint  is  loose  and  grating, 
a  very  fair  result  may  frequently  be  obtained  by  means  of  this  kind  ;  the  sujipura- 
tion  ceases,  the  granulations  begin  to  organize,  fibrous  bands  form  around,  or,  if 
the  disease  is  far  advanced,  between  the  bones,  and  rei^air  takes  place  so  far  as 
the  previous  destruction  and  the  health  of  the  patient  will  allow  it. 

Great  care  is  required  throughout  to  keep  the  limb  in  position  and  prevent 
displacement.  Partly  owing  to  the  weight  of  the  lower  segment,  partly  to  the 
action  of  the  flexor  muscles,  one  bone  is  certain  to  be  displaced  from  the  other  if 


PYEMIC  ARTHRITIS.  563 

the  joint  is  left  to  itself  without  jjropcr  splints  ;  and  later,  when  the  attack  has 
snbsided  and  the  cicatricial  tissue  has  begun  to  contract  and  grow  rigid,  there  may 
be  the  mortification  of  finding  that  the  joint  is  fixed  in  such  a  position  that  the 
limb  is  almost  useless,  unless  excision  or  some  other  operation  is  performed. 

Amputation  may  be  required  in  the  later  stages  of  the  disease,  to  prevent  the 
patient  sinking  from  hectic  or  exhaustion,  or  because  the  limb  is  too  much  dis- 
organized to  be  of  any  use.  It  should  never  be  performed  during  the  acute 
inflammatory  period,  except  as  a  last  resource  to  save  the  patient  from  dying  of 
septicaemia,  and  then,  if  the  joint  is  a  large  one,  the  prognosis  is  almost  hopeless. 
In  the  elbow  and  shoulder,  very  good  results  may  be  obtained  by  excision,  better 
than  by  waiting  for  ankylosis  ;  and  the  same  plan  may  be  followed  in  the  case  of 
the  hip,  when  the  upper  extremity  of  the  bone  or  the  acetabulum  is  extensively 
diseased,  with  the  view  of  saving  the  patient  from  the  effects  of  prolonged 
suppuration. 

Arthritis  from  Secondary  Infection. 
{a)  Pycemic  Arthritis. 

Inflammation  of  joints  is  of  common  occurrence  in  pyaemia,  although,  with- 
out any  reason  being  known,  it  varies  very  much  both  in  frequency  and  intensity. 
In  some  cases  a  large  number  of  joints  is  involved  within  the  first  few  days,  and 
if  the  patient  lives  sufficiently  long,  the  destruction  is  rapid  and  complete  ;  in 
others  only  one  is  attacked,  or  one  or  two  at  long  intervals,  and  the  effusion 
remains  in  the  condition  of  a  simple  purulent  synovitis  for  a  considerable  time 
before  it  involves  the  tissues  around. 

It  always  begins  as  synovitis,  and  the  effusion  is  purulent  from  the  first ;  gen- 
erally it  is  of  a  peculiarly  oily  character,  and  greenish  or  yellow  in  color,  from 
the  blood  with  which  it  is  mixed.  If  the  attack  is  an  acute  one,  this  is  succeeded 
by  suppurative  arthritis  :  the  synovial  membrane  becomes  swollen  and  vascular, 
the  surrounding  tissues  sodden  and  oedematous,  and  within  forty-eight  hours  the 
cartilages  undergo  necrosis  and  the  joint  is  hopelessly  disorganized.  If,  on  the 
other  hand,  it  is  chronic,  the  interior  of  the  joint  may  retain  its  smooth  and  even 
character  for  days,  without  any  evidence,  even  of  hyperaemia  ;  and  at  the  end  of 
that  time  the  effusion  may  spontaneously  disappear,  leaving  the  joint  capable  of  a 
certain  range  of  movement,  but  generally  more  or  less  crippled  from  fibrous 
adhesions,  or  weakened  from  the  extreme  distention  of  the  capsule. 

Symptoms. — Pyaemic  synovitis  is  rapid  and  very  insidious  in  its  onset, 
often  beginning  without  any  complaint  of  pain.  One  of  the  joints,  especially 
the  knee,  or  (it  is  said)  the  right  sterno-clavicular,  suddenly  becomes  filled  with 
fluid  ;  the  synovial  cavity  is  distended ;  fluctuation  is  distinct  ;  and  the  limb 
assumes  of  itself  the  characteristic  flexed  position.  The  skin  at  first  is  pale,  or 
marked  by  a  scattered  erythema  ;  very  soon,  if  the  capsule  gives  way,  it  becomes 
soft  and  doughy,  pitting  on  pressure,  and  of  a  peculiarly  dusky  hue  ;  and  then, 
as  a  rule,  the  pain  becomes  very  severe.  In  the  acute  cases  a  rigor  is  not 
uncommon  at  the  commencement ;  the  muscular  wasting  is  peculiarly  rapid  ;  the 
cartilages  may  be  destroyed  within  forty-eight  hours ;  starting-pains  are  very 
severe  ;  and,  owing  to  the  great  amount  of  fluid  and  the  rapidity  of  the  destruc- 
tion, displacement  of  the  ends  of  the  bone  is  very  likely  to  occur,  unless"  special 
precautions  are  taken  to  prevent  it.  In  the  more  chronic  ones  there  is  less  heat 
and  less  tension  ;  the  skin  is  unaffected  ;  often  there  is  no  increase  in  the  consti- 
tutional symptoms  ;  and  not  unfrequently  the  effusion  disappears  from  the  joints 
almost  as  rapidly  as  it  came,  and  perhaps  makes  its  appearance  in  another. 
Pathological  dislocation,  particularly  of  the  hip  joint,  is  not  uncommon  under 
these  conditions,  forming  the  so-called  dislocation  by  distention;  the  head  of  the 
bone  lies  still  within  the  capsule,  which  it  has  stretched  over  itself.  It  differs 
from  dislocation  by  destruction  in  that  the  cartilages  on  the  articular  surfaces  and 
the  bones  beneath  them  are  intact. 

Treatment. — Careful  examination  should  be  made  every  day  in  a  case  of 


564    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

l)ya;mia.  to  make  sure  that  no  joint  is  attacked.  At  the  first  sit^n  the  limb  should 
i)e  placed  on  a  splint  in  a  suitable  position,  well  jjacked  with  cotton-wool  and 
bandaged.  The  effusion  may  subside  within  twenty-four  hours,  leaving  the 
articulation  stiffened  and  weakened,  l)ut  without  any  more  serious  result  ;  but  if 
it  continues,  or  if  the  tension  increases,  or  the  skin  becomes  red  and  dusky,  steps 
should  be  taken  at  once  to  empty  it  thoroughly.  Aspiration  may  be  tried  first ; 
and  occasionally  after  this  absorption  begins  and  there  is  no  re-accumulation  ;  more 
frequently  the  in"Lj)rovement  is  only  temporary,  and  it  becomes  neces.sary  to  lay 
the  joint  open  freely,  wash  it  out  thoroughly  with  some  antiseptic,  if  possible 
before  the  surface  is  destroyed,  and  drain  it.  Even  after  this,  supposing  the  pus 
is  not  allowed  to  collect  anywhere  in  the  interior,  recovery  with  a  certain  but 
limited  amount  of  movement  is  possible  ;  much  more  fre(|uently,  however,  either 
the  cartilages  undergo  necrosis,  granulations  sj^ring  from  the  ends  of  the  bones, 
and  o.sseous  ankylosis  ensues  ;  or  the  patient  sinks  from  some  other,  often  visceral, 
complication,  or  from  exhaustion.  Amputation,  if  the  patient  recovers,  may  be 
required  al  a  later  period,  either  because  the  limb  is  useless,  or  to  save  the  patient 
from  hectic  or  amyloid  disease. 

(J))  Puerperal  Arthritis. 

This  is  a  form  of  pyaemia  consequent  on  septic  absorption  from  the  interior 
of  the  uterus  after  parturition,  due  in  most  cases  to  the  retention  and  decomposi- 
tion of  some  portion  of  the  placenta.  vSo  far  as  the  joint  affection  is  concerned, 
it  does  not  differ  materially  from  other  forms;  occasionally  it  is  very  acute, 
leading  to  rapid  disorganization  and  destruction  ;  more  frec}uently  it  is  sub-acute, 
or  chronic,  affecting  often  the  knee  joint  only  ;  and  then,  supposing  the  uterus  is 
thoroughly  disinfected,  and  no  further  absorption  or  complication  sets  in,  the 
prognosis  is  fairly  good. 

(r)  Exanthcjnatic  Arthritis. 

Inflammation  of  the  joints  is  of  common  occurrence  in  connection  with  the 
exanthemata,  sometimes  appearing  during  the  course  of  the  disease,  more  frequently 
afterward,  as  one  of  the  seciuelre.  In  many  cases  it  is  distinctly  pyoemic,  due  to 
septic  absorption  from  ulcers  upon  the  skin  or  the  mucous  membranes,  and  does 
not  differ  in  any  material  respect  from  ordinary  ]^yajmia  ;  in  some,  however,  it 
never  pa.sses  beyond  the  stage  of  synovitis,  and  the  effusion  is  absorbed  again 
without  leading  to  any  more  serious  result  than  stiffening  and  weakening  of  the 
articulation ;  and  occasionally  it  is  to  all  appearance  identical  with  acute 
rheumatic  fever  or  the  acute  form  of  osteo-arthritis. 

In  typhoid,  the  hip  seems  to  suffer  more  frequently  than  other  joints  ;  and 
even  dislocation  may  take  place  suddenly,  without  warning  of  any  kind.  The 
muscles  are  relaxed  ;  the  capsule  of  the  joint  is  distended  ;  the  fluid  gradually 
insinuates  itself  between  the  articular  surfaces,  and  a  very  slight  degree  of  flexion 
and  abduction  is  sufficient  to  tilt  the  head  of  the  bone  out  of  the  acetabulum. 
Owing  to  the  want  of  power  of  the  muscles,  and  to  the  fact  that  the  capsule  is 
not  torn,  the  symptoms  at  the  first  are  not  so  marked  as  in  traumatic  dislocation  ; 
later,  when  the  patient  recovers,  the  deformity  becomes  characteristic. 

Scarlatinal  arthritis  is  generally  polyarticular,  and  clo.sely  resembles  acute 
rheumatic  fever,  affecting  sometimes  the  i)ericardium  or  the  cardiac  valves,  and 
being  followed  occasionally  by  embolism  and  chorea.  It  usually  occurs  during 
the  decline  of  the  fever  or  even  during  the  period  of  convale.scence.  In  other 
cases  it  is  distinctly  pyaemic,  ending  in  suppuration.  Variola,  measles,  dysentery, 
and  even  mumps,  are  in  rare  cases  followed  by  similar  consequences. 

(^/)    Urethral  Arthritis. 

Closely  akin  to  this  is  a  form  of  arthritis  dependent  upon  some  lesion  of,  or 
injury    to,    the   genito-urinary  mucous    membrane.      It    is    most  common    after 


URETHRAL  ARTHRITIS.  565 

gonorrhcea  (though  the  proportion  of  cases  in  which  it  occurs  is  exceedingly 
small),  whence  its  common  name,  gonorrhcjual  rheumatism  ;  but  it  may  follow  any 
urethral  discharge,  or  even  the  [)assage  of  a  catheter,  and,  though  much  more 
rarely,  a  similar  affection  may  occur  in  women  in  connection  with  menstruation, 
following  parturition  or  dependent  upon  leucorrhoea.  According  to  Clement 
Lucas  it  is  present  sometimes  in  cases  of  ophthalmia  neonatorum. 

The  nature  of  this  affection  is  even  more  doubtful  than  that  of  the  exanthe- 
matic  variety.  In  some  cases  it  appears  to  be  pygemic,  due  to  septic  absorption 
from  ulceration  of  the  urethra,  and  ending  in  acute  sui)puration  and  destruction 
of  the  joint ;  but  in  the  majority  there  is  very  litde  tendency  to  the  formation  of 
pus.  That  it  is  directly  connected  with  the  condition  of  the  urethral  mucous 
membrane  is  shown  by  the  fact  which  has  many  times  been  noted,  that  the  inflam- 
mation is  liable  to  return,  not  only  with  every  succeeding  attack  of  gonorrhoia, 
but  even  when,  without  this,  the  urethral  mucous  membrane  is  subjected  to  any 
unusual  degree  of  irritation  (possibly  in  these  cases  the  gonorrhoea  is  latent).  It 
seems  probable  that  it  is  due  to  the  absorption  of  some  poison  from  the  urethra, 
and  the  gonococcus  has  been  found  on  several  occasions  in  the  fluid  of  the  joint ; 
but  it  is  also  possible  that  it  may  be  the  result  of  reflex  irritation  of  the  nervous 
system.  Ord,  for  example,  has  shown  that  a  form  of  arthritis  not  altogether  unlike 
this  occasionally  attacks  women  who  suffer  from  menstrual  troubles,  the  inflamma- 
tion returning  at  each  period  until  the  climacteric  is  passed  ;  and  although  this, 
too,  may  be  explained  as  the  result  of  absorption,  it  is  peculiarly  significant  that  in 
several  of  the  cases  in  which  there  w^as  ovarian  tenderness  with  neuralgia  on  one 
side  of  the  body,  the  disease  was  limited  to  the  joints  on  that  side. 

The  clinical  symptoms  and  the  pathological  changes  in  some  of  the  more 
severe  cases  resemble  those  of  acute  osteo-arthritis,  especially  that  variety  which 
occasionally  follows  exposure  to  cold  or  over-exertion  shortly  after  parturition  or 
miscarriage  ;  but  the  analogy  must  not  be  pushed  too  far.  Heart  complications 
are  not  unknown  in  connection  with  it,  but  they  are  decidedly  rare. 

Symptoms. — Urethral  arthritis  exists  in  two  well-defined  varieties  :  acute, 
attended  with  fibrinous  efl"usion,  and  involving  all  the  fibrous  tissues  around  and 
belonging  to  the  joint,  so  that,  when  it  subsides,  dense  fibrous  ankylosis  is  left ; 
and  chronic,  in  which  the  symptoms  are  not  so  severe  and  the  effusion  is  serous  in 
character,  but  which  also  leaves  behind  it  considerable  stiffness.  As  in  pyaemia, 
tendons  and  tendon  sheaths  are  not  unfrequently  attacked  as  well,  and  occasionally 
other  fibrous  tissues  not  connected  with  joints,  such  as  the  lumbar  aponeurosis,  the 
annular  ligaments,  and  even  the  sclerotic  coat  of  the  eye. 

The  acute  form  is  not  unlikely  to  be  mistaken  for  acute  suppurative  arthritis, 
though  pus  is  rarely  present,  and  the  constitutional  symptoms  are  much  less  intense. 
There  is  seldom  a  rigor,  although  a  certain  amount  of  shivering  is  not  uncommon  ; 
the  temperature  is  not  very  high  or  the  pulse  rapid,  and  the  appetite  even  may  be 
fairly  good.  At  the  first  onset  several  joints  are  swollen  and  painful,  but  it  soon 
settles  down  to  one  or  two  of  the  larger  ones,  the  knee  and  ankle  in  particular. 
The  skin  is  tightly  stretched,  red  and  shining  ;  often  there  are  red  lines  running  up 
to  the  neighboring  glands,  but  it  does  not  pit  on  pressure  ;  the  outline  of  the  part 
is  even  and  rounded,  the  shape  of  the  synovial  sac  is  lost,  the  tendon -sheaths  and 
the  fibrous  tissues  around  are  filled  with  inflammatory  exudation,  the  temperature 
is  raised,  and  the  pain,  especially  when  the  part  is  touched  or  moved,  is  almost 
intolerable.  The  worst  points  generally  correspond  to  the  attachment  of  the  liga- 
ments. At  the  end  of  a  week  or  ten  days  the  severity  of  the  symptoms  begins  to 
subside,  the  pain  becomes  less  intense  (except  when  an  attempt  is  made  to  move 
the  part),  the  redness  disappears,  and  the  skin  becomes  more  or  less  wrinkled. 
The  effusion  is  absorbed  to  some  extent,  but  a  very  great  deal  of  it  becomes 
organized  inside  the  joint  as  well  as  round  it,  and  the  ankylosis  may  be  so  firm 
as  to  give  rise  to  the  suspicion  of  its  being  osseous.  For  this  reason,  and  because 
the  ligaments  become  soft  and  yielding  almost  at  the  first,  very  great  care  is  necessary 
to  prevent  displacement  and  to  keep  the  joint  fixed  in  the  most  useful  position. 


566    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

In  the  chronic  form  the  exudation  is  less  fibrinous  and  is  restricted  chiefly  to 
the  interior  of  the  joint.  The  shai>e  of  the  swelling  follows  the  outline  of  the 
synovial  sac,  there  is  less  exudation  around,  the  pain  is  not  so  severe,  the  f)atient 
may  even  be  a!>le  to  get  about  to  some  extent,  and,  although  there  is  a  great 
tendency  to  recurrence,  each  time  interfering  with  the  action  of  the  joint  more 
and  more,  there  is  rarely  the  same  rigid  degree  of  ankylosis.  Softening  of  the 
ligaments,  however,  is  very  liable  to  occur,  and  if  the  tarsal  joints  and  the  plantar 
ligaments  are  involved,  a  very  painful  form  of  flat-foot  may  result. 

The  diagnosis  of  the  acute  form  rarely  presents  any  difficulty  ;  in  no  other 
variety  of  inflammation,  scarcely  even  in  acute  rheumatic  fever,  is  the  pain  so  in- 
tense, and  from  this  it  can  be  distinguished  at  once  by  the  difference  in  the  con- 
stitutional symptoms  and  the  extent  to  which  the  efl"usion  involves  the  periarticular 
tissues.  The  chronic  variety,  on  the  other  hand,  closely  resembles  subacute  and 
chronic  svnovitis,  esi:>ecially  when  it  involves  the  knee  joint  only,  and  it  is  not 
improbable,  especially  as  in  many  cases  there  is  only  an  insignificant  gleet,  that  the 
real  cause  is  frequently  overlooked. 

Prognosis  and  Treatment. — Urethral  arthritis  is  naturally  more  common 
in  young  adult  life,  but  it  may  occur  at  any  age,  and  when  it  is  due  to  gonorrhoea, 
it  may  set  in  at  any  period  of  the  disease.  Perfect  recovery  is  rare;  absolutely 
rigid  ankylosis,  with  complete  muscular  atrophy,  is  not  uncommon,  and  the  dis- 
ease may  return  again  and  again  until  the  patient  is  hopelessly  crippled. 

The  condition  of  the  urethra  or  vagina  requires  particular  attention  ;  every 
attempt  must  be  made  to  allay  the  irritation  of  the  mucous  membrane  as  soon  as 
possible.  The  use  of  sedative  and  astringent  injections  and  bougies  does  not  ap- 
pear to  be  attended  with  any  special  degree  of  danger.  Constitutional  treatment, 
so  far  as  the  joint  affection  is  concerned,  is  of  very  little  avail.  Iodide  of  potash, 
salicylate  of  soda,  and  the  other  remedies  usually  of  service  in  rheumatic  fever, 
seem  here  to  fail  completely.  The  chief  reliance  must  be  placed  upon  local 
measures,  and  especially  upon  those  that  check  the  effusion.  The  limb  should  be 
placed  upon  a  splint  and  raised,  the  skin  covered  o\-er  with  extract  of  belladonna 
and  glycerine,  invested  with  layer  after  layer  of  cotton-wool,  and  then  bandaged 
as  tightly  as  possible.  In  acute  cases  it  is  necessary  to  place  the  patient  under  an 
ansesthetic  to  effect  this  thoroughly,  owing  to  the  severity  of  the  pain  ;  and,  as  a 
rule,  it  is  as  well  to  give  a  hypodermic  injection  of  morphia  as  soon  as  consciousness 
returns ;  but  there  is  nothing  so  effectual  for  getting  rid  of  the  exudation,  and,  as 
this  subsides,  the  pain  and  the  inflammation  and  the  tendency  to  displacement  dis- 
appear with  it.  It  may  require  renewing  on  the  second  or  third  day,  and  by  that 
time  the  outline  of  the  bones  becomes  distinct  again. 

After  the  acute  stage  has  subsided  and  the  joint  has  become  cold,  every 
attempt  must  be  made  to  restore  its  mobility.  Bli-sters  and  counter-irritants  may 
be  used  to  procure  resolution  of  the  exudation  that  has  become  already  organized, 
or  the  adhesions  may  be  broken  down  under  an  ansesthetic  ;  passive  motion  and 
massage  must  be  commenced  as  soon  a.s  the  condition  of  the  part  will  allow  it,  a 
certain  amount  of  pressure  being  maintained  in  the  intervals  by  means  of  properly 
contrived  elastic  supports  ;  and  hot-water  douching,  galvanism,  friction,  and  every 
other  measure  that  can  improve  the  circulation  and  nutrition  must  be  employed  to 
prevent  the  wasting  of  the  muscles  and  the  stiffening  of  the  joint.  Improvement 
is  always  gradual,  and  there  is  at  first  a  great  tendency  to  relapse,  so  that  a 
certain  amount  of  caution  is  necessary  ;  but  if  the  treatment  is  kept  up,  a  very 
great  deal  may  be  effected,  so  long,  at  least,  as  the  adhesions  are  extra-articular ; 
if  thev  lie  inside  the  synovial  cavity  they  are  almost  sure  to  form  again,  however 
often  they  may  be  broken  down. 

Gouty  Arthritis. 

Gouty  arthritis  is  occasionally  met  with  in  young  adults,  and  has  even  been 
known  in  children,  but  is  much  more  common  toward  and  after  middle  life.  It 
mav  be  acute  or  chronic ;  the  former,  at  least,  is  mixh  more  frequently  met  with 


G  O  UTY  AR  THRITIS.  5  6  7 

in  men  than  women.  The  tendency  to  it  is  hereditary,  but  the  numljer  and  sever- 
ity of  the  attacks  are  dependent,  to  a  very  large  extent,  u])on  the  mode  of  life, 
and  ])articiilarly  ujion  the  diet  of  the  individual.  The  smaller  joints  are  usually 
affected  first,  especially  the  metatarso-phalangeal  articulation  of  the  great  toe  (jjos- 
sihly  because  it  is  so  liable  to  injury  from  ill-fitting  boots),  but  none  are  exempt, 
and  it  is  not  uncommon  to  find,  post-mortem,  abundant  deposits  of  urate  of 
soda  in  all  the  larger  ones,  even  though  there  is  no  history  of  their  having  been 
inflamed. 

In  acute  cases,  provided  the  joint  has  not  been  attacked  many  times  before, 
the  changes  are  merely  those  of  acute  synovitis  ;  all  the  softer  tissues  are  hyper- 
Kiiiic  and  filled  with  exudation  ;  the  cavity  is  distended  with  a  more  or  less  turbid 
fluid  in  which  there  is  abundance  of  urate  of  soda,  and  all  the  loose  tissue  around 
is  infiltrated  too.  In  chronic  cases  and  after  repeated  attacks,  the  changes  are 
more  permanent.  In  the  slighter  forms  there  is  merely  a  chalky  deposit  of  urate 
of  soda  on  the  surface  and  in  the  substance  of  the  cartilages  ;  but,  after  the  dis- 
ease has  lasted  some  time,  the  bones,  ligaments,  and  all  the  structures  around  are 
loaded  with  masses  of  the  same  material  to  such  an  extent  that  nodes  formed  from 
it  {tophi)  project  beneath  the  skin.  Coincident  with  this,  and  possibly  to  some 
extent  dependent  upon  it,  are  degenerative  changes  similar  to  those  met  with  in 
other  examples  of  chronic  inflammation.  The  matrix,  as  the  cartilage,  breaks  up 
into  fibrils,  the  corpuscles  increase  in  number,  and  where  there  is  any  pressure  or 
friction  it  becomes  so  absorbed  and  worn  that  in  places  it  disappears  altogether  and 
leaves  the  surface  of  the  bone  exposed.  Then  this  undergoes  similar  changes  ;  the 
margins  grow  out  into  irregular  nodules,  the  shape  of  the  articular  surface  is 
entirely  altered,  and  the  distortion  and  impairment  of  mobility  are  as  bad  as  in 
chronic  osteo-arthritis.  Later,  suppuration  may  break  out  in  the  cellular  tissue, 
leaving  sinuses  discharging  a  chalk-like  substance  from  time  to  time  ;  and  anky- 
losis even  has  been  known  to  occur  in  cases  in  which  the  inflammation  was  more 
than  usually  jjersistent. 

The  symptoms  of  an  acute  attack  are  very  characteristic.  It  nearly  always 
begins  in  the  night,  toward  early  morning  ;  sometimes  it  is  preceded  by  general 
malaise  for  several  days  ;  occasionally  it  follows  an  accident.  The  pain  is  most 
intense,  coming  on  in  paroxysms;  it  is  usually  described  as  resembling  the  boring 
of  a  red-hot  iron.  There  is  extreme  tenderness,  even  the  pressure  of  the  sheet 
cannot  be  borne.  The  skin  is  of  a  peculiar  dusky-red  color ;  the  whole  of  the 
joint  is  swollen  and  burning  hot,  and  all  the  surrounding  tissues  are  thickened  and 
oedematous.  At  the  first  onset  there  may  be  a  feeling  of  chilliness,  even  a  slight 
rigor  ;  vtry  often  there  is  a  certain  degree  of  fever,  but  it  is  seldom  severe,  and 
usually  subsides  of  itself  in  the  course  of  the  morning  as  the  pain  grows  less  intense. 
In  really  bad  cases  this  is  repeated  night  after  night  for  upward  of  a  week,  the  days 
being  passed  in  comparative  comfort,  except  for  the  feeling  of  exhaustion  and  dis- 
tress, the  nights  in  agonizing  pain.  As  the  attack  subsides  the  swelling  disappears, 
the  skin  over  the  joint  peels  off,  and  if  it  is  the  first,  or  one  of  the  first,  no  visible 
effect  is  left.  Not  unfrequently  a  second  or  even  a  third  joint  is  attacked  as  the 
first  is  getting  well,  but  the  inflammation  is  seldom  so  severe. 

In  the  chronic  form  the  pain,  heat,  swelling,  and  redness  are  not  so  marked, 
although  they  vary  very  much  from  time  to  time  and  the  patient  is  seldom  free  from 
them  for  long.  The  amount  of  deformity  is  much  more  serious  ;  the  loss  of  mobil- 
ity is  often  very  great,  and  there  is  an  especial  tendency  to  the  permanent  deposit 
of  urate  of  soda  in  the  form  of  chalk-stones.  The  hands  are  nearly  always  affected  ; 
the  metacarpo-phalangeal  joints  are  flexed  and  adducted,  so  that  the  fingers  slant 
down  to  the  ulnar  side  ;  distal  phalangeal  ones  may  be  hyper-extended  ;  the 
knuckles  are  enlarged  and  flattened  ;  movements  are  much  impaired  ;  the  skin 
is  smooth  and  glossy,  and  the  temperature  is  usually  raised.  Other  signs  are  gener- 
ally present  to  assist  the  diagnosis.  Little  cysts  filled  with  fluid  form  on  the 
dorsal  surface  and  sides  of  the  fingers  ;  neuralgia  and  cramp  are  of  common  occur- 
rence ;  a  burning  pain  in  the  heel  is  very  often  experienced,  especially  at  night ; 


56S    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

there  is  a  constant  tendency  to  flatulence  and  dyspepsia  ;  the  urine  is  loaded  with 
uric  acid,  giving  rise  to  attacks  of  urethritis  and  cystitis  ;  the  skin  is  liable  to  eczema 
and  psoriasis,  the  tongue  and  the  pillars  of  the  fauces  become  smooth  and  glossy  ; 
the  teeth  become  loose,  and  without  the  least  sign  of  decay  drop  out  quietly  of 
themselves,  and  the  least  indiscretion  in  diet  causes  the  greatest  distress. 

Treatment. — Rest,  position,  a  moderate  degree  of  warmth,  and,  if  it  can 
be  borne,  the  pressure  of  cotton-wool  lightly  ajjplied,  are  especially  useful  in  mod- 
erating hypera^mia  of  the  acute  form.  The  pain  may  be  relieved  to  some  extent 
by  laying  over  the  part  lint  dipped  in  a  lotion  containing  a  grain  of  atropin  and  eight 
grains  of  morphia  to  the  ounce,  and  covering  it  with  oiled  silk,  or  by  using  a  solu- 
tion of  menthol  in  the  same  way.  Lead  lotion  is  better  avoided,  and  leeching  is 
positively  injurious.  The  bowels  should  be  opened  freely  and  as  soon  as  possible, 
preferably  with  gray  powder  or  calomel  and  colocynth  ;  and  if  the  patient  is  young 
and  healthy  and  the  attack  is  severe,  colchicum  should  be  given  with  small  doses 
of  iodide  of  potash,  quinine,  and  sulphate  of  magnesia.  Whether  it  should  be 
tried  in  other  cases  is  more  doubtful  ;  its  value  is  proportionate  to  the  acuteness 
of  the  attack  ;  in  many  people  it  causes  sickness,  purging,  and  great  depres- 
sion ;  so  that  if  it  has  disagreed  with  the  patient  on  any  previous  occasion,  or  if 
the  pulse  is  weak  and  feeble,  and  particularly  if  the  gout  is  chronic,  never  really 
disappearing,  and  the  present  attack  is  merely  a  sudden  exacerbation,  it  should  be 
given  in  very  moderate  doses,  and  for  a  short  time  only,  leaving  off  at  once  if  any 
signs  of  depression  make  their  appearance.  On  the  other  hand,  there  is  no  doubt 
that  it  agrees,  exceedingly  well  in  many  cases,  and  that  by  taking  it  occasionally 
with  quinine,  and  using  other  precautions,  many  patients  are  able  to  keep  them- 
selves free  from  severe  or  prolonged  attacks  for  years  without  suffering  any  ill 
effects. 

In  the  chronic  form  a  great  deal  may  be  done  by  appropriate  treatment  to 
relieve  the  stiffness  of  the  joints  and  ])revent  wasting  and  deformity.  Warmth  is 
especially  serviceable  ;  sometimes  when  there  is  a  large  deposit  of  urate  of  soda, 
a  lotion  containing  a  drachm  of  bicarbonate  of  soda  or  five  grains  of  lithia  to  the 
ounce  may  be  applied  with  benefit.  Hot  fomentations,  local  vapor-baths,  and 
massage,  gently  applied  so  as  to  encourage  the  flow  of  lymph  as  much  as  pos- 
sible, are  certainly  of  use.  In  some  places,  especially  over  the  knuckles,  the  skin 
has  a  tendency  to  give  way  and  leave  persistent  ulceration,  but  every  care  should 
be  taken  to  keep  it  intact  as  long  as  possible. 

The  general  treatment,  both  in  the  acute  and  chronic  form,  is  even  more 
important.  The  diet  must  be  carefully  restricted  ;  it  must  be  nutritious  and 
palatable,  but  all  highly  seasoned  and  rich  dishes  should  be  avoided,  and  particu- 
larly any  excess  in  meat.  Alcohol  is  better  abandoned  altogether,  certainly  malt 
liquors  must  be  ;  but  a  distinction  must  be  drawn  in  this  respect  between  an  acute 
attack  of  gout  in  a  young  man  and  an  apparently  similar  comjjlaint  in  one  who 
is  old  and  feeble,  unable  to  digest  without  assistance,  and  liable  to  attacks  of 
cardiac  intermittence  from  dyspepsia  ;  champagne,  sherry,  and  new  wines  of  all 
kinds  should,  however,  certainly  be  interdicted  ;  whether  port,  particularly  old 
port,  in  moderation  deserves  the  opprobium  that  has  been  heaped  upon  it  is  more 
than  doubtful ;  certainly  it  is  less  injurious  than  many  kinds  of  so-called  claret. 
Alkalies  may  be  taken  in  moderation,  but  it  must  be  remembered  that  many  of 
them,  particularly  the  potash  salts,  have  a  distinctly  lowering  effect.  The  large 
amount  of  fluid  that  is  usually  taken  with  them  in  the  form  of  mineral  waters  is 
beneficial  to  some  extent,  as  it  prevents  concentration  of  the  urine  and  increases 
the  amount  of  excrementitious  matter  discharged.  Tonics,  iron  and  quinine,  are 
often  necessary,  especially  in  the  chronic  form.  Baths  are  of  the  greatest  value, 
though  much  of  the  reputation  many  foreign  health-resorts  enjoy  is  really  earned 
by  the  dietetic  and  other  restrictions  that  are  willingly  submitted  to  away  from  home. 
The  clothing  should  be  warm,  a  fair  amount  of  regular  exercise  taken,  the  condi- 
tion of  the  bowels  and  the  state  of  the  digestion  carefully  attended  to,  and  over- 
work, mental  as  well  as  bodily,  avoided  as  far  as  may  be. 


RHEUMATIC  ARTHRITIS. 


569 


Rheumatic  Arthritis. 

In  acute  rheumatic  fever,  although  the  effusion  is  chiefly  collected  in  the 
synovial  cavity,  the  surrounding  tissues  are  always  infiltrated  to  some  extent.  As 
a  rule  it  subsides  without  leaving  any  permanent  change  ;  the  exudation,  which  is 
rather  more  fibrinous  than  it  is  in  simple  synovitis,  is  completely  absorbed,  and 
the  joint,  though  it  may  be  stiff  for  a  time,  recovers  its  mobility.  Sometimes, 
however,  the  attack  persists  and  becomes  chronic  in  one  or  more  of  the  joints, 
and  occasionally  it  is  chronic  from  the  first,  the  inflammation  coming  on  slowly 
and  quietly  as  a  result  of  exposure  to  cold  and  wet.  In  these  cases  the  tissues  are 
liable  to  undergo  more  permanent  changes  ;  the  cartilage  is  opaque  and  dull  ;  the 
surface  is  irregular;  it  is  thickened  in  some  places  and  thinned  by  absorjjtion  in 
others;  the  cells  are  increased  in  number  and  their  definite  character  is  lost  ;  the 
matrix  is  fibrillated,  giving  it  a  velvety  appearance,  and  in  a  few  cases  even  the 
bone  underneath  is  unduly  vascular.  In  short,  the  changes  are  practically  identi- 
cal with  those  that  occur  in  osteo-arthritis,  and  the  resemblance  is  heightened  by 
the  fact  that,  in  very  old-standing  cases,  eburnation  may  be  present,  and  out- 
growths, partly  cartilaginous,  partly  bony,  form  round  the  edges. 

In  the  acute  stage  the  symptoms  are  distinctly  characteristic,  and  there  is 
rarely  any  difficulty  in  the  diagnosis.  Later,  however,  when  merely  the  chronic 
degenerative  changes  are  left,  there  is  such  little  difference  between  this  affection 
and  many  of  the  diseases  that  are  classed  together  under  the  general  name  of 
osteo-arthritis  that  a  separate  description  is  unnecessary.  The  chief  feature  is  the 
rigidity  and  thickening  of  the  capsule  and  periarticular  tissue,  consequent  upon 
the  organization  of  the  exudation,  but  this  is  by  no  means  confined  to  this  disease 
and  cannot  be  regarded  as  distinctive. 


i   A^-: 


rrtiv 


^^ 


■-^. 


Fig.  239. — Under  Surface  of  Patella,  showing  Velvety 
Degeneration  of  Cartilage  in  Incipient  Osteo-Arthritis. 


r . 


y 


Fig.  24c. — Knee  joint,  showing  the  Cartilage  Removed 
from  corresponding  surfaces  of  Patella  and  Exter- 
nal Condyle,  with  lipping  of  margins  and  thicken- 
ing  of  synovial  folds. 


Osteo-Arthritis. 

Osteo-arthritis  is  a  general  term  applied  to  a  group  of  diseases  which  resemble 
each  other  more  or  less  in  their  pathological  features,  but  which  differ  widely 
in   their  symptoms,  causes,    and   results.      Many   of  them   have  been  described 

37  ' 


570    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


already  under  different  headings,  and  will  only  be  alluded  to  here.  Rheumatoid 
arthritis,  chronic  rheumatic  arthritis,  arthritis  deformans,  rheumatic  gout,  nodosity 
of  the  joints,  malum  coxai  senile,  and  many  other  names  have  been  given  to  some 
of  its  varied  forms. 

Pathology. —  The  ])athological  appearances  are  distinctive.  The  centre  of 
the  articular  cartilages,  where  they  are  subjected  to  the  greatest  amount  of  friction 
and  are  furthest  away  from  the  arterial  circle  which  supplies  them  with  blood, 
becomes  rough  and  fibrillated,  so  that,  when  placed  under  water,  the  surface  has 
the  appearance  of  very  coarse  velvet  (Fig.  239).  The  upper  layers  are  affected 
first ;  the  primary  capsules  are  enlarged  and  filled  with  secondary  ones  ;  the  matrix 
is  softened  ;  the  capsules  form  communications  with  each  other  ;  the  superficial 
ones  degenerate,  break  down,  and  discharge  their  contents  into  the  joint ;  and  at 
length  only  a  number  of  fibrils  is  left,  projecting  side  by  side  into  the  synovial 
cavity.  Gradually  the  degenerative  process  involves  these  too,  and  the  cartilage 
disappears  layer  by  layer  until  the  bone  is  exposed  (Fig.  240). 

This  soon  becomes  affected  in  the  same  way  ;  the  cancellous  tissue  of  the 
articular  ends  grows  more  open  and  more  vascular ;  absorption  takes  place  where 
it  is  subjected  to  pressure ;  the  shape  is  altogether  changed ;  and  even  when  no 
marginal  outgrowths  are  produced  there  is  a  very  considerable  degree  of  deformity 
(Fig.  242).  The  superficial  layer,  however,  in  many  cases  undergoes  a  totally 
different  transformation  ;  it  becomes  harder  and  denser,  until  it  resembles  ivory 
or  porcelain.  Whether  it  is  a  product  of  the  articular  lamella,  or  is  due  to  calci- 
fication in  the  deeper  layers  of  the  cartilage,  is  uncertain  ;  but  in  any  case  it 
becomes  white,  dense,  and  highly  polished  from  the  friction  it  receives.  In  some 
cases  the  whole  of  the  articular  area  is  eburnated  in  this  way  and  the  surface  is 
perfectly  uniform  and  even  ;  in  others,  especially  in  hinge-joints,  it  is  cut  into 
grooves  from  mutual  friction  (Fig.  241);  and  in  others  again  worm-eaten  patches 
and  bright,  highly-polished  ones  lie  side  by  side. 

Around  the  margin  of  the  joint,  where  there  is  no  pressure,  the  effect  of  the 
continual  irritation  is  altogether  different.  Fibrillation  of  the  matrix  and  pro- 
liferation of  the  cells  take 
place,  it  is  true  ;  but  instead 
of  being  worn  away,  the 
cartilage  increases  im- 
mensely in  thickness  and 
forms  overhanging  lips  and 
nodules  which  project  over 
the  articular  edge.  Later, 
many  of  these  become  ossi- 
fied, and  at  length,  as  the 
bone  is  gradually  worn 
away  in  the  centre,  and 
produced  in  excess  all 
round  the  margin,  the 
shape  of  the  surface  be- 
comes entirely  altered. 
The  head  of  the  femur,  for 
example,  is  worn  away  and 
flattened  from  above ;  the 
neck  is  absorbed ;  while 
beneath,  on  the  under  sur- 
face, there  is  an  immense 
accumulation  of  new- 
formed  tissue.  As  a  rule, 
when  this  occurs,  the  op- 
posing surfaces  are  similarly 
affected.     Sometimes  a   fair  amount  of  movement  is  still  allowed  to   take  place 


\ 


"N.. 


Fig.    241. — Advanced    Osteo-.Arthrilis    of    Elbow,  with    Ehurn.iteil    and 
Grooved  Articular  Surfaces  and  Enormous  Lips  of  Bone  (Osteophytes). 


OSTE  0-AR  THRITIS. 


571 


between  them  ;  but  occasionally  they  lock  into  each  other  and  become  dovetailed 
in  such  a  way  that  practically  the  joint  is  fixed.  True  ankylosis  is  rarely  met 
with  except  in  the  spine.  Osteophytes  of  a  similar  description  are  produced  on 
the  shaft  of  the  bone,  around  the  attachment  of  the  capsule,  and  higher  up  in 
connection  with  the  periosteum,  but  their  size  diminishes  rapidly  as  they  recede 
from  the  joint  (Fig.  241).  Occasionally  plates  and  nodules  of  cartilage  and 
even  of  bone  are  produced  independently  in  the  thickness  of  the  fibrous  tissue. 

It  is  probable  that  the  change  is  first  manifested  by  the  cartilages,  but  the  syn- 
ovial lining  of  the  joint  is  affected  almost  as  soon.  It  becomes  more  vascular  and 
swollen  ;  the  fat-cells  disappear  :  the  exudation  that  is  j^oured  out  from  the  blood- 
vessels undergoes  organization,  and  the  folds  and  fringes,  which  normally  are  but 
slightly  developed  around  the  margins  of  the  joint,  become  enormously  hyper- 
trophied.  The  surface  is  roughened  with  numerous  little  outgrowths,  and  these 
increase  in  number  and  size  until  they  form  pedunculated  masses,  which  branch  in 
all  directions  and  cover  the  whole  of  the  interior.  In  extreme  cases,  there  is  no 
trace  of  the  original  structure  to  be  seen  at  the  base.  Very  often  the  ends  of 
these  grQwths  become  bulbous  or 
club-.shaped,  and  then  cartilage- 
corpuscles  and  sometimes  even 
bony  nuclei  make  their  appear- 
ance in  them.  Occasionally  they 
are  detached  altogether  and  drop 
off  as  foreign  bodies  (Fig.  243). 

In  the  early  stages  the  cap- 
sule and  the  ligaments  rarely  show 
any  extensive  change  ;  they  are 
merely  sw^ollen  and  thickened  in 
proportion  to  the  hypersemia ; 
but  later  they  may  be  profoundly 
affected.  Sometimes  they  are 
rigid,  contracted,  and  incorpo- 
rated with  the  fibrous  tissues 
around,  until  movement  is  almost 
impossible ;  sometimes,  on  the 
other  hand,  they  appear  to  de- 
generate, and  are  softened  and 
loosened  to  such  an  extent  that 
the  ends  of  the  bones  become 
displaced,  and  even  dislocation 
may  occur.  As  in  the  other 
tissues,  the  result  of  the  persistent 
irritation  is  sometimes  thickening 
and  organization,  sometimes  de- 
generation and  absorption,  according  to  the  pressure  and  friction  to  which  they 
are  subjected. 

The  interior  of  the  joint  presents  the  most  varied  appearance.  In  some 
cases,  as  already  mentioned,  it  is  covered  all  over  with  arborescent  growths  ;  in 
others  there  are  only  a  few  large  ones  here  and  there,  and  in  others  again  it  is 
immensely  enlarged  and  perfectly  smooth,  as  if  the  fibrous  tissue  of  the  capsule 
had  become  thinned  and  atrophied.  Not  unfrequently  these  different  conditions 
may  all  be  met  with  together.  In  one  place  there  are  den.se,  rigid  bands,  standing 
out  by  themselves  ;  in  another  the  fibrous  tissue  is  thin  and  yielding,  and  is  forced 
out  among  the  surrounding  structures  so  as  to  form  a  kind  of  hernial  protrusion. 
Large  pouches  developed  in  this  way,  and  communicating  by  a  long  and  narrow 
neck  with  the  synovial  cavity,  are  of  common  occurrence  in  many  forms  of  osteo- 
arthritis. Sometimes  they  are  formed  from  bursae,  which  undergo  similar  changes 
and  gradually  enlarge  until  they  come  into  contact  and  finally  into  communica- 


Fig.  242. — Head  of  Femur,  showing  the  absorption  above 
and  the  accumulation  below,  until  an  appearance  is  pro- 
duced closely  similar  to  that  of  impacted  intra-articular 
fracture  with  bony  union. 


5  72    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

tioii  with  the  joint ;  much  more  often  they  are  genuine  hernial  protrusions,  due  to  the 
thinner  and  weaker  parts  of  the  capsule  being  slowly  forced  out  by  the  intraarticular 
l)ressure.  They  are  most  common  in  the  knee,  projecting  through  the  jjosterior 
ligament,  but  I  have  met  with  them  in  the  ankle,  elbow,  shoulder,  wrist,  and  hip. 
They  may  be  very  small  ;  but  not  unfre(iuently,  especially  when  they  find  a  con- 
venient interspace,  they  form  gigantic  thin-walled  cysts,  which  approach  nearer 
and  nearer  to  the  skin  until  they  either  break  of  themselves  or  are  opened.  In 
the  knee  they  may  stretch  half-way  down  the  leg,  and  point  in  the  calf  below  the 
muscular  mass  of  the  gastrocnemius ;  in  the  shoulder  they  form  a  swelling  under 
the  coracoid  process  and  down  below  the  middle  of  the  arm,  along  the  course  of 
the  biceps  tendon  ;  in  the  ankle  they  may  occ^ir  either  at  the  front  or  the  back  of 
the  joint ;  but,  wherever  it  is,  the  place  of  their  appearance  is  no  proof  of  the 
l)lace  of  their  communication.      I  have  many  times  dissected  them  out,  and  have 


,-<s:^_ 


vxVi?-^" 


Fig.  243. — Papillary  Synovitis,  with  but  little  change 
in  the  cartilage. 


Fig.  244. — Shoulder  Joint  Laid  Open  from  the  Outside. 
The  biceps  tendon  is  absorbed  and  has  formed  a 
new  attachment  for  itself  in  the  groove  ;  the  head 
of  tiie  bone  has  left  the  glenoid  fossa  and  formed 
a  new  highly-polished  articular  facet  for  itself  on 
the  under  surface  of  the  acromion.  The  interior 
of  the  synovial  cavity  is  thrown  into  folds.  The 
affection  is  nearly  always  bilateral,  which  effect- 
ually excludes  the  idea  of  injury. 


often  found  a  long,  devious  channel,  winding  under  the  tendons,  so  that  when 
pressure  was  made  upon  the  sac  the  sides  were  brought  together  and  none  of  the 
fluid  could  be  returned  into  the  joint.  This  fact  should  be  carefully  noted,  as  it 
is  by  no  means  uncommon  to  find  large  cystic  swellings  of  this  sort  without  any 
clear  evidence  of  disease  of  the  joint ;  and  in  such  cases  it  is  exceedingly  difficult 
to  prove  that  no  communication  e.xists. 

The  synovial  fluid  x"^  ecpially  variable;  generally  it  is  fairly  clear  or  slightly 
turbid,  especially  when  the  attack  is  acute  ;  occasionally  it  is  a  light  straw  color 
and  gelatinous  in  character,  not  like  synovia  ;  in  some  cases  the  quantity  is 
enormous  ;  and  in  others  it  may  be  so  scanty  that  much  of  the  pain  and  difficulty 
of  movement  may  be  reasonably  assigned  to  its  deficiency. 

Muscular  wasting,  affecting  the  extensors  first,  but  by  no  means  confined  to 
them,  is  peculiarly  rapid  in  this  form  of  arthritis.     The  tendons  in  the  neighbor- 


OSTEO-ARTHRITIS.  573 

hood  of  the  joint  sometimes  become  ossified  ;  more  fre(iuently  they  are  completely 
torn  away,  esi)ecially  when,  like  the  biceps,  they  traverse  the  synovial  cavity; 
this  one  freipiently  disai)pears  altogether,  the  muscle  forming  a  new  attachment  to 
the  groove  of  the  humerus  as  it  i)asses  out  under  the  capsule,  and  the  head  of 
the  bone  developing  a  new  socket  on  the  under  surface  of  the  acromion  (Fig.  244). 
Even  the  surrounding  connective  tissue  becomes  cedematous,  infiltrated  with 
lymph  in  parts,  and  absorbed  in  others,  so  that  the  outline  of  the  limb  is  altered 
altogether  and  the  skin  is  shiny  and  smooth. 

Suppuration  is  exceedingly  rare.  When  it  does  occur  it  is  nearly  always 
due  to  the  formation  of  hernial  protrusions  which  have  grown  so  large  that  at 
length  they  have  either  been  opened  or  have  l)roken  of  themselves,  and  so  have 
established  a  communication  between  the  joint  and  the  exterior.  Sometimes, 
however,  even  then  the  tissues  are  able  to  resist  successfully.  I  have  known  a 
chronic  sinus  in  the  arm,  in  connection  with  osteo-arthritis  of  the  shoulder,  dis- 
charge for  years  without  destructive  inflammation  ever  setting  in. 

The  true  nature  of  this  affection  is  very  obscure.  It  may  be  acute,  but 
nearly  always  it  is  very  chronic.  In  part  it  appears  to  be  a  result  of  simple 
degeneration,  for  slight  degrees  of  it  are  met  with  in  healthy  old  age  and  in  joints 
that  have  been  kept  at  rest  for  a  long  time  ;  but  as  a  rule  there  is  in  addition 
distinct  evidence  of  some  slight  but  persistent  irritant  impairing  nutrition  still 
further,  and  leading  to  the  production  of  the  irregular  hypertrophied  masses 
round  the  margins.  Occasionally  it  occurs  in  children  (the  acute  form  only)  ; 
but  with  this  exception  it  is  distinctly  a  disease  of  advancing  age.  In  many 
instances  no  definite  cause  can  be  found  ;  in  a  large  proportion  there  is  a  family 
history  of  gout,  rheumatism,  or  both  together.  Constant  exposure  to  cold  and 
wet  undoubtedly  brings  it  on,  and  partly  from  this,  partly  because  there  is  a 
hereditary  tendency  to  it,  it  is  much  more  common  in  certain  countries  than  in 
others.  Sometimes,  especially  in  the  hip,  it  occurs  very  rapidly  after  injury.  Its 
symptoms  in  certain  cases  are  so  severe  and  the  pain  so  great  that  it  may  easily  be 
mistaken  for  acute  rheumatic  fever ;  in  others  it  appears  to  be  a  sequela  of  this 
di.sease.  Finally  a  peculiar  variety  of  it,  associated  with  very  definite  clinical 
symptoms,  occasionally  breaks  out  suddenly  in  the  course  of  certain  affections  of 
the  nervous  system,  chiefly  locomotor  ataxy. 

Acute  Osteo-arthritis. — This  form  is  distinguished  from  the  others  by  the 
severity  of  the  symptoms  and  the  rapidity  of  its  onset.  It  is  more  common  in 
women  than  in  men,  and  may  appear  at  any  age,  even  in  childhood.  The  most 
striking  feature  is  the  extreme  degree  of  rigidity  it  leaves.  The  fibrous  structures 
are  the  i)arts  chiefly  involved  ;  there  is  very  little  eburnation,  and  it  is  not  usual  to 
find  much  marginal  hypertrophy  ;  the  synovial  membrane  is  velvety  and  thickened  ; 
there  is  no  excess  of  fluid  ;  the  cartilage  is  thinned  and  eroded  in  places  ;  but  the 
capsule,  ligaments,  and  all  the  connective  tissue  around  are  welded  together  into 
such  a  rigid  mass  that  there  is  scarcely  any  possibility  of  movement.  In  some 
cases  the  ends  of  the  bones  are  displaced  as  well ;  in  others  the  rigidity  is  made 
worse  by  the  degeneration  of  the  muscles,  which  become  converted  into  fibrous 
cords. 

This  condition,  or  one  resembling  it  so  closely  that  it  cannot  be  distinguished, 
is  met  with  under  very  varied  circumstances.  It  is  most  common  in  young  women, 
and  can  sometimes  be  traced  to  menstrual  irregularity  ;  not  unfrequently,  especially 
when  there  is  a  strong  family  history  of  gout,  it  is  assigned  to  exposure,  to  cold,  or 
wet ;  sometimes  it  does  not  set  in  until  the  climacteric  ;  and  I  have  known  an 
exceedingly  severe  form  occur  from  catching  cold  three  weeks  after  parturition. 
Urethral  arthritis,  scarlatinal  rheumatism,  and  acute  rheumatic  fever  are  all  of  them 
occasionally  followed  by  it,  convalescence  progressing  up  to  a  certain  point,  and 
then  fresh  and  even  more  persistent  trouble  making  its  appearance  ;  and  at  times  it 
breaks  out  suddenly  with  a  severity  only  equaled  by  that  of  rheumatic  fever,  with- 
out it  being  possible  to  assign  a  reason. 

The  larger  joints  are  usually  the  ones  attacked,  often  several  of  them  at  the 


574    DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 

same  time  ;  but  there  is  no  tendency  for  the  inflammation  to  fly  from  one  to  the 
other,  as  it  does  in  rheumatic  fever.  The  affected  parts  are  exceedingly  painful ; 
there  is  a  considerable  degree  of  swelling,  but  round  the  joint  rather  than  in  it ; 
the  skin  is  hot  and  red  ;  there  is  great  tenderness  on  jiressure,  very  often  for  some 
distance  above  and  below  ;  and  the  least  attempt  at  movement  is  checked  by  the 
muscles  at  once.  The  constitutional  disturbance  is  not  very  severe  ;  that  is  to  say, 
the  fever  is  not  very  high  ;  and  the  profuse  sweating  and  the  tendency  to  involve 
serous  structures  which  are  so  characteristic  of  rheumatic  fever  are  rarely  present. 
As  the  inflammation  decreases,  the  swelling  subsides  ;  the  tissues  begin  to  waste  ; 
and  the  ends  of  the  bones  and  the  rigid  tendons  and  muscles  stand  out  promi- 
nently under  the  skin.  Relapses  and  apparent  convalescence,  often  lasting  for 
years  before  it  is  real,  are  the  rule. 

The  treatment  of  this  affection  is  very  unsatisfactory.  If  there  is  a  distinctly 
gouty  history  small  doses  of  colchicum  with  alkalies  and  iodide  of  potash  may  be 
tried  ;  guaiacum  is  entirely  useless  and  salicylate  of  soda  seems  to  have  but  little 
real  effect.  The  anaemia,  which  always  accompanies  it,  and  which  often  persists 
afterward,  should  be  treated  with  iron,  cod-liver  oil,  quinine,  and  arsenic.  During 
the  acute  stage  the  diet  must  be  restricted,  but  afterward  it  should  be  nourishing, 
without  being  too  rich.  Whatever  precautions  are  taken,  more  or  less  rigidity  is 
sure  to  be  left,  so  that  it  is  absolutely  necessary  to  keep  the  limbs  in  proper  posi- 
tion by  means  of  splints  from  the  very  first.  Pressure  and  cold  may  be  used  to 
limit  the  amount  of  exudation,  opium  and  belladonna  to  relieve  the  pain  ;  later, 
when  the  acute  stage  has  subsided,  counter-irritation,  especially  flying  blisters, 
applied  every  two  or  three  days  to  different  parts  of  the  joint,  massage,  warm 
douching,  and  prolonged  hot  baths  are  of  the  greatest  service.  Galvanism  has 
undoubtedly  some  influence  in  maintaining  the  nutrition  of  the  muscles,  and  may 
be  used  for  this.  Afterward,  when  the  inflammation  has  altogether  disappeared, 
and  the  joints  are  left  rigid,  wasted,  and  more  or  less  ankylosed,  an  attempt  may 
be  made  by  means  of  tenotony,  passive  motion,  and  breaking  down  the  adhesions, 
to  restore  them  to  something  like  their  normal  condition. 

Chronic  Osteo-arthritis. — This  exists  in  many  forms,  but  they  are  all  peculiarly 
insidious  in  their  onset,  and  as  a  rule  steadily  progressive,  although  now  and  then 
their  course  is  interrupted  by  a  subacute  attack. 

One  of  the  most  common  begins  in  the  smaller  articulations,  usually  rather 
late  in  adult  life,  and  spreads  gradually  from  them  to  the  larger.  It  is  more  fre- 
quent in  women  than  in  men,  is  always  polyarticular  from  the  first  and  often  sym- 
metrical. The  changes  are  characteristic.  There  is  an  enlargement  and  flatten- 
ing of  the  knuckles  and  the  phalangeal  joints,  and  the  fingers  are  deflected  and 
the  movements  limited.  Then,  by  degrees,  the  larger  articulations  are  attacked 
and  more  or  less  crippled  by  changes  in  the  shape  of  the  ends  of  the  bones.  The 
hand,  for  example,  is  flexed  and  pronated  ;  the  hip  flexed  and  adducted  ;  and  the 
knee  flexed,  and  sometimes  displaced  backward  as  well  by  the  persistent  contrac- 
tion of  the  hamstrings.  Even  the  spine  and  the  lower  jaw  finally  become  involved. 
Lips  are  thrown  out  round  the  margins  of  the  joints ;  the  capsule  becomes 
thickened  and  rigid  in  places,  thin  and  yielding  in  others  ;  and  where  the  synovial 
membrane  is  superficial,  as  round  the  patella,  irregularly  shaped  villous  outgrowths 
can  be  felt  gliding  on  the  cartilaginous  surface  beneath  as  the  joint  is  flexed  and 
extended. 

Minor  degrees  of  this,  sometimes  causing  considerable  deformity,  are  of  com- 
mon occurrence  in  old  people,  often  without  their  being  aware  of  it.  It  seems  to 
be  in  them  rather  a  result  of  degeneration,  and  the  change  is  so  gradual,  and  the 
stiff"ness  comes  on  so  slowly,  that  they  seldom  notice  one  or  the  other.  In  younger 
patients  the  course  is  usually  more  broken  and  varied  from  time  to  time  by  sub- 
acute attacks,  each  of  which  leaves  the  condition  of  the  joint  rather  worse  than  it 
was  before.  The  afi'ected  part  is  hot  and  swollen  ;  the  skin  is  red  and  rather 
glazed  ;  the  muscles  are  in  a  state  of  rigid  contraction  ;  and  movement  is  attended 
with  a  considerable  degree  of  pain.     After  a  while  this  subsides  and  the  eff"usion  is 


OSTE  0-A  R  THRITIS.  5  7  5 

partly  absorbed,  but  the  change  in  the  shape  of  the  articular  surface  persists  ;  the 
synovial  fringes  that  have  grown  during  the  inflammatory  period  and  the  marginal 
lips  and  bosses  do  not  disappear  ;  the  range  of  movement  is  limited  partly  by  the 
tension  of  the  capsule  and  the  fibroid  degeneration  of  the  muscles,  partly  by  the 
premature  locking  of  the  enlarged  ends  ;  and  creaking,  grating,  and  crackling  of 
the  most  varied  description  can  be  felt  and  heard  whenever  there  is  the  least 
change  of  position.  In  the  intervals  between  these  attacks  the  patient  is  fairly 
comfortable  ;  stiffness  in  the  morning  on  getting  up,  or  after  prolonged  rest,  is  very 
common,  but  this  usually  wears  off  in  the  course  of  the  day,  so  far  as  the  distortion 
of  the  articular  surface  will  allow.  Pain  is  rarely  severe,  although  not  unfrequently 
there  is  a  great  deal  of  aching  at  night  or  in  cold  and  damj)  weather.  P.very  in- 
discretion in  diet  is  resented  at  once,  but  there  is  no  fever  or  impairment  of  health 
other  than  that  occasioned  by  the  inability  to  take  active  exercise. 

In  other  cases  this  disease  is  distinguished  by  an  enormous  collection  of  fluid 
in  the  synovial  cavity.  This  variety  is  more  common  in  the  knee  than  elsewhere, 
but  it  may  affect  any  of  the  larger  joints.  In  its  most  chronic  form,  in  which 
there  is  simple  distention  with  stretching  of  the  capsule  and  ligaments,  until  the 
bones  are  forced  far  away  from  each  other  and  fluctuation  can  be  felt  in  every 
direction,  it  is  known  as  hydrops  articuli  or  hydrarthrosis  ;  there  is  no  increased 
vascularity;  the  synovial  membrane  is  slightly  thickened  and  opaque,  often  rather 
yellow  in  color  ;  the  cartilages  are  a  little  fibrillated  and  thinned,  and  the  bones 
are  lipped  to  a  certain  extent,  but  the  cavity  may  be  large  enough  to  hold  two  or 
three  pints  of  fluid.  In  some  cases  the  synovial  membrane  is  perfectly  smooth  ;  in 
most,  however,  it  is  covered  with  rough,  shaggy  growths,  containing  nodules  of 
cartilage,  and  sometimes  the  interior  resembles  a  coarse  sheep-skin  mat  rather  than 
the  lining  membrane  of  a  joint. 

This  form  of  osteo-arthritis  is  frequently  complicated  with  the  presence  of 
synovial  cysts,  which  may  originate  de  novo  as  protrusions  of  the  lining  membrane 
of  the  joint  between  some  of  the  thicker  fasciculi,  or  may  be  developed  from 
bursae.  The  most  common  is  the  one  that  protrudes  between  the  inner  head  of 
the  gastrocnemius  and  the  semi-membranosus,  and  forms  a  swelling  on  the  inner 
side  of  the  popliteal  space,  tense  and  hard  when  the  limb  is  extended,  but  so  soft 
that  it  can  scarcely  be  detected  in  flexion  ;  they  may,  however,  develop  almost 
anywhere,  at  any  weak  part  of  the  capsule,  and  in  any  number. 

In  the  majority  of  cases  osteo-arthritis  is  polyarticular,  but  sometimes,  espe- 
cially where  the  hip  is  concerned,  it  remains  limited,  or  almost  limited,  to  one 
joint  for  years.  The  bone  is  the  part  chiefly  affected,  the  ligaments  waste  and 
the  capsule  becomes  rigid  ;  but  these  changes  are  very  slight  in  comparison.  The 
neck  of  the  femur  may  be  completely  absorbed  ;  the  head  replaced  by  a  growth 
of  bone  springing  from  just  above  the  lesser  trochanter  ;  lips  and  processes  thrown 
out  to  such  an  extent  that  movement  is  almost  impossible,  and  the  acetabulum 
enlarged  to  twice  its  natural  size.  The  limb  is  wasted,  shortened,  and  so  stiff"  that 
it  can  scarcely  be  bent  at  the  hip  at  all ;  it  is  the  seat  of  a  constant  wearing  pain  ; 
when  any  attempt  is  made  to  use  the  joint  the  grating  can  often  be  heard  some 
distance  away,  and  the  lameness  may  be  so  extreme  as  to  disable  the  patient. 
This  particular  variety  is  most  common  in  old  age  (whence  its  name,  malum  coxce 
se7iile),  but  it  sometimes  occurs  in  young  subjects  after  a  severe  fall  ui)on  the 
trochanter  and  then  is  exceedingly  rapid.  I  have  known  it  already  far  advanced 
as  early  as  nineteen  ;  the  limb,  within  a  twelvemonth  of  the  accident,  had  become 
atrophied  until  it  was  scarcely  half  the  circumference  of  its  fellow;  it  was  an  inch 
and  a  half  shorter,  and  was  everted  and  fixed  to  such  an  extent  that  it  could 
scarcely  be  moved  ;  and  all  this  had  taken  place  without  any  definite  family  his- 
tory of  gout  or  rheumatism,  or  any  evidence  of  such  an  affection  in  the  other 
joint.  In  connection  with  this  particular  form,  it  is  of  great  importance  to  note 
that  the  appearance  of  the  limb  is  practically  the  same  as  that  of  impacted  fracture 
through  the  base  of  the  neck  ;  but  if  a  definite  history  of  gradually  increasing 
disability  can  be  obtained,  there  is  very  little  difficulty  in  distinguishing  one  from 


576     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

the  other.  Similar  changes  have  been  known  to  occur  in  the  case  of  the  Inimcriis, 
but  they  are  very  rare  in  comparison. 

Treatment. — At  the  commencement,  before  the  effusion  has  become  organ- 
ized and  definite  changes  have  been  produced  in  the  structure  of  the  joint,  the 
treatment  of  osteo-arthritis  may  be  attended  with  very  satisfactory  results.  After- 
ward little  can  be  done  beyond  trying  to  preserve  the  movement  of  the  part  as  far 
as  possible  and  to  prevent  any  further  outbreak. 

The  clothing,  not  only  for  the  joint  itself,  but  for  the  whole  body,  should  be 
light  but  warm  ;  cold  and  damp  are  particularly  to  be  avoided.  The  diet  should 
be  carefully  regulated  ;  sugar,  excess  of  meat,  and  alcohol  seem  especially  injurious, 
but  in  this  resi)ect  each  individual  must  be  a  rule  for  himself.  The  bowels  should 
be  kept  regular  ;  the  skin  should  be  made  to  act  freely ;  a  Turkish  bath  may  be 
taken  now  and  then  ;  and,  if  possible,  a  residence  in  a  suitable  climate  should  be 
selected. 

Moist  heat,  kept  up  for  a  considerable  length  of  time  each  day,  and  some- 
times several  times  a  day,  is  very  beneficial.  It  may  easily  be  ajjplied  to  most 
joints  by  means  of  a  local  vapor-bath  ;  where  this  is  not  practicable,  flannel,  or 
spongio-piline,  wrung  out  of  water  as  hot  as  can  be  borne  and  covered  with  oiled 
silk,  may  be  tried.  Greater  effect  may  be  produced  by  combining  this  with 
counter-irritants,  especially  turpentine  and  tincture  of  iodine.  Flying  blisters 
frequently  repeated,  hot  douches,  shampooing,  and  massage  applied  every  other 
day,  are  especially  beneficial  toward  the  end  of  the  attacks,  when  a  certain  amount 
of  grating  and  creaking  can  be  felt,  and  the  muscles  are  beginning  to  waste. 
Galvanism  may  be  used  at  the  same  time,  and  passive  motion  should  be  carefully 
and  methodically  carried  out.  Nothing  is  so  likely  to  permanently  stiffen  a  joint 
affected  with  osteo-arthritis  as  prolonged  rest. 

Iron  and  quinine  are  very  often  recpiired,  as  in  many  cases  the  health  fails 
to  a  very  serious  extent ;  sometimes  arsenic  agrees  exceedingly  well,  the  appetite 
returning  and  the  strength  improving  almost  at  once.  Iodide  of  potash  seems 
to  have  little  real  influence,  and  is  sometimes  injurious  from  the  depression  it 
causes.  Alkalies  and  colchicum  may  be  tried,  especially  if  there  is  a  strong 
tendency  to  gout,  but  otherwise  they  are  of  little  avail ;  and  the  same  may  be 
said  of  salicylate  of  soda  ;  sometimes  it  is  beneficial  just  at  first,  but  this  does 
not  last  long. 

Constitutional  treatment,  in  short,  can  do  little  more  than  maintain  the 
general  nutrition  and  check  the  tendency  to  recurrence. 

When  the  effusion  in  the  joint  is  excessive  in  amount,  an  attempt  may  be 
made  to  reduce  it  by  means  of  counter-irritation  and  pressure.  If  this  fails, 
aspiration  may  be  tried,  or  the  injection  of  tincture  of  iodine,  diluted  with  equal 
parts  of  water.  Every  precaution  must  of  course  be  adopted  to  avoid  getting  too 
severe  a  reaction  ;  the  limb  must  be  kei)t  upon  a  sjjlint,  well  raised  and  bandaged, 
and  an  ice-bag  must  be  laid  over  the  joint.  More  frequently  the  reaction  either 
is  not  sufficient  to  excite  absorption,  or  fails  altogether  ;  the  synovial  membrane 
seems  entirely  callous.  In  such  a  case  as  this,  if  the  patient  is  young,  requiring 
to  lead  an  active  life,  and  is  incapacitated  by  the  condition  of  the  joint,  it  may 
be  laid  open  freely  (under  proper  precautions),  some  of  the  redundant  synovial 
tissue  excised,  the  rest  scraped  out  to  a  certain  extent,  and  then,  after  the  hem- 
orrhage has  been  stopped,  it  may  be  drained  thoroughly,  well  packed,  and  placed 
upon  a  splint,  as  after  the  operation  of  arthrectomy.  The  measure  is  a  severe 
one,  and  should  not  be  adopted  imless  the  patient  is  in  a  perfect  state  of  health, 
but  it  has  been  followed  by  conspicuous  success. 

Outlying  cysts  and  diverticula  are  to  be  treated  on  the  same  jn-inciples.  It  is 
impossible  in  the  majority  of  cases  to  prove  that  they  do  not  communicate  with 
the  joint,  and  accordingly  they  must  always  be  given  the  benefit  of  the  doubt. 
Sometimes,  but  very  rarely,  they  are  absorbed  under  the  influence  of  counter- 
irritants,  and  cause  no  further  trouble.  More  frequently  they  can  be  prevented 
from  increasing  by  means  of  suitably  arranged  pressure.      If  this  fails,  aspiration 


CHARCOT'S  DISEASE.  577 

may  be  tried  first  ;  but  if,  in  si)ite  of  this,  the  cyst  ])ersistently  enlarges,  causing 
a  serious  degree  of  weakening,  and  practically  disabling  the  patient,  it  should  be 
excised.  I  have  performed  this  operation  on  several  occasions  at  the  knee, 
removing  the  bursa  which  projects  between  the  inner  head  of  the  gastrocnemius 
and  the  semi-membranosus,  and  stitching  up  the  neck  of  the  communication  with 
catgut,  and  the  result  has  been  very  satisfactory.  Unfortunately,  in  many  of  the 
cases  in  which  cysts  form,  the  disease  is  so  extensive  that  this  is  practically  out  of 
the  question. 

Charcot's  Disease. 

The  most  peculiar  form  of  osteo-arthritis  is  that  which  occurs  in  association 
with  affections  of  the  nervous  system,  especially  locomotor  ataxy,  and  which  is 


\ 


Fig.  245. — Shoulder  Joint  from  a  Case  of  Charcot's  Disease. 

known  as  Charcot's  disease,  from  the  physician  who  first  described  it.  So  far  as 
their  general  features  are  concerned,  the  pathological  changes  are  of  the  same 
description  as  those  that  occur  in  other  forms  of  osteo-arthritis,  but  the  rapidity 
with  which  they  set  in,  the  extent  to  which  the  destruction  is  carried,  and 
generally  the  entire  absence  of  pain,  stamp  it  at  once  as  something  that  must 
stand  by  itself  What  relation  it  bears  to  the  ataxy  is  an  entirely  different 
question.  When  it  occurs  (and  it  is  only  present  in  a  relatively  small  proportion) 
it  usually  breaks  out  at  an  early  period  of  the  disease,  when  the  first  signs  are 
scarcely  marked  ;  and  I  have  known  a  typical  example  of  it  in  a  patient  in  whom 
at  the  time  the  closest  investigation  did  not  reveal  anything  but  local  anaesthesia. 
Similar  affections  have  been  met  with  in  other  diseases  and  injuries  of  the  nervous 


578    DISEASES  AND  INJURES  OF  SPECIAL  STRUCTURES. 


system,  though  much  more  rarely.  It  has  been  recorded  in  hemiplegia,  in  para- 
plegia from  Pott's  disease,  in  poliomyelitis,  and  in  two  instances,  at  least,  in 
wounds  of  the  spinal  cord  ;  and  osseous  ankylosis  of  the  finger  joints  has  been 
known  to  follow  section  of  the  nerves  of  the  forearm.  It  is  not  at  all  improbable 
that  it  is  really  associated  with  the  changes  in  the  peripheral  nerves  rather  than 
with  any  special  disease  of  the  central  nervous  system,  though,  of  course,  if  it 
occurs  in  connection  with  the  one,  it  may  also  occur  in  connection  with  the 
other. 

Whether,  again,  it  should  be  regarded  as  a  special  disease,  cau.sed  by  impair- 
ment of  nerve  influence,  or  merely  as  rheumatic  gout-,  occurring  in  a  joint  which 
has  lost  all  sensation  (so  far  as  pain  is  concerned),  and  which,  therefore,  is  very 
likely  to  be  subjected  to  the  most  injurious  degrees  of  violence,  is  also  an  open 
question.  Pain  is  present,  it  is  true,  and  is  very  acute  in  a  small  minority  of  cases, 
but,  as  a  rule,  it  is  soon  followed  by  anaesthesia ;  and  even  when  it  does  occur  it 
does  not  appear  to  bear  the  same  relation  to  the  severity  of  the  inflammation  that 
might  be  expected,  judging  from  what  is  usual  in  other  forms  of  arthritis  ;  it  seems 

something  altogether  peculiar, 
dependent  upon  the  changes  tak- 
ing place  in  the  nerves  themselves, 
rather  than  upon  the  degree  of 
tension  in  the  ti.ssues  of  the  joint. 
Too  much  reliance,  therefore, 
must  not  be  placed  upon  that. 
It  is  more  important,  however, 
that  this  disease  has  been  known 
to  occur  in  patients  while  they 
were  confined  to  bed.  That 
walking  about  upon  a  knee  joint, 
devoid  of  all  sensation,  in  which 
the  ligaments  have  given  way  and  the  bones  are  so  soft  that  they  would  literally 
be  ground  down  by  the  least  pressure,  would  produce  very  extensive  changes, 
similar  in  many  respects  to  those  actually  met  with,  may  be  admitted  at  once ; 


Fig.  246. — Fingers  of  the  Same  Patient. 


Fig.  247. — Elbow  Joint  from  a  Case  of  Charcot's  Disease. 


but  if  it  can  be  clearly  established  that  the  same  effect  follows  sometimes  when  the 
joint  is  kept  practically  at  rest,  the  theory  that  the  destruction  is  due  to  the  injury, 
as  in  the  case  of  perforating  ulcer,  must  break  down.  The  analogy  between  the 
two  cases  is  very  distant ;  perforating  ulcer  nearly  always  gets  well  of  itself  if  the 
foot  is  placed  under  favorable  conditions ;  this  form  of  joint  disease,  when  it  is 
once    thoroughly  declared,    never  attempts   anything    of  the    kind.     It    proves 


CHARCOT'S  DISEASE. 


579 


nothing,  one  way  or   the  other,  that  the  ordinary  form  of  rheumatic   gout   may 
occur  in  patients  suffering  from  locomotor  ataxy. 

The  knee  joint  is  affected  far  more  frequently  than  any  other.  Suddenly, 
almost  from  one  day  to  another,  \vitl*)ut  warning  of  any  kind,  except,  perhaps,  a 
certain  amount  of  grating,  an  immense  swelling  makes  its  appearance,  partly  due  to 
effusion  in  the  joint,  partly  to  the  oedema  of  the  surrounding  soft  tissues.  Some- 
times with  this  there  is  a  certain  degree  of  fever  and  pain,  and  the  skin  is  hot  and 
red  ;  but  this  soon  subsides  and  suppuration  very  rarely  occurs.  The  outline  of 
the  bones  is  completely  lost,  the  swelling  is  globular,  tense,  and  resistant,  scarcely 
pitting  on  pressure;  movement  is  attended  with  grating,  and  the  joint  is  loose,  so 
that  the  articular  surfaces  can  be  shifted  in  all  directions  ;  but  still  the  patient  can 
use  it  to  a  certain  extent,  especially  as  it  is  usually  entirely  free  from  pain.  Then, 
after  a  time,  the  effusion  becomes  absorbed  or  organized,  the  swelling  diminishes  in 
size,  and  hard  nodules,  due  to  the  formation  of  cartilage  or  dense  fibrous  tissue  in 
the  periarticular  tissue,  make  their  appearance.  The  articular  ends  of  the  bones 
disappear,  the  ligaments  become  softened  or  worn  away ;  crepitus,  as  of  two  frac- 


Fjgs   248  and  249.— Knee  Joint  from  a  Case  of  Locomotor  Ataxy  (Morrant  Baker's  case) 


tured  surfaces,  is  felt  when  the  part  is  manipulated ;  movement  can  take  place  in 
any  direction ;  the  leg,  for  example,  can  be  extended  until  it  lies  flat  upon  the 
anterior  surface  of  the  thigh ;  the  patient  loses  all  power,  and  the  most  extreme 
distortion  follows  (Figs.  245,  246,  and  247). 

The  pathological  changes  are  the  same  as  those  that  take  place  in  osteo- 
arthritis ;  there  is  chronic  inflammation  of  all  the  tissues  of  the  joint  with  atrophy, 
only  this  is  extreme.  The  cartilages  become  fibrillated  and  disappear ;  the  liga- 
ments are  softened  and  worn  away ;  the  bones  are  affected  with  rarefying  osteitis, 
so  that  spontaneous  fracture  is  not  uncommon  ;  the  surrounding  tissues  are  filled 
with  inflammatory  exudation,  which  sometimes  becomes  organized,  so  that  osteo- 
phytes and  free  bodies  and  occasionally  great  lips  of  bone  are  formed ;  but  there 
is  rarely  any  eburnation,  and  the  ends  of  the  bones  seldom  show  that  adaptation 
to  each  other  which  is  so  common  a  feature  of  rheumatoid  arthritis  ;  the  destruc- 
tion is  so  great  that  they  are  reduced  to  two  rounded  sticks,  one  of  which  may  fit  to 
some  extent  in  a  hollow  on  the  top  of  the  other,  but  which  not  uncommonly  simply 
lie  side  by  side,  so  that  the  limb  is  shortened  by  many  inches,  and  the  joint  is 
reduced  to  the  condition  of  a  flail  (Figs.  248  and  249).     In  many  instances  the 


58o     DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 

amount  of  destruction  falls  far  short  of  this;  but  striking  examples  have  been 
recorded  in  which  the  ends  of  the  bones  have  entirely  disappeared,  and  the  joint 
been  completely  disorganized  within  six  weeks. 


Tubercular  Arthritis. 

Tubercular  infection  of  joints  gives  rise  to  a  peculiar  and  characteristic  form 
of  inflammation  which  in  all  respects  closely  resembles  that  caused  by  the  i)resence 
of  tubercle  in  other  i)arts  of  the  body.  It  is  much  more  common  in  children  than 
in  adults,  although  it  may  occur  at  any  time  of  life  (even  old  age  is  not  exempt)  ; 
it  begins  in  the  most  insidious  way  ;  sometimes  there  is  a  distinct  history  of  injury  ; 
more  often  nothing  definite  can  be  ascertained  ;  occasionally  every  such  cause  can 
be  positively  excluded,  as  when,  for  e.xample,  a  child  lying  in  bed  with  caries  of 
the  spine  is  found  to  have  developed  disease  of  the  hip  ;  its  progress  is  exceedingly 
slow,  and  although  it  may  subside  at  any  time,  the  tendency  is  to  run  on  to  the 
formation  of  a  lowly  organized  granulation  tissue,  which,  as  it  spreads  wider  and 
wider,  gradually  undergoes  caseous  degeneration  in  the  centre,  breaks  down,  and 
liquefies,  forming  what  is  known  as  a  caseous  abscess.  It  is  identical  with  what 
was  formerly  described  as  strumous  or  scrofulous  synovitis  and  arthritis.  The 
general  resemblance  between  the  clinical  characters  and  the  main  ])athological 
features  of  strumous  disease  of  joints  and  tubercular  affection  of  other  organs  had 
long  been  organized  ;  it  was  well  known  that  they  often  occurred  together ;  that 
the  same  circumstances  favored  their  development ;  that  caseous  foci  were  present 
in  both,  and  that  in  many  cases  of  primary  joint  disease  the  lungs  and  other 
organs  become  affected  later  with  typical  miliary  tubercle  ;  but  it  was  not  until  the 
discovery  and  cultivation  of  the  tubercle  bacillus  that  the  identity  was  established 
and  confirmed  beyond  all  question  by  experiment. 

The  inflammation  either  begins  in  the  synovial  membrane  or  the  bone ;  car- 
tilage and  ligament  are  probably  never  involved  first.  The  bacillus  enters  the  body 
through  the  mucous  membrane  of  the  alimentary  canal  or  of  the  respiratory  tract, 
rarely  through  a  wound.  Sometimes  apparently  it  is  arrested  in  the  lymphatic 
glands  and  retained  until  its  vitality  is  lost ;  in  other  instances  it  passes  through 
them,  or  infects  them  one  after  the  other  until  it  gains  the  larger  trunks  and  enters 
the  blood  stream;  or  again  it  merely  causes  a  local  inflammation,  which  is 
scarcely  noticed,  so  slight  are  the  symptoms,  until  some  trivial  injury  wakes  it 
into  life,  and  perhaps,  by  rupturing  some  of  the  small  vessels,  forces  the  caseous 
mass  at  once  into  the  general  circulation.  In  any  case  it  is  brought  at  length  to 
the  more  vascular  parts  of  the  joint  where  the  blood-stream  is  quickest  and  where, 
owing  to  the  rapidity  of  their  growth,  the  tissues  are  least  capable  of  resisting  its 
influence. 

Even  then  its  action  may  be  averted.  If  the  dose  is  small  and  if  the  tissues 
are  healthy,  there  is  no  doubt  that  very  often  the  germ  is  either  destroyed  or  en- 
capsuled,  or  got  rid  of  in  some  other  way,  so  that  no  harm  results.  The  younger 
the  patient  and  the  younger  the  tissue  the  greater  the  danger  ;  and  if,  either  from 
some  hereditary  or  acquired  cause,  the  nutrition  of  the  part  is  feeble  ;  or  if,  from 
some  recent  injury,  there  is  an  extravasation  of  blood,  surrounded  by  a  mass  of 
recently  formed  granulation  tissue,  the  bacilli  may  continue  to  grow  and  spread 
wider  and  wider,  until  at  length  a  group  of  miliary  tubercles  is  formed  and  casea- 
tion sets  in.  In  children  the  synovial  membrane  and  the  growing  portions  of  the 
bone  are  involved  with  nearly  equal  frequency,  so  that  in  them  primary  tubercular 
synovitis  is  as  common,  or  nearly  as  common;  as  tubercular  articular  osteitis  ;  in 
adults,  on  the  other  hand,  in  whom  the  bones  have  attained  their  full  development 
and  have  lost  their  embryonic  tissue,  the  former  is  much  more  common  than  the 
latter.  Injury,  although  it  is  not  essential,  must  be  regarded  as  a  very  decided 
predisposing  cause,  not  only  from  the  hyperemia  that  attends  it,  but  because  the 
inflammation  that  follows  lowers  the  vitality  of  the  tissues  and  renders  them  less 


TUBERCULAR   ARTHRITIS. 


581 


capable  of  resistance.  The  same  may  be  said  of  the  exposure  to  cold  and  wet  and 
the  exhaustion  which  are  not  unfreciuently  considered  the  starting-points  of  a  dis- 
tinctly tubercular  affection. 

Pathological  Appearances. — {a)  The  changes  that  take  place  in  the 
synovial  membrane  are  the  same,  whether  the  inflammation  begins  in  it  or  sjjreads 
to  it  from  the  bone,  although  of  course  in  the  latter  they  make  their  appearance 
later  and  are  to  a  certain  extent  ma.sked  by  the  rest. 

The  softer  and  more  vascular  parts,  such,  for  example,  as  the  folds  in  the 
interior  of  the  knee  joint,  are  affected  first.  The  endothelium  is  detached  ;  the 
surface  loses  its  glistening  appearance ;  the  areolar  tissue  becomes  soft  and  melts 
away  ;  lymjjh  pours  through  the  walls  of  the  vessels  and  the  exudation  increases, 
until  at  length  the  membrane  is  replaced  by  a  soft,  gelatinous,  pinkish-gray  mass 
of  granulation  tissue  many  times  as  thick,  and  very  ill  supplied  with  blood.  In 
this,  typical  miliary  tubercles  may  be  found  here  and  there,  and,  though  often 
only  after  a  long  search,  tubercle  bacilli.  As  the  exudation  becomes  more  abun- 
dant it  forces  its  way  between  the  surrounding  structures  in  all  directions.  It 
grows  into  the  cavity  until  this  is  nearly  obliterated  ;  it  spreads  on  the  surface  of 
the  cartilages,  eating  them  out  in  little  circular  pits,  until  the  bone  beneath  is 


Fig.  250. — Femur,  showing  the  Commence- 
ment of  Tubercular  Disease  under  the 
Xeck  of  the  Bone  on  the  Upper  Surface 
of  Diaphysis. 


Fig.  251. — Tihia,  showing  Tubercular  Disease  ad- 
vancing from  the  Epiphysial  Line,  round  the 
Edge  of  the  Epiphysis  to  the  Under  Surface  of 
the  Articular  Cartilage,  which  it  is  gradually 
eroding. 


exposed,  to  be  attacked  in  turn  ;  and  it  works  its  way  through  the  capsule,  and 
spreads  in  the  loose  tissue  around,  until  the  shape  of  the  synovial  sac  is  entirely 
lost,  and  the  swelling  is  perfectly  uniform  in  outline  and  consistence.  In  some 
cases  the  joint  is  surrounded  by  a  mass  of  this  gelatinous  tissue  upward  of  an  inch 
and  a  half  in  thickness. 

As  time  passes  further  changes  make  their  appearance.  The  fluid  in  the 
interior  loses  its  synovial  character,  and  becomes  more  and  more  turbid  until  at 
length  it  resembles  pus.  The  dense  fibrous  tissue  of  the  capsule  and  ligaments 
become  infiltrated  with  the  growth  and  softened,  so  that  the  ends  of  the  bones  are 
no  longer  held  together,  and  displacement  follows.  Caseation  occurs  in  the  thick- 
ness of  the  granulation  tissue  ;  and  finally  liquefaction  takes  place.  Sometimes 
the  abscess,  as  it  is  usually  called,  points  on  the  exterior  and  bursts,  leaving  a 
sinus  guarded  at  the  orifice  by  a  mass  of  pale,  flabby  granulations,  and  leading 
down  into  the  thickness  of  the  gelatinous  tissue  ;  sometimes  it  opens  into  the  joint 
as  well,  and  after  a  while  suppurative  arthritis  is  added  to  the  rest. 

{b)  When  the  inflammation  begins  in  the  bone,  the  pathological  appearances 
are  somewhat  different.  It  may  start  in  the  epiphysis  or  on  the  articular  surface 
of  the  diaphysis  (Fig.  250)  ;  but  invariably  it  attacks  the  part  where  growth  is 


582    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

most  rapid  and  the  blood  supply  most  active.  Sometimes  the  onset  is  very  insidi- 
ous ;  one  or  two  hypercemic  spots  make  their  appearance  by  the  side  of  the 
ei)iphysial  cartilage;  rarefying  osteitis  sets  in  ;  masses  of  fungating  granulations 
are  formed  ;  and  the  bony  trabeculae  are  absorbed,  until,  if  the  disease  spreads 
laterally,  the  epiphysis  may  be  completely  detached  from  the  shaft.  More  often 
it  spreads  toward  the  articular  surface  and  gradually  works  its  way  until  it  reaches 
the  cartilage  that  covers  the  end  of  the  bone  (Fig.  251).  In  a  little  while  this  is 
either  absorbed,  eaten  away  from  beneath,  or  detached  in  great  flakes,  and  then 
the  granulations  sprout  into  the  synovial  cavity,  infecting  the  surface  all  the  more 
rapidly  because  of  the  previous  irritation.  Caseation,  as  a  rule,  follows  sooner  or 
later,  and  then  liquefaction  ;  sometimes,  however,  they  never  occur,  and  large 
portions  of  bone  or  even  whole  bones  are  removed  and  replaced  by  soft  granula- 
tions without  any  abscess  ever  being  formed. 

In  other  cases  the  inflammation  is  more  acute  ;  sequestra  of  a  peculiar  conical 
shape  are  formed,  the  base  covered  with  articular  cartilage,  the  apex  lying  near 
the  centre  of  the  epiphysis;  suppuration  occurs  at  an  early  period,  and  de- 
structive arthritis  is  soon  added  to  the  rest.  Probably,  as  has  been  pointed  out 
by  Koenig,  these  cases  are  due  to  embolism  ;  a  mass  of  tuberculous  material  is 
set  free  from  some  distant  focus  and  carried  into  one  of  the  nutrient  branches 
until  it  becomes  impacted,  and  the  whole  area  supplied  by  that  vessel  perishes 
(Fig.  252). 

In  the  later  stages,  and  after  suppuration  has  set  in,  the  result  is  much  the 
same,  wherever  the  disease  commenced.  The  articular  cartilages  are  removed  by 
sloughing  or  absorption  ;  the  bones  are  exposed,  eroded,  and  carious;  necrosed 
fragments  are  present  here  and  there  in  the  pus  that  surrounds  them  ;  the  liga- 
ments are  destroyed,  so  that  displacement  or  even  dislocation  is  allowed  ;  and  the 
synovial  membrane,  the  capsule,  and  the  periarticular  tissues  are  converted  into  a 
soft,  gelatinous  mass,  in  which  a  few  fibres  can  still  be  found  mixed  with  caseous 
debris  and  pus. 

Repair. — Repair  and  organization  of  the  exudation  are  possible  at  every 
stage,  and  it  rarely  happens,  even  in  the  worst  cases,  that  no  trace  is  to  be  found. 
{a)  Before  caseation  has  taken  place  recovery  may  be  almost  perfect  ;  the  tuber- 
cular masses  are  either  absorbed  or  encapsuled  ;  dense  fibrous  tissue,  or,  if  they  lie 
in  the  bone,  a  ring  of  sclerosis,  forms  around  them,  and,  unless  roused  into  activity 
again  by  injury  or  some  other  accidental  cause,  they  may  remain  quiet  for  the  rest 
of  life,  and  gradually  undergo  degeneration,  leaving  merely  a  little  stiff"ness  or 
weakness  behind. 

If,  however,  the  disease  is  more  widely  spread — if,  for  example,  the  whole  of 
the  synovial  membrane  is  involved,  or  part  of  the  bone  has  undergone  necrosis — 
such  perfect  repair  can  scarcely  take  place,  though,  still,  if  the  health  improves 
and  the  tissues  are  better  nourished  and  better  able  to  resist  infection,  the  joint  may 
be  saved,  stiffened  to  a  certain  extent  from  the  masses  of  fibrous  tissue  formed 
around  and  inside  it.  Such  cases  are  not  uncommon  in  children.  It  is  well  known 
that  the  tuberculous  tendency,  when  the  joints  are  concerned,  is  of  limited  dura- 
tion. As  puberty  is  reached  and  the  ])eriod  of  active  growth  gives  way  to  that  of 
mature  organization,  the  tissues  lose  their  susceptibility  to  its  influence,  and  the  in- 
flammatory process  comes  to  an  end,  repair  setting  in  sometimes  almost  suddenly. 
It  is  by  no  means  unusual  to  meet  with  adults,  apparently  strong  and  healthy 
themselves,  yet  bearing  very  manifest  traces  of  extensive  diseases  from  which  they 
suffered  in  childhood. 

(J))  Even  when  caseation  has  occurred  and  the  centre  of  the  mass  has  under- 
gone liquefaction,  so  that  a  large  cold  abscess  is  formed,  repair  is  still  possible  to 
a  certain  extent.  The  abscess  is  bounded  by  a  layer  of  granulation  tissue  thrown 
out  by  the  surrounding  structures,  which  are  constantly  striving  to  protect  them- 
selves against  the  invading  tubercles.  Sometimes  these  cease  to  extend  ;  the 
liquid  portion  of  the  mass  is  slowly  absorbed  ;  the  residue  becomes  encapsuled, 
perhaps  calcified ;    the   surrounding   granulation   tissue  grows  hard,  dense,   and 


TUBERCULAR  ARTHRITIS.  583 

fibroid,  and  the  disease  comes  to  an  end  ;   but  tlie  chances  of  this  are  much  more 
remote. 

(r)  If  suppurative  arthritis  follows,  recovery  without  ankylosis  is  practically 
out  of  the  question  :  generally  it  is  osseous ;  the  cartilages  are  destroyed,  the 
granulations  that  spring  from  the  ends  of  the  bones  gradually  obliterate  the  syno- 
vial cavity  and  are  converted  into  bone.  Sometimes,  however,  it  remains  fibrous, 
and  a  certain  though  very  limited  degree  of  mobility  is  allowed.  The  rest  of  the 
limb  in  these  cases  usually  suffers  very  severely  ;  the  growth  is  checked,  the  mus- 
cles are  wasted,  the  skin  is  riddled  with  sinuses  or  disfigured  by  deep  sunken 
cicatrices;  residual  abscesses  occur  from  time  to  time  in  the  old  scar  tissue,  and 
often  there  is  great  deformity  from  the  displacement  or  dislocation  of  the  ends  of 
the  bones. 

Hectic  and  amyloid  degeneration  may  occur  as  complications  at  a  later 
period,  brought  on  by  the  profuse  and  continuous  suppuration.  Phthisis  is  rare, 
but  tubercular  meningitis  is  not  at  all  uncommon.  It  may  occur  at  any  period  of 
the  disease,  but  in  the  majority  of  cases  it  breaks  out  either  at  the  commencement 
of  suppuration  or  when  the  caseous  foci  and  the  granulations  surrounding  them  are 
disturbed  by  some  accidental  violence,  such  as  over-exertion,  or  by  operation. 
The  frequency  of  its  occurrence  is  one  of  the  main  arguments  for  the  free  and 
early  removal  of  the  caseous  mass,  even  if  it  involves  excision,  as  it  nearly  always 
does  in  the  case  of  the  hip. 

Symptoms. — Pain,  heat,  and  swelling  are  always  present,  although  they 
vary  very  much  in  degree;  the  skin  is  never  red,  unless  suppuration  has  taken 
place  ;  on  the  contrary,  owing  to  the  way  in  which  it  is  stretched  by  the  exuda- 
tion beneath,  it  is  not  unfrequently  peculiarly  white  and  marked  with  enlarged 
cutaneous  veins — whence  the  name,  tumor  albiis  or  lohite  swelling,  often  given  to 
this  form  of  joint  disease. 

The  pain  is  very  variable.  When  the  inflammation  begins  in  the  bone,  it  is 
often  an  early  symptom,  and,  like  all  bone  pain,  is  worse  at  night  and  after  exer- 
tion. Moreover,  under  these  conditions,  starting-pains  soon  make  their  appear- 
ance, and  the  bone  is  often  exceedingly  tender  on  pressure.  On  the  other  hand, 
in  tubercular  synovitis,  it  may  be  entirely  wanting,  and  the  joint  may  attain  a  very 
considerable  size,  and  even  displacement  occur  from  softening  of  the  ligaments, 
without  there  ever  having  been  more  than  a  transient  complaint. 

Increased  tenipe7-ature  is  much  more  constant,  although  the  rise  may  be  very 
slight,  and,  especially  in  the  case  of  a  deeply-buried  joint,  such  as  the  hip,  very 
difficult  to  estimate.  Great  care  must  be  taken,  in  examining  the  two  limbs,  that 
exactly  the  same  spots  are  compared,  that  they  are  both  exposed  the  same  length 
of  time,  and  that  one  has  not  been  unduly  manipulated. 

The  character  and  situation  of  the  swelling  are  most  important.  In  tubercular 
synovitis  it  causes  a  soft  uniform  enlargement  of  all  the  superficial  parts,  so  that  the 
bony  prominences  are  concealed  and  the  outline  of  the  limb  is  even  and  rounded. 
In  the  knee  there  is  at  first  merely  a  slight  fullness  on  either  side  of  the  ligamentum 
patellae  ;  then  the  hollows  by  the  side  of  the  patella  are  filled  up,  and  the  subcrural 
pouch  is  converted  into  a  soft,  rounded  mass,  which  stands  out  all  the  more  promi- 
nently from  the  wasting  of  the  quadriceps  above.  In  the  elbow,  the  swelling  shows 
itself  first  on  either  side  of  the  triceps  tendon,  and  in  the  ankle  by  the  tendo- 
Achillis.  In  the  hip  it  is  much  more  difficult  to  estimate,  but  by  flexing  and 
abducting  the  thigh  as  far  as  the  patient  will  allow,  the  hollow  of  Scarpa's  triangle 
can  be  mapped  out  distinctly  and  the  least  elevation  detected.  There  is  no 
increase  in  the  amount  of  fluid  ;  the  swelling  is  soft,  elastic,  perfectly  uniform  in 
consistence,  and  conceals  every  bony  projection  and  every  prominent  ligament 
and  tendon. 

In  articular  osetitis,  on  the  other  hand,  at  least  in  the  early  period  before  the 
joint  cavity  is  involved,  the  shape  is  much  less  uniform.  The  swelling  does  not 
follow  the  outline  of  the  synovial  sac  ;  it  spreads  up  over  the  periosteal  surface  of 
one  of  the  bones  ;  and  very  often   it   is   limited  or  nearly  so  to  one  side  of  the 


584    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

joint  :  moreover,  it  is  firmer  and  more  uneven  in  consistence,  and  not  unfrequently 
it  is  exceedingly  tender. 

Impairment  of  the  function  of  the  part  is  one  of  the  earliest  signs.  The  range 
of  movement  is  restricted,  leading  in  the  lower  extremity  to  lameness.  Flexion 
is  more  free  than  extension,  but  neither  is  allowed  to  its  full  limit ;  and  as  the 
disease  advances  this  becomes  much  more  marked.  The  position  of  the  limb  is 
altered  ;  the  hip  is  fle.xed  and  adducted  ;  the  knee  flexed  and  rotated  out ;  the 
ankle  more  or  less  extended  ;  and,  especially  in  the  case  of  the  two  former,  this 
movement  may  in  the  later  stages  of  the  disease  be  carried  to  its  utmost  limits. 
At  first,  the  flexed  position  is  assumed  voluntarily  as  that  which  gives  the  greatest 
ease  ;  but  afterward  it  is  kept  up  and  exaggerated  by  the  spasmodic  contraction  of 
the  flexor  muscles  ;  and  ultimately,  when  the  ligaments  are  softened  and  the 
articular  surfaces  worn  away,  it  ends,  if  left  to  itself,  in  pathological  displacement 
and  dislocation. 

Muscular  icasting  or  loss  of  tone  is  rarely  absent.  Usually  it  affects  the 
extensors  ;  thus  the  flattening  of  the  buttock  is  one  of  the  earliest,  and,  because  it 
cannot  be  imitated,  one  of  the  most  valuable  signs  of  hip-disease ;  but  it  may 
involve  all  the  muscles  of  the  limb,  so  as  to  cause  a  diminution  in  the  general 
circumference.  In  the  shoulder,  the  deltoid  and  supraspinatus  suffer  first;  in  the 
knee,  the  quadriceps ;  and  in  the  ankle  the  muscles  of  the  calf. 

The  constitutional  symptoms  at  the  beginning  are  very  insignificant.  Later, 
when  starting-pains  make  their  appearance,  and  when  the  synovial  swelling 
increases  in  size,  there  is  a  certain  degree  of  fever,  especially  of  an  evening,  the 
appetite  fails,  and  health  and  strength  begin  to  give  way.  If  the  case  is  left  to 
itself,  and  abscesses  are  allowed  to  form  and  break,  the  downward  progress  becomes 
more  and  more  rapid.  The  patient  is  worn  out  by  the  constant  pain  and  want  of 
sleep  ;  there  is  a  continuous  and  often  profuse  discharge  of  pus  from  the  sinuses 
round  the  joint;  the  temperature  is  constantly  above  normal ;  night-sweats  set 
in  in  a  very  large  proportion  of  cases  ;  and  the  patient  sinks  from  hectic  or 
amyloid  disease,  or  else  tubercular  deposits  make  their  appearance  in  other  organs. 

Diagnosis. — The  diagnosis  of  tubercular  arthritis  in  the  early  stages  of  the 
disease  is  often  a  matter  of  the  greatest  difficulty  ;  the  swelling  may  be  of  the  most 
insignificant  character  ;  the  pain  very  doubtful  (and  especially  in  the  case  of 
children  often  stigmatized  as  merely  growing  pains)  ;  and  the  temperature  scarcely 
raised  ;  but  these  symptoms  and  muscular  wasting  very  rarely  fail  altogether.  It 
is  distinguished  from  all  other  forms  of  arthritis  by  the  peculiar  insidiousness  of 
its  attack  and  by  its  obstinate  tendency.  It  is  much  more  common  in  the  young 
than  in  the  old,  but  it  may  appear  at  any  period.  Even  when  it  starts  from  an 
injury,  it  does  not,  like  ordinary  traumatic  synovitis,  follow  at  once  ;  it  may  be 
months  before  anything  definite  is  found  ;  and  it  very  rarely  happens  that  it  is 
possible  to  assign  even  an  approximate  date  for  its  commencement.  If  other 
symptoms  of  scrofula  are  present  (chronic  glandular  enlargement,  for  example, 
obstinate  pulmonary  or  nasal  catarrh,  or  persistent  dermatitis),  the  probability  is 
no  doubt  very  much  greater ;  and  the  same  may  be  said  when  either  there  is  a 
distinct  family  history  of  tuberculosis,  or  when  the  aspect  of  the  patient  is  such 
as  to  suggest  the  peculiar  diathesis  that  predisposes  to  it ;  but,  beyond  all  ques- 
tion, tubercular  arthritis  (though,  of  course,  unless  it  is  due  to  a  wound,  it  must 
be  a  secondary  affection,  spreading  from  some  other  part  of  the  body)  may  occur 
in  the  absence  of  any  other  sign  of  such  a  disease,  and  without  any  manifest  pre- 
disposition to  it. 

Prognosis. — Many  things  have  to  be  taken  into  consideration  in  the  prog- 
nosis of  tubercular  arthritis.  The  family  history,  the  evidence  of  a  special  diathe- 
sis, and  particularly  the  presence  of  any  other  scrofulous  or  tubercular  aff'ection 
are  of  very  great  importance.  The  more  distinct  and  well-defined  the  exciting 
cause  the  better  ;  those  cases  are  peculiarly  ill-omened  in  which,  while  the  patient 
is  confined  to  bed,  one  of  the  joints  becomes  affected  without  it  being  possible 
to  assign  a  reason.     The  period  of  the  disease  again  is  of  very  material  influence  ; 


TUBERCULAR  A^RTHRITIS.  585 

there  is  much  better  hope  before  caseation  has  commenced  ;  if  suppuration  has 
once  occurred,  recovery  is  not  only  more  doubtful,  and  the  tendency  to  secondary 
comi)lications  much  greater,  but  the  prognosis,  so  far  as  the  joint  is  concerned,  is 
very  decidedly  worse  ;  more  or  less  ankylosis  must  follow.  A  great  deal  depends 
upon  the  circumstances  of  the  patient,  whether  he  can  afford  the  necessary  time 
and  the  necessary  treatment.  The  statistics  drawn  from  private  practice,  and  as 
Howard  Marsh  has  shown,  from  institutions  in  which  an  unlimited  stay  is  allowed, 
are  entirely  different  from  those  of  general  hospitals,  into  which  patients  can  only 
be  admitted  for  a  short  time,  until  the  severity  of  the  immediate  symptoms  has 
subsided.  Fortunately,  tuberculosis  of  joints  is  in  most  cases  a  disease  of  early 
life  ;  as  puberty  approaches,  the  tendency  to  chronic  inflammation  and  caseation 
subsides  ;  and  even  though  the  disease  has  reached  an  advanced  stage,  and  sup- 
puration has  occurred,  the  sinuses  not  unfre([uently  dry  up,  the  carious  bone 
becomes  dense  again,  the  granulation  tissue  becomes  organized,  and  the  joint  is 
left  distorted,  misshapen,  seamed  with  cicatrices,  and  permanently  ankylosed,  but 
safe,  under  all  ordinary  conditions,  for  the  rest  of  life. 

Senile   Tuberculosis. 

During  adult  life  tubercular  arthritis  is  not  a  common  affection,  although 
instances  of  it  may  be  met  with  every  now  and  then,  originating  in  the  synovial 
membrane.  After  sixty  years  of  age,  Paget  has  shown  that  the  bones,  joints, 
lymphatic  glands,  testicles,  and  other  structures  which  appear  to  be  the  seat  of 
election  of  scrofula  in  the  young,  again  become  liable  to  a  similar  affection.  In 
all  probability,  this  is  due  to  a  local  tuberculosis,  in  the  same  way  as  the  ordinary 
strumous  or  scrofulous  joint  disease  of  childhood  ;  certainly  it  is  in  a  very 
large  proportion  of  the  cases.  There  is  the  same  insidious  beginning,  the  same 
soft,  pulpy  swelling  around  the  joint,  leading  to  the  smooth,  uniform  enlargement 
characteristic  of  tuberculous  synovitis  ;  there  is  the  same  tendency  to  softening 
of  the  ligaments  and  displacement  of  the  ends  of  the  bones,  but,  as  might  be 
expected  from  the  diminished  reparative  power  of  the  tissues,  the  risk  of  sup- 
puration and  destruction  is  very  much  greater.  Abscesses  form  at  an  early  period, 
and  discharge  themselves  externally,  leaving  sinuses  lined  and  covered  with  pale, 
flabby  granulations  ;  the  cartilages  slough,  the  bones  become  exposed  and  carious, 
so  that  a  probe  introduced  into  one  of  the  sinuses  sinks  deeply  into  their  substance, 
and  in  a  very  short  time,  compared  with  what  takes  place  in  young  subjects,  the 
joint  is  hopelessly  disorganized. 

Treatment. — The  general  treatment  of  tubercular  arthritis,  so  far  as  the 
early  stages  of  the  disease  are  concerned,  is  perfectly  definite.  There  is  no  doubt 
it  is  parasitic  in  its  origin,  and  everything  is  good  that  tends  to  increase  the 
resisting  power  of  the  tissues  or  check  the  growth  of  the  infection.  If  only  suffi- 
cient time  can  be  gained,  and  maturity  reached,  without  the  disease  have  extended 
too  far,  there  is  every  hope  of  recovery. 

Good  food,  fresh  air  (preferably  at  the  seaside),  cod-liver  oil,  iron,  quinine, 
tonics,  etc.,  are  the  chief  hope  for  improving  the  general  nutrition.  Absolute  rest, 
until  every  trace  of  tenderness,  swelling,  and  muscular  rigidity  has  departed,  cold, 
compression,  and,  to  a  much  less  extent,  counter-irritation,  are  the  main  local 
measures.  Heat,  and  everything  that  tends,  like  use  or  exercise,  to  increase  the 
amount  of  blood  flowing  through  the  part,  are  positively  injurious.  The  injections 
of  carbolic  acid  (which  are  strongly  recommended  by  Hueter)  and  other  germicides 
are  of  very  doubtful  value.*  If  a  sufficient  length  of  time  can  be  given  up  to 
this  treatment ;  if  the  rest  is  absolute,  upon  a  splint ;  and  if  the  disease  is  taken 
at  a  sufficiently  early  period,  recovery  without  loss  of  health,  and  without  stiffness 
of  the  joint,  may  be  confidently  looked  forward  to,  in  all  but  a  few  cases  in  which 
the  constitutional  predisposition  is  overpowering. 

*  [Injections  of  iodoform  emulsion  are  sometimes  of  great  service.] 
'38 


586    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

When  the  disease  is  further  advanced,  esijecially  if  the  joint  has  had  a  fair  trial 
and  has  relapsed;  when  the  synovial  meml)rane  is  obviously  becoming  thicker 
and  more  pulpy  in  spite  of  j)rolonged  rest  under  the  best  available  circumstances; 
and  when  the  persistent  local  pain  renders  it  j^ractically  certain  that  there  is  a  focus 
of  disease  in  one  of  the  epiphyses,  the  question  arises  whether  it  is  not  advisable 
to  treat  it  as  a  locally  malignant  disease,  lay  the  joint  freely  open,  and  excise  the 
whole  of  the  affected  part.  This  operation  is  known  as  artlircctoviy,  when  only 
the  diseased  jjortions  are  removed,  and  as  excision  when  the  articular  ends  are 
formally  resected  in  accordance  with  the  rules  laid  down  by  the  anatomy  of  the 
part.  The  former  is  practically  limited  to  the  knee;  in  the  hip  and  ankle  it  is 
almost  impossible  to  expose  the  whole  synovial  surface,  and  in  the  elbow  it  does 
not  give  sufficient  mobility. 

That  arthrectomy,  where  it  is  practicable,  is  to  be  preferred  to  excision,  is 
beyontl  cpiestion.  The  growth  of  the  limb  is  not  affected;  tubercular  foci  may 
be  scraped  out  without  interfering  with  the  ei)iphy.ses ;  the  length  is  not  altered  ; 
if  the  disease  is  removed  before  the  cartilages  are  seriously  affected,  a  great  degree 
of  movement  is  retained  ;  and  it  is  practicable  in  the  youngest  children,  while 
excision  is  not.  It  is  true  that  a  certain  amount  of  support  is  required  afterward 
to  prevent  flexion,  but  this  is  the  case  in  excision  as  well. 

Nor  is  there  any  doubt  that  in  advanced  disease,  where  there  is  extensive 
caries  or  necrosis,  or  where  there  are  many  sinuses  leading  down  through  masses 
of  pulpy  tissue  to  a  disorganized  joint,  excision  of  a  more  or  less  formal  character 
is  advisable,  practically  as  an  alternative  to  amputation. 

The  real  point  at  the  present  day  is  whether  arthrectomy,  or,  failing  that, 
excision,  should  be  performed  at  an  earlier  period  in  tubercular  arthritis,  as  an 
alternative  to  rest,  as  soon  as  caseation  has  made  it  appearance,  long  l)efore  the 
abscesses  have  broken  externally,  and  the  case  has  become  complicated  by  the 
addition  of  suppurative  arthritis. 

On  the  one  hand  there  is  a  caseous  focus  with  the  prospect  of  liquefaction, 
possibly  ending  in  suppurative  arthritis  or  general  tuberculosis,  possibly,  after 
protracted  treatment,  becoming  absorbed  as  the  patient  gets  older,  but  leaving 
the  limb  withered,  shortened,  wasted,  jierhaps  seamed  with  cicatrices,  and  more 
or  less  ankylosed. 

On  the  other  we  have  an  operation  which  may  shorten  and  impair  the  growth 
of  the  limb,  but  which  should,  if  successful,  allow  the  jjatient  to  get  about  within 
two  or  three  weeks,  or  months  at  the  most,  and  render  him  free  for  the  rest  of  life 
from  the  danger  of  tubercular  infection.  At  the  same  time,  it  must  be  admitted 
that  there  is  a  certain,  though  slight  risk  ;  that  there  is  some  danger  of  septic 
arthritis  ;  that  there  is  a  possibility  of  some  of  the  caseous  material  being  driven 
into  the  circulation  during  the  course  of  the  operation,  and  causing  thereby  the 
very  ill  it  is  intended  to  avoid.  That  this  is  not  imaginary  is  proved  by  the  fact 
that  at  least  ten  ])er  cent,  of  the  deaths  after  operations  of  this  kind  are  due  to 
acute  miliary  tuberculosis. 

At  present  the  evidence  is  not  sufficient  to  settle  the  question  one  way  or  the 
other,  l^robably  if  the  treatment  were  begun  sufficiently  early  and  carried  out 
sufficiently  thoroughly,  and  for  a  proper  length  of  time,  it  would  not  arise  at  all. 
Unhappily,  in  the  majority  of  patients  that  apply  to  hospitals  the  disease  is  far 
advanced  and  is  months  old  already. 

Rest  must  certainly  be  tried  thoroughly  first.  Whether,  if  it  has  failed  once, 
it  should  be  repeated,  in  the  hope  that  the  ])atient  will  be  able  to  live  down  the 
bacillus,  must  depend  to  a  great  extent  upon  the  joint  involved  and  the  condition 
of  life.  In  the  case  of  the  hip,  for  example,  unless  two  or  three  years  can  be  given 
up  absolutely,  under  the  best  conditions,  the  treatment  must  not  be  blamed  for  the 
result.  Operation  is  certainly  advisal)le  where,  as  in  the  case  of  the  knee,  and 
sometimes  the  ankle,  it  is  possible  to  clear  out  a  caseous  focus  from  the  interior  of 
the  bone,  without  the  articulation  being  seriously  involved  ;  and  there  is  no  doubt 
that  the  results,  so  far  as  the  healing  of  the  wound  is  concerned  (primary  intention 


TUBERCULAR  ARTHRITIS.  587 

is  absolutely  necessary)  have  improved  immensely  with  greater  ex[)erience  as  to 
what  is  required  ;  but  it  has  not  yet  been  j^roved  that  the  ultimate  results  of  more 
extensive  operations,  especially  in  the  case  of  the  hip  joint,  are  very  far  superior, 
either  as  regartls  mortality  or  utility,  to  those  of  the  expectant  plan,  and  although 
it  is  admitted  that  they  are  necessary  in  many  cases,  they  cannot  be  recommended 
for  general  adoption. 

Cold  abscesses  may  be  drained,  or,  if  they  are  moderate  in  size,  treated  in  the 
way  recommended  by  Barker.  The  fluid  is  drawn  off  with  a  hollow  needle  and 
an  emulsion  of  iodoform  in  glycerine  thrown,  in  ;  this,  by  virtue  of  its  high  specific 
gravity,  sinks  into  the  deepest  part  of  the  tuberculous  cavities  and  even  penetrates 
through  the  thick  deposit  of  caseous  matter.  Others  have  employed  a  five  per 
cent,  solution  of  the  same  drug  in  ether ;  but  care  must  be  taken,  if  the  al).scess  is 
of  any  size,  not  to  cause  iodoform  poisoning. 

Relapses  are  of  common  occurrence,  whether  tubercular  arthritis  is  treated  by 
prolonged  rest  or  by  operation.  Some  of  these  are  true  relapses,  due  to  the  death  or 
removal  of  the  tubercle  bacilli  having  been  incomplete,  and  to  the  conditions  that 
favor  their  growth  having  suddenly  been  revived  :  a  sprain,  for  example,  causing 
slight  hyi^erffimia,  may  wake  into  activity  again  the  germs  that  are  lying  latent  in 
an  old  tubercular  joint ;  but  not  improbably,  especially  when  they  take  the  form 
of  residual  abscesses,  many  of  these  are  merely  due  to  the  imperfectly  nourished 
scar  tissue  breaking  down  from  some  accidental  cause,  and  do  not  imply  a  return 
of  the  specific  disorder. 

Arthrectomy. — By  this  is  understood  the  complete  removal  of  all  the  diseased 
structures  from  a  joint  without  interfering  more  than  is  absolutely  necessary  with 
the  growth  or  the  length  of  the  limb.  Practically  it  is  limited  to  tubercular  dis- 
ease of  the  knee  joint,  though  in  exceptional  cases  it  may  be  performed  upon  the 
hip  or  ankle.  As  the  amount  of  movement  retained  afterward  is  in  most  cases 
limited  (it  depends,  of  course,  upon  the  extent  of  the  disease)  it  cannot  compare 
with  excision  of  the  elbow  or  shoulder. 

The  line  of  incision  varies  with  the  locality  of  the  disease.  Where  there  is  a 
distinct  enlargement  of  one  of  the  condyles,  without  the  synovial  membrane 
being  much  thickened,  a  longitudinal  incision  down  the  side  of  the  joint  is  suffi- 
cient. If,  on  the  other  hand,  the  mischief  is  more  extensive,  the  whole  of  the 
interior  of  the  articulation  must  be  thoroughly  exposed.  This  may  be  done  either 
by  a  transverse  incision  across  the  patella,  the  two  fragments  being  wired  together 
afterward  ;  or  better,  by  the  old  fashioned  semicircular  incision  for  resection, 
carried  a  little  further  down  over  the  tubercle  of  the  tibia.  This  projection  of 
bone  can  be  separated  from  the  shaft  with  a  stout  scalpel  (it  is  part  of  the  epiphy- 
sis and  remains  for  a  long  time  cartilaginous),  or  if  it  is  bony,  with  a  chisel,  and 
then  turned  upward  with  the  patella  on  to  the  femur.  A  single  median  longitudi- 
nal incision  dividing  the  patella  vertically,  does  not  allow  the  sides  of  the  joint  to 
be  examined  ;  but,  if  the  disease  is  not  far  advanced,  it  is  probable  that  sufficient 
space  may  be  obtained  by  two,  one  on  each  side,  without  a  transverse  one,  and 
without  dividing  the  ligamentum  patellae,  as  recently  practiced  by  Sendler. 

As  it  is  very  important  to  prevent  oozing  after  the  operation,  Esmarch's  ban- 
dage is  not  used,  but  the  limb  is  raised  vertically  for  a  few  minutes,  after  Lister's 
plan,  and  the  circulation  controlled  by  "an  elastic  tourniquet.  Experiment  has 
shown  that  the  presence  of  coagula  under  these  conditions  is  distinctly  favorable  to 
the  development  of  miliary  tubercle,  and  interferes  with  primary  union.  So  far  as 
possible  the  diseased  structures  are  dissected  out,  cutting  through  the  healthy  tissue 
outside  them  ;  crushing  or  bruising  them  in  the  process  is  liable  to  force  some  of 
the  caseous  debris  into  the  open  vessels,  especially  where  the  bone  is  exposed.  The 
thickened  synovial  membrane,  for  example,  after  the  flap  is  reflected,  is  carefully 
dissected  off  the  under  surface,  commencing  at  the  toj),  and  passing  completely 
round  the  reflection  under  the  crureus  on  to  the  surface  of  the  femur.  The  sides  are 
treated  in  the  same  way,  the  crucial  and  posterior  ligaments  being  thoroughly 
cleaned,  but,  if  possible,  preserved  intact.  Sometimes  a  sequestrum  is  found  and 
can  be  removed  ;  but,  as  a  rule,  if  the  bones  are  involved,  a  gouge  must  be  used  to 


588    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

scoop  out  the  soft  caseous  material  and  the  iiiiiltrated  cancellous  tissue  around. 
For  this  Barker  recommends  a  hollow  instrument  connected  by  a  rubber  tube  with 
a  receiver,  as  by  it  the  debrie  can  be  washed  away  from  the  surface  of  the  wound 
at  once. 

After  the  whole  interior  has  been  thoroughly  examined,  the  bleeding  points 
are  secured  (they  can  easily  be  seen  by  relaxing  the  tourni(iuct  for  a  moment),  all 
oozing  stoi)ped  l)y  flushing  the  wound  with  a  solution  of  iodine  or  corrosive  subli- 
mate in  water  as  hot  as  can  be  borne,  and  the  stitches  inserted,  a  sponge  being  left 
in  until  they  are  all  in  position.  The  surface  may  be  dusted  with  iodoform,  if  it  is 
not  too  extensive,  or  brushed  over  with  a  solution  of  the  same  drug  in  ether.  It  is 
believed,  though,  perhaps,  on  insufficient  evidence,  that  it  has  some  special  action 
on  the  tubercle  bacillus.  Kocher  recommends,  in  the  case  of  the  shoulder,  that 
the  cavity  should  be  filled  with  iodoform  gauze,  and  left  for  three  days,  before  the 
sutures  are  fastened  up,  so  great  is  the  importance  of  preventing  extravasation  and 
keejMng  the  wound  dry. 

Drainage  tubes  are  advisable,  although  their  presence  necessitates  the  dressing 
being  changed  sooner  than  may  otherwise  be  necessary.  The  joint  is  carefully 
packed  with  an  absorbent  dry  dressing,  the  edges  of  the  wound  not  being  covered 
by  the  first  layer,  so  that  if  any  fluid  is  secreted,  it  is  forced  out  through  the  lips 
at  once ;  and  then  fixed  on  a  splint  or  with  a  plaster  bandage,  and  kept  absolutely 
at  rest.  For  the  first  twenty-four  hours  it  should  be  raised  to  the  vertical  position, 
if  possible,  in  order  to  check  the  flow  of  blood  and  to  diminish  the  chance  of 
oozing.  Afterward  the  dressings  are  changed  when  required,  but,  as  there  should 
be  no  discharge,  they  may  often  be  left  for  a  fortnight. 

A  splint  must  be  worn  afterward  until  the  growth  of  the  limb  is  complete. 


DISEASES    OF   SPECIAL    JOINTS. 


Disease  of  the  Hip. 

Tubercular  arthritis  of  the  hip  is  much  more  common  in  children  than  adults, 
a  very  large  proj)ortion  of  the  cases  occurring  between  five  and  ten  years  of  age. 
Usually  there  is  a  history  of  injury,  or  of  exposure  to  cold  and  wet,  or  of  some 
specific  fevers,  generally  measles  ;  but  in  the  vast  majority  it  is  impossible  to  trace 
a  direct  connection. 

Pathology. — Disease  of  the  hip,  in  children,  almost  always  begins  in  the 
bone;  sometimes,  especially  in  older  jjatients  in  whom  growth  has  nearly  ceased, 
it  commences  in  the  synovial  membrane,  but  probably  never  in  the  ligaments  or 
cartilages.  The  appearance  of  ulceration,  so  often  de- 
scribed on  the  latter,  is  really  due  to  absorption  by  the 
granulations  springing  from  the  bone  ;  and  the  hyperaemia 
and  softening  of  the  round  ligament,  which  are  still  more 
common,  are  accounted  for,  partly  by  the  development 
of  the  collateral  circulation,  partly  by  the  early  extension 
of  the  inflammation.  The  head  and  neck  of  the  femur 
lie  entirely  within  the  capsule,  so  that  inflammation  in- 
volving the  growing  part  of  the  bone  must  implicate  the 
synovial  cavity  within  a  very  short  time. 

In  a  small  proportion  of  cases  the  disease  starts  in 
the  acetabulum,  prol)ably  in  connection  with  the  Y-shaped 
epiphysis;  but,  according  to  Wright,  in  90  per  cent,  of 
those  subjected  to  excision,  the  head  or  neck  of  the 
femur  was  the  part  first  involved.  In  upward  of  half, 
however,  the  acetabulum  was  superficially  diseased. 

The  favorite  locality  is  on  the  under  surface  of  the 
neck  of  the  bone,  on  the  articular  side  of  the  diaphysis ;  i)robably  this  is  the  part 
upon  which  strains  fall  most  frequently,  or  it  may  be  due  to  the  fact  that  most  of  the 


Fig.  252. — Sequestrum  on  Under 
Surface  of  Neck  of  Femur. 


DISEASE  OF  THE   HIP  JOINT. 


5S9 


Pig.  253. — Separation  of  Head  of  Femur  as  a 
Sequestrum. 


vessels  enter  here.  In  some  cases,  especially  the  more  acute  ones,  there  is  a  seques- 
trum such  as  might  be  caused  by  tubercular  embolism  (Fig.  252)  ;  in  others,  there 
is  a  layer  of  characteristic  gray  granulations  spreading  quietly  along  the  growing 
bone,  and  undermining  the  epiphysis.  Sometimes  the  osseous  nucleus  of  the  head 
is  almost  unaffected  ;  sometimes  granulations  spring  up  in  it  as  well,  and  gradu- 
ally eat  away  the  articular  cartilage  from  beneath.  The  trochanteric  epiphysis,  on 
the  other  hand,  is  very  rarely  involved. 

The  earlier  changes  are  seldom  seen.  If  the  treatment  is  commenced  at 
once  and  carried  out  thoroughly,  the  soft  granulations  become  organized,  the 
tubercular  deposit  is  absorbed  or  encapsuled,  and  complete  restoration  takes  place. 

As  the  disease  advances  the  synovial  membrane  becomes  thickened,  softened, 
and  vascular,  although  it  very  rarely  shows  such 
complete  pulpy  degeneration  as  it  does  in  the 
knee.  The  fluid  in  the  joint  is  turbid,  with 
flakes  of  lymph  and  fragments  of  cartilage. 
The  firm,  fibrous  parts  of  the  capsule  are 
affected  least  ;  the  soft  and  delicate  structures 
attached  to  the  posterior  intertrochanteric  line, 
and  the  loose  mass  that  fills  up  the  cotyloid 
notch,  suffer  the  most.  In  some  cases  the  head 
of  the  bone  is  completely  separated,  almost 
unchanged,  and  lies  as  a  loose  sequestrum 
in  the  interior  (Fig.  253)  ;  in  others,  when 
the  joint  is  opened  the  articular  cartilage  is 
hanging  in  shreds,  loosened  and  detached  by 
the  granulations  springing  from  the  bone  be- 
neath ;  the  osseous  centre  is  eroded,  carious, 
and  greatly  reduced  in  size  (Fig.  254)  ;  and 
no  trace  of  ligamentum  teres  can  be  found. 

The  acetabulum  fares  no  better,  even  when  the  disease  is  femoral  from  the 
first :  the  disease  spreads  along  the  synovial  folds  ;  the  cartilage  is  partly  eaten 
away  by  the  granulations  springing  from  the  femur,  partly  detached  by  those 
growing  from  the  base  beneath  :  the  bone  is  exposed  and  carious  ;  sometimes 
there  are  sequestra  here  and  there  ;  and  not  unfrequently,  especially  in  old, 
neglected  cases,  the  cavity  is  enlarged  upward  and 
backward,  from  the  pressure  of  the  head  of  the  bone 
in  extreme  flexion. 

The  neck  of  the  femur  may  be  shortened  by 
caries  eating  into  it  from  the  epiphysial  surface,  but 
it  usually  acts  as  a  barrier.  Sometimes,  however, 
the  disease  spreads  down  it,  gradually  absorbing 
the  cancellous  tissue  in  the  interior,  and  replacing  it 
by  a  mass  of  caseating  granulations,  until  at  length 
the  medullary  canal  of  the  bone  is  reached,  and 
chronic  tubercular  osteomyelitis  is  added  to  the  rest. 

Later,  as  the  caseous  deposit  begins  to  liquefy 
and  break  down,  the  inflammation  spreads  from  the 
capsule  to  the  periosteum  covering  the  upper  part 
of  the  shaft.  Caseous  abscesses  make  their  appear- 
ance around  the  joint ;  sometimes  they  occur  inde- 
pendently, originating  in  the  soft  and  gelatinous 
periarticular  tissue:  sometimes  they  are  due  to  the  F'g.  254^Advanced  Tubercular  Disease 

.     -.  ..,  ,.".  oi   xiead  ot    remur,  snowing  the  ex- 

innammation  in  the  bone  working  its  way  to  the  tent  and  directions  of  the  destruc- 
surface  outside  the  attachment  of  the  capsule.     Then        "°"' 

the  skin  and  the  tissues  around  become  undermined  ;  the  caseous  deposits  extend 
until  they  either  break  of  themselves  or  are  opened  ;  and  true  suppurative  arthritis 
sets  in  as  well. 


590    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

When  this  occurs,  the  process  of  destruction  proceeds  at  a  much  more  rapid 
rate  ;  ])ortions  of  the  acetabuhim  underj^o  necrosis  ;  the  floor  is  ])erforated  ;  large 
intrapelvic  abscesses  form  ;  the  rim  is  destroyed  ;  the  cup-shaped  cavity  is  immensely 
enlarged,  especially  upward  and  backward,  the  direction  in  which  it  is  subjected 
to  the  pressure  of  the  femur  ;  the  cartilages  disai)pear  ;  the  ligaments  are  softened 
and  infiltrated  to  such  an  extent  with  the  inflammatory  exudation  that  they  no 
longer  hold  the  bones  together ;  the  head  of  the  femur,  if  it  is  not  already  de- 
stroyed, is  detached  ;  the  neck  is  eaten  away  ;  and  the  upper  end  of  the  shaft, 
with  the  great  trochanter,  eroded,  softened,  and  carious,  is  forced  by  the  persistent 
muscular  contraction  through  the  upper  and  back  segment  of  the  joint,  plowing 
its  way  out  partly  through  the  rim  of  the  acetabulum,  jjartly  through  the  capsule, 
until  what  remains  of  it  rests  upon  the  dorsum  of  the  ilium,  causing  dislocation  by 
destruction. 

It  must  not  be  forgotten  that,  provided  the  patient  escape  the  dangers  of 
complications  and  intercurrent  disorders,  the  process  of  destruction  may  come  to 
an  end  at  any  time,  and  repair  gain  the  upper  hand.  Tubercular  arthritis  is  dis- 
tinctly of  limited  duration  :  after  a  time  it  ceases  to  spread  ;  the  granulations 
become  partly  absorbed,  partly  organized;  the  caseous  masses  are  encajjsuled  or 
discharged  externally,  often  leaving  sinuses  behind  ;  and  ankylosis,  fibrous  or 
osseous,  with  more  or  less  distortion  and  deformity,  results. 

Symptoms. — LimJ>ing,  caused  by  the  rigidity  of  the  muscles  and  the 
endeavor  to  save  the  joint  as  far  as  possible,  is  the  first  symptom  noticed  in  most 
instances.  The  hip  is  never  quite  straightened  in  walking;  the  amount  of  flexion 
allowed  is  limited,  so  that  the  step  is  short,  and  very  often  at  the  same  time  the 
toes  are  turned  out  more  than  those  of  the  other  foot.  At  first  it  is  only  present, 
or  at  least  noticeable,  when  the  child  is  tired,  and  it  may  be  painless  ;  later,  it 
becomes  continuous  and  is  attended  with  such  suffering  that  the  child  can  hardly 
rest  any  weight  upon  the  affected  leg. 

Fain  in  the  earlier  stages  is  very  variable.  In  chronic  cases  in  particular  it 
is  exceedingly  slight,  and  is  often  regarded  as  merely  growing-pain,  coming  on 
after  any  unusual  exertion.  In  acute  ones,  on  the  other  hand,  and  when  the  bone  is 
exposed,  it  may  be  of  the  most  intense  description,  the  patient  sitting  grasping 
the  limb  with  both  hands  to  prevent  the  least  movement,  and  crying  out  with 
apprehension  if  any  one  approaches  the  bed.  Starting  pains  at  night  are  often 
very  severe  when  the  cartilage  is  partly  separated  from  the  bone  on  which  it  rests. 

T/ie  locality  of  the  pain  is  very  remarkable.  In  a  large  proportion  of  cases  it 
is  referred  to  the  skin  on  the  inner  side  of  the  knee  joint,  sometimes  to  the  front, 
and  it  is  not  an  unusual  thing  to  find  that  the  knee  has  been  examined  time  after 
time,  painted  with  iodine,  blistered,  and  even  placed  on  a  splint,  while  the  real 
seat  of  the  disease  has  been  entirely  overlooked.  In  other  instances  it  is  referred 
to  the  hip  itself  generally,  or  to  the  front  of  the  thigh,  or  even  to  the  leg  ;  some- 
times, particularly  in  the  acetabular  form,  it  is  chiefly  seated  in  the  iliac  fossa 
above  Poupart's  ligament,  or  over  the  tendon  of  the  adductor  longus.  The 
explanation  is  to  be  found  in  the  fact  that  pain,  caused  by  irritation  of  a  deeply 
seated  branch  of  a  nerve,  is  usually  referred  to  one  of  the  cutaneous  divisions, 
just  as  cancer  of  the  larynx  causes  pain  in  the  ear,  and  a  stone  at  the  neck  of 
the  bladder  gives  rise  to  an  intense  cutting  sensation  at  the  end  of  the  prepuce. 
The  cutaneous  division  of  the  obturator  is  the  one  most  often  selected,  because 
of  the  peculiar  distribution  of  that  nerve  to  the  inside  of  the  hip  joint  and  to 
the  ligamentuni  teres  ;  but  it  may  be  referred  to  the  middle  or  internal  cutaneous 
of  the  anterior  crural,  and  even  to  the  long  saphenous  and  the  branches  of  the 
sciatic  plexus.  There  does  not  appear  to  be  any  constant  relation  between  the  seat 
of  pain  and  the  extent  or  position  of  the  disease,  though  when  it  is  severe,  espec- 
ially at  night,  it  may  be  taken  as  indicating  that  the  bone  is  involved. 

Tenderness  on  pressure  is  usually  distinct  at  an  early  period,  especially  in 
Scarpa's  triangle,  just  below  Poupart's  ligament,  and  behind  the  great  trochanter — 
in  other  words,  where  the  joint  is  most  superficial — and  in  association  with  other 


DISEASE  OF  THE  HIP  JOINT. 


591 


symptoms  is  of  very  great  value  in  distinguishing  hysterical  affections  of  the  hip 
from  real.  In  the  former,  it  is  usually  cutaneous,  and  often,  if  the  attention  is 
diverted,  deep,  steady  pressure  is  well  borne  ;  in  the  latter  this  is  reversed,  and 
superficial  tenderness  is  rarely  present  unless  the  inflammation  is  acute  or  there  is 
commencing  suppuration.  Sudden  jarring  of  the  heel  or  knee,  so  as  to  bring  the 
two  articular  surfaces  smartly  into  contact  with  each  other,  causes  pain  at  an  early 
period  of  the  disease,  and  should  always  be  avoided. 

The  attitude  of  the  limb  is  of  very  great  importance.  Throughout  the  dis- 
ease, from  first  to  last,  the  hii),  if  left  to  itself,  is  always  flexed.  The  two  legs 
may  be  i)laced  apparently  in  fiill  extension  side  by  side  upon  a  couch,  with  the 
knees  perfectly  straight,  but  this  is  due  to  the  curving  forward  of  the  luml)ar  verte- 
bra (lordosis)  in  compensation,  and  if  the  hand  is  placed  beneath  the  loins,  the 


Fig.  255. 


alteration  can  be  felt  at  once — the  back  does  not  rest  upon  the  couch.  If  now, 
with  the  hand  still  there,  the  affected  limb  is  gently  raised,  the  vertebral  column 
gradually  becomes  straight,  and  the  hollow  disappears.  The  number  of  degrees 
through  which  the  limb  must  be  moved,  in  order  to  effect  this,  may  be  taken  as 
the  measurement  of  the  flexion  of  the  joint. 

For  purposes  of  diagnosis,  Thomas  places  the  patient  upon  a  table  or  hard 
couch,  flexes  the  sound  limb  until  the  thigh  touches  the  abdomen  and  the  leg  the 
thigh,  and  then  directs  the  patient  to  straighten  out  as  far  as  possible  the  hip  that 
is  diseased.  As  the  back  is  straight  and  the  pelvis  fixed,  measurement  of  the  angle 
is  easy  (Fig.  255). 

It  rarely  happens,  however,  that  the  flexion  is  perfectly  straight.  In  the  early 
stages  there  may  be  a  considerable  degree  of  abduction  and  apparent  lengthening. 
In  the  later,  there  is  always  adduction  and  apparent  shortening  ;   that  is  to  say, 


592    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

when  the  patient  is  lying  down  with  the  limbs  parallel  and  extended  (the  lordosis 
being  neglected  for  the  time),  the  foot  of  the  affected  side  ai>pears  either  much 
lower  or  much  higher  than  that  of  the  sound  one.  That  the  alteration  in  length  is 
apparent  only  at  this  stage  can  be  shown  at  once  by  examining  the  jjelvis  ;  the  iliac 
spines  are  raised  or  lowered  exactly  in  ])roportion  to  the  feet,  but  it  is  necessary 
to  make  certain  of  this,  as  later,  the  shortening  often  becomes  real. 

The  association  of  al)duction  witii  api)arent  lengthening,  and  adduction  with 
apparent  shortening,  is  sufficiently  obvious.  The  angle  of  lateral  deviation  is  fixed 
absolutely  beyond  the  jjaticnt's  control,  so  that  the  legs,  when  they  are  ])laced  side 
by  side,  cannot  be  at  right  angles  with  the  pelvis.  If  now  the  lower  limbs  are 
brought  into  the  same  straight  line  with  the  trunk,  it  follows  as  a  natural  conse- 
quence that  the  pelvis  must  be  tilted.  Just  as  in  flexion  there  is  a  corresponding 
degree  of  lordosis,  so  in  this  there  must  be  a  compensatory  lateral  deviation  of  the 


v^=^?^ 


/ 


iM'fl 


Fig.  256. — Attitude  in  Early  Stage 
of  Hip-disease;  the  hip  and 
knee  flexed,  and  the  heel 
rested. 


Fig.  257. — Side  View  of  the 
same. 


spine.  The  same  thing  holds  good,  whether  it  is  abduction  or  adduction,  only 
the  tilting  is  in  the  opposite  direction  (Figs.  258  and  259). 

The  measure  of  this  tilting  may  be  taken  by  abducting  or  adducting  the 
affected  limb  from  the  middle  line,  until  a  tape,  stretched  from  the  e])isternal 
notch  to  the  inner  malleolus  of  the  sound  leg,  passes  exactly  over  the  umbilicus, 
showing  that  there  is  no  lateral  curve,  and  crosses  at  right  angles  another  which 
joins  together  the  two  anterior  superior  spines. 

Later  in  the  course  of  the  disease,  adduction  is  caused  by  the  alteration  in 
shape  of  the  articular  ends  of  the  bones,  and  by  their  displacement  or  dislocation  ; 
and  then  it  is  always  associated  with  real  shortening.  Occasionally  adduction 
of  both  limbs,  with  extreme  eversion  (scissor-legged  deformity),  is  met  with, 
probably,  as  suggested  by  Lucas,  brought  on  by  the  patient  involuntarily  twisting 
his  leg  into  the  best  position  for  progression  under  the  circumstances. 

Many  reasons  have  been  assigned  for  the  change  in  the  position  of  the  affected 
limb.  Flexion,  as  already  mentioned,  is  present  throughout.  In  the  early  period, 
while  it  is  still  slight,  and  associated  with  abduction  and  eversion,  it  is  assumed 


DISEASE  OF  THE  HIP  JOINT. 


593 


l)ecause  it  is  the  position  of  greatest  ease — that  which  causes  least  tension  on  the 
muscles  and  ligaments  and  least  pressure  ui)on  the  head  of  the  bone;  and  it  has 
been  found  by  experiment  that  this  is  the  position  in  which  the  capacity  of  the 
hip  joint  for  fluid  is  the  greatest.  Afterward,  however,  when  it  is  combined  with 
adduction  and  inversion  and  is  carried  (as  it  frequently  is  if  left  to  itself)  to  such 
a  degree  that  the  limb  is  bent  to  an  acute  angle  with  the  trunk,  this  holds  good  no 
longer,  and  the  cause  then  is  the  spasmodic  contraction  of  the  flexors.  Just  as  in 
the  knee  joint  they  gradually  flex  the  leg  upon  the  thigh  until  the  calf  is  in  contact 
with  the  ham,  so  here  they  overcome  the  extensors,  and  flex  and  adduct  the  thigh 
upon  the  trunk,  until,  if  it  is  not  checked  in  some  way,  the  limb  can  go  no  further. 
Muscular  7c>asti/ig  affecting  the  extensors  is  one  of  the  earliest  and  most 
valuable  signs.  The  gluteus  maximus  on  the  aff'ected  side  is  flattened  and  feels 
flabby  in  comparison  with  the  other  ;  and  the  lower  gluteal  fold  is  partially 
obliterated.     This  atrophy  is  probably  reflex,  due,  it  may  be,  to  some  form  of 


Fig.  258.— The  Legs  Parallel 
and  the  Pelvis  tilted,  because 
the  angle  of  the  affected  limb 
(whether  it  is  abducted  or  ad- 
ducted)  is  fixed,  and  beyond 
the  patient's  control. 


Fig.  259. —  Pelvis  Brought  to  its  Proper  Position  by 
abducting  the  thigh  on  the  diseased  side. 


descending  neuritis,  and  must  be  distinguished  from  that  form  occurring  later  in 
the  disease,  and  affecting  all  the  muscles  of  the  limb  equally,  caused  by  disuse. 

Impaired  mobility,  which  is  always  present  from  the  very  earliest  days  of  the 
disease,  is  the  most  valuable  symptom.  At  first  it  is  due  to  muscular  rigidity  and 
spasm,  and  disappears  completely  under  an  anaesthetic  ;  later  it  is  caused  by  adhe- 
sions round  or  inside  the  joint,  and  at  length  in  some  cases  by  bony  ankylosis. 
Perfect  extension  is  impossible  ;  apparently  it  may  be  carried  out,  but  this  is  a 
deception,  due  to  the  lordosis.  Perfect  flexion  is  equally  out  of  the  question.  If 
the  finger  is  placed  on  the  anterior  superior  spine  of  the  ilium  on  the  sound  side, 
and  the  limb  is  flexed,  taking  care  to  keep  it  in  a  straight  line  with  the  body, 
without  abducting  it,  the  pelvis  remains  perfectly  steady  until  the  front  of  the  thigh 
touches  the  abdomen  ;  if  the  same  is  then  done  on  the  diseased  side,  the  jjelvis 
begins  to  rotate  from  under  the  finger,  sooner  or  later,  according  to  the  degree  of 
limitation.       Rotation    is  equally  important ;    if  the  thigh  is  flexed  to  a  right 


594    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

angle  upon  the  trunk,  absolute  freedom  of  movement  should  be  allowed  in 
either  direction.  It  is  almost  certain  that  hip-disease  is  not  present,  if,  with 
the  patient  lying  on  his  back,  with  the  hip  and  knee  flexed  until  the  foot  of  the 
affected  limb  rests  upon  the  couch  by  the  knee  of  the  sound  one,  the  thigh  can  be 
abducted  until  it  rests  ui)on  its  outer  side.  In  this  position  there  is  an  immense 
strain  thrown  upon  the  inner  part  of  the  capsule,  and  if  there  is  the  least  degree 
of  inflammation,  the  pelvis  will  rock  from  one  side  to  the  other  instead. 

S7i.ielling  is  exceedingly  significant,  not  so  much  of  the  existence  of  hip- 
disease,  for  it  may  be  absent  at  the  first,  but  of  the  stage  which  has  been  reached. 
If  it  occurs  in  the  early  days,  filling  up  the  hollow  of  Scarpa's  triangle  when  the 
limb  is  flexed  and  abducted,  it  points  to  effusion  in  the  synovial  sac,  such  as  is 
more  usually  met  with  in  rheumatic  and  traumatic  synovitis  than  in  tubercular 
disease.  Later  it  may  be  best  appreciated  by  grasping  the  joint  between  the  fin- 
ger and  thumb,  from  before  backward.  Definite  thickening  of  the  base  of  the 
great  trochanter  is  almost  proof  of  caseation  :  general  infiltration  of  the  periarticu- 
lar tissues  rarely  comes  on  until  the  disease  is  far  advanced. 

Alteration  in  the  Letigth  of  the  Limb. — Apparent  lengthening  and  shortening 
have  been  already  mentioned  ;  they  are  due  entirely  to  abduction  or  adduction. 
Real  lengthening  is  very  doubtful.  It  is  just  possible  that  it  may  occur  from  in- 
creased growth  of  the  limb ;  but  the  circumstance  must  be  quite  exceptional,  and 
it  must  not  be  forgotten  that  inequality  of  the  two  legs  is  by  no  means  unusual. 
The  head  of  the  femur  is  sometimes  separated  from  the  acetabulum  by  fluid  insinu- 
ating itself  between  the  two  cartilaginous  surfaces  ;  and  possibly  the  same  thing 
may  be  effected  by  the  growth  of  granulation-tissue  from  one  or  both  of  the  bones, 
but  either  of  these  conditions  would  prevent  the  limb  being  placed  in  extension, 
and  measurement  taken  with  the  least  degree  of  flexion  is  most  deceptive. 

Real  shortening,  on  the  other  hand,  at  a  later  period  of  the  disease,  may  be 
caused  in  various  ways.  In  the  most  common,  the  head  of  the  femur  and  the  rim 
of  the  acetabulum,  against  which  it  is  driven  by  the  muscular  contraction, 
mutually  destroy  each  other.  Pressure  on  inflamed  bone  very  rapidly  causes  ab- 
sorption and  disintegration  ;  the  head  of  the  femur  diminishes  in  size  at  the  same 
time  that  it  cuts  away  through  the  margin  of  the  acetabulum,  and  the  mutual  de- 
struction, even  if  it  does  not  end  in  a  kind  of  dislocation,  causes  a  very  consider- 
able degree  of  shortening.  In  rarer  cases  the  floor  of  the  acetabulum  is  per- 
forated ;  or  the  head  of  the  bone  is  pushed  out  from  the  socket  by  the  fluid  that 
accumulates  behind  it,  forming  what  is  known  as  dislocation  /n'  distention ;  or 
the  epiphysis  is  separated  from  the  neck,  and  the  latter  is  carried  up  against  the 
upper  and  back  part  of  the  capsule  of  the  joint.  In  addition,  the  limb  is  always 
shortened  by  the  loss  of  the  ei'iphysis  and,  what  is  much  more  important,  by  the 
general  failure  in  nutrition  of  the  part. 

A  sliding-rod  should  always  be  used  to  estimate  this  in  preference  to  a  tape, 
and  the  measurements  should  be  taken  from  the  anterior  superior  spine  to  the  in- 
ternal malleolus,  but  there  are  many  sources  of  fallacy.  A  slight  degree  of  flexion 
causes  a  diminution  in  length.  Owing  to  the  alteration  in  the  shape  and  position 
of  the  articular  surfaces,  real  shortening  is  always  associated  with  adduction  ;  as  a 
consequence  the  pelvis  is  tilted  to  one  side,  and  when  the  legs  are  brought  to  the 
same  line  with  the  body,  apparent  shortening  is  added  to  the  real.  In  most  cases, 
therefore,  it  is  necessary  to  supplement  this  by  Nelaton's  line,  Bryant's  triangle,  or 
by  measurement  of  the  bones  of  the  limb  sei)arately. 

Increase  of  temperature  is  very  rarely  present  in  tubercular  arthritis,  unless 
there  is  an  acute  abscess  ai)proaching  the  surface. 

As  the  disease  advances,  other  symptoms  begin  to  appear.  The  deformity 
due  to  destruction  of  the  bones  and  ligaments  becomes  more  marked  ;  flexion  and 
adduction  grow  worse  ;  the  shortening  of  the  limb  is  no  longer  apparent,  but  real ; 
wasting  is  no  longer  confined  to  the  extensors,  but  involves  all  the  structures  of 
the  thigh  ;  starting  pains  make  their  appearance  at  night,  and  ca.seation  soon 
follows. 


DISEASE  OF  THE   HIP  JOINT.  595 

True  sui)piiration  is  a  complication  and  may  not  make  its  appearance  so  long 
as  the  skin  is  intact.  Sooner  or  later,  however,  some  caseous  focus  in  the  centre  of 
a  mass  of  granulations  slowly  softens,  and  becomes  licjuid.  Usually  this  begins 
in  the  interior  of  the  joint,  and  often  in  the  interior  of  the  Ijone ;  but  occasion- 
ally it  is  periarticular  from  the  first.  The  orifice  in  the  capsule,  however,  is 
generally  very  small  and  is  easily  overlooked.  The  direction  the  fluid  takes 
depends  on  anatomical  relations.  It  may  work  its  way  out  through  the  posterior 
thin  part  of  the  capsule  behind,  and  point  under  the  gluteus  maximus,  or  pa.ss 
under  the  transverse  ligament  to  the  inner  side  of  the  limb.  Sometimes  it  comes 
out  through  the  front,  along  the  course  of  the  branches  of  the  external  circumflex, 
or,  in  older  patients,  it  opens  into  the  bursa  under  the  psoas.  A  very  common 
situation  for  it  to  show  itself  is  just  in  front  of  the  insertion  of  the  tensor  fasciae 
femoris,  guided,  in  all  probability,  by  the  firm  sheet  of  fibrous  tissue  that  lies 
beneath  it ;  but  it  may  run  up  the  sheath  of  the  psoas  or  work  its  way  into  the 
perineum,  and  burst  into  the  ischio-rectal  fossa  or  even  into  the  rectum.  Intra- 
pelvic  collections  of  this  kind  nearly  always  point  to  disease  of  the  acetabulum  ; 
sometimes  they  originate  independently  on  the  pelvic  side  between  the  bone  and 
the  obturator  fascia  ;  in  other  cases  they  are  due  to  perforation  of  the  floor.  Even 
when  small  their  presence  can  usually  be  detected  by  examination  with  the  finger 
in  the  bowel ;  as  they  enlarge  they  spread  upward,  causing  a  fullness  in  the  iliac 
fossa  over  Poupart's  ligament,  and  pointing  generally  near  the  anterior  superior 
spine.  When  the  disease  involves  the  pubes,  the  opening  is  usually  either  by  the 
side  of  the  adductor  longus  tendon,  or  in  the  groove  between  the  scrotum  or 
labium  and  the  thigh.  Old  cases  of  hip-disease  very  commonly  present  sinuses 
discharging  a  thin  purulent  fluid  from  time  to  time,  in  several  of  these  situations. 

Constitutional  Symptoms. — In  the  early  stage  of  hip  disease  these  are 
very  slight.  Caseation  and  liquefaction  may  generally  be  suspected  if  there  is 
definite  and  regular  rise  of  temperature  every  evening.  Later,  when  suppuration 
occurs,  this  is  always  present.  Hectic,  the  various  forms  of  fever  caused  by  septic 
absorption  from  ill-drained  suppurating  cavities,  amyloid  disease,  and  other 
troubles  which  are  not  uncommonly  met  with  at  a  later  period  still,  must  be 
regarded  as  complications  which  occur  in  tubercular  arthritis  in  common  with 
other  varieties  of  joint  disea.se. 

Diagnosis. — Advanced  hip  disease  is  usually  clear  at  the  first  glance  :  in  the 
early  stages  the  diagnosis  is  often  a  matter  of  the  utmost  difficulty.  The  symp- 
toms are  very  slight ;  many  of  them  are  present  in  other  affections,  and  worst  of 
all,  as  it  is  necessary  to  prove  that  the  joint  is  sound,  they  are  often  imitated  with 
great  exactne.ss  in  hysteria.  The  examination  must  be  thorough ;  no  symptoms 
may  be  neglected  ;  but  the  limitation  of  movement  even  in  the  slightest  degree, 
the  wasting  of  the  extensors,  and  the  position  assumed  by  the  limb,  are  certainly 
the  most  important. 

The  diagnosis  must  be  made  from  other  diseases  of  the  hip  joint ;  malforma- 
tions ;  diseases  of  other  joints  ;  inflammation  of  neighboring  structures,  and 
hysteria. 

Inflammation  of  the  hip  joint  due  to  other  causes  is  very  rarely  insidious. 
Traumatic  synovitis  may  occur  in  children,  and  requires  especial  care,  as  after  a 
temporary  improvement  it  becomes  sometimes  the  starting-point  of  tubercular  dis- 
ease. Syphilitic  inflammation  is  rare,  even  in  the  hereditary  form,  and  probably 
could  only  be  diagnosed  by  the  result  of  specific  treatment.  Rheumatic  synovitis 
is  much  more  acute,  and  chronic  rheumatoid  arthritis,  which  does,  as  a  rare  excep- 
tion, affect  the  hip  in  children,  may  be  distinguished  by  the  character  of  the  artic- 
ular changes 

Congenital  dislocation  of  the  hip,  rickets,  and  infantile  paralysis  sometimes 
produce  a  condition  of  things  which  in  the  absence  of  any  history,  or  if  the 
patient  is  hysterical,  may  give  rise  to  considerable  difficulty.  Movement,  how- 
ever— especially  rotation  in  the  flexed  position  of  the  limb — is  rarely  restricted. 

Tubercular  disease  of  the  sacro-iliac  joint  may  present  essentially  the  same 


596    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


symptoms  ;  in  addition,  however,  there  is  always  pain  in  attemi)ting  to  separate  or 
press  together  the  ihac  crests ;  and  usually  there  is  a  certain  amount  of  fullness 
over  the  joint  posteriorly.  Lateral  curvature  of  the  spine,  which  may  result  from 
disease  of  the  hip,  is  occasionally  mistaken  for  antl  treated  as  the  primary 
affection.  Mistaking  disease  of  the  hip  for  disease  of  the  knee,  owing  to  the  ])ain 
in  the  latter,  is  much  more  common.  It  must  not  be  forgotten,  however,  that  the 
two  may  occur  together. 

Chronic  osteitis  or  periostitis  of  the  upper  end  of  the  femur  is  most  difficult, 
especially  as  it  is  always  associated  with  a  certain  degree  of  synovitis.  The 
severity  of  the  pain,  especially  at  night,  the  great  tenderness  over  the  trochanter, 
and  possibly  the  early  development  of  oedema  of  the  skin  covering  it,  distinguish 
them,  but  exploratory  incision  is  generally  recjuired.  The  same  difficulty  occurs 
with  a  rare  form  of  central  sarcoma  involving  the  upper  end  of  the  bone. 

Inflammation  of  the  bursa  under  the  psoas,  or  of  the  psoas  itself,  imitates  hip 
disease  exceedingly  well,  especially  in  young  adults.  The  bursa,  generally  s[)eak- 
ing,  develops  in  childhood,  but  does  not  attain  a  very  large  size  for  some  years, 
and  rarely  communicates  with  the  joint  until  late  in  adult  life.  As  a  rule,  the 
diagnosis  can  be  made  by  the  free  rotation  allowed  when  the  hip  joint  is  flexed. 
More  rarely  the  same  thing  occurs  in  connection  with  one  of  the  gluteal  bursge. 

rerityi)hlitis,  iliac  and  psoas  abscesses,  and  inflammation  in  connection  with 
the  lymphatic  glands,  or  wnth  the  cellular  tissue  around  the  hip  joint,  occasionally 
give  rise  to  a  certain  amount  of  difficulty  ;  but  this  nearly  always  results  from  special 
attention  being  paid  to  one  single  symptom.  If  the  whole  case  is  thoroughly  and 
carefully  investigated,  such  a  mistake  can  scarcely  occur. 

The  same  may  be  said  of  hysteria  :  the  position  of  the  limb  may  be  exact ; 
the  pain  may  be  felt  in  the  knee  ;   there  may  be  limitation  of  movement  just  as 

there  is  in  real  disease  of  the  joint, 
but  it  rarely  happens  that  these 
symptoms  are  in  accordance  with 
each  other.  Cutaneous  tenderness, 
for  example,  may  be  e.vcessive 
without  there  being  any  pain  on 
deep-seated  pressure;  intra-artic- 
ular  pressure  may  be  well  borne 
when  the  hand  is  applied  to  the 
heel,  but  exceeding  painful  when 
the  knee  is  touched  ;  or  there  is 
some  other  gross  discrepancy  which 
effectually  negatives  the  idea  of 
serious  disease. 

The  Stages  of  Hip  Disease. 

— For  convenience  in  description 

it   is   usual   to  divide    hij)  disease 

into  various  periods  distinguished  by  certain  clinical  features,  of  which  the  position 

assumed  by  the  limb  is  the  one  usually  selected. 

In  the  first,  flexion  is  slight,  and  is,  or  is  not,  accompanied  by  slight  abduction. 
In  the  second,  flexion  is  well  marked  ;  abduction  and  apparent  lengthening 
are  present  as  a  rule :   sometimes,  however,  there  is  adduction. 

In  the  third,  flexion  is  combined  with  adduction  and  apparent  or  real 
shortening. 

As,  however,  this  gives  little  or  no  guidance  for  treatment,  and  as  it  cannot 
be  said  that  the  ]!Osition  of  the  limb  invariably  corresponds  with  the  pathological 
changes,  a  classification  closely  resembling  that  proposed  by  Adams  is  more  .satis- 
factory. 

First  stage  :  to  the  beginning  of  caseation,  without  thickening  of  the  base  of 
the  trochanter  or  an  evening  rise  of  temperature.  Perfect  recovery  possible,  the 
granulation  tissue  being  completely  aksorbed  or  organized. 


Fig.  260. — Attitude  of  Advanced  Hip  Disease. 


HIP   DISEASE. 


597 


Second  stage:  caseation,  but  no  general  thickening  around  the  joint  or 
periarticular  infiltration.  Recovery  more  doubtful,  with  great  danger  of  relapse, 
some  risk  of  general  tubercular  infection,  and  some  limitation  of  movement. 

Third  stage  :  the  capsule  softened  ;  the  limb  adducted  ;  the  shortening  apparent 
at  first,  but  later  becoming  real ;  extra-articular  supiniration  ;  and  permanent 
deformity  with  much  greater  risk  of  tuberculosis  and  liability  to  the  various  forms 
of  septic  infection,  hectic,  and  amyloid  disease.  If  the  patient  escapes  these  dan- 
gers the  tubercular  process  may  come  to  an  end  ;  and  gradual  organization  take 
place,  with  the  formation  of  residual  abscesses  from  time  to  time. 

Treatment. — The  general  principles  are  of  the  most  simple  character. 
Every  care  must  be  taken,  by  appropriate  hygiene,  good  food,  tonics,  cod-liver  oil, 
etc.,  to  improve  the  general  health,  as  already  described.  The  first  thing  is  to 
bring  the  limb  into  good  position  ;  the  second  to 
keep  it  absolutely  at  rest  until  it  has  thoroughly 
recovered.  During  the  acute  stage  and  so  long  as 
the  pain  is  severe,  the  child  should  be  confined  to 
bed ;  afterward,  if  it  can  be  kept  under  proper 
supervision,  it  may  be  allowed  to  get  about  on 
crutches,  with  the  limb  protected  against  move- 
ment and  accident  by  means  of  a  suitable  apparatus. 
There  is  no  doubt  that  the  evil  effects  of  a  pro- 
longed confinement  to  bed  have  been  much  ex- 
aggerated ;  but,  on  the  other  hand,  provided  the 
deformity  is  corrected,  and  the  limb  is  properly 
secured,  no  purpose  is  served  by  retaining  the  child 
there  during  the  long  period  of  convalescence. 

{a)  In  the  First  Stage. — The  apparatus  in 
general  use  is  either  a  long  splint  with  weight  ex- 
tension, or  Thomas'  splint ;  but  the  surgeon  must 
be  prepared  to  make  use  of  others,  such  as  Byrant's 
(Fig.  261),  or  to  devise  them  for  use  in  exceptional 
cases,  where,  for  example,  there  is  disease  of  both 
hips  or  some  unusual  deformity. 

Weight  extension  is  advisable  if  the  symptoms 
are  very  acute  ;  it  prevents  intra-articular  pressure 
as  well  as  friction,  and  secures  complete  muscular 
relaxation.  It  is  most  easily  applied  by  means  of 
an  ordinary  stirrup,  fastened  above,  as  well  as 
below,  the  knee  with  circular  pieces  of  strapping 
and  a  bandage.  Care  must  be  taken  that  there  is 
no  pressure  upon  the  malleoli ;  and  that  the  weight 
is  not  applied  for  some  hours  after  the  stirrup  is 
finished,  for  fear  of  the  strapping  giving  way. 
Three  or  four  pounds  are  sufficient  for  a  child  ;  six 
or  eight  for  a  young  adult. 

The  position  of  the  patient  is  secured  by  means 
of  a  long  splint,  reaching  from  the  axilla  to  below 
the  foot,  applied  to  the  sound  side  of  the  body. 
In  the  case  of  a  child  the  shoulders  should  be  fas- 
tened down  by  means  of  a  chest-band  and  braces, 
so  that  he  cannot  raise  himself  from  the  recumbent 
position.  The  direction  in  which  extension  is  made 
depends  upon  the  attitude  of  the  limb.  If  the 
patient  is  under  an  anaesthetic,  and  the  hip  joint 
lies  perfectly  straight,  showing  that  the  deformity 
is  purely  muscular,  extension — provided  it  is  begun 
before  the  muscles  regain  their  tone — may  be  made 


598    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

in  the  axis  of  the  body.  The  steady  jnill  uijon  the  limb,  as  consciousness  returns, 
prevents  the  spasmodic  contraction  causing  any  pressure  upon  the  articular  sur- 
faces. If,  on  the  other  hand,  an  anaesthetic  is  not  given,  if'there  are  fibrous 
adhesions  present,  or  if  the  muscles  have  degenerated  and  become  rigid,  .so  that 


/ 


mm 


imm. 


•^-^^.»a?^^]aj^~^«^a^^ij^,Tiegst:;,j^  — ' 


y 


KiG.  262. — Weight  Extension  in  the  Faulty  Position.     Abduction  and  Flexion. 

the  limb  cannot  at  once  assume  a  straight  position,  extension  must  be  made  in 
the  axis  of  the  limb,  and  the  angle  gradually  straightened  every  two  or  three 
days.      In  this  way  the  opposing  structures,  whatever  they  may  be,  are  slowly 


...i,it.~#«<awi^,iiii* 


Fig.  263  — The  same,  but  with  the  Limb  Adducted  and  Flexed. 

stretched  until  the  desired  length  is  obtained.  Extension  made  in  the  straight 
line  at  once  causes  the  pelvis  to  tilt  either  forward  or  to  one  side,  according  to 
the  character  of  the  deformity,  and  forces  the  head  of  the  bone  against  the 
acetabulum,  the  resisting  structures  in  front  acting  as  the  fulcrum  of  a  lever. 


HIP  DISEASE. 


599 


Fig.  264. — Diagrammatic 
sections  of  Trunk  and 
Lower  Extremity,  show- 
ing application  of  hip- 
splint  and  hoops. 


Fle.xion  is  generally  easily  remedied  by  this,  so  long  as  it  is  dependent  upon 
muscular  rigidity  or  extra-articular  fibrous  adhesions.  Ever- 
sion  or  inversion  of  the  foot  can  be  cured  at  the  same  time, 
either  by  placing  the  side  jjortions  of  the  stirrup  rather 
obli(]uely  u|)on  the  limb,  or  by  adjusting  to  its  outer  side  a 
short  splint  with  a  cro.ss-piece  at  the  bottom,  which  can  be 
raised  at  one  end  and  lowered  at  the  other  until  the  re<juired 
correction  is  made.  A  moderate  degree  of  abduction  is 
not  objectionable  ;  indeed,  it  is  to  some  extent  beneficial, 
and  should,  for  example,  be  maintained  after  excision,  as,  by 
causing  apparent  lengthening,  it  tends  to  correct  any  real 
shortening  ;  but,  for  the  same  reason,  adduction  is  espe- 
cially to  be  avoided.  Marsh  recommends  that,  where  its 
extent  is  at  all  serious,  counter-extension  should  be  made 
from  the  splint  on  tlie  sound  side  of  the  limb  in  the  opposite 
direction — that  is,  toward  the  head  of  the  bed — so  that  the 
pelvis  may  be  slowly  twisted  round.  Thomas's  splint,  how- 
ever, is  more  likely  to  succeed. 

With  regard  to  the  length  of  time  this  treatment  should 
be  maintained,  no  general  rule  can  be  laid  down.  The  faulty 
position  of  the  limb  must  be  corrected,  the  muscular  rigidity 
must  disai)pear,  and  when  the  weight  is  reduced  by  slow  de- 
grees, there  must  be  no  tendency  to  return  of  the  flexion.  It 
may  be  many  months  before  this  takes  place,  and  even  then 
the  limb  must  be  protected  by  means  of  a  Thomas's  splint;  the  patient  must  be 
contented  to  get  about  on  crutches  with  a  patten  under  the  opposite  foot ;  the 
weight  should  be  reapplied  at  night,  and  careful 
watch  must  be  kept  for  any  return  of  the  pain  or 
muscular  rigidity. 

Thomas's  splint,  on  the  other  hand,  aims  at 
securing  muscular  relaxation,  not  by  extension,  but 
simply  by  rendering  the  joint  absolutely  rigid.  The 
muscles  are  in  a  state  of  spasm,  because  the  least 
movement  causes  pain  ;  if  the  joint  is  fixed  so  that 
motion  is  impossible,  they  relax  of  themselves  and 
allow  the  limb  to  become  straight.  The  only  ex- 
tending force  is  the  weight  of  the  part,  and  this,  even 
when  there  are  fibrous  adhesions  round  the  joint, 
is  generally  sufficient  to  correct  the  deformity 
without  having  recourse  to  other  measures.  In  the 
hands  of  the  inventor  (who  uses  it  for  all  stages  of 
the  disease)  it  has  proved  most  successful,  but  it  is 
by  no  means  easy  to  apply  properly  and  effectually  ; 
the  surgeon  must  be  able  to  manipulate  it  himself, 
and  adapt  it  constantly  to  the  varying  circumstances 
of  each  patient  ;  and  this  cannot  be  done  without 
considerable  experience. 

It  consists  of  a  flattened  bar  of  malleable  iron, 
sufficiently  strong  to  bear  the  weight  of  the  patient 
without  l)ending,  and  long  enough  to  reach  from  the 
angle  of  the  scapula  to  below  the  calf.  This  is  bent 
so  as  to  fit  in  the  lumbar  region,  just  external  to  the 
posterior  superior  spine,  curve  forward  under  the 
gluteal  fold,  and  run  down  the  leg  slightly  to  the 
inner  side  of  its  middle  line.  In  addition,  it  is 
slightly  twisted  on  its  long  axis  in  the  gluteal  region, 
so   that  while  the  lumbar  portion  looks  forward  and  inward,  the  lower  half  is 


Fig.    26 


-Measuring  for 
Splint. 


Thomas's 


6oo    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


directed  slightly  outward  ;  the  extent  of  this  twist  varies  with  the  build  of  the 
l)atient,  and  must  be  increased  if  the  splint  has  any  tendency  to  shift  away  from 
the  spine.  On  this  are  riveted  three  metal  hoops,  one  round  the  chest,  the 
second  round  the  thigh  just  below  the  gluteal  fold,  and  the  third  round  the  calf; 
the  first  equal  to  five-sixths  of  the  circumference,  the  other  two  about  two-thirds, 
at  their  respective  sites.  These  are  not  fastened  in  the  centre,  but  rather  to 
one  side,  so  that  one  arm  is  longer  than  the  other  ;  that  is  to  say,  if  the  right 
hip  is  affected,  the  left  arms  of  the  three  hoops  are  the  longer,  reaching  to  almost 
the  middle  line,  and  cling  closely  to  the  skin  ;  the  right  ones  are  shorter,  and 
somewhat  set  away.  The  upper  crescent  is  closed  round  the  chest  by  means  of  a 
strap  and  buckle  and  the  splint  is  fixed  to  the  chest  and  to  the  limb  by  means  of 
two  flannel  bandages. 

The  age  and  sex  of  the  patient,  the  side  that  is  affected,  and  any  peculiarities 
as  regards  position  must  be  noted.  The  chief  measurements  are  the  circumference 
of  the  body  at  the  nipple-line ;  of  the  thigh,  two  inches  below  the  gluteal  fold  ; 
and  of  the  leg  below  the  calf ;  and  the  length  from  the  nipple-line  to  the  same  two 
places. 

In  every  case  the  splint  should  be  modeled  to  the  sound  side  of  the  body,  no 
matter  how  great  may  be  the  degree  of  flexion.  Padding  should  be  used  freely  to 
fill  up  the  hollow  under  the  loins  and  in  the  bend  of  the  knee,  so  that  the  patient 
may  rest  comfortably  upon  the  bar  ;  gradually,  as  the  cotton -wool  gives  way  and 
becomes  compressed,  the  body  and  limb  sink  with  it,  and  straighten  themselves 
out.     Of  course,  if  the  deformity  is  considerable,  the  hoop  that  goes  .round  the 

thigh  cannot  be  closed  at  first,  and 
its  sides  may  even  require  to  be  pro- 
longed ;  and  care  must  be  taken  to 
prevent  the  back  of  the  heel  resting 
iij^on  the  lowermost  hoop.  Slight 
alterations  of  this  kind  can  be  easily 
effected  by  wrenches,  but  it  is  sel- 
dom practicable  to  bend  the  main 
support  of  the  splint  so  as  to  fit  the 
limb  without  injuring  it  more  or 
less,  and  it  is  not  necessary  ;  the  splint  answers  quite  as  well  if  it  is  modeled  to 
the  sound  side  of  the  body  from  the  first. 


Fig.  266. — Thomas's  Wrenches  for  .■Mtering  Splint. 


Fig.  267. — Showing  Method  of  Lifting  Patient. 


Special  attention  must  be  paid  to  the  method  of  aj^plication  of  the  splint  and 
bandages.    The  long  arm  of  the  upper  hoop  is  bent  to  fit  closely  to  the  body  ;  the 


HIP  DISEASE. 


60 1 


short  one  is  opened  sufficiently  to  place  it  in  position  ;  and  the  strap  of  the  body- 
band  is  fastened  round  the  chest,  care  being  taken  that  the  buttock  rests  well  in 
the  hollow.  Two  bandages  are  required  ;  one  broad,  for  the  body  ;  the  other 
narrow,  for  the  leg.  In  each  case  they  must  be  fastened  to  the  splint  first.  The 
former  is  to  draw  the  vertical  bar  well  toward  the  spine  ;  the  operator  stands  upon 
the  sound  side,  pa.sses  the  end  of  the  bandage  first  under  the  splint,  then  between 
the  body  and  the  splint  (leaving  an  end  sufficiently  long  to  be  firm),  and  then 
round  body  and  splint  from  below  upward.  The  direction  of  the  other  depends 
upon  the  inversion  or  eversion  of  the  limb,  the  turns  being  made  to  correct  the 
deformity  as  far  as  possible.  While  it  is  being  applied,  the  foot  should  be  held 
slightly  inverted,  in  the  natural  position.  The  whole  splint  is  prevented  from 
slipping  down  by  means  of  a  brace  over  the  shoulder  ;  if  there  is  abduction,  it  is 
placed  on  the  affected  side,  if  adduction  on  the  sound  one.  So  long  as  the 
symptoms  are  acute  the  patient  is  confined  to  bed,  and  he  should  not  be  allowed 
to  get  about  until  the  leg  and  back  are  perfectly  straight. 

Whenever  the  deformity  is  at  all  serious  a  double  splint  should  be  used,  the 
two  vertical  bars  being  connected  together  so  as  to  ensure  complete  rigidity. 

Abduction  is  checked 
by  lowering  the  longer 
limb  of  the  upper  cres- 
cent until  it  sweeps  down 
upon  the  lower  ribs  or 
even  between  the  ribs  and 
the  iliac  crest ;  adduction 
by  adding  a  pelvic  hoop 
on  the  affected  side  just 
below^  the  iliac  crest,  join- 
ing it  to  the  upper  one  by 
a  lateral  bar,  and  then 
bandaging  the  body  to 
both  the  vertical  supports. 
If  there  is  any  knock-knee 
the  outer  limbs  of  the  two 
lower  hoops  may  be  con- 
nected in  the  same  way. 
Inversion  and  eversion  can 
be  greatly  improved  by 
bandaging,  or,  so  long  as 
the  patient  is  in  bed,  by 
fastening  a  transverse  bar 
to  the  lower  end  of  the 
splint  so  as  to  tilt  the  limb 
in  either  direction  as  re- 
quired. The  ironwork  is 
either  covered  over  with 
leather,  or  with  metal  foil 
if  there  is  any  difficulty  in 
keeping  it  clean. 

The  splint  must  be 
worn  day  and  night  until 
the  muscles  round  the 
joint  show  evident  signs 
of  wasting,  and  the  limb 
is  painless  and  straight. 
Then  it  may  be  laid  aside 
at  night ;  a-nd  after  a  time, 
if  no  rigidity  or  flexion  makes  its  appearance,  it  may  be  abandoned  altogether, 
39 


Fig 


Fig.  269. — Double 
Thomas's  Splint. 


. — Thomas's  Hip-splint  Arranged  for  Walk- 
ing, with  Crutches  and  Patten  under  Foot  on 
Sound  Side. 


6o2     DISEASES  AND   INJURIES    OE  SPECIAL   STRUCTURES. 

the  child  simply  getting  about  with  a  j)atten  and  crutches  ;  but  the  majority 
recjuire  it  for  one  or  two  years  at  least,  and,  if  the  disease  was  at  all  advanced 
before  applying  for  treatment,  sometimes  for  very  much  longer. 

(/;)  Second  Stage. — If,  when  the  case  is  first  seen,  there  is  distinct  thickening 
round  the  base  of  the  great  trochanter,  with  a  regular  rise  of  temperature  of  an 
evening,  or  if  prolonged  rest  has  been  tried  without  success  or  with  only  a  slight 
degree  of  improvement,  and  that  of  a  temporary  character,  it  becomes  a  cpiestion 
whether  it  would  not  be  advisable  to  remove  the  whole  tubercular  focus,  or,  in 
other  words,  perform  excision,  insteatl  of  waiting  for  the  time  when  the  disease 
will  cease  to  extend.  A  further  trial  should  certainly  be  made  if  the  circumstances 
under  which  the  patient  is  placed  are  favorable,  if,  for  example,  two  or  three  years 
can  be  given  up,  in  the  hope  that  as  the  patient  grows  older  the  tendency  will 
cease  and  organization  take  place  ;  but  if  this  is  not  possible,  the  more  active 
treatment  is  the  better.  In  any  case  the  limb  will  be  more  or  less  crippled  and 
ankylosed,  and  it  is  better  to  remove  the  whole  source  of  disease  at  once  (provided 
primary  union  is  ensured),  even  if  a  little  more  than  is  absolutely  necessary  is 
taken  away,  than  to  leave  it  to  certain  suppuration  and  destructive  arthritis,  in  the 
hope  that  the  pus,  after  it  has  burrowed  outside  the  joint  and  undermined  the 
surrounding  tissues  for  two  or  three  years,  will  carry  away  all  the  tuberculous 
material  and  gradually  dry  up. 

Acute  abscesses  occurring  in  connection  with  hip  disease  should  be  opened 
and  drained  as  in  other  parts  of  the  body.  Cold  ones,  caused  by  the  softening 
and  liquefaction  of  caseous  deposits,  occasionally,  under  the  influence  of  rest  and 
food,  diminish  in  size,  gradually  dry  up,  and  disappear  ;  but  even  when  this  does 
happen,  healing  is  frequently  imperfect,  and  later,  if  from  any  cause  the  health 
fails,  the  abscess  is  very  likely  to  fill  again.  Aspiration  and  the  injection  of  iodo- 
form emulsion  may  be  tried  if  they  are  small,  although  with  some  risk  of  iodoform 
poisoning  ;  but  the  rule  should  be  to  open  them  freely,  wash  out  their  contents 
thoroughly,  drain  them,  and  if  possible  remove  the  source  from  which  they  spring. 
Counter-irritation,  painting  with  iodine,  for  example,  may  be  of  some  little  use 
in  the  early  days  of  the  disease,  and  may  relieve  pain  and  tension  in  the  deeper 
parts,  but  it  can  have  no  influence  on  caseation,  unless,  perhaps,  it  hastens  its  lique- 
faction. Many  of  these  abscesses  are  peculiarly  tortuous,  making  their  way  under 
the  muscles  and  sheets  of  fascia  ;  and  not  unfrequently  they  communicate  by  nar- 
row channels  with  very  much  larger  collections,  which,  owing  to  their  depth,  are 
not  apparent,  so  that  great  care  is  required  to  prevent  the  openings  becoming  val- 
vular. In  any  case,  as  they  are  dependent  upon  diseased  bone  (except  in  the  rare 
instances  in  which  they  are  peri-articular  from  the  first),  they  are  sure  to  contract 
into  sinuses  which,  until  the  cause  comes  away  of  itself — or,  better,  is  removed — 
will  continue  to  discharge  a  certain  amount  of  serum  mixed  with  flakes  of  caseous 
debris. 

Later  in  the  course  of  the  disease,  years  perhaps  after  apparent  recovery, 
residual  abscesses  are  not  uncommon.  Apparently  the  cicatricial  tissue  around 
the  joint  is  very  poorly  nourished  and  is  liable  to  break  down  if  it  is  injured  in 
any  way,  or  even  from  over-exertion.  In  some  instances  these  abscesses  are 
acute  and  of  very  large  size  ;  but,  as  a  rule,  if  they  are  opened  at  once,  they 
heal  up  within  a  very  short  time. 

{c)  In  the  final  stage,  when  the  limb  is  shortened  and  wasted,  more  or  less 
ankylosed,  and  there  are  open  sinuses  here  and  there  round  the  joint,  leading  down 
to  bare  and  carious  bone,  an  attempt  must  be  made  to  improve  the  position  by 
extension  (tenotomy  may  be  occasionally  required,  but  forcibly  breaking  down 
adhesions  should  be  avoided  as  far  as  possible),  and  to  reduce  the  amount  of  dis- 
charge by  scraping  out  the  sinuses  and  removing  the  softened  necrosed  portions  of 
bone.  In  many  of  these  cases  the  true  tubercular  process  has  either  come  to  an 
end  altogether  or  is  merely  local,  causing  the  discharge  of  a  little  caseous  pus  now 
and  then  from  some  cavity  in  the  bone  ;  and  the  inflammation  is  simply  kept  up  by 
septic  conditions  or  by  sequestra  not  yet  separated. 


SACROILIAC  DISEASE.  603 

The  object  is  to  save  the  patient  from  the  daiiLjers  of  hectic  and  amyloid  de- 
generation. When  the  head  of  the  femur  is  lying  detached  and  loose  in  the 
cavity  of  an  abscess,  or  the  upper  end  of  the  bone  is  softened  and  carious,  or 
portions  of  the  acetabulum  have  undergone  necrosis,  a  more  formal  operation  is 
necessary,  and  a  kind  of  excision  (differing  entirely  from  that  which  is  done  in  the 
earlier  days  of  the  disease)  may  be  performed,  the  sinuses  being  laid  open  and  the 
whole  of  the  diseased  bone  being  as  far  as  possible  removed.  [Excision  of  the 
head  of  the  femur  should  be  performed  by  Koenig's  operation,  which  consists  in 
temi)orarily  detaching  the  outer  and  inner  borders  of  the  trochanter  major  from 
the  shaft  by  the  chisel,  then  cutting  through  the  central  portion,  and  then  the  neck 
of  the  femur  ;  or,  the  whole  trochanter  may  be  separated  from  the  shaft,  and 
restored  after  the  diseased  mass  is  removed.]  The  same  thing  may  be  required  in 
the  case  of  intra-pelvic  sup]xiration,  to  provide  free  exit  through  the  acetabulum 
and  prevent  the  pus  extending  indefinitely  among  the  tissues  and  perhaps  dis- 
charging itself  eventually  into  the  rectum  or  the  ischio-rectal  fossa. 

[There  can  no  longer  be  question  concerning  the  great  value  of  the  injection 
of  iodoform  emulsion  in  cases  of  tubercular  affections  of  the  joints.  The  dangerous 
toxic  effects  of  iodoform  are  not  noticed  when  the  iodoform  is  suspended  in 
glycerine  or  olive  oil.  (Senn.)  In  many  injections  practiced  by  myself  at  the 
Presbyterian  Hospital,  I  have  not  met  with  a  single  instance  of  iodoform  poison- 
ing. I  saw  one  case  at  the  Marine  Hospital,  where  the  drug  was  used  in  ethereal 
solution.] 

Finally,  amputation  may  be  advisable,  either  because  excision  has  been  per- 
formed and  the  limb  is  useless,  or  to  save  the  patient  from  sinking  from  hectic  or 
amyloid  disease.  If  the  pelvis  is  involved  to  any  extent  the  prospect  is  very  un- 
favorable ;  but  even  then  sometimes  the  health  improves  ;  the  discharge  dimin- 
ishes in  amount  and  escapes  more  freely,  loose  fragments  of  bone  come  away  from 
time  to  time,  very  often  with  the  formation  of  residual  abscesses,  and  at  length 
only  one  or  two  sinuses  are  left,  discharging  a  small  quantity  of  lymph  mixed  with 
flakes  of  caseous  debris. 

A  slight  degree  of  amyloid  disease  does  not  preclude  either  excision  or  ampu- 
tation ;  in  many  cases  it  has  been  noticed  that  as  the  wound  diminished  in  size  and 
the  discharge  grew  less,  the  waxy  color  gradually  disappeared,  the  liver  became 
small  again,  and  albumin  ceased  to  appear  in  the  urine. 

Osseous  ankylosis  in  a  faulty  position  may  be  treated  either  by  division  of  the 
neck  of  the  femur,  or,  as  the  condition  of  the  upper  end  of  the  bone  is  more  than 
doubtful,  and  it  is  not  impossible  that  the  hyperemia  following  the  operation 
might  cause  all  the  mischief  to  return,  preferably  by  section  through  the  bone,  in 
the  neighborhood  of  the  lesser  trochanter.  It  may  be  accomplished  either  with  a 
chisel  or  with  a  saw.  Sayre  recommends  the  excision  of  a  portion  of  the  bone 
so  as  to  secure  the  formation  of  a  false  joint ;  but  unless  so  much  is  removed  as  to 
make  union  altogether  doubtful,  it  is  almost  sure  to  be  osseous. 


Sacro-iliac  Disease. 

Tubercular  disease  of  the  sacro-iliac  joint  is  very  rare  in  childhood,  but  is  not 
uncommon  in  young  adult  life.  Nearly  always  it  can  be  traced  back  to  some  in- 
jury ;  there  is  an  extravasation  of  blood,  generally  in  the  cancellous  tissue  of  the 
bones,  but  perhaps  sometimes  between  the  cartilaginous  surfaces,  which,  though 
they  lie  in  contact  with  each  other,  are  not  fused  together  ;  the  vitality  of  the  tissues 
is  lowered,  and  tubercle-bacilli  gain  access  to  the  part,  and  the  characteristic  gran- 
ulation tissue  begins  to  develop. 

The  subsequent  changes  are  identical  with  those  that  occur  in  other  articula- 
tions :  the  cartilage  and  the  bony  trabeculse  are  absorbed  ;  the  neighboring  liga- 
ments are  softened,  so  that  the  joint  loses  its  sense  of  stability  ;  the  amount  of  gran- 


6o4    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Illation  tissue  increases  until  its  nutrition  begins  to  fail,  and  then  caseation  and 
liquefaction  follow,  forming  cold  abscesses  filled  with  a  mixture  of  caseous  debris, 
leucocytes,  serum,  and  shreds  of  connective  tissue.  Sometimes  these  make  their 
way  out  directly  backward,  and  point  over  the  joint  itself;  occasionally  they 
spread  upward  to  the  lumbar  region  ;  more  frequently  they  extend  forward,  and 
either  follow  the  psoas  or  pass  out  of  the  pelvis  through  the  sacro-sciatic  foramen, 
or  into  the  ischio-rectal  fossa,  or  even  into  the  rectum.  If  left  to  themselves  they 
break,  there  is  a  profuse  discharge  for  a  time,  and  then,  sooner  or  later,  unless 
steps  are  taken  to  i)revent  it,  pyogenic  organisms  as  well  find  their  way  in. 

Symptoms. — At  its  commencement,  disease  of  the  sacroiliac  joint  is  even 
more  insidious  than  that  of  the  hip.  There  is  a  sense  of  fatigue  or  of  fugitive  pain 
of  an  evening  or  after  exertion.  The  limb  feels  weak,  standing  on  that  leg  is 
avoided,  the  weight,  even  in  sitting,  is  thrown  as  much  as  possible  on  the  opposite 
side  of  the  body,  the  patient  begins  to  limp,  the  gait  becomes  altered,  the  step  in 
walking  is  shortened,  and  the  least  extra  strain,  such  as  lifting  a  heavy  weight,  even 
coughing,  sneezing,  or  straining  at  stool,  is  checked  at  once  by  the  pain.  The 
locality  in  which  this  is  felt  is  very  variable ;  most  frequently  it  follows  the  course 
of  the  obturator  nerve,  and  is  referred  to  the  hip  or  knee,  but  it  may  follow  that 
of  the  sciatic,  or  be  referred  to  the  back,  or  the  gluteal  region,  or  even  to  the  anus. 
In  many  cases  it  is  very  severe,  especially  when  any  weight  or  pressure  is  allowed 
to  fall  upon  the  joint. 

The  limb  is  flexed  at  the  hip  and  abducted  :  apparent  lengthening  is  usually 
present.  There  is  tenderness  on  pressure  over  the  posterior  surface  of  the  joint ; 
frequently  the  temperature  is  slightly  raised,  and  the  skin  appears  puffy.  The 
glutei  waste  to  a  certain  extent  from  disuse,  and  make  this  more  prominent. 
Pressure  upon  the  iliac  spines  is  often  exceedingly  painful. 

Abscesses  that  advance  posteriorly  can  naturally  be  detected  at  once  ;  those 
on  the  anterior  surface  of  the  joint  may  sometimes  be  felt  through  the  rectum,  or 
in  young  and  thin  adults  a  certain  amount  of  deep  resistance  can  be  made  out 
by  pressure  on  the  abdomen,  but  as  a  rule  they  are  not  detected  until  they  are 
beginning  to  a])proach  the  surface. 

Diagnosis. — Inflammation  of  the  sacro-iliac  synchondrosis  may  occur  in 
gonorrhcjual  rheumatism,  pyremia,  and  in  arthritis  deformans  ;  the  two  former,  how- 
ever, are  never  insidious  or  chronic  in  their  course,  but  commence  rapidly  with 
acute  symptoms,  while  the  latter  only  occurs  at  a  much  more  advanced  period  of 
life,  and  has  no  tendency  to  run  on  to  caseation  or  suppuration. 

In  its  early  stage  it  is  very  liable  to  be  mistaken  for  tubercular  arthritis  of 
the  hip,  especially  that  variety  which  commences  in  the  acetabulum.  The  posi- 
tion of  the  limb  may  be  the  same  ;  the  pain  may  be  felt  at  the  hip  or  knee  ;  limp- 
ing and  apparent  lengthening  are  present  in  both,  and  unless  great  care  be  taken, 
movements  at  the  hip  joint  are  restricted  and  painful,  because  they  are  communi- 
cated to  a  slight  extent  to  the  sacro-iliac  one  above.  Tenderness  on  pressure  and 
puffiness  over  the  sacro-iliac  articulation  are,  however,  never  present  in  hip 
disea.se;  nor  does  pre.ssure  upon  the  iliac  spines,  squeezing  them -together  or  apart, 
ever  cause  pain.  It  must  not  be  forgotten  that  the  two  may  occur  in  the  same 
subject,  either  independently  or  from  the  disease  having  extended  along  the  psoas 
from  one  to  the  other. 

Necrosis  of  the  pelvis  or  sacrum  may  occur  and  give  rise  to  symptoms  some- 
what similar  ;  sciatica  may  be  mistaken  for  it,  though  the  converse  is  much  more 
likely  to  happen  ;  spinal  disease  may  give  rise  to  a  certain  amount  of  difiiculty  ; 
and  occasionally  symptoms  closely  resembling  it  are  present  in  hysteria. 

Prognosis. — The  prognosis  is  always  unfavorable,  but  so  long  as  caseation 
does  not  occur  it  is  by  no  means  hopeless.  A  large  amount  of  bone  may  be  re- 
moved by  fungating  caries  and  cicatrization  follow,  leaving  even  a  certain  degree 
of  deformity,  without  of  necessity  sujjpuration  ever  taking  place.  If,  however, 
caseation  and  liquefaction  do  make  their  appearance,  the  jirospect  of  recovery  is 


TUBERCULAR  DISEASE  OF  THE   KNEE  JOINT.  605 

much  more  doubtful.  It  means  tliat  the  l)alance  of  ];o\ver  lies  on  the  side  of  the 
bacilli  ;  that  the  resistance  the  tissues  can  offer  to  their  encroachment  is  very 
feeble  ;  and  that  in  all  probability  the  ])rogress  of  the  case  will  l)e  simply  from  bad 
to  worse,  until  at  length  hectic  and  exhaustion  set  in.  In  only  one  ca.se  (Hilton's) 
is  recovery  known  to  have  taken  i)lace  without  operation  after  .supi)uration  had 
occurred. 

Treatment. — Absolute  and  prolonged  rest  is  even  more  es.sential  in  this 
than  in  disea.se  of  the  hip.  The  loins,  the  pelvis,  and  the  lower  liml)S  must  be 
rendered  perfectly  immovable  by  means  of  a  large,  well-padded  girdle  of  leather  or 
l^laster,  carried  down  as  low  as  the  knee,  and  the  patient  must  be  strictly  confined 
to  the  recumbent  j^osition  without  being  allowed  to  move  on  any  consideration. 
For  the  disea.se  it.self  in  this  stage  very  little  can  be  done  ;  tonics,  good  food,  cod- 
liver  oil,  and  everything  that  can  improve  the  nutrition  of  the  tissues  must  be 
given  freely  ;  and,  if  possible,  the  patient  should  have  .sea  air.  The  only  local 
application  of  any  service  is  the  actual  cautery,  which  does  diminish  to  some  ex- 
tent the  deep-seated  hypersemia  and  tension. 

If  caseation  and  liquefaction  set  in  and  the  patient  is  otherwise  healthy,  the 
cavity  should  be  thoroughly  cleared  out,  washed  with  iodoform  emulsion,  and 
drained,  so  that  no  fluid  may  remain  behind  to  decompose.  If  the  bones  are  in- 
volved the  carious  portion  must  be  freely  gouged  out  and  treated  in  the  .same  way. 
This,  however,  had  better  not  be  attempted  if  there  is  any  evidence  of  phthisis,  or 
of  tubercular  mischief  elsewhere.  Recovery,  with  cicatrization  of  the  cavity  left,  is 
still  possible  after  suppuration,  so  long  as  the  affection  remains  local,  although  the 
probability  is  very  much  less.  [Tubular  drainage  after  Sayre's  method,  in  selected 
cases  may  be  used  to  advantage.  This  consists  essentially  in  chiseling  an  open- 
ing through  the  bone  at  the  seat  of  the  disease,  then  by  means  of  an  incision  over 
the  crest  passing  an  oakum  rope  or  tube  drain  through  the  incision  and  out 
through  the  opening  in  the  bone  ;  through  this  the  cavity  may  be  well  cleansed 
and  proper  disinfection  ])racticed.] 


Tubercular  Disease  of  the  Knee  Joint. 

Tubercular  inflammation  of  the  knee  may  commence  either  in  the  synovial 
membrane  or  the  bone.  In  the  former  case  (Fig.  271)  the  whole  of  the  synovial 
lining  and  the  loose  soft  tissue  around  are  converted  into  a  mass  of  gelatinous 
granulations,  in  which  typical  miliary  tubercles  may  be  found  here  and  there,  and 
sometimes  tubercle  Vjacilli.  It  may  bean  inch  and  a  half  in  thickness  ;  the  cavity 
may  be  almost  obliterated  ;  the  cartilages  eaten  away  around  their  margin  ;  the 
ligaments  softened,  the  fibres  of  the  capsule  separated  from  each  other,  and  the 
vascular  periarticular  tissues  everywhere  infiltrated  to  such  an  extent  that  the 
outline  of  the  joint  is  perfectly  uniform  and  the  skin  tense  and  white  {tumor 
albus) . 

In  the  latter,  when  the  tuljercular  deposit  occurs  primarily  in  the  bone  (Fig. 
270),  the  changes  are  to  some  extent  the  same,  but  they  differ  materially  in  detail. 
As  in  the  hip,  the  neighborhood  of  the  epiphysis  (particularly  the  articular  surface 
of  the  shaft)  is  the  part  attacked  ;  sometimes  it  is  the  femur,  sometimes  the  tibia 
(Fig.  251).  A  wedge-shaped  sequestrum  is  occasionally  present;  in  other  in- 
stances there  is  merely  a  mass  of  gray  granulations  in  the  cancellous  tissue,  slowly 
enlarging  at  the  periphery  and  ca.seating  in  the  centre.  Whichever  it  is,  the 
perio.steal  surface  is  quickly  covered  with  a  layer  of  new  bone,  so  that  escape  is 
barred  in  that  direction.  If  the  inflammation  is  acute,  and  the  epiphysis  is  in- 
volved— if,  that  is  to  say,  tubercular  embolism  on  a  large  scale  has  taken  place — 
the  articular  cartilage  perishes  with  the  bone  on  which  it  rests,  and  the  interior  of 
the  joint  is  gained  at  once  :  when,  on  the  other  hand,  the  attack  is  more  chronic, 
the  granulations  slowly  approach  the  articular  lamella  ;  the  joint  becomes  more  or 
less  filled  with  fluid  ;  and  the  cartilage  is  absorbed  from  beneath  or  detached  in 


'1^ 


I 


6d6     diseases  and   INJURIES   OF  SPECIAL   STRUCTURES. 

flakes  and  thrown  off  into  the  interior.      In  many  instances  the  tubercular  infil- 
tration spreads  from  the  epiphysial  line  directly  to  the  caijsiile  of  the  joint. 

Resolution  and  cicatrization  occur  in  this  as  in  other  forms  of  tubercular  in- 
flammation, and.  except  in  the  very  worst  cases,  some  trace  of  repair  is  always  to 

be  found.  Caseation  may  begin 
in  the  thickness  of  the  synovial 
membrane,  or  in  the  substance  of 
the  bone ;  but  in  many  instances, 
I  "•       ,  ,         even  when  there  is  very  consider- 

1     '    --_  — 'Tal^^vw,  •:  — v_,  able  deformity,  it  never  appears  at 

/  ,^j|p   '"^^  '"»         all;    or,   if  it   does,    the  jjroducts 

f 'T^B  --—«—••«!«..-  are  absorbed  and  removed  without 

leaving  any  evidence  of  their  pres- 
ence. The  granulation-tissue  fill- 
ing up  the  cancellous  spaces  of  the 
bone,  replacing  the  cartilages  and 
rJ:-  occupying  the  synovial  cavity  and 

1  the  interstices  around  it,  gradually 

'I  becomes     organized ;     the     joint- 

\  -    cavity  is  obliterated  ;  and  the  ends 

of  the  bones  are  tied   rigidly  to- 
/  I-  i  gether. 

•  On  the  other  hand,  the  case- 

ous foci  may  enlarge,  become  more 
and  more  liquid,  and  ultimately 
form  cold  abscesses  which  spread 
slowly  in  the  direction  of  least  re- 
sistance, preceded  always  by  the 
,.,._..,,        T  u      •.     f  XI  ,,„•.»,     tubercular  deposit      Even  then,  if 

Fig.  270.— Chronic  Osteitis  of  Inner  Tuberosity  of  Tibia  with  ,..,,■,  r  ■    1 

Consecutive  Arthritis.  thcv  lic  in  the  thickne.ss  01  Synovial 

membrane  or  in  the  substance  of 
the  bone,  and  burst  externally,  repair  may  take  place,  with  a  certain  amount  of 
stiffness.  The  whole  of  the  infecting  material  is  discharged,  or,  if  any  is  left,  the 
tissues  are  able  to  deal  with  it,  and  organization  gains  the  upper  hand.  But 
where,  as  in  some  instances,  caseation  is  almost  general,  so  that  the  ends  of  the 
bones  are  completely  bared,  and  the  whole  of  the  cartilage  detached  ;  or  where 
true  suppuration  sets  in  and  involves  the  joint  cavity,  the  destruction  is  so  great 
that  only  bony  ankylosis  is  possible. 

Symptoms. — Tubercular  inflammation  of  the  knee  joint  is  essentially  a  dis- 
ease of  childhood  or  of  young  adult  life.  The  synovial  form  is  almost  as  frequent 
as  the  osteal ;  but,  in  the  early  stages  at  least,  one  can  usually  be  distinguished 
from  the  other. 

Pain,  heat,  swelling,  and  impairment  of  function  are  never  wanting,  although 
they  vary  considerably  in  different  ca.ses.  There  is  no  redness  of  skin  until  sup- 
puration sets  in  and  approaches  the  surface.  On  the  contrary,  owing  to  the  way 
in  which  it  is  stretched  by  the  chronic  effusion  beneath,  it  is  often  so  peculiarly 
white  that  this  form  of  inflammation  used  to  be  distinguished  from  all  others  by 
the  name  of  white  swelling  or  tumor  albus.  Later,  characteristic  displacement 
makes  its  appearance  ;  the  joint  becomes  stiffened  and  rigid  ;  abscesses  form  ; 
grating  and  starting  pains  follow  ;  and,  in  short,  all  the  symptoms  of  de.structive 
arthritis  are  developed. 

The  aspect  differs  according  to  the  seat  of  the  disease.  When  all  the  soft 
tissue  around  and  between  the  ends  of  the  bones  is  ecjually  infiltrated,  the  outline 
is  perfectly  uniform  ;  no  depressions  or  elevations  are  to  be  seen  anywhere. 
The  hollows  on  either  side  of  the  ligamentum  patelLne  are  filled  up  the  first ;  and 
by  degrees  all  the  rest  share  the  same  fate,  until  the  skin  is  stretched  evenly 
over  the  whole.     When,  on  the  other  hand,  the  bone  is  attacked  the  first,  or  even 


TUBERCULAR   DISEASE  OE  THE   KNEE  JOINT. 


60  ■ 


chiefly,  the  swelling  is  limited,  or  at  least  is  most  marked  on  one  side;   it  extends 
much    further    up    and    down    the 


(- 


••a^ 


v^. 


""■% 


r 


\ 


-1 


Fig.  271. —  Primary  Tubercular  Synovitis. 


bone,  owing  to  the  thickening  of 
the  jjeriosteum,  and  is  not  restricted 
by  the  limits  of  the  synovial  mem- 
brane. There  may  be  some  fluid 
in  the  joint,  or  some  thickening  of 
the  synovial  and  peri-synovial  tis- 
sues, but  it  is  not  sufficient  to  ob- 
scure the  enlargement  of  the  bone 
and  make  the  swelling  uniform. 

TAe  degree  and  the  locality 
of  the  pain,  as  might  be  expected, 
show  a  certain  difference.  In 
primary  tubercular  synovitis  the 
disease  is  often  far  advanced  before 
the  child  complains  at  all,  and 
even  then  it  is  only  an  ill  defined 
aching,  worse  after  exertion ;  in 
the  osteal  form,  on  the  other  hand, 
it  is  one  of  the  earliest  symptoms, 
and  is  especially  severe  at  night. 

The  same  may  be  said  with 
regard  to  local  tenderness.  In 
primary  synovitis  the  joint  (so 
long  as  it  is  not  extended  or  flexed 

too  far)  may  be  handled  freely.  When  the  tubercular  centre  is  in  the  bone 
the  swelling  is  usually  exceedingly  tender,  sometimes  all  over,  but  in  many 
cases  especially  at  one  small  spot,  the  skin  over  which  is  puffy  and  oedematous. 
In  the  same  way  starting  pains  at  night  commence  at  an  earlier  period  in  the 
osteal  form  and  are  more  severe. 

The  other  symptoms  are  common  to  the  two  and  are  equally  marked 
in  both. 

Movemejit  is  always  limited.  Complete  extension  of  a  knee  joint  that  is  in 
the  least  degree  inflamed  is  impossible  ;  and  conversely  a  knee  that  can  be  ex- 
tended thoroughly  is  not  inflamed.  This  does  not  depend  upon  the  amount  of 
fluid  present,  although  it  is  true  that  the  capacity  of  the  synovial  cavity  is  greatest 
when  the  joint  is  flexed  about  15°,  but  on  the  fact  that  in  extension  all  the  fibrous 
structures  around  and  in  the  joint,  except  those  on  the  anterior  surface,  are  put 
upon  the  stretch.  Complete  flexion  is  equally  limited,  but  this  is  more  difficult 
to  prove. 

The  temperature  of  the  joint  is  always  raised.  Great  care  is  required  in 
establishing  this  :  the  knees  must  have  been  exposed  an  equal  length  of  time ;  the 
suspected  one  must  not  have  been  manipulated  ;  and  the  same  points  on  each  must 
be  compared  ;   but,  if  this  is  done,  the  result  may  be  absolutely  relied  upon. 

Muscular  toasting,  especially  of  the  quadriceps,  makes  its  appearance  at 
a  very  early  period  ;  it  may  be  distinctly  marked  by  the  end  of  two  or  three 
weeks. 

Displacement  of  the  tibia  again  occurs  unusually  soon.  The  joint  is  kept  in 
the  flexed  position,  so  as  to  relax  the  muscles  and  ligaments  as  far  as  possible  : 
the  two  bones  simply  rest  upon  each  other ;  the  ligaments  are  softened  by  the 
inflammation,  and  in  the  position  of  semi-flexion  are  nearly  all  relaxed;  the  ham- 
strings are  in  a  state  of  spasmodic  contraction,  and  from  their  position  act  with 
peculiar  advantage;  the  weight  of  the  limb,  and,  if  the  patient  is  in  bed,  the 
pressure  of  the  clothes  upon  the  inner  side  of  the  foot,  help ;  and  as  a  result 
the  tibia  is  displaced  bodily  backward  upon  the  femur,  and  is  at  the  same  time 
rotated  outward.     In  the  treatment  of  chronic  disease  of  the  knee,  the  prevention 


6o8    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


of  this  displacement  is  of  special  imi)ortance  ;    if  it  is  allowed  to  take  place,  and 
the    ligaments  become   firm   again,  as   they  do  as  soon  as  the  inflammation    has 

subsided,  it  is  almost  impossible 
to  bring  the  tibia  forward  upon 
the  femur.  The  flexion  may  be 
cured  and  the  two  made  parallel ; 
but  the  femur  is  and  remains  in 
front  of  the  tibia,  so  that  merely 
the  posterior  margin  of  the  con- 
dyles rests  upon  the  upper  surface 
of  the  tuberosities. 

As  the  inflammation  advances 
these  symptoms  steadily  become 
worse.  The  joint,  if  left  to 
itself,  is  flexed  until  the  calf  is 
in  contact  with  the  ham  and  the 
tibia  is  almost  pulled  off  the 
femur ;  the  pain  grows  more 
severe  ;  the  swelling  increases  in 
size  ;  abscesses  make  their  appear- 
ance and  burst  externally,  leav- 
ing sinuses  lined  with  pale,  flabby 
granulations  ;  starting  pains  come 
on,  showing  that  the  articular 
cartilages  are  in  part  destroyed  ; 
the  least  attempt  at  movement, 
even  touching  the  bed,  causes 
intense  suffering ;  and,  finally, 
sup])urative  arthritis  is  added  to 
the  rest. 
The  constitutional  symptoms  at  first  are  but  slightly  marked  ;  as  the  disease 
advances  a  certain  amount  of  fever  makes  its  appearance,  especially  of  an  evening  ; 
the  health  begins  to  fail,  partly  from  this,  partly  from  the  pain  and  the  want  of 
exercise  ;  and  the  patient  loses  flesh  and  strength.  Later,  when  suppuration  occurs, 
this  is  much  more  marked  ;  the  temperature  becomes  characteristic  of  hectic  ;  the 
emaciation  is  extreme  ;  the  appetite  is  completely  lost ;  the  face  is  flushed  ;  there 
are  profuse  night-sweats,  and  in  some  cases  the  strength  fails  to  such  an  extent  that 
it  is  difficult  to  believe  that  the  disease  of  the  knee,  bad  though  it  may  be,  is  the 
only  trouble  from  which  the  patient  is  suffering. 

Diagnosis. — The  age  of  the  patient,  the  peculiarly  insidious  character  of 
the  disease,  the  difficulty  of  assigning  even  an  approximate  date  for  its  commence- 
ment, and  the  soft,  doughy,  semi-elastic  feeling,  are  distinctive.  In  primary 
tubercular  synovitis  the  outline  of  the  joint  alone  is  sufficient ;  no  other  affection 
causes  such  a  perfectly  even,  rounded  swelling.  When  the  disease  begins  in  the 
bone  the  difficulty  may  be  somewhat  greater,  but  chronic  osteitis  of  the  articular 
ends  of  the  bones  very  rarely  occurs  in  children  or  young  adults,  except  from 
tubercle  or  syphilis. 

The  history  of  the  case  is  often  exceedingly  misleading,  the  lameness  comes 
on  so  gradually,  that  very  often  it  is  not  noticed  by  the  j^arents  until  the  disease  is 
far  advanced,  and  they  may  insist  that  the  child  has  been  perfectly  well  until  a 
day  or  two  before.  Such  evidence,  however,  is  worthless  in  comparison  with  that 
afforded  by  the  change  in  the  physical  characters  of  the  joint  and  the  wasting  of 
the  limb. 

The  difficulty  is  greatest  in  the  case  of  syphilitic  synovitis.  This  is  more 
common  in  the  hereditary  than  in  the  acquired  variety,  and  is  usually  secondary 
to  osetitis  or  periostitis  of  the  articular  ends  ;  when,  however,  the  synovial 
membrane    is    involved    by   itself,    it    resembles   tubercular    inflammation    very 


Fig.  272. — Section  Through  a  Knee-joint,  from  a  case  of  advanced 
tubercular  disease.  The  bones  are  atrophied,  the  cartilages  gone 
both  from  femur  and  patella,  and  the  tibia  hopelessly  displaced 
backward. 


TUBERCULAR  DISEASE  OF  THE  KNEE  JOINT 


609 


closely.  As  a  rule,  the  course  is  more  rapid  and  the  consistence  of  the  swelling 
is  seldom  so  uniform  :  but  in  any  case  of  doubt,  or  where  there  is  a  history  of 
recent  syphilis,  it  is  advisable,  in  addition  to  local  measures,  to  try  the  effect  of 
mercury  and  iodide  of  potash  in  small  doses.  Occasionally  the  difficulty  is 
increased  by  the  fact  that  tubercular 
arthritis  makes  its  appearance  sud- 
denly, or  perhaps  is  roused  into  greater 
activity  by  the  cachexia  attendant  on 
secondary  syphilis. 

Other  forms  of  synovitis  can  be 
distinguished  almost  at  once  by  the 
rapidity  of  their  onset  (tubercular 
arthritis  is  always  an  affair  of  months, 
often  of  years),  by  the  fluid  character 
of  the  effusion,  or  by  the  tendency  to 
organization  of  the  inflammatory  pro- 
ducts, leading  to  the  formation  of  syn- 
ovial fringes,  or  the  production  of 
fibrous  adhesions.  It  is  not  improba- 
ble, however,  that  senile  tuberculosis 
and  Charcot's  disease  are  occasionally 
confused  with  each  other  at  the  begin- 
ning. 

Hysteria  may  attack  the  knee 
joint  almost  as  frequently  as  the  hip, 
and  by  prolonged  disuse  may  lead  to  a 
great  amount  of  wasting  and  some 
rigidity.  It  can,  however,  be  nearly 
always  distinguished  by  the  incon- 
gruity of  the  symptoms  it  presents. 

Prognosis. — In  spite  of  the  size 
of  the  articulation,  the  prognosis  in 
tubercular  inflammation  of  the  knee  is 
distinctly  more  favorable  than  in  that 
of  the  hip  :  the  joint  is  more  super- 
ficial ;  the  bones  can  be  fixed  more 
easily,  and  if  a  caseous  focus  makes  its 
appearance  in  either  the  femur  or  the 
tibia,  it  can  be  scooped  out  from  the 
side  without  interfering  with  the  syn- 
ovial cavity.  Everything,  however, 
depends  upon  the  period  at  which  the 
diagnosis  is  made,  and  the  thorough- 
ness with  which  the  treatment  is  caried  out.  Recovery  may  be  perfect ;  or 
fibrous  ankylosis,  allowing  more  or  less  movement,  may  be  left ;  or  the  bones 
may  be  fused  together ;  or,  finally,  excision  or  amputation  may  be  required. 

Treatment. — The  principles  are  the  same  as  those  already  detailed.  The 
greatest  attention  must  be  paid  to  the  general  health  ;  the  limb  must  be  brought 
into  good  position  and  kept  absolutely  at  rest ;  if  caseation  sets  in  and  the  inflam- 
mation does  not  subside,  the  focus  of  disease,  whether  it  is  in  the  synovial  mem- 
brane or  the  bone,  must  be  thoroughly  cleared  away ;  if  this  cannot  be  done 
without  removing  the  articular  ends,  or  if  ankylosis  has  taken  place  in  such  a 
position  that  the  limb  is  useless,  excision  must  be  performed  ;  and  if  the  patient  is 
in  danger  of  sinking  from  hectic,  or  if  the  constitutional  condition  is  such  that  a 
a  possibly  protracted  convalescence  could  not  be  borne,  the  thigh  must  be 
amputated. 

The  position  for  the  knee  is  almost  straight ;   if  it  has  already  become  bent,  it 


Fig.  273. — Thomas's 
Knee-splint  with 
patten. 


Fig.  274. — Thomas's  Knee 
splint  applied. 


6io     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

must  be  slowly  and  quietly  brought  nearly  into  line  again,  either  by  means  of 
weight  extension  or  with  Thomas's  splint.  If  the  former  is  used,  the  same  precau- 
tions must  be  taken  as  in  the  case  of  the  hip  joint,  to  make  the  extension  in  a  line 
with  the  leg  and  not  with  the  body,  so  as  to  avoid  causing  intra-articular  pressure. 
This  may  be  accomplished  by  placing  the  leg  upon  a  well-padded  horizontal  rest 
at  a  suitable  height  above  the  bed,  and  adjusting  a  weight  by  means  of  a  stirrup. 

Thomas's  knee-splint  is  no  less  valuable  than  that  devised  for  the  hip. 
It  consists  of  an  upper  ring  fitting  accurately  round  the  thigh  as  high  up 
as  possible,  and  of  a  strength  proportionate  to  the  weight  of  the  patient ; 
and  of  two  upright  iron  rods,  coming  down  one  on  each  side  of  the  leg  and 
terminating  below  in  a  patten.  These  should  be  so  long  that  no  part  of  the  foot 
can  in  any  way  touch  the  ground  when  the  splint  is  adjusted.  The  u])per  ring, 
which  is  thickly  padded  on  its  inner  side  and  behind  where  the  tuberosity  of  the 
ischium  rests  upon  it,  is  placed  at  an  angle  of  45°  with  the  inner  of  the  two 
uprights.  In  front,  where  it  lies  just  below  Poupart's  ligament,  it  is  nearly  straight, 
to  correspond  with  the  flattened  surface  of  the  front  of  the  thigh  ;  behind  it  is 
fuller;  and  at  the  outer  end,  which  lies  under  the  anterior  superior  spine,  it  is 
more  sharply  bent  than  at  the  inner.  The  outer  upright  is  attached  exactly  at 
the  mid-lateral  line ;  the  inner  one  should  be  a  little  in  front  of  it.  This  ring  is 
supported  in  jjosition  by  a  broad  strap  passing  from  front  to  back  over  the  sound 
shoulder. 

Between  the  two  uprights  there  is  a  broad  apron  of  leather  extending  from 
above  the  middle  of  the  thigh  to  below  that  of  the  leg,  so  that  the  limb  rests  on 
it,  between  the  bars.  Near  its  upper  end  there  are  two  slits,  one  on  each  side,  for 
the  bandages  that  are  used  to  fix  the  thigh.  This  part  of  the  limb  must  be  as  firm 
as  possible.  Two  bandages  are  employed,  one  for  each  bar  ;  and  each  passes  round 
the  limb  and  one  bar  first,  and  then  outside  everything,  round  splint  and  limb. 
The  object  is  to  fix  it  so  that,  when  the  patient  is  lying  down,  the  patten  below 
the  foot  can  be  raised  or  lowered,  moving  from  the  hip  joint,  without  the  knee 
experiencing  the  least  sensation.  The  leg,  which  need  not  be  fastened  so  firmly, 
is  secured  by  a  stirrup  attached  to  a  bar  at  the  bottom  of  the  splint  (but  not  with 
the  view  of  causing  extension)  as  well  as  with  side  bandages.  If  the  knee  is  much 
bent,  the  apron  cannot  be  used  ;  the  patient  must  be  kept  in  bed  with  the  patten 
supported  and  raised,  so  that  the  weight  of  the  limb  gradually  straightens  out  the 
joint.  Afterward,  when  the  position  is  better  and  the  acute  symptoms  have  sub- 
sided, a  patten  is  placed  under  the  opposite  foot  to  equalize  the  two  limbs,  and  the 
patient  is  allowed  up,  on  crutches,  resting  a  little  of  his  weight  on  the  tuberosity 
of  the  ischium. 

In  the  case  of  younger  children,  or  where  the  pressure  of  the  ring  on  the 
inner  side  of  the  thigh  causes  inconvenience,  the  limb  must  be  secured  by  leather 
splints  or  by  plaster-of-Paris,  gum  and  chalk,  or  some  other  of  the  appliances 
described  under  the  head  of  fractures,  but  they  do  not  secure  such  absolute 
rigidity. 

In  the  vast  majority  of  cases,  if  the  child  can  only  be  tided  over  a  period  of 
one  or  two  years,  a  fairly  good  result  may  be  obtained  by  this.  Splints  may  have 
to  be  worn  for  a  very  long  time  ;  the  range  of  movement  may  be  limited,  and  the 
muscles  may  waste  considerably,  but  the  growth  of  the  part  is  not  affected,  and  by 
degrees  the  risk  of  general  tuberculosis  and  of  relapses  becomes  less  and  less. 

In  the  synovial  form  elastic  compression,  by  means  of  many  layers  of  absor- 
bent wool,  may  be  tried  with  advantage;  it  helps  to  reduce  the  hyper?emia, 
promotes  absorption,  and  keeps  the  part  in  the  most  perfect  rest.  When  the 
disease  commences  in  the  bones,  especially  when  there  is  a  tendency  to  starting 
pains  at  night,  progress  may  be  checked,  for  a  time  at  least,  by  means  of  the 
actual  cautery,  applied  at  a  black  heat,  while  the  patient  is  under  an  anaesthetic. 

If  caseation  and  liquefaction  occur  in  the  synovial  membrane,  the  cavity 
should  be  tapped  and  injected  with  iodoform  emulsion  [with  antiseptic  precau- 
tions], in  the  hope  that,  if  this  mass  of  caseous  material  is  dealt  with  thoroughly, 


TUBERCULAR   DISEASE  OF  THE  ANKLE  JOINT.  6ii 

the  disease  will  cease  to  spread,  and  that  under  proper  treatment  organization  and 
cicatrization  will  progress  until  the  age  is  reached  when  the  tendency  is  for  the  tuber- 
cular process  to  come  to  an  end.  In  the  osteal  form,  when  a  tender  and  swollen 
spot  can  be  definitely  distinguished  on  one  side  of  the  joint,  unless  the  symptoms  , 
speedily  and  thoroughly  disappear,  there  should  be  no  hesitation  in  making  an 
exploratory  incision  ;  and  if  the  periosteum  is  thickened  or  separated  from  the 
comi)act  layer  of  the  shaft  by  inflammatory  effusion  or  a  deposit  of  new  bone,  it 
should  be  carried  into  the  substance  of  the  bone  beneath.  It  is  no  uncommon 
thing,  when  performing  excision  for  old  disease  of  the  knee  joint,  ankylosed  in  a 
faulty' position,  to  find  a  cavity  sometimes  containing  a  sequestrum  in  one  or 
other  of  the  bones,  communicating  with  the  interior  by  means  of  a  long,  narrow 

sinus. 

If  the  thickening  of  the  synovial  membrane  continues  to  increase  in  spite  ot 
treatment,  arthrectomy  may  be  performed,  but  it  is  an  operation  that  recpiires  the 
greatest  care.  Every  particle  of  soft  gelatinous  tissue  must  be  removed,  and 
primary  union  must  be  ensured  ;  if  suppuration  follows,  the  limb  has  nearly  always 
to  be  amputated.  A  movable  joint  can  usually  be  obtained,  but  splints  are 
required  for  many  years,  to  prevent  flexion. 

Excision  may  be  reserved  for  those  cases  in  which  the  articular  ends  of  the 
bones  are  too  much  involved,  or  in  which,  after  the  disease  has  subsided,  the  limb 
is  practically  useless,  owing  to  the  amount  of  flexion  or  of  displacement  of  the 
tibia. 

Tubercular  Disease  of  the  Ankle  Joint. 

Tubercular  inflammation  of  the  ankle  joint  usually  begins  in  the  synovial 

membrane,  but  it  may  extend  from  the  lower  end  of  the  tibia,  or  more  rarely  from 

the  fibula  or  the  astragalus.     The  general  symptoms  and  treatment  are  identical 

with  those  given  already,  but  there  are  certain  points  that  require  a  little  further 

detail. 

The  diagnois  is  often  a  matter  of  great  difficulty.  The  astragalo-scaphoid 
and  astragalo-calcanean  articulations  are  exceedingly  close,  and  if  they  are  diseased 
the  symptoms  are  almost  the  same.  Pain,  heat,  swelling,  and  limping,  caused  by 
impaired  mobility  of  the  part,  are  always  present,  and  the  greatest  care  may  be 
necessary  to  separate  disease  of  one  joint  from  that  of  the  other. 

The  swelling  is  most  characteristic  when  seen  from  behind  ;  it  takes  the  form 
of  a  soft,  puffy  fullness,  lifting  up  the  extensor  tendons  in  front,  and  occupying 
the  hollows  on  either  side  of  the  tendo-Achillis.  Special  attention  should  always 
be  paid  to  this.  Movement  may  appear  to  be  free,  but  the  foot  can  never  be  flexed 
or  extended  so  far  as  the  opposite  one.  Heat,  muscular  wasting,  pain,  and  ten- 
derness on  pressure  vary  very  greatly  in  different  cases. 

The  diagnosis  must  be  made  from  disease  of  the  neighboring  bones,  tubercular 
infiltration  of  other  joints,  and  eff"usion  into  the  sheaths  of  the  tendons  round  the 
joint.  In  many  cases,  even  when  sinuses  are  present,  it  is  almost  impossible  to 
make  certain  without  exploration. 

The  treatment  consists  in  perfect  rest,  combined  with  elastic  compression, 
until  all  the  tenderness  and  rigidity  have  subsided.  The  foot  must  be  kept  accu- 
rately at  a  right  angle  the  whole  time,  or  otherwise,  if  the  joint  does  recover  with 
a  certain  degree  of  stiff"ness,  an  operation  may  be  required  afterward  to  correct  it. 
Caseation  may  be  treated  [first  by  injection  of  iodoform  emulsion,  and  after- 
ward] by  free  incision  and  erasion  with  a  sharp  spoon,  but  arthrectomy  or  removal 
of  the  whole  synovial  surface  is  not  so  successful  as  it  is  in  the  knee.  When  the 
bones  are  involved  an  attempt  must  be  made  to  open  and  drain  the  caseating 
focus  ;  or  if  this  is  too  extensive,  and  the  disease  is  limited,  excision  may  be 
tried,  but  the  operation  is  not  a  very  successful  one  and  entails  a  protracted  con- 
valescence. Excision  of  the  os  calcis  or  astragalus  sometimes  succeeds  ;  and  if 
the  anterior  part  of  the  foot  is  perfectly  sound,  osteoplastic  resection  after  the 


6i2     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

method  of  Mikulicz  is  strongly  recommended.  The  heel,  with  the  astragalus,  os 
calcis,  and  the  soft  parts  over  them,  is  removed  entirely  ;  the  articular  surface  of 
tibia  and  fibula  above,  and  of  the  scaphoid  and  cuboid  below,  are  sawn  off,  and 
the  front  of  the  foot  is  brought  vertically  under  the  leg,  so  that  the  toes  assume 
the  position  of  extreme  equinus.  MacCormac  has  performed  this  operation  on 
several  occasions  with  a  very  good  result. 

Finally,  when  the  other  bones  of  the  tarsus  are  too  much  diseased,  or  the 
jxitient's  health  is  beginning  to  suffer,  or  suppurative  arthritis  has  set  in,  either 
Syme's  or  Tripier's  amputation  must  be  performed. 


Tubercular  Disease  of  the  Shoulder  Joint. 

Tubercular  inflammation  of  the  joints  of  the  upper  extremity  (except  per- 
haps the  carpus)  is  more  amenable  to  treatment.  The  articulations  are  smaller 
and  more  accessible  ;  they  have  not  the  same  amount  of  work  to  do,  nor  is  the 
work  so  severe  ;  and  the  patient  can  rest  them  more  easily  without  being  confined 
to  bed. 

In  the  shoulder  joint  the  inflammation  usually  commences  in  the  synovial 
membrane  ;  sometimes,  however,  the   upper   epiphysis  of  the  humerus   is  almost 

excavated  from  the  interior  by  masses  of  granulation- 
tissue.  Owing  to  the  freedom  with  which  the  scapula 
moves  upon  the  thorax,  the  joint  is  kept  at  rest,  and, 
as  pain  is  rarely  severe,  the  disease  may  almost  run  its 
course  and  lead  to  fibrous  ankylosis  without  being 
noticed.  The  movements  are  awkward,  especially 
overhand  ones  ;  there  is  a  certain  amount  of  tender- 
ness on  pressure,  chiefly  when  the  bone  is  affected  ; 
muscular  wasting  (particularly  of  the  deltoid  and 
supraspinatus)  is  very  distinct;  but  suppuration  is 
rare,  and  the  gelatinous  infiltration  is  seldom  suffi- 
ciently extensive  to  cause  much  swelling. 

The  local  treatment  simply  consists  in  jjerfect 
rest ;  even  the  fingers  should  not  be  used  until  the  ac- 
tive stage  is  passed.  If,  from  the  severity  of  the  pain 
at  night,  or  from  tenderness  on  pressure,  there  is 
a  suspicion  that  the  upper  epiphysis  is  involved,  the  actual  cautery  may  be  tried  ; 
and  if  it  continues  in  spite  of  this,  an  exploratory  incision  should  be  made  down 
and  into  the  bone  from  the  outer  side.  Necrosis  is  rare,  but  occasionally  the  head 
is  completely  eaten  away  by  fungating  caries  and  caseation.  If  suppuration  oc- 
curs in  connection  with  the  synovial  membrane  the  pus  usually  makes  its  way  under 
the  deltoid  either  to  the  front  or  the  back  of  the  joint.  Recovery  is  the  rule,  but 
even  in  the  slightest  cases  a  very  considerable  degree  of  stiffness  is  often  left ;  for- 
tunately the  use  of  the  limb  is  but  little  impaired,  and  it  is  rarely  advisable  to 
break  down  adhesions.  Erasion  and  excision  are  seldom  called  for  [but  here,  as 
elsewhere,  the  iodoform  emulsion  properly  injected  often  arrests  the  progress  of 
the  disea.se]. 


Fig. 


275. — Se(|uestnim  in    Head   of 
Humerus. 


Tubercular  Disease  of  the  Elbow  Joint. 

This  is  very  common  in  children,  and  is  usually  assigned  to  accident  ;  as  a 
rule  it  begins  in  the  synovial  membrane  ;  the  epiphyses  are  not  so  frecpiently  in- 
volved as  in  other  bones. 

The  early  symptoms  are  obscure  and  ill-defined.  There  is  a  little  fullness  on 
either  side  of  the  tendon  of  the  triceps,  the  muscles  of  the  upper  arm  are  wasted, 
complete  extension  cannot  be  carried  out,  though  the  other  movements  may  appear 
fairly  free,  and  the  joint  is  held  rigidly  flexed  at  an  angle  of  about  135°.  After  a 
little  time  the  fullness  makes  its  appearance  over  the  head  of  the  radius  on  the  outer 


TUBERCULAR   DISEASE  OF  THE   ELBOW  JOINT.         613 


side  of  the  joint  as  well ;  the  swelling  becomes  more  distinct  :  rotation  at  the 
shoulder  joint  replaces  pronation  and  supination  ;  the  temperature  of  the  skin  is 
distinctly  raised,  and  the  diagnosis  is  beyond  dispute. 

As  time  passes  the  swelling  of  the  case  is  neglected,  grows  larger  and  larger 
until  the  joint  is  completely  involved  in  a  spindle-shaped  mass  the  size  of  which 
is  exaggerated  by  the  wasting  of  the  muscles  ;  caseation  sets  in  and  is  followed 
by  li([uefaction  ;  the  skin  becomes  thin  and  undermined  ;  and  at  length  the  ab- 
scesses break  externally,  leaving  sinuses  filled  with  a  mass  of  soft,  pulpy  granula- 
tion tissue.  Finally  suppuration  occurs  and  the  pus  makes  its  way  into  the 
synovial  cavity,  destroying  utterly  the  cartilages  and  bones,  which  are  already  in 
great  measure  eroded  and  replaced  by  the  tubercular  deposit. 

If  the  treatment  is  commenced  at  once,  recovery  may  be  looked  forward  to 
with  a  fair  range  of  movement.  The  joint  must  be  enveloped  in  cotton-wool  and 
fixed  with  plaster- of- Paris  or  gum  and  chalk,  so  that  not  the  slightest  movement 
is  possible  Scott's  dressing  may  be  applied  underneath  for  a  week  or  two,  but 
care  must  be  taken,  especially  in  children,  that  it  does  not  irritate  the  skin  too 
much.  If  this  is  kept  up  for  some  months,  the  splints  being  changed  as  often  as 
necessary,  the  inflammatory  exudation  disappears,  and  though  the  muscles  waste 
considerably  the  joint  is  rarely  much  stiffened  or  seriously  reduced  in  strength. 

When  the  case  is  not  seen  until  the  disease  is  further  advanced  the  same 
treatment  should  be  tried,, 
but  the  hope  of  success  is 
not  nearly  so  good  ;  at  the 
best  a  large  amount  of  the 
exudation  must  become  or- 
ganized, leaving  the  joint 
more  or  less  rigid  ;  and  for 
this  reason  it  is  essential  to 
maintain  the  flexed  posi- 
tion. When  abscesses  make 
their  appearance  they  must 
be  opened  and  drained,  or 
if  they  are  limited  in  size 
and  the  tissues  round  them 
are  fairly  firm,  they  may 
be  thoroughly  scraped  out 
and  filled  with  iodoform. 
Finally,  excision  may  be 
performed,  either  with  the 

view  of  removing  the  whole  tubercular  mass,  and  therefore  during  the  course  of 
the  disease,  or  afterward,  for  ankylosis  in  a  faulty  position,  especially  as  the  results 
of  this  operation  are  exceedingly  good  even  in  the  case  of  children. 


Fig.  276. — Disease  of  Elbow  Joint. 


Tubercular  Disease  of  the  Wrist  Joint. 

Disease  of  the  wrist  may  begin  either  in  the  bones  or  the  synovial  membrane, 
probably  in  the  former  the  more  frequently  of  the  two ;  but,  whichever  it  is,  it 
very  soon  extends  until  the  whole  of  the  articulation  is  involved.  Certainly  the 
majority  of  cases  that  I  have  seen  have  occurred  after  puberty,  and  many  of  them 
late  in  life. 

The  symptoms,  as  in  tubercular  arthritis  generally,  are  peculiarly  insidious. 
Limitation  of  movement  is  hard  to  detect,  but  it  is  usually  present ;  wasting  of  the 
muscles  of  the  forearm  is  one  of  the  earliest  signs,  and  a  characteristic  ill-defined 
swelling,  which  runs  transversely  over  the  dorsum  of  the  wrist,  obliterating  the 
distinctness  of  the  different  tendons.  At  the  same  time  there  is  a  sense  of  weak- 
ness, the  hand  is  rested  whenever  there  is  a  chance,  the  joint  is  unconsciously 
flexed  and  slightly  adducted,  and  the  temperature  of  the  part  is  distinctly  raised, 


6i4    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

1)ut  pain  is  seldom  present.  If  the  case  is  left  to  itself  the  ordinary  conseciuences 
— caseation,  licpiefaction,  and  suppuration — make  their  ap|)earance  sooner  or  later. 
Like  the  same  disease  when  it  affects  other  joints,  tubercular  arthritis  of  the 
wrist  in  its  early  stages  is  very  amenal)le  to  treatment,  provided  it  is  carried  out 
thoroughly,  locally  and  constitutionally.  The  joint  must  be  [injected  with  iodo- 
form emulsion  and]  kept  upon  a  splint,  with  even,  equable  ]jressure  all  round  it, 
and  not  even  a  finger  allowed  to  move  for  months,  until  the  heat  and  swelling 
have  entirely  subsided  ;  and  even  then  it  must  be  well  guarded  for  fear  of  relapse. 
In  the  later  ones,  when  caseation  and  caries  have  occurred,  more  good  may  be 
done  in  the  same  way,  laying  open  and  scraping  out  sinuses  and  removing  carious 
portions  of  bone  from  time  to  time,  than  by  any  formal  excision. 


LOOSE  BODIES  IN  JOINTS. 

Loose  bodies  of  various  kinds  are  occasionally  met  with  in  the  interior  of 
joints,  giving  rise  to  peculiar  and  very  characteristic  symptoms. 

Some  of  them  are  like  the  melon-seed  bodies  found  in  bursee  and  ganglions, 
mere  concretions  of  fibrin  which  swell  up  on  the  addition  of  acetic  acid,  so  as  to 
become  almost  translucent,  and  show  no  other  sign  of  structure  than  a  faint  con- 
centric marking  round  a  granular  nucleus. 

Whether  blood  effused  into  the  cavity  of  the  joint  can  give  rise  to  loose 
bodies  is  somewhat  doubtful ;  but  there  is  no  (]uestion  that,  sometimes  at  least, 
they  originate  as  extravasations  in  synovial  villi,  which  later  become  pedunculated 
and  fall  off  into  the  synovial  cavity. 

By  far  the  majority  of  these  growths  begin  in  the  villi  wliicli  are  so  common 
round  the  margins  of  the  articular  cartilages,  where  the  synovial  membrane  is 
reflected  upon  itself,  and  are  the  result  either  of  injury  or  of  slight  degrees  of 
osteo-arthritis.  This  may  account  for  the  fact  that  they  occur  so  freijuently  in 
young  adults,  and  in  the  knee,  which  surpasses  all  other  joints  of  the  body  to  such 
an  extent  in  the  size  of  its  synovial  membrane  and  the  range,  variety,  and  im- 
mense leverage  of  its  movements.  The  little  projection,  once  formed,  continues 
to  enlarge  ;  cartilage  corpuscles,  which  are  so  often  met  with  in  this  situation  that 
they  must  almost  be  regarded  as  normal,  make  their  appearance  in  the  end  ;  and 
at  length  it  assumes  the  form  of  a  more  or  less  rounded  body,  suspended  by  a 
narrow  neck  of  fibrous  tissue  which  may  easily  be  torn  across  on  any  sudden  move- 
ment. True  bone  is  not  unfrequently  developed  in  the  interior  of  the  larger  ones, 
the  cartilage-corpuscles  immediately  round  the  osseous  nucleus  being  ranged  in 
vertical  columns,  and  those  near  the  surface  flattened  out,  just  as  they  are  in  the 
normal  hyaline  cartilage  at  the  end  of  a  bone.  One  of  the  most  common  situa- 
tions is  in  the  inter-condyloid  notch  of  the  femur  ;  and  then,  unless  it  is  dislodged, 
in  process  of  time  the  abnormal  growth  wears  out  a  bed  for  itself,  so  that  it 
acquires  the  appearance  of  a  portion  of  the  articular  surface  broken  away  from 
the  rest.  As  the  cartilage  is  not  unfrequently  worn  away  from  one  side  of  it, 
leaving  the  bone  exposed,  the  resemblance  is  exceedingly  close.  Hum[)hry,  how- 
ever, has  shown  that,  although  this  may  possibly  have  happened  in  one  or  two 
instances  as  the  result  of  a  violent  wrench,  there  is  no  proof  of  its  ever  having 
followed  a  blow.  Even  those  that  contain  bone  are  nearly  always  developed  from 
villi  ;  they  lie  latent  for  years,  slowly  increasing  in  size  and  becoming  more 
complex  in  structure ;  then  suddenly  they  are  dislodged  from  the  cavity  they  have 
worn  for  themselves,  and  it  is  imagined  they  are  just  broken  off.  Their  structure 
is  not  identical  with  that  of  the  articular  border.  A  certain  amount  of  fibro- 
cartilage  can  always  be  found  as  well  as  true  cartilage,  and  usually  there  is  some 
trace  of  it  on  that  surface  which  has  apparently  been  se]')arated  from  the  bone  by 
fracture.  The  osseous  nucleus  is  irregular  in  outline,  the  bone  development  im- 
perfect, and  the  size  often  greater  than  that  of  the  cavity  from  which  it  seems  to 
have  been  broken  out,  so  that  when  fitted  in  it  rises  above  the  surrounding  level. 


LOOSE  BODIES  IN  JOINTS.  615 

In  exceptional  cases  loose  bodies  are  derived  from  other  sources.  Osteophytes, 
for  example,  are  sometimes  accidentally  detached  from  the  margin  of  a  bone 
affected  with  osteo-arthritis.  Portions  of  the  semilunar  cartilages  are  torn  off. 
In  one  instance  the  nucleus  was  found  to  be  the  point  of  a  needle.  In  another 
there  was  a  pedunculated  sarcoma.  Fatty  outgrowths,  almost  detached,  are  not 
uncommon,  and  Paget,  Teale,  and  others  have  described  a  process  of  (luiet  necro- 
sis, in  which  pieces  of  the  articular  cartilage,  with  or  without  a  portion  of  the 
underlying  bone,  exfoliate  after  injury,  and  drop  into  the  joint,  without  causing 
any  of  the  symptoms  usual  under  such  circumstances. 

As  a  rule  foreign  bodies  are  single,  especially  when  they  occur  after  injury  ; 
in  cases  of  osteo-arthritis  there  may  be  any  number.  For  the  most  part  the  size  is 
small,  but  they  have  been  met  with  as  large  as  the  patella  and  even  larger. 

Symptoms. — A  certain  degree  of  uneasiness  and  weakness,  caused  by  the 
increased  synovial  effusion,  is  usually  present  when  there  is  a  foreign  body,  whether 
it  is  loose  in  the  anterior  of  the  joint  or  floating  at  the  end  of  a  pedicle  ;  but  the 
most  striking  effect  is  produced  when  it  is  caught  between  the  bones.  The  patient, 
while  in  the  act  of  walking,  is  suddenly  seized  with  the  most  intense  pain  ;  all 
power  of  the  limb  is  lost  and  he  drops  to  the  ground,  very  often  sick  or  fainting  ; 
it  has  slipped  between  the  articular  ends,  and,  as  the  limb  is  straightened  it  acts 
as  a  wedge,  forcing  them  apart,  straining  all  the  ligaments,  and  crushing  the 
cartilages.  If  it  is  fairly  caught  and  held,  the  joint  is  locked  and  cannot  be  used 
again  until  the  body  slips  out  or  is  dislodged  by  manipulation  ;  if,  as  it  usually 
does,  it  just  escapes,  the  patient  is  able  to  move  the  limb  after  the  pain  has  sub- 
sided :  but  in  either  case  the  synovial  cavity  rapidly  becomes  filled  with  fluid,  and 
an  attack  of  acute  synovitis,  similar  to  that  following  any  kind  of  sprain,  sets  in. 
Generally  speaking,  the  patient  soon  becomes  aware  of  the  presence  of  a 
loose  body,  and  very  often  is  able  to  find  it  by  a  little  manipulation.  The  most 
common  situation  in  the  case  of  the  knee  is  on  the  outer  side  of  the  joint,  just 
above  the  condyle  ;  sometimes  they  can  be  felt  at  once,  at  other  times  only  with 
the  greatest  difficulty  and  after  repeated  examination,  and  they  slip  aside  again  as 
soon  as  they  are  fomd.  If  they  are  left,  they  may  remain  latent  for  months 
without  causing  a  fresh  attack  ;  or  they  may  be  caught  every  day,  and  even  several 
times  a  day.  After  a  time  the  repeated  attacks  of  synovitis  lead  to  degeneration 
of  the  synovial  membrane;  it  becomes  thickened  and  covered  over  with  fringes  ; 
chronic  synovitis  sets  in,  and  the  attacks  are  felt  with  less  severity,  but  the  condi- 
tion of  the  joint  is  practically  irremediable. 

Hypertrophied  fringes  in  osteo-arthritis,  pedunculated  masses  of  fat  project- 
ing from  the  ligamenta  alaria  or  mucosum,  and  displaced  or  elongated  semilunar 
cartilages,  give  rise  to  symptoms  of  the  same  character  but  less  intensity.  In  the 
end,  however,  the  synovial  membrane  of  the  joint  becomes  disorganized  in  the 
same  way  ;  movement  becomes  restricted  and  painful ;  and  walking  is  almost  im- 
possible from  the  feeling  of  insecurity. 

Treatment. — If  the  joint  is  locked  the  loose  body  must  be  dislodged  by  ap- 
propriate manipulation,  and  the  effusion  that  follows  checked  by  cold  and  jjressure. 
As  soon  as  the  inflammation  has  subsided  an  attempt  must  be  made  to  find  the  body 
(for  which  the  assistance  of  the  patient  is  usually  necessary)  and  fix  it  in  some  out- 
lying or  superficial  part  of  the  joint.  A  very  convenient  way  of  doing  this  is  to 
envelope  the  joint  in  a  sheet  of  chamois  leather  spread  with  lead  plaster,  placed 
behind  the  limb,  and  then  carefully  brought  up  on  each  side  of  it.  If  this  can  be 
done  the  patient  is  safe  for  the  time. 

Except,  perhaps,  in  the  case  of  advanced  osteo-arthritis,  or  when  the  synovial 
membrane  is  covered  all  over  with  masses  of  vill,  there  is  no  doubt  loose  foreign 
bodies  should  be  removed  as  soon  as  possible  ;  and  the  same  may  be  said  of  many 
pedunculated  ones  when  they  can  be  isolated,  as  by  their  presence  they  merely 
tend  to  induce  the  same  changes  in  the  rest  of  the  synovial  lining,  until  at  length 
its  condition  becomes  hopeless.  The  operation,  if  due  precaution  is  taken  to 
ensure  absolute  cleanliness,  is  exceedingly  successful. 


6i6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

The  limb  should  be  i)laced  upon  a  splint  for  at  least  forty-eight  hours  before, 
in  order  that  the  patient  may  become  accustomed  to  it  ;  the  confinement  alone  is 
sufficient  in  many  cases  to  cause  a  certain  degree  of  feverishness.  The  skin,  in- 
struments, hands,  etc.,  should  be  thoroughly  cleansed  with  an  antisej^tic ;  the 
foreign  body  fixed,  either  between  the  finger  and  thumb,  or  by  driving  through  it 
a  straight  needle  and  pinning  it  down  to  the  bone  (I  have  known  it  escape  even 
then)  and  an  incision  made  down  on  to  it  so  that  it  may  be  squeezed  out  without 
manipulation.  A  catgut  suture  should  be  used  to  unite  the  synovial  membrane  ; 
all  hemorrhage  stopped  ;  the  edges  of  the  wound  brought  accurately  together  ; 
some  iodoform  dusted  over  the  incision,  and  the  limb  replaced  upon  the  splint  and 
thoroughly  i)acked  all  round  so  that  there  can  be  no  hyperaimia  or  exudation.  This 
should  be  left  for  a  week  ;  at  the  end  of  that  time  the  wound  is  healed  ;  the  splint 
may  be  left  off  and  the  patient  allowed  to  move  the  limb  in  bed,  although  the 
joint  usually  requires  support  for  some  time  longer.  When  there  are  a  number  of 
loose  bodies  this  is  impracticable  and  the  joint  must  be  laid  freely  open  and  washed 
out.  If  any  one  of  them  is  pedunculated,  the  incision  should  be  made  over  it  as 
nearly  as  possible,  so  as  to  get  at  the  pedicle  and  divide  it. 

Formerly  an  indirect  method  was  occasionally  employed.  The  synovial  cap- 
sule of  the  joint  was  divided  subcutaneously  with  a  long  tenotomy  knife,  and  an 
attempt  made  to  force  the  cartilage  through  the  opening  into  the  subcutaneous  cel- 
lular tissue,  in  which  it  would  be  left,  either  permanently  or  until  the  wound  in 
the  joint  had  healed.  The  operation,  however,  is  very  much  more  difficult  to 
perform,  and  it  has  not  been  shown  to  possess  any  advantage  in  the  way  of  safety. 


ANKYLOSIS. 

Ankylosis  in  the  strict  sense  of  the  term  signifies  the  angular  position  of  a 
joint;  but  this  meaning  has  long  since  been  lost,  and  now  it  is  used  indiscrimi- 
nately for  articulations  that  have  become  stiff  from  organic  changes  in  the  struc- 
tures immediately  around  them  without  reservation  as  to  angle.  It  may  be 
l)ony  or  fibrous,  and  the  latter  may  be  either  intra  or  extra-articular,  although 
clinically  it  is  often  difficult  to  distinguish  one  from  the  other  ;  but  the  term  is  not 
applicable  to  cases  in  which  the  limitation  of  movement  is  clue  to  the  contraction 
of  structures  not  directly  connected  with  the  joint  (the  cicatrices  of  burns,  for 
example,  or  the  degeneration  of  distant  muscles),  or  those  in  which  the  cause 
is  merely  muscular  spasm  that  disappears  at  once  under  an  anjesthetic. 

The  distinction  between  true  and  false  ankylosis  should  be  dropped.  The 
latter  is  used  by  some  for  simple  muscular  contraction,  while,  by  others,  it  is  re- 
stricted to  cases  in  which  there  are  definite  organic  changes  in  the  tissues  outside 
the  capsule. 

Causes. — Ankylosis  is  in  most  cases  the  product  of  inflammation  ;  but  any- 
thing that  impairs  the  nutrition  of  a  joint  for  any  length  of  time — prolonged  con- 
finement, for  example,  in  one  position,  or  section  of  the  nerves  going  to  it — is 
liable  to  produce  it.  Perfect  movement  naturally  cannot  take  place  without 
perfect  nutrition,  so  that  a  certain  degree  of  stiffness  is  intelligible  under  these  con- 
ditions ;  but  it  is  difficult  to  explain  the  bony  union  which  has  been  known  to 
occur. 

The  degree  of  rigidity  depends  to  some  extent  upon  the  character  of  the  inflam- 
mation (chronic  rheumatism,  for  example,  has  a  special  tendency  toward  organiza- 
tion and  rigidity),  but  much  more  upon  the  de])th  to  which  the  tissues  of  the  joint 
are  involved.  In  sprains  the  loose  and  soft  cellular  tissue  outside  the  capsule,  the 
ligaments  and  surrounding  muscles,  usually  suffer  most,  so  that  the  chief  obstruc- 
tion is  extra-articular  ;  the  interior  of  the  synovial  cavity  may,  it  is  true,  be  filled 
with  blood  ;  but,  except  in  those  cases  in  which  it  becomes  organized  as  a  lining 
membrane,  it  seldom  causes  any  after-trouble.  Chronic  rheumatism  attacks  the 
fibrous  structures  chiefly,  so  that  the  capsule,  ligaments,  fasciae,  and  tendon  sheaths 


ANKYLOSIS.  617 

aroniul  are  weldccl  together  into  rigiil,  unyiehlin<,f  l)ands.  In  urethral  arthritis  and 
the  acute  form  of  osteo-arthritis,  intra-articular  changes  generally  occur  as  well 
the  cartilages  undergoing  fil)rous  degeneration  at  their  margins  and  growing  together 
so  as  in  great  measure  to  obliterate  the  cavity.  Sometimes  the  union  is  so  firm 
that  it  is  almost  impossible  to  believe  it  is  not  osseous.  Tubercular  arthritis  pre- 
sents every  grade  of  ankylosis.  If  the  disease  is  limited  to  one  part  of  the  capsule, 
or  to  the  periarticular  tissues,  the  rigidity  is  comparatively  slight.  If  the  ligaments 
have  been  softened  and  have  contracted  again,  and  if  the  margins  of  the  cartilages 
have  been  invatled  by  granulations  springing  from  the  synovial  folds,  the  range  of 
movement  is  much  more  restricted  ;  but  if  the  disease  has  progressed  further  still 
before  repair  and  organization  began,  and  the  surface  of  the  cartilages  has  been 
destroyed  and  the  bones  laid  bare,  the  rigidity  becomes  absolute  ;  dense  intra- 
articular adhesions  pass  across  the  joint  in  all  directions,  and  not  unfrequently  as 
time  passes  become  converted  into  bone.  The  same  thing  occurs  in  suppurative 
arthritis  ;  if  the  cartilages  are  preserved,  and  the  disease  is  limited  to  the  capsule 
and  the  periarticular  tissues,  a  fair  range  of  movement  may  be  regained  ;  but  if 
once  the  ends  of  the  bones  are  laid  bare  and  become  carious,  osseous  ankylosis,  or 
union  by  such  dense  fibrous  tissue  that  it  can  scarcely  be  distinguished  from  it,  is 
almost  certain. 

Prolonged  confinement  in  certain  positions  may  cause  serious  stiffness,  and 
in  one  or  two  instances  has' resulted  in  total  obliteration  of  the  joint  cavity.  As, 
however,  the  limbs  in  young  children  are  often  held  rigidly  fixed  for  years  together 
without  any  such  result,  rest  is  probably  not  the  only  factor.  It  is  most  frequent 
in  connection  with  the  finger  joints  and  in  patients  who  are  already  past  middle 
life  ;  the  application  of  a  straight  splint  in  such  cases,  even  for  a  week  or  two,  may 
be  followed  by  a  degree  of  rigidity  that  requires  as  many  months  before  it  disap- 
pears ;  and  this  may  occur  without  injury  of  any  kind  and  in  the  entire  absence  of 
evidence  of  gout  or  rheumatism.  Over-extension,  causing  slight  but  persistent 
tension  upon  one  part  of  the  capsule,  may  be  the  cause  ;  the  irritant  is  a  feeble  one, 
but  it  may  be  sufficient,  under  the  conditions,  to  impair  the  nutrition  of  the  tis- 
sues and  make  them  dense  and  rigid,  unable  to  yield  on  one  side  or  bend  upon 
the  other.  The  same  thing  has  been  noted  on  several  occasions  after  nerve  section. 
After  sprains  and  other  injuries  when  the  tissues  are  filled  with  extravasated 
blood,  and  in  patients  who  are  subject  to  attacks  of  rheumatic  gout,  prolonged 
repose  without  massage  or  passive  motion  is  almost  certain  to  cause  some  degree  of 
fibrous  ankylosis.  The  lymph  that  fills  the  softened  synovial  folds  becomes  organ- 
ized into  dense  cicatricial  tissue  ;  the  capsule  grows  hard  and  thick  ;  the  ligaments 
shorten  and  become  rigid  ;  the  tendons  are  glued  to  their  sheaths  ;  and  all  the  peri- 
articular tissues  are  matted  together.  In  a  few  instances  the  change  is  not  limited 
to  this ;  the  cartilages  become  fibrous,  and  fuse  where  they  are  in  contact  with 
each  other ;  intra-articular  adhesions  are  formed  as  well;  and  sometimes  even 
bony  ankylosis  follows. 

The  pathological  changes  in  a  case  of  ankylosis  are  the  result  partly  of  in- 
flammation, partly  of  atrophy.  When  there  is  bony  union,  the  fusion  may  be  so 
complete  that  even  the  site  of  the  joint  cavity  can  no  longer  be  traced.  The 
trabecular  are  arranged  as  uniformly  and  as  regularly  along  the  lines  of  pressure  as 
if  the  joint  had  never  existed  at  all  (Fig.  277).  The  muscles  undergo  fatty  degen- 
eration and  waste  away  ;  the  ligaments  disappear  or  become  ossified  ;  and  no  sign 
of  capsule,  synovial  membrane,  or  cartilage  is  left ;  there  is  merely  an  irregularly 
thickened  fibrous  mass  surrounding  the  periosteum  where  the  joint  originally  was. 
In  the  fibrous  form  the  wasting  is  less  marked,  depending  upon  the  range  of 
movement  left ;  but  in  those  cases  of  intra-articular  ankylosis  in  which  the 
greater  part  of  the  cavity  of  the  joint  is  filled  up  by  short,  dense,  fibrous  bands, 
mixed  here  and  there  with  cartilage  cells,  the  difference  is  very  slight.  P^ven  when 
the  change  falls  short  of  this  the  capsule  is  thickened  and  rigid,  especially  along 
the  inner  side  of  the  joint  where  it  is  thrown  into  folds  when  the  limb  is  flexed  ; 
the  ligaments  contracted  ;  the  fibrous  tissue  around  converted  into  a  dense  un- 
40 


6i8     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


Fi&.  277. —  Osseous  Ankylosis  of  Elbow  Joint. 


yielding  mass  ;   the  cartilages  wasted  and  thinned  ;    the   tendons  glued   to   their 
sheaths  ;  and   the  skin  bound  tightly  down  by  the  wasting  of  the  cellular  tissue 

beneath,  as  if  it  were  shrunken  on  to  all 
the  bony  prominences.  Sometimes  all 
these  changes  exist  together  ;  sometimes 
there  is  only  a  single  adhesion  inside  the 
joint  cavity,  the  tip  of  a  synovial  fringe 
for  example.,  tied  down  by  a  fibrous 
band  to  some  distant  part  of  the  cap- 
sule ;  and  often  it  is  impossible  to  say 
what    the   condition    of    the    joint    may 

I^Bl^^^^  ^^^'  ^"*^  ^^*^^^    ^^'^  ^^  ^^  involved,  without 

♦♦33^BSPjfts>v«  placing  the  patient  under  an  anaesthetic 

and  ascertaining  the  range  of  movement 
and  the  strength  of  the  obstacles  that 
prevent  it. 

Diagnosis.  —  Bony  ankylosis   can 

;nosed  by  the  extreme  mus- 

and  the  entire  absence  of 

the  part  is  roughly  man- 

iig^^^~^u^f^^^iii~Z,.Ll^V^-„-_i     iljulated.      it  there  is  the  least  degree  of 

mobility  left,  too  small  to  be  appreciated 
by  the  hand,  the  muscles  round  the  joint 
involuntarily  start  into  spasmodic  con- 
traction as  .soon  as  any  force  is  used  ;  with  bony  ankylosis  they  remain  absolutely 
flaccid.  The  distinction  between  intra-  and  extra-articular  rigidity  turns  rather 
upon  the  cause  than  upon  any  symptom  that  may  be  present  ;  it  is  rarely  possible 
to  be  certain,  but  probably  the  former  is  seldom  met  with  by  itself. 

Treatment. — Bony  Ankylosis. — In  many  cases  this  is  the  best  result  that  can 
be  obtained  under  the  circumstances,  and  provided  the  position  is  good,  it  should 
not  be  touched.  If,  for  example,  the  elbow  is  flexed  to  a  right  angle  (or  prefer- 
ably a  little  less)  the  hand  can  be  used  for  all  ordinary  purposes  with  perfect  free- 
dom ;  when  it  is  more  open,  so  that  the  fingers  cannot  be  brought  to  the  mouth, 
it  becomes  a  question  whether  excision  should  not  be  performed.  The  hip  and 
knee  when  nearly  straight  impair  the  power  of  the  limb  very  little,  although  the 
gait  is  awkward  ;  if,  however,  they  are  much  flexed,  excision  (removing  a  wedge- 
shaped  piece)  should  be  performed  in  the  one  case,  osteotomy  (either  through  the 
neck  or  below  the  trochanter)  in  the  other.  In  the  case  of  the  shoulder,  ankle, 
and  fingers,  neighboring  joints  compensate  so  thoroughly  that  active  treatment  is 
rarely  necessary.  Bony  ankylosis  of  the  temporo-maxillary  artictdation,  on  the 
other  hand,  naturally  cannot  be  left. 

Fibrous  Ankylosis. — The  function  of  the  part  maybe  restored,  or  at  least  im- 
proved, by  stretching  the  adhesions,  or  forcibly  breaking  them  down.  Nothing, 
however,  may  be  attempted  so  long  as  there  is  the  least  degree  of  inflammation  ; 
it  would  merely  cause  a  fresh  attack,  the  danger  that  is  feared  the  most. 

The  probability  of  inflammation  depends  chiefly  upon  the  nature  of  the 
original  cause.  If  this  was  traumatic — if,  for  example,  the  joint  was  sprained  or 
dislocated,  and  the  injury  repaired  at  once — the  risk  is  exceedingly  small  ;  break- 
ing an  adhesion  across,  once  for  all,  in  a  healthy  person,  is  not  more  likely  to 
cause  inflammation  than  breaking  a  bone.  If,  on  the  other  hand,  it  was  consti- 
tutional, whether  due  to  gout,  rheumatism,  tubercle,  or  any  other  cause,  and  the 
same  diathesis  is  present  still,  there  is  no  question  that  violent  manipulation  may 
be  followed  by  very  serious  results.  Fortunately,  even  in  these  cases,  the  predis- 
posing causes  are  not  always  of  the  same  intensity  ;  gout  and  rheumatism,  for  ex- 
ample, admit  of  being  alleviated  ;  and,  especially  in  the  case  of  joints  and  bones, 
the  susceptibility  to  tubercle  is  of  limited  duration  ;  so  that,  by  selecting  a  i)roper 
time,  when  the  general  health  is  good  and  the  skin  over  the  affected  joint  perfectly 


EXCISION  OF  JOINTS.  619 

cool,  and  by  adopting  suitable  precautions  before  and  after,  a  very  great  deal  may 
be  effected  in  the  vast  majority  of  instances,  with  the  minimum  of  risk. 

The  other  question,  whether  the  adhesions  should  be  broken  down  once  for 
all  (under  an  annesthetic  if  necessary),  or  gradually  stretched  little  by  little  until 
they  give  way  sufficiently  to  allow  free  movement,  is  more  easy.  This  depends 
almost  entirely  upon  their  e.xtent.  If  they  are  small  and  few  in  number,  or  if  they 
are  so  situated  that  they  can  be  taken  one  by  one — round  the  capsule  of  a  joint, 
for  example — and  snapped  acro.ss  by  successive  rapid  action,  the  chance  of  inflam- 
mation following  is  very  much  less  than  if  they  are  strained  each  day  by  the 
application  of  some  continuous  force,  and  recovery  is  more  perfect.  It  is  mainly 
owing  to  their  skill  in  localizing  lesions  of  this  kind,  in  the  neighborhood  of  joints, 
and  to  the  experience  they  have  gained  in  the  necessary  manipulation,  that  bone- 
setters  have  acquired  so  great  reputation  with  many  people,  in  spite  of  their  fre- 
quent failures,  and  in  not  a  few  cases  disastrous  results.  Very  little,  on  the  other 
hand,  can  be  done  in  this  way  in  the  case  of  the  short  and  dense  intra-articular 
adhesions  that  form  after  suppuration  or  advanced  tubercular  disease.  These  may 
be  stretched  to  a  certain  extent  by  continued  traction  so  as  to  alter  the  position  of 
the  limb  if  that  is  faulty;  but,  as  a  rule,  any  attempt  at  restoring  mobility  by  more 
active  measures  is  only  too  likely  to  end  in  failure. 

Tenotomy  is  rarely  required  in  cases  of  fibrous  ankylosis,  except  for  distant 
tendons  or  thickened  portions  of  the  fascia  that  have  undergone  passive  contrac- 
tion. The  punctures  should  always  be  allowed  to  heal  soundly  before  the  least 
manipulation  or  extension  is  attempted  for  fear  of  the  skin  giving  way. 

Whichever  plan  is  adopted,  it  must  always  be  remembered  that  tearing, 
stretching,  or  cutting  the  resisting  bands  is  only  half  the  cure.  Owing  to  pro- 
longed rest,  all  the  structures  around  the  joint  are  wasted,  stiffened,  and  incapable 
of  work,  and,  after  all  gross  mechanical  obstacles  have  been  removed,  these  must 
be  brought  into  a  thorough  state  of  nutrition  before  they  can  be  expected  to  work 
freely  and  painlessly.  The  joint  must  be  well  steamed  and  douched  ;  all  the 
tissues  kneaded  thoroughly  and  well  rubbed  with  oil ;  the  muscles  manipulated 
and  stretched  ;  and  passive  and  what  are  known  as  resistive  movements  assiduously 
practiced. 


SECTION  VI.— EXCISION  OF  JOINTS. 

By  excision  is  understood  the  formally-planned  removal  of  more  or  less  of  the 
articular  surfaces  of  a  joint,  not  merely  the  synovial  membrane  (erasion)  or  the 
part  that  is  obviously  diseased.  It  may  be  required  either  for  injury  (this  is  some- 
times distinguished  as  primary  excision),  disease,  or  deformity. 

{a)  In  cases  of  injury,  excision  is  performed  as  an  alternative  to  amputation. 
Except  at  the  hip  joint,  it  is  the  more  serious  operation  of  the  two,  entailing  pro- 
longed confinement,  and  should  not  be  preferred  unless  the  age  and  constitution 
of  the  patient  (particularly  the  state  of  the  kidneys)  are  favorable.  It  is  essential 
that  the  main  blood-vessels  and  nerves  of  the  part  should  be  intact,  and  the  skin 
not  too  much  bruised. 

(J))  For  Disease. — Tubercular  arthritis  is  the  most  frequent  cause,  osteo- 
arthritis an  exceptional  one,  and  other  forms  of  disease  still  more  rare.  For  it  to 
succeed,  the  inflammation  must  be  chronic  or  past ;  the  age  of  the  patient  suit- 
able ;  the  viscera  sound  fwithout  amyloid  degeneration,  or,  at  the  very  most,  a  sus- 
picion of  it)  ;  the  bone  not  too  extensively  diseased  (if  the  epiphyses  are  cut  away 
the  growth  and  utility  of  the  limb  are  so  much  impaired  as  to  raise  the  question 
whether  amputation  would  not  have  been  better)  ;  and  all  the  soft  parts  involved 
capable  of  free  removal. 

{/)  For  Deformity. — This  may  be  the  result  of  injury,  or  of  antecedent  in- 
flammation— septic,  tubercular,  or  rheumatic — or  in  some  rare  cases  it  may  be  con- 
genital.    The  question  here  is    an  entirely  different    one,   depending  upon  the 


620     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

utility  of  the  joint  in  its  deformed  position  ;  the  probable  utility  of  the  part  after 
excision,  judging  from  previous  exj^erience  ;  and  the  possibility  of  rectifying  the 
deformity  more  or  less  completely  by  some  less  serious  operation,  such  as  subcu- 
taneous osteotomy. 

General  Principles. — The  soft  parts  are  incised  in  such  a  way  as  to  expose  the 
interior  of  the  joint  with  the  minimum  of  injury  to  the  structures  around.  The 
epiphysial  lines  must  be  kept  intact.  How  much  bone  is  taken  away  (beyond  that 
which  is  diseased)  is  regulated  by  the  kind  of  union  that  is  required,  bony  or 
fibrous.  The  whole  of  the  disease  must  be  removed  ;  if  there  are  outlying  sin- 
uses or  tubercular  foci  in  the  bones,  they  must  be  thoroughly  scraped  out.  Perfect 
drainage  must  be  provided  for,  and  the  dressing  and  splints  must  be  arranged  so 
as  to  keep  the  part  at  rest  and  exert  sufficient  pressure  upon  it,  while  at  the  same 
time  they  admit  of  being  changed,  if  required,  with  the  minimum  of  disturbance. 
Passive  motion,  if  enough  bone  has  been  taken  away,  need  not  be  commenced 
until  the  wound  is  practically  sound  ;  but  where,  as  in  the  case  of  the  wrist, 
tendons  that  move  other  joints  have  been  exposed  and  handled,  these  should  be 
worked  after  the  first  day  in  order  to  prevent  the  formation  of  adhesions. 

The  preservation  of  the  periosteum  is  only  to  be  attempted  when  a  great  re- 
production of  bone  is  advisable.  If  the  bones  are  soft  and  inflamed,  as  in  most 
instances  of  tubercular  arthritis,  its  separation  presents  no  difficulty,  but  in  pri- 
mary excisions  it  adheres  so  closely  that  very  often  it  is  too  much  bruised  to  live. 

In  cases  of  fibrous  union  and  when  movement  is  desired,  massage,  shampooing, 
and  galvanism  should  be  commenced  as  soon  as  possible.  The  muscles  and  nerves 
are  atrophied  from  prolonged  disuse,  the  circulation  through  the  limb  is  very  feeble, 
and  it  requires  much  time  and  patience  to  bring  back  the  part  to  its  normal  state 
of  nutrition. 

EXCISION  OF  SPECIAL  JOINTS. 

I.   The  Upper  Extremity. 
Excision  of  the  Shoulder  Joint. 

This  may  be  required  for  injury  or  disease.  Ankylosis  is  compensated  for  so 
thoroughly  by  the  mobility  of  the  scapula  that  it  is  a  question  whether  operation 
is  advisable.  It  has  also  been  performed  for  unreduced  dislocation  in  which  the  head 
of  the  bone  was  resting  upon  the  brachial  plexus,  and  for  tumors  in  connection 
with  the  upper  extremity  of  the  humerus. 

{a)  Injury. — In  this  case  the  operation  merely  consists  in  removing  com- 
minuted, displaced,  and  detached  fragments  of  bone  through  the  wound  (enlarg- 
ing it  if  necessary),  cleansing  the  cavity  thoroughly,  and  providing  free  drainage. 

{b)  Disease. — Tubercular  osteitis  of  the  head  of  the  humerus,  involving  the 
synovial  lining  secondarily  and  spreading  to  the  glenoid  fossa,  is  the  most  fre- 
quent cause  ;  but,  even  in  this,  expectant  treatment,  removing  carious  or  necrosed 
fragments  of  bone  and  scraping  out  old  sinuses,  is  usually  followed  by  such  a  good 
result  that  excision  is  seldom  practiced.  For  other  forms  of  inflammation — osteo- 
arthritis, urethral  arthritis,  acute  necrosis,  or  chronic  suppuration — it  is  still  more 
rare. 

The^  usual  incision  is  vertical,  between  three  and  four  inches  in  length,  be- 
ginning just  outside  the  coracoid  process,  on  a  level  with  it,  and  carried  through 
the  skin,  fascia,  and  deltoid,  down  to  the  bone.  If  the  arm  is  rotated  outward 
and  the  soft  part  drawn  to  the  sides,  the  tendon  of  the  biceps  is  exposed  at  the 
bottom.  This  should  be  preserved  if  possible ;  sometimes  it  is  in  a  pulpy 
condition,  or  has  already  been  eroded,  and  occasionally  it  is  fixed  firmly  to  the 
bone  in  its  groove,  and  the  upper  end  of  it  lost.  The  capsule  is  then  freely 
opened  and  the  condition  of  the  i^arts  examined  before  determining  how  much  it  is 
necessary  to  take  away. 

So  far  as  the  subsequent  utility  of  the  linib  is  concerned,  there  is  no  doubt 
that  the  more  of  the  bone  that  is    left  the  better.     Partial  resections  (in  which 


EXCISION  OF  THE  ELBOW  JOINTS.  621 

some  of  the  head  is  left,  the  rest  being  gouged  away)  give  better  results  than  when 
the  anatomical  neck  is  divided  ;  and  this  is  to  be  preferred  to  the  surgical  neck. 
The  whole  of  the  disease  must  be  removed  (and  in  cases  of  tumors  springing 
from  the  head  of  the  bone  one-third  and  in  some  cases  even  more  of  the  shaft 
has  been  excised,  preserving  the  elbow  and  the  hand),  but  consistently  with  this, 
as  little  as  possible  of  the  healthy  bone.  The  (juestion  of  subperiosteal  excision 
is  still  open,  but  there  is  ground  for  believing  that  where  it  is  practicable  the  results 
are  superior  to  the  other  method. 

If  the  surgical  neck  requires  division  the  arm  must  be  strongly  rotated  out- 
ward by  the  assistant  as  soon  as  the  capsule  is  opened,  in  order  that  the  tendon  of 
the  subscapularis  may  be  cut;  and  then  inward  for  the  short  external  rotators. 
As  soon  as  this  is  done  the  head  of  the  bone  rises  well  up  into  the  wound,  and  may 
be  either  sawn  off  with  a  narrow-bladed  saw  in  situ,  the  soft  parts  being  protected 
and  held  aside  by  retractors,  or  thrust  bodily  out.  The  glenoid  fossa  very  rarely 
requires  more  than  the  application  of  a  gouge. 

[Prof.  Senn's  method  of  exposing  the  shoulder  joint  by  temporary  resection  of 
the  acromion,  was  performed  by  the  editor  at  the  Rush  Medical  College  Clinic, 
January,  1893.  The  operation  is  not  difficult  of  performance,  and  the  conserva- 
tion of  muscular  attachments  by  this  procedure  is  of  extreme  value  in  the  result.] 

A  counter-opening  at  the  back  of  the  joint  is  usually  advisable  for  drainage. 
The  wound  is  thoroughly  cleansed  ;  the  margins  drawn  together  with  sutures  ;  a 
large  tube  placed  across  it ;  and  the  cavity  of  the  axilla,  the  space  behind  the 
shoulder,  and  the  outer  side  and  front  of  the  arm  thoroughly  packed  with  wood- 
wool. Stromeyer's  elbow  cushion  should  be  used  as  long  as  the  patient  is  in  bed, 
and  passive  motion  commenced  as  soon  as  the  condition  of  the  wound  allows  it, 
the  fingers  and  wrist  being  exercised  from  the  first. 

Results. — All  underhand  movements  can  be  carried  out  exceedingly  well ; 
elevation  above  the  horizontal  line  is  only  possible  in  those  cases  in  which  the  head 
of  the  bone  is  partially  preserved  or  reproduced  ;  in  all  others  the  deltoid  loses  its 
fulcrum,  and  the  perfect  apposition  of  the  two  bones,  which  enables  rotation  of 
the  scapula  to  raise  the  arm,  becomes  impossible. 

Excision  of  the  Elbow  Joint. 

Primary  excision  for  compound  comminuted  fracture  extending  into  the  joint 
is  very  successful.  As  usual  in  primary  operations,  the  reaction  is  greater  than  in 
the  cases  of  disease,  and,  if  suppuration  occurs,  a  very  large  amount  of  callus  may 
be  thrown  out,  endangering  the  movement  of  the  joint.  It  is  chiefly  required 
when  the  lower  end  of  the  humerus  is  comminuted.  When  this  occurs  it  is  prac- 
tically impossible  to  restore  the  fragments  to  their  proper  position,  and  owing  to 
the  irregularity  of  the  articular  surface  and  the  filling  up  of  the  coronoid  and  ole- 
cranon fossge,  a  much  wider  range  of  movement  can  be  obtained  by  operation. 

Excision  for  Disease. — Tubercular  arthritis  is  the  usual  cause,  but  the  pro- 
portion of  cases  in  which  the  operation  is  required  is  a  very  small  one.  Strumous 
disease  of  the  elbow  joint  is  essentially  an  affection  of  childhood,  a  time  in  which 
excision  should  if  possible  be  avoided,  owing  to  the  way  in  which  it  interferes 
with  the  growth  of  the  arm  ;  and  in  the  vast  majority  of  instances,  if  the  patient's 
surroundings  can  be  improved,  the  joint  kept  at  rest  upon  a  splint,  abscesses 
opened  from  time  to  time,  and  sinuses  and  carious  bone  scraped  out,  the  result  is 
an  exceedingly  good  one.  The  range  of  movement,  it  is  true,  may  not  be  so 
wide  ;  but  if  proper  attention  is  paid  to  position  it  is  usually  sufficient,  and  there 
is  no  risk  of  a  "flail  joint,"  or  of  failure  of  growth.  There  is  certainly  the 
danger  of  the  tuberculosis  becoming  general,  but  it  rests  with  the  advocates  of 
excision  to  prove  that  this  is  serious.  Of  course,  if  the  bone  is  so  extensively 
diseased  that  repair  is  unlikely,  or  if  improvement  does  not  take  place  under 
ordinary  treatment,  or  if  the  amount  of  discharge  is  so  great  that  there  is  risk  of 
the  general  health  failing,  there  should  be  no  hesitation. 


622     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


For  other  diseases  excision  is  rarely  necessary  ;  l)iit  it  may  be  performed  for 
supijiirating  osteo-arthritis  (in  a  patient  sixty-three  years  of  age  under  my  care 
the  result  was  most  successful),  and  for  chronic  suppuration  consequent  upon  injury 
or  jjya^mia. 

///  cases  of  deformity,  whether  arising  from  old  unreduced  dislocation,  from 
ankylosis  after  inflammation,  or  from  cicatricial  contraction  of  the  soft  parts, 
excision  often  gives  a  very  good  result.  The  (juestion  as  to  its  advisability  turns 
upon  the  usefulness  of  the  arm  and  the  occupation  of  the  jjatient.  liony  ankylosis 
at  an  angle  of  75°  to  80°  is  a  wonderfully  slight  impediment  to  many  jjeople  ;  on 
the  other  hand,  if  the  angle  is  in  the  least  degree  obtuse,  so  that  the  patient  can 
neither  feed  himself  with  an  ordinary  spoon  or  fork  nor  place  his  hand  at  the  back 
of  his  head,  the  arm  is  almost  useless. 

Operation. — An  elastic  band  may  be  applied  around  the  arm,  but  the  bleed- 
ing is  usually  slight.  The  shoulder  is  raised  on  a  pillow  and  the  forearm  held  by 
an  assistant.  If  the  right  elbow  is  in  question,  the  arm  should  be  held  across  the 
patient,  with  the  olecranon  presenting  upward,  the  operator  standing  on  the  same 
side,  the  assistant  on  the  opposite  one.  If  the  left,  it  is  more  convenient  for  the 
surgeon  to  stand  upon  the  right.  A  linear  incision,  four  inches  in  length,  is  made 
over  the  back  of  the  joint,  its  centre  corresponding  to  the  tijj  of  the  olecranon. 
It  should  lie  just  to  the  inner  side  of  the  middle  of  the  arm  and  be  carried  right 
down  to  the  bone  at  once,  splitting  the  fascia  of  the  triceps  longitudinally.  The 
next  step  is  to  detach  from  the  bone  the  aponeurosis  covering  the  back  of  the 
olecranon,  first  upon  the  outer  side,  then  upon  the  inner,  until  the  narrower  part 
of  the  process  is  reached.  In  cases  of  disease  this  is  easily  accomplished  with  a 
blunt  elevator,  but  in  primary  excision  it  is  more  difficult.  If  now  the  olecranon 
is  cut  across  with  a  pair  of  bone  forceps,  the  cavity  of  the  joint  is  ojjened,  the 
triceps  and  the  jwsterior  parts  of  the  lateral  ligaments  are  detached  from  the  ulna 
without  risking  the  insertion  of  the  muscle  into  the  fascia,  and  abundant  space  is 
obtained  for  separating  the  soft  parts  from  the  condyles. 

This,  especially  in  cases  of  injury,  is  the  most  tedious  part  of  the  operation. 
The  inner  side  must  be  cleared  first,  taking  care  of  the  ulnar  nerve,  which  is  seldom 

seen.  The  soft  parts  are  raised  with  the  thumb 
from  the  bone  beneath,  and  carefully  sepa- 
rated from  their  attachment  with  a  stout 
scalpel,  keeping  the  knife  parallel  to  the  nerve. 
The  external  is  treated  in  the  same  way,  the 
a.ssistant  helping  by  keeping  the  arm  as  nearly 
vertical  as  possible.  As  soon  as  this  is  done 
the  end  of  the  humerus  protrudes  through 
the  incision,  and  the  bone  can  be  cleared 
with  ease  as  high  as  necessary.  How  much 
should  be  removed  depends  upon  the  general 
condition  ;  the  whole  of  the  cartilaginous 
surface  should  certainly  come  away,  the  line 
of  section  passing  above  the  condyles  ;  but 
the  age  of  the  patient,  the  cause,  whether 
injury  or  disease,  and  the  state  of  the  arm, 
which  in  some  ca.sesof  old  ank\losis  is  greatly 
wasted,  must  all  be  taken  into  consideration. 
The  stump  of  the  olecranon  and  the  head 
of  the  radius  are  then  cleared  in  the  same  way 
and  sawn  across  together,  above  the  insertion 
of  the  biceps.  It  is  often  recommended  to 
open  the  joint  above  the  olecranon,  and 
remove  the  necessary  portions  of  the  ulna  and 
radius  first;  but  I  have  found  the  method  described  more  expeditious. 

In  tubercular  disease  the  condition  of  the  synovial  membrane  and  of  the  bones 


J 


Fig.  278. — Seclionof  the  Bones  in  Excision  of 
the  Elbow  Joint. 


EXCISION  OF  THE   WRIST. 


623 


may  renuire  attention.  One  or  two  small  arteries  may  need  to  be  tied  or  twisted, 
but  there  is  very  little  bleeding.  The  wound  can  usually  be  washed  out  at  once 
with  a  hot  solution  of  corrosive  sublimate,  and  sutured,  leaving  an  orifice  in  the 
middle  for  drainage,  or  better,  a  short  drainage-tube. 

Many  splints  have  been  devised  for  use  after  this  operation  ("some  surgeons 
use  none  at  all)  ;  but  as  convenient  a  contrivance  as  any,  at  least  while  the  patient 
is  in  bed,  is  an  inside  angular  one,  interrupted  and  hinged  opposite  the  elbow, 
proviiled  with  a  rounded  end  (as  in  Carr's  splint)  for  the  fingers,  and  with  two 
cross-l)ars  underneath,  so  that  it  may  be  slung  from  a  pulley  over  the  bed,  and 
supported  by  a  counterpoise  of  shot.  With  this  the  dressings  are  easily  changed  ; 
the  angle  can  be  altered  if  required,  the  fingers  can  be  exercised,  and  the  patient 
can  sit  up  and  move  about  in  bed  without  the  least  fear  of  disturbing  the  wound. 

Passive  movement  of  the  fingers  and  wrist  should  be  commenced  at  the  end 
of  the  first  week  ;  the  new  joint  need  not  be  moved  until  the  wound  is  nearly 
sound.  \{  too  little  bone  has  been  taken  away,  passive  motion  will  not  prevent 
osseous  union.  In  some  cases  all  the  movements  of  the  joint — flexion,  extension, 
pronation,  and  supination — are  almost  perfect  from  the  first  ;  but  these  are  the 
exceptions.  In  the  majority  there  is  very  little  power  for  some  time,  but  gradu- 
ally, as  the  muscles  grow  accustomed  to'  their  shortened  position,  and  as  the 
nutrition  improves  under  the  influence  of  galvanism,  massage,  passive  motion,  and 
exercise,  the  strength  returns,  and  the  range  increases  until  it  is  almost,  if  not 
quite,  as  good  as  in  the  normal  arm.  This  may  take  place  even  after  a  twelve- 
month. 

If  the  movement  becomes  restricted,  in  spite  of  passive  motion,  the  cjuestion 
must  be  considered  whether  the  operation  should  be  repeated  and  more  bone 
removed,  or  the  limb  allowed  to  become  rigid  (as  it  cannot  be  prevented)  at  the 
most  convenient  angle.  If,  on  the  other  hand,  a  flail  joint  results,  the  usefulness 
may  be  greatly  increased  by  providing  the  patient  with  a  suitable  leather  or  poro- 
plastic  splint,  taking  the  whole  of  the  arm  and  the  forearm  as  far  as  the  wrist. 


Excision  of  the    Wrist. 

This  is  very  rarely  required  except  for  strumous  disease.      I  have  on  several 
cases  performed   a  partial  operation  in    cases  of  injury,  removing  bruised  and 
broken  fragments  of  bone  with  a  good  result; 
but   an  accident  that  rendered  complete  ex- 
cision necessary  would  almost  certainly  cause 
too  great  destruction  of  the  soft  parts. 

It  may  be  performed  in  various  ways, 
but  the  two  chief  are  those  practiced  first 
by  Lister  and  by  Langenbeck. 

I.  Lister  s  Operation. — Two  lateral  in- 
cisions are  made  ;  the  whole  of  the  carpal 
bones  except  the  hook  of  the  unciform  and 
the  osseous  portion  of  the  pisiform  are  re- 
moved, and  five  tendons  only  (the  carpal 
flexors  and  extensors)  divided  at  their  in- 
sertion. 

Esmarch's  bandage  is  applied  and  the 
adhesions  broken  down.  The  first  incision 
begins  on  the  middle  of  the  dorsal  aspect  of 
the  radius,  on  a  level  with  the  styloid  pro- 
cess, and  runs  thence  to  the  radial  side  of 
the  base  of  the  second  metacarpal  and  along 
the  bone  ft»r  half  its  length.  Its  first  part 
lies  just  internal  to  the  extensor  secundi  inter- 
nodii,  and  it  turns  just  before  it  reaches  the  radial  artery 


Fig.  279. — Lister's    Incision  for  Excision  of  the 
Wrist. 


If  carried  down  to 


624     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  bone  at  once  it  necessarily  cuts  across  the  extensor  carpi  radialis  brevior ;  this 
may,  however,  be  avoided  with  a  bttle  care  and  the  tendon  divided  immediately 
afterward  at  its  insertion. 

The  tendon  of  the  long  extensor  of  the  carpus  is  then  separated  from  its 
attachment ;  the  radial  artery  with  the  tendons  of  the  thumb  drawn  outward  ;  the 
trapezium  detached  from  the  rest  of  the  carpus  with  cutting-forceps,  and  all  the 
tendons  on  the  dorsal  surface  of  the  carpus  raised  from  the  bones  beneath  as  far 
toward  the  ulnar  side  as  possible.  They  should  not  l)e  lifted  out  of  their 
grooves  on  the  radius. 

The  second  incision  is  on  the  palmar  asi)ect  of  the  ulnar  side.  It  begins 
two  inches  above  the  joint,  internal  to  the  flexor  carpi  ulnaris,  and  is  carried 
down  to  the  middle  of  the  fifth  metacarpal.  The  tendon  of  the  extensor  carpi 
ulnaris  is  cut  at  its  insertion  ;  the  dorsal  and  internal  lateral  ligaments  divided, 
and  the  raising  of  the  extensor  tendons  completed  by  working  toward  the  radial 
side. 

The  soft  parts  on  the  palmar  surface  are  separated  next,  the  pisiform  bone 
witli  the  tendon  of  the  flexor  ulnaris  being  detached  from  the  rest  and  the 
unciform  process  cut  off.  The  wrist  in  doing  this  must  be  flexed  and  care  must 
be  taken  not  to  work  down  on  to  the  metacarpus  for  fear  of  the  deep  palmar  arch. 
The  anterior  ligament  of  the  carpus  is  divided  at  the  same  time. 

The  carpal  bones  (except  the  trapezium)  can  now  be  extracted  through  the 
ulnar  incision  with  sequestrum-forceps,  the  ends  of  the  ulna  and  radius  forced  out, 
and  their  articular  surfaces  removed  with  a  gouge  or  saw,  as  the  ca.se  requires. 


Fig.  280. — Lister's  Splint  for  Excision  of  the  Wrist. 

The  Styloid  process  of  the  ulna  should  be  left,  and  the  tendons  on  the  dorsum  of 
the  radius  disturbed  in  their  grooves  as  little  as  they  can  be. 

The  metacarpus  is  then  treated  in  the  same  way  :  the  trai)ezium  dissected  out, 
taking  care  of  the  tendon  and  the  artery  (if  this  bone  appears  fairly  sound  it  may 
be  left),  and  the  articular  surface  removed  from  the  pisiform  bone. 

Lister's  splint,  with  a  cork  pad  to  support  the  fingers  in  semi-flexion,  and 
a  bar  for  the  thumb,  is  nearly  always  used.  The  fingers  and  thumb  must  be 
thoroughly  flexed  and  extended  at  every  joint  after  the  second  day,  in  order 
that  the  tendons  may  cut  channels  for  themselves  in  the  va.scular  lymph  that  fills 
the  wound  ;  but  the  wrist  itself  must  be  kept  at  rest  until  union  is  assured. 

2.  Latigenbecfi  s. — A  single  incision  four  inches  in  length  is  made  along  the 
dorsal  surface  of  the  wrist  between  the  tendons  of  the  exten.sor  secundi  internodii 
and  the  exten.sor  indicis,  commencing  well  above  the  wrist  joint  and  ending  at 
the  middle  of  the  second  metacarpal  bone  on  its  ulnar  side.  The  tendons  on  the 
radial  side  of  the  incision  are  then  lifted  up  from  the  radius  and  the  carpus,  with 
the  periosteum,  so  that  the  sheaths  are  not  opened  ;  the  proximal  row  of  carpal 
bones  separated  from  each  other  and  extracted  one  by  one,  beginning  with  the 
scaphoid,  and  then  the  second  row  treated  in  the  same  manner.  It  must  be  re- 
membered that  in  cases  of  stnmious  disease  the  bones  are  softened  ;  the  ligaments 
for  the  most  part  easily  divided  ;  and  the  soft  tissues  around  matted  together  so 
that  they  can  be  much  more  easily  detached  ;  otherwise  this  operation  is  one  of 
considerable  difficulty. 

The  cases  for  which  excision  of  the  wrist  is  required  are  few  and  far  between. 


EXCISION  OF  THE   HIP  JOINT.  625 

In  young  subjects,  if  caseation  is  not  yet  far  advanced,  a  very  great  deal  can  be 
done  by  rest,  tonics,  and  thorougli  general  treatment,  the  joint  being  easily  pro- 
tected afterward.  If  caseation  and  suj^puration  have  occurred  already,  local 
operations,  such  as  gouging  out  soft  carious  bone  and  packing  the  cavities  with 
iodoform  gauze,  frecpiently  suffice,  and  leave  a  very  useful  hand.  In  older  people 
it  is  so  often  associated  with  plithisis  that  great  care  must  be  taken  in  the  selection 
of  cases.  The  operation  itself  sometimes  yields  a  very  good  result;  but,  on  the 
other  hand,  not  unfrecpiently  all  the  tendons  become  matted  together,  or  the 
tubercular  disease  returns,  or  suppuration  sets  in,  or  the  patient's  health  begins  to 
fail  and  amputation  has  to  be  performed.  In  what  proportion  of  cases  this  occurs 
it  is  impossible  to  say,  but  there  is  reason  to  believe  that  it  is  a  very  large  one. 

The    TJiunib  and  Eifiger  Joints. 

Excision  of  the  metacarpo-phalangeal  articulation  of  the  thumb  may  be  per- 
formed without  difficulty  through  a  vertical  dorsal  incision.  It  is  sometimes  re- 
quired for  compound  comminuted  fractures  or  old  unreduced  dislocations,  and 
gives  an  excellent  result.  Occasionally  a  similar  operation  is  advisable  in  injuries 
of  other  joints. 

ri.   The  Lower  Extremity. 

The  Hip  Joint. 

Excision  of  the  hip  is  performed  for  compound  comminuted  fractures  of  the 
head  of  the  bone  (such  cases  are  very  rare  in  civil  life),  as  an  alternative  to  am- 
putation, and  occasionally  for  old  unreduced  dislocations.  The  total  number  of 
these,  however,  is  very  small ;  nearly  always,  when  excision  of  the  hip  is  mentioned, 
the  presence  of  tubercular  arthritis  is  implied. 

The  operation  may  be  performed  either  through  an  anterior  or  a  posterior 
incision  ;  the  former  is  preferred  if  the  disease  is  in  its  earliest  stages,  before  sup- 
puration has  occurred,  and  when  there  is  reasonable  hope  of  securing  ])rimary 
union  ;  the  latter  if  the  parts  are  disorganized  and  a  large  amount  of  discharge 
expected. 

(i)  The  Anterior  Method. — The  patient  is  placed  on  his  back  with  the  limb 
slightly  flexed.  The  incision,  three  or  four  inches  in  length,  is  begun  immediately 
below  the  anterior  superior  spine  and  carried  downward  and  a  little  inward,  par- 
allel and  just  external  to  the  sartorius,  so  as  to  open  up  the  capsule  of  the  joint 
at  once  between  this  muscle  on  the  inner  side,  and  the  tensor  fascise  femoris  and 
the  glutaeus  medius  on  the  outer.  A  deeper  incision  is  now  made  in  the  capsule, 
parallel  to  its  fibres  :  the  soft  parts  are  pushed  on  either  side  with  an  elevator,  the 
finger  introduced  to  examine  the  part,  and  a  narrow-bladed  saw  passed  down  by 
its  side  on  to  the  top  of  the  neck.  As  soon  as  this  is  divided  the  head  of  the 
femur  is  grasped  with  a  pair  of  forceps  and  twisted  out.  If  the  acetabulum  or  the 
great  trochanter  is  involved,  the  carious  bone  is  gouged  away,  and  any  caseous 
deposit  in  the  neighborhood  thoroughly  scraped  out.  Then  the  wound  is  washed 
out  with  a  hot  antiseptic  solution  ;  dried  thoroughly  ;  dusted  with  iodoform  and 
sewn  up,  leaving  a  drainage-tube  of  suitable  size.  As  Barker  has  shown,  the  actual 
cavity  left  by  this  operation  is  a  very  small  one,  and  in  a  certain  proportion  of 
cases  primary  union  can  be  obtained.  This,  however,  is  only  practicable  in  the 
earlier  stages  of  the  disease. 

(2)  The  Posterior  Method. — The  patient  lies  upon  the  sound  side  near  the 
edge  of  the  table.  The  incision,  three  to  four  inches  in  length,  begins  about 
midway  between  the  anterior  superior  spine  and  the  great  trochanter,  and,  as 
Jacobson  recommends,  is  carried  downward  over  the  middle  of  the  latter,  so  as 
to  end  upon  the  shaft.  If  it  is  taken  round  the  trochanter,  it  encroaches  upon  the 
substance  of  the  muscles.     The  capsule  is  opened  freely  by  deepening  the  incision  ; 


626    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  soft  parts  are  separated  from  the  bone  with  an  elevator,  the  periosteum  as  a 
rule  coming  away  without  difficulty,  and  as  soon  as  the  parts  are  sufficiently  free 
the  neck  is  divided  with  a  keyhole  saw.  The  finger  should  be  used  to  jjrotect 
the  soft  parts  on  the  inner  side.  Afterward  the  condition  of  the  acetabulum  must 
be  e.xamined  ;  any  se(iuestra  that  are  present  removed  ;  and  if  there  is  any  evidence 
of  a  pelvic  abscess  (which  may  often  be  ascertained  previously  by  rectal  exami- 
nation) sufficient  of  the  floor  taken  away  to  ensure  thorough  drainage. 

[These  methods  are  vastly  inferior  to  that  of  Koenig,  which  in  every  case 
where  the  trochanter  is  sound  should  be  adopted  in  ])reference;  or  the  method 
may  be  modified  by  the  preservation  of  the  entire  trochanter.  The  ojjeration  as 
modifietl  is  performed  as  follows:  A  curved  incision  is  made,  commencing  just 
below  the  crest  of  the  ilium  and  directly  over  the  trochanter  major,  and  extending 
downward  about  two  inches.  The  incision  is  deepened  until  the  trochanter  is 
exposed.  By  means  of  a  chisel  the  trochanter  is  separated  at  its  base  from  the 
shaft  of  the  bone  at  the  upper  level  of  the  neck  of  the  femur.  The  trochanter, 
with  the  muscles  intact,  is  now  turned  upward,  and  the  neck  of  the  femur  with 
the  capsule  are  exposed  to  view.  Incise  the  capsule,  examine  the  joint  after 
irrigation.  If  there  is  much  caries  of  the  head  of  the  bone,  it  may  now  be 
removed  by  a  {<t\s  blows  of  the  mallet  and  chisel,  dividing  the  neck  close  to  the 
head,  if  the  neck  is  sound,  or  close  to  the  trochanters,  if  required.  The 
acetabulum  is  now  thoroughly  scraped  with  the  sharp  spoon,  and  every  vestige 
of  diseased  tissue  removed.  The  cavity  is  now  irrigated  with  iodine  water, 
dried  and  packed  with  iodoform  gauze,  leaving  a  projecting  portion  behind  the 
trochanter.  The  trochanter  major  is  now  brought  down  to  the  shaft  and  sewed 
down  to  the  periosteum  by  two  or  three  interrupted  sutures  of  chromicized  catgut. 
The  wound  is  then  closed  by  sutures,  except  a  space  behind  the  trochanter,  where 
the  gauze  projects.  The  usual  antiseptic  dressing  is  ajjplied,  and  rest  secured  by 
plaster-of-Paris  splint.  Extension  should  be  continuously  maintained  during  the 
healing  process.  By  this  operation  the  muscles  are  preserved  in  their  integrity, 
and  the  motions  of  the  limb  after  the  operation  are  but  little  imi)aired.] 

The  after-treatment,  whichever  incision  is  practiced,  consists  in  perfect  rest 
in  a  position  of  extension  with  slight  abduction.  In  the  case  of  the  anterior 
method  a  Thomas's  splint  may  be  applied  after  the  first  week. 

The  indications  for  this  operation  have  been  discus.sed  already.  By  some 
surgeons  it  is  performed  as  soon  as  caseation  is  certain  ;  by  others  only  as  an  alter- 
native to  amputation,  when  it  is  clear  that  the  recuperative  power  of  the  ])atient 
unaided  is  incajjable  of  dealing  with  the  disease.  The  difference  in  opinion 
appears  to  have  arisen  chiefly  from  the  difference  in  the  conditions  under  which 
the  j)atients  are  placed. 

The  results  of  the  two  operations  naturally  differ  very  greatly.  An  excellent 
liml)  is  left  after  early  excision,  if  the  wound  heals  up  at  once  ;  if  it  does  not,  and 
there  is  reason  to  believe  that  primary  union  is  not  invariable,  the  condition  of  the 
patient  is  very  serious  ;  but  as  yet  hardly  anything  is  known  with  regard  to  the 
ultimate  effect,  and  this,  of  course,  is  the  true  criterion.  Late  excision  undoubtedly 
leaves  a  wasted  and  shortened  limb,  but  the  credit  of  this  must  not  be  laid  wholly 
at  the  door  of  the  operation  ;  had  this  not  been  performed,  it  is  (juestionable 
whether  the  limb  would  have  been  any  better,  and  it  is  quite  possible  that  the 
patient  would  not  have  survived  the  prolonged  suppuration  without  some  amyloid 
degeneration.  The  comi)arison,  if  there  can  be  one,  should  be  made,  not  between 
the  results  of  early  and  late  excision,  but  between  the  results  of  early  excision  on 
the  one  hand,  and  those  of  the  natural  |)rocess  of  cure  with  a  very  few  cases  of 
late  excision  on  the  other. 

Excision  of  the  Knee  Joint. 

Primary  excision  has  been  performed  in  a  few  cases  of  gunshot  wounds,  but 
the  conditions  under  which  so  serious  an  operation  is  admissible  are  very  rare. 
Chronic  disease  involving  the  bones  is  the  general  cause  (erasion  or  arthrectomy 


EXCISION  OF  THE  KNEE  JOINT.  627 

is  to  be  preferred  as  long  as  the  soft  parts  only  are  concerned)  ;  osteo-arthritis, 
limited  to  one  joint  in  a  patient  otherwise  healthy  and  not  too  old  ;  ankylosis  in 
a  faulty  i)Osition,  and  compound  transverse  fractures  of  the  jjatella,  in  which  it  is 
impossible  to  bring  the  fragments  together  without  shortening  the  limb,  are  occa- 
sional ones. 

Operation. — Many  different  incisions  are  recommended  by  different  oj^era- 
tors,  depending  partly  upon  the  advisability  of  removing  or  leaving  the  yjatella. 
The  ordinary  one  is  semicircular  in  shai)e,  the  bone  being  taken  away. 

It  commences  behind  the  condyle  on  the  side  that  is  furthest  from  the 
operator,  passes  down  over  the  ligamentum  patellae,  and  is  continued  up  to  a 
corresponding  point  on  the  opposite  side.  The  lateral  ligaments  are  divided, 
but  it  should  stop  short  of  the  internal  .saphena  vein.  The  flap  thus  marked  out 
is  then  reflected  upward  and  the  joint  freely  opened  by  a  second  incision  convex 
u])ward,  starting  from  the  extremities  of  the  first  and  carried  through  the  tendon 
of  the  quadriceps  above  the  patella.  In  many  instances  it  is  advisable  to  slit  the 
tendon  uj)  still  higher  by  vertical  incision  in  the  middle  line.  The  whole  of 
the  great  suprapatellar  pouch  must  be  exposed  and  thoroughly  scraped  out,  and  in 
the  case  of  children  suffering  from  chronic  disease  of  the  synovial  membrane  it 
not  unfrequently  extends  nearly  half-way  up  the  femur. 

The  other  incisions  are  transverse  across  the  patella,  opening  the  joint  above 
and  below  the  bone  and  removing  it  at  once  ;  transverse,  dividing  the  patella  in 
two,  so  that  it  may  be  wired  together  again  afterward  (this  helps  to  prevent  dis- 
placement of  the  tibia  backward,  but  it  renders  the  complete  removal  of  all  the 
pulpy  tissue  more  difficult)  ;  and  semilunar,  across  the  tubercle  of  the  tibia.  This 
process  belongs  to  the  epiphysis  and  can  easily  be  separated  with  a  chisel  (in  many 
cases  a  stout  scalpel  will  answer)  carrying  the  ligamentum  patellae  with  it,  so  that 
the  whole  of  the  front  wall  of  the  knee  joint  is  reflected  in  a  single  flap.  After- 
ward if  the  patella  is  left,  it  may  be  fixed  down  again  by  means  of  a  wire  or 
chromic  catgut  suture. 

As  soon  as  the  joint  is  freely  opened  the  suprapatellar  pouch  must  be  cleared 
out,  the  rest  of  the  soft  structures  being  dealt  with  later.  The  femur  is  then  pushed 
as  far  on  the  surface  of  the  tibia  as  possible  (the  popliteal  artery  is  well  out  of  the 
way)  ;  a  cut  made  through  the  soft  tissues  covering  it  for  the  saw,  and  the  articular 
surface  removed,  the  line  of  section  being  at  right  angles  to  the  shaft  (a  little  more 
usually  has  to  come  away  from  the  inner  side  than  from  the  outer)  from  above 
downward  and  slightly  from  behind  forward.  Butcher's  saw  may  be  used,  but  an 
ordinary  one  answers  as  well.  The  level  of  the  epiphysis  is  marked  by  the  adduc- 
tor tubercle,  and  the  incision  should  not  be  carried  above  this  ;  if  the  disease 
extends  higher,  it  must  be  scraped  or  gouged  away. 

The  position  of  the  bones  is  then  reversed,  the  tibia  brought  in  front  of  the 
cut  section  of  the  femur  and  the  upper  surface  with  the  semilunar  cartilages  resting 
upon  it  sawn  off.  As  a  rule,  it  is  sufficient  to  remove  the  articular  lamella  ;  if  there 
is  a  soft  or  carious  spot  in  one  of  the  tuberosities  it  can  be  gouged  out  and  an 
opening  for  drainage  made  through  its  base  on  to  the  anterior  surface  of  the  bone. 
The  anterior  crucial  ligament  must  always  be  sacrificed,  but  in  many  cases  it  is 
possible  to  preserve  the  attachment  of  the  posterior  one,  and  if  this  can  be  done  it 
renders  the  bones  much  more  secure. 

After  this  the  synovial  membrane  covering  the  posterior  ligament  and  that 
which  lines  the  posterior  pouches  (often  in  these  cases  very  much  increased  in 
size),  can  be  dissected  off  or  scraped  away  without  difficulty.  Every  particle  of 
soft  tissue  must  be  removed,  as  persistence  of  the  tubercular  growth  is  one  of  the 
main  causes  of  failure. 

If  the  posterior  crucial  ligament  has  been  preserved  the  bones  are  fairly  secure 
without  anything  else.  Where  it  has  been  divided  the  cut  surfaces  may  be  sutured 
together  with  steel  pins  driven  obliquely  through  both  bones  so  as  to  cross  each 
other  near  the  line  of  union,  or  with  wire  silk,  or  stout  chromic  gut.  Afterward 
one  or  two  drainage-tubes  must  be  inserted  according  to  the  amount  of  discharge 


628    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

expected,  the  wound  thoroughly  washed  out,  all  bleeding  stopped,  and  the  anterior 
flaj)  adjusted  and  fastened  down.  A  back  sj)lint  interrupted  opjjosite  the  knee, 
and  provided  with  a  foot-piece  to  prevent  any  drojiping  of  the  toes,  must  always 
be  used.  It  may  be  made  of  wood  or  of  tinned  iron,  and  it  should  be  i>rovided 
with  two  cross-bars,  so  that  it  can  be  slung  from  a  pulley  over  the  bed  and  supported 
by  a  counterjioise  of  shot.  If  this  is  well  adjusted  and  the  mattress  cut  away  on 
the  diseased  side  from  below  the  fold  of  the  buttock,  the  limb  swings  absolutely 
free,  entirely  out  of  the  patient's  control.  It  may  be  secured  either  with  two 
interrupted  side-splints  like  an  ordinary  compound  fracture,  or  with  a  mixture  of 
paraffin  and  wax  applied  hot,  as  recommended  by  How.se.  \n  either  case  the 
fixation  is  absolute.  Union  is  fairly  sound  in  a  successful  ca.se  at  the  end  of  six 
weeks,  and  the  patient  may  then  be  allowed  to  get  about  on  crutches,  the  limb 
being  protected  either  with  a  poroplastic  casing  or  with  Thomas's  knee-splint. 
Some  appliance  of  this  kind  must  be  worn  for  several  years,  in  the  case  of 
children,  until  the  period  of  growth  has  cea.sed. 

The  details  naturally  require  modification  in  many  particulars.  The  patella, 
for  example,  is  sometimes  preserved,  its  articular  surface  being  thoroughly  gouged 
away,  or  it  is  divided  and  sutured  together  again.  Sometimes  it  is  sufficient  merely 
to  shave  off  the  ends  of  the  bones,  and  occasionally  the  bones  themselves  can  be 
left  untouched,  only  the  soft,  pulpy  synovial  tissue  being  removed,  as  in  erasion, 
but  when  this  is  done  great  care  is  required  to  prevent  flexion  afterward. 

Results. — Excision  of  the  knee  rarely  succeeds  in  patients  over  thirty  years 
of  age,  or  in  those  under  ten  ;  in  the  former  the  reparative  powers  fail,  in  the 
latter  the  growth  of  the  limb  is  too  much  impaired.  Puberty  is  the  most  favor- 
able time.  In  some  few  cases  a  movable  joint  has  been  obtained  (in  erasion  in 
which  the  articular  surfaces  are  not  taken  away,  this  is  usually  the  case,  and  .some- 
times the  range  is  nearly  as  good  as  the  normal  one),  but  it  is  certainly  wiser  to 
try  for  bony  ankylosis.  Failure  may  occur  from  the  whole  of  the  tubercular 
disease  not  having  been  removed,  from  the  strength  of  the  patient  being  unequal 
to  the  strain,  or  from  too  much  bone  having  been  taken  away.  In  this  ca.se,  even 
if  union  does  take  place,  the  limb  remains  .so  weak  and  wasted,  and  is  so  much 
shorter  than  the  other,  that  amputation  is  usually  preferred.  Later,  even  after 
years  have  passed,  the  osseous  union  sometimes  yields  and  causes  serious  deformity. 

Excisiofi  of  the  Ankle. 

This  operation  is  rarely  practiced  ;  the  reparative  power  of  the  foot  is  not 
very  great,  stability  and  firmness  especially  are  required,  and  neither  in  the  case 
of  disease  nor  injury  is  the  mischief  likely  to  be  limited.  Compared  with  excision, 
Syme's  amjnitation  involves  very  much  less  risk,  and  may  be  relied  upon  for  an 
excellent  practical  result. 

It  may  be  performed  either  by  two  lateral  incisions,  or  an  anterior  trans- 
verse one. 

In  the  former  (i)  an  incision  is  made  on  the  outer  side  of  the  foot  over  the 
peronaei  tendons,  from  two  inches  above  the  external  malleolus  to  within  an  inch 
of  the  base  of  the  fifth  metatarsal  bone.  The  skin  and  the  periosteum  are  raised 
from  off  the  bone,  the  tendons  drawn  to  one  side,  the  fibula  divided  at  the  upper 
angle,  and  the  lower  end  drawn  out  from  al)ove  and  removed,  dividing  the  external 
lateral  ligament.  The  foot  is  then  turned  over  and  (2)  an  incision  similar  in 
length  and  direction  made  along  the  posterior  margin  of  the  internal  malleolus, 
the  tendons  and  periosteum  being  treated  in  the  same  way.  The  lower  end  of 
the  tibia  is  then  forced  into  the  wound,  by  everting  the  foot,  and  removed  with  a 
narrow  saw  ;  the  upper  surface  of  the  astragalus  is  treated  in  the  same  way,  the 
whole  of  the  gelatinous  tissue  scraped  out,  and  the  woimd  thoroughly  washed  out 
and  drained.  If  the  astragalus  is  much  involved  it  is  better  to  scoop  it  out  of  its 
periosteal  shell  altogether. 

The  anterior  transverse  incision  is  more  simple.     A  cut  is  made  across  the 


EXCISION  OF  THE  ANKLE.  629 

front  of  the  joint,  beginning  at  the  tip  of  one  malleolus,  dividing  all  the  tendons, 
the  anterior  tibial  vessels  and  the  nerve,  and  ending  at  the  corresponding  point  on 
the  opposite  side.  The  ligaments  are  then  divided  as  far  as  may  be  necessary,  the 
under  surfaces  of  the  ti])ia  and  the  upjjer  of  the  astragalus  successively  exposed  and 
removed,  all  carious  bone  gouged  away  with  the  granulation  tissue,  and  then 
the  tendons  and  the  nerve  sutured  together.  The  skin  wound  should  unite  by 
the  first  intention.  An  outside  angular  splint,  with  the  knee  well  bent,  is  the  best 
appliance  until  the  seat  of  injury  is  partially  consolidated  and  the  discharge  reduced 
in  amount,  and  after  that  a  plaster  or  paraffin  bandage,  strengthened,  if  necessary, 
by  slips  of  tin. 


630    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  VII. 

IXJUR/ES  AXD  DISEASES  OF  THE  HEAD. 

SECTION    1.— MALFORMATIONS. 

ENCEPHALOCELE  AXD  MENINGOCELE. 

An  encephalocele  is  a  congenital  tumor  caused  by  the  abnormal  expansion  of 
some  part  of  the  cerebral  vesicles,  so  that  the  brain  substance  i^rotrudes  between 
the  bones  of  the  skull  and  prevents  their  proper  development.  In  a  meningocele 
the  protrusion  consists  of  dura  mater  and  arachnoid  only,  but  this  is  very  much 
more  rare.  When  in  addition  to  the  brain  substance  there  is  a  great  collection 
of  fluid,  causing  immense  distention  of  the  ventricle,  it  is  known  as  hydrenceph- 
alocele. 

An  encephalocele  can  only  develop  at  those  parts  of  the  skull  which  normally 
contain  processes  of  the  ventricles  ;  immediately  over  the  nose,  that  is  to  say,  cor- 
responding to  the  anterior  cornua  (the  exactly  median  situation  is  due  to  secondary 
growth  of  the  bones)  ;  behind  the  mastoid  process,  where  the  lateral  cornua  come 
down  ;  and  in  the  neck  and  occipital  region  over  the  fourth  ventricle.  A  few 
cases  are  recorded  of  a  similar  prolongation  of  the  third  ventricle  into  the  pharynx, 
through  the  sphenoid,  or  between  it  and  the  ethmoid.  Encephalocele  has  noth- 
ing to  do  with  the  fontanelles. 

The  occipital  is  the  most  common,  the  portion  of  the  occipital  bone  between 
the  inion  and  the  foramen  magnum  being  deficient.     The  frontal  comes  next ;  the 

others  are  very  rare.  Many  cases  of  supposed  menin- 
gocele, especially  in  the  occipital  region,  are  in  all 
probability  encephaloceles  in  which  the  brain  substance 
has  either  atrophied  or  has  never  been  developed. 
Hydrencephalocele  explains  itself. 

An  encephalocele  forms  a  roundish,  sessile,  or 
jjedunculated  tumor,  of  very  variable  size  (sometimes  a 
n^iCre  nodule,  sometimes  larger  than  the  rest  of  the 
child's  head)  projecting  from  the  surface  of  the  cra- 
nium. The  skin  covering  it  is  generally  normal,  but 
it  may  be  excoriated  ;  and,  when  the  distention  has 
taken  place  very  early  in  life,  so  that  the  development 
of  the  dorsal  mesoblastic  plates  has  been  checked,  it 
may  consist  merely  of  the  undifferentiated  brain  tissue 
and  meninges,  covered  over  with  epidermis,  as  in  some 
analogous  cases  of  spina  bifida.      It  swells  up  and  be- 

F.G.    a8i  -.Meningocele    at   Root  of  ^^^^^^^    ^^^^^  ^^.j^^^   ^j^^    ^j^jj^    ^^.j^^^  3,^^j    ^^^^^^\\y   admits 

of  partial  reduction  on  pressure,  although  this  may 
cause  convulsions  and  other  cerebral  symptoms.  Occasionally  the  outline  of  the 
opening  in  the  cranial  bones  can  be  felt  distinctly. 

An  encephalocele  is  usually  opaque,  with  indistinct  fluctuation,  and  is  only 
partially  reducible  ;  and  it  pulsates  distinctly.  A  true  meningocele  is  always 
small  and  as  a  rule  pedunculated  ;  its  contents  admit  of  complete  reduction,  and, 
if  it  is  large  enough  it  is  perfectly  translucent.  Hydrencephalocele  is  always  very 
large  and  unusually  pendulous,  the  rest  of  the  child's  head  being  ill-developed. 

In  some  instances,  particularly  when  the  tumor  is  situateil  over  the  glabella 
and  the  skin  covering  it  is  red  and  vascular,  great  care  is  required  to  distinguish 
it  from  a  navus.     They  are  both  congenital  and  reducible  ;  tTiey  both  swell  up 


INJURIES  OF  THE  SCALP.  631 

when  the  child  cries  ;  the  color  is  the  same  ;  and  if  the  intracranial   tumor  is  a 
small  one,  reduction  of  its  contents  need  not  be  followed  by  any  cerebral  symp- 
toms ;  and  it  need  not  exhibit  any  arterial  pulsation.      I  have  known  the  diagnosis 
left    undecided     by    surgeons    who    were 
certainly  capable  of  discriminating,  if  any 
were. 

Prognosis. — If  the  protrusion  is 
small  and  the  skin  covering  it  healthy,  it 
may  not  interfere  with  life;  and  in  a  few 
raie  cases  it  has  hapjiened  that  as  growth 
proceeded  the  neck  of  the  tumor  has  be- 
come more  and  more  constricted,  until  at 
length  it  cea.sed  to  have  any  connection 
with  the  interior  of  the  skull.  Large  ones 
as  a  rule  continue  to  increase  until  they  f,c.  282.— Encephaioceie. 

rupture. 

Treatment. — The  growth  should  be  carefully  protected  from  injury  and 
not  otherwise  interfered  with  e.xcept  under  one  condition — that  it  is  on  the  point 
of  rupture.  Repeated  tappings  and  injections  of  Morton's  fluid  have  succeeded 
in  cases  of  meningocele,  as  in  spina  bifida  ;  but,  except  in  those  instances  in  which 
from  the  small  size  or  pedunculated  character  of  the  tumor  there  is  some  prospect 
of  natural  cure,  the  probability  of  a  good  result  is  very  remote. 


SECTION  II.— INJURIES  OF  THE  HEAD. 

These  include  injuries  of  the  scalp,  of  the  bones,  and  of  the  brain. 

The  .scalp  may  be  bruised  or  cut ;  there  may  be  hemorrhage,  either  externally 
or  into  the  tissues  ;  the  pericranium  may  be  stripped  off,  the  bone  bruised  or 
fractured  ;  blood  extravasated  between  it  and  the  dura  mater,  or  between  the 
membranes,  of  the  brain  ;  and  the  brain  itself  contused  or  torn.  No  wound  or 
blow,  however  slight,  should  be  neglected ;  even  when  the  superficial  structures 
have  escaped  unhurt  there  may  be  serious  injury  to  the  much  more  important 
ones  beneath.  Afterward  inflammation  may  set  in,  even  though  there  is  no  ex- 
ternal wound.  If  this  occurs  it  may  attack  the  scalp  or  the  loose  cellular  tissue 
beneath  ;  it  may  begin  in  the  bone,  causing  osteophlebitis  and  necrosis,  and  end- 
ing either  in  general  pyaemia  or  in  thrombosis  of  the  sinuses,  inflammation  of  the 
membranes  or  cerebral  abscess,  according  to  the  method  of  its  extension  ;  and 
finally  it  may  start  in  the  brain  itself. 

Injuries  of  the  Scalp. 

The  scalp  presents  certain  anatomical  features  of  considerable  surgical  im- 
portance. The  skin  in  the  first  place  is  so  closely  bound  down  to  the  aponeurosis 
beneath,  that  merely  cutaneous  wounds  never  gape,  and  superficial  inflammation 
is  never  attended  by  much  swelling  or  redness.  For  the  same  reason  contusions 
often  cause  what  apparently  are  incised  wounds.  Further,  the  chief  vessels  lie 
between  the  aponeurosis  and  the  skin,  and  are  imbedded  in  such  dense  tissue  that 
when  they  are  cut  they  cannot  retract,  and  can  hardly  be  tied.  On  the  other 
hand,  beneath  the  aponeurosis  the  tissue  is  so  loose  that  blood  or  pus  can  collect 
until  the  skin  floats  as  on  a  water-bed,  bounded  by  the  zygoma,  the  eyebrows,  and 
the  superior  curved  line  ;  and  the  scalp  can  be  stripped  off  and   hang  down  in 


632    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

flaps.  Sloughing,  however,  owing  to  the  position  of  the  vessels,  is  rarely  caused 
in  this  way.  Finally,  the  i)ericranium  is  easily  separated  from  the  bone,  except 
at  the  sutures  ;  it  only  supplies  the  outer  table,  not  the  diploe  or  the  inner,  so  that 
when  necrosis  occurs  from  this  cause  the  sequestrum  is  usually  sujjerficiai.  It  is 
peculiar  also  that  it  hardly  ever  produces  any  new  bone  to  repair  an  injury. 

Contusions  of  the  Scalp. 

The  blood  may  be  extravasated  (i)  in  the  scalp  itself;  (2)  in  the  sub-aponeuro- 
tic  layer  ;  or  (3)  between  the  pericranium  and  the  bone. 

The  first,  owing  to  the  denseness  of  the  tissue,  is  always  insignificant.  The 
second  may  be  either  diffuse,  and  of  enormous  extent,  or  circumscribed,  and  then 
very  often  it  is  curiously  deceptive.  The  blood  around  the  margin  coagulates  into 
a  hard,  dense  ring,  the  inner  edge  of  which  is  sharp  and  well-defined,  while  the 
outer  is  beveled  off;  in  the  centre  it  remains  fluid,  so  that  when  the  finger  is 
pressed  upon  it  the  margin  stands  out  as  clearly  as  the  edge  of  a  dei)ressed  frac- 
ture, for  which  it  may  easily  be  mistaken.  The  ring,  however,  is  distinctly  raised 
above  the  level  of  the  surrounding  bone,  and  it  can  always  be  indented.  I  have 
known  the  opposite  mistake  made.  Absces.ses  sometimes  give  rise  to  the  same 
kind  of  impression,  and  it  must  be  remembered  that  the  presence  of  a  hematoma 
does  not  exclude  the  existence  of  a  fracture. 

The  third  (cephalhematoma)  only  occurs  in  infants  and  nearly  always  from 
injuries  received  at  birth.  It  is  most  common  on  the  parietal  bone,  though  I  have 
seen  it  on  the  occipital,  and  it  is  easily  recognized  by  the  way  in  which  it  is 
limited  to  one  bone  ;  it  never  extends  over  the  sutures.  Like  the  former,  the 
margin  becomes  hard,  and  a  certain  amount  of  organization,  and  even  ossifica- 
tion, takes  place  ;  the  centre  remains  fluid,  and  for  a  long  time  gives  rise  to  a 
sensation  of  parchment  crackling  when  pressed  upon. 

Absorption  in  all  these  cases  is  slow,  but,  unless  inflammation  sets  in,  they 
should  never  be  incised  ;  and  aspiration  is  rarely  necessary.  The  cephalh^ematoma 
of  infants  should  never  be  touched  ;  in  other  cases  lead  lotion  may  be  applied  at 
first,  or,  if  the  patient  will  lie  down,  an  ice-bag,  to  check  the  extravasation  and 
hyper^emia ;  afterward  well-applied  pressure  is  the  most  efficient  remedy. 

Wounds  of  the  Scalp. 

These,  like  contusions,  may  be  superficial,  involving  the  skin  only  ;  or  extend 
into  the  subaponeurotic  layer  ;  or  lay  the  bone  bare.  The  first  are  rarely  of  any 
extent ;  in  the  second,  if  the  hair  is  entangled  in  machinery,  or  the  head  caught 
under  a  cart-wheel,  the  whole  scalp  may  be  detached  and  hang  down  in  a»flap, 
but  it  rarely  sloughs;  in  the  third  there  is  an  additional  danger,  for  the  bone  is 
exposed,  and  is  often  brui.sed  or  scratched.  Hemorrhage  from  the  torn  vessels 
is  often  abundant,  but  neither  ligature  nor  torsion  is  of  any  use.  Pressure  stops 
it  at  once.  Acupressure  may  be  used,  but  a  bandage  is  nearly  always  sufficient; 
care,  however,  is  neces.sary,  as  it  may  be  applied  so  tightly  as  to  cause  a  slough. 

Treatment. — Scalp  wounds  require  no  special  treatment,  the  same  princi- 
ples must  be  followed  as  elsewhere  ;  the  only  peculiarities  are  the  extraordinary 
vitality  of  the  skin,  and  the  ease  with  which  inflammation,  if  it  once  sets  in, 
spreads  in  all  directions.  Therefore  no  portion  of  scalp  should  ever  be  sacrificed, 
no  matter  how  bruised  or  dirty  it  is  ;  and  perfect  cleanliness  and  perfect  drainage 
must  be  insisted  on.  If  this  is  carried  out,  they  maybe  treated  like  other  wounds, 
and  with  exceptional  success. 

The  head  must  be  shaved  around  the  injury,  the  wound  carefully  explored 
and  wash  d  out  thoroughly  with  an  antiseptic,  all  oozing  stopped,  and  any  bag- 
ging or  collecting  of  fluid  prevented.  Counter-openings  may  be  made  and  drain- 
age-tubes inserted,  if  there  is  a  dependent  pouch  ;  but  in  most  cases  it  is  sufficient 
to  support  the  skin  well  against  the  skull  so  as  to  keep  it  at  rest  and  ensure  early 


WOUNDS  OF  THE  SCALP.  633 

adhesion.  Then  the  edges  of  the  wound  may  be  dusted  over  with  iodoform  and 
covered  with  an  absorbent  dressing,  such  as  wood-wool,  or  a  sponge  wrung  out  of 
carbolic  solution.  There  is  no  objection  to  the  use  of  sutures,  if  care  is  taken  ;  but 
of  course,  if  the  wound  is  tightly  sewn  up,  and  suppuration  allowed  to  take  place 
beneath,  .serious  consecpiences  must  ensue.  Even  if  half  the  scalp  is  stripped  off 
and  hangs  down  the  back  of  the  neck,  or  over  the  face,  it  may  be  treated  in  this 
way,  and  often  will  adhere  at  once.  If  it  does  not,  the  under  surface  throws  out 
granulations,  and  union  takes  place  by  the  third  intention.  In  all  cases  of  severe 
injury  the  patient  should  be  confined  to  bed,  and  kept  perfectly  quiet,  on  low 
diet ;  and  care  mu.st  be  taken  that  the  bowels  do  not  become  confined.  It  must 
never  be  forgotten  that,  in  addition  to  the  scalp  wound,  there  may  be  very  great 
injury  to  the  brain. 

So  long  as  there  is  no  pain  or  fever,  the  wound  should  be  left  alone.  If, 
however,  one  spot  is  tender,  or  if  the  temperature  rises,  or  if  there  is  any  shivering, 
it  must  be  exposed  at  once  and  carefully  examined  ;  it  nearly  always  means  that 
some  of  the  secretion  is  pent  up.  As  a  rule  it  is  sufficient  to  introduce  a  probe 
or  to  loosen  a  suture  :  a  drop  or  two  of  fluid  escapes  and  the  symptoms  are  re- 
lieved at  once. 

Erysipelas  sometimes  attacks  scalp  wounds,  but  they  are  not  more  liable  to  it 
than  others  that  are  equally  exposed.  The  danger  is  that  the  superficial  wound 
may  close,  and  the  discharge  collect  and  decompose  beneath.  The  cellular  tissue 
is  so  loose  that  suppuration  soon  spreads  all  over  the  head  ;  the  scalp  becomes 
boggy  and  cedematous  ;  the  eyelids  are  swollen  and  the  forehead  reddened  ;  the 
pulse  becomes  quick  and  feeble;  the  temperature  rises  ;  delirium  sets  in  ;  and  the 
condition  becomes  one  of  extreme  gravity.  If  left  to  itself  the  whole  of  the  cellu- 
lar tissue  may  slough,  leaving  the  bone  absolutely  bare  ;  or  the  patient  may  sink 
from  exhaustion  or  septic  poisoning  (especially  as  this  is  likely  to  occur  in  those 
whose  health  is  broken  down),  or  the  inflamma- 
tion may  spread  along  the  emissary  veins  into 
the  diploe  and  sinuses  of  the  cranium,  and  set 
up  thrombosis  and  pyaemia.  In  such  a  case  the 
wound  must  be  laid  open  at  once,  only  such 
sutures  being  left  as  are  absolutely  necessary  to 
prevent  a  flap  hanging  down  ;  small  incisions, 
parallel  to  the  main  arteries  and  going  right 
down  to  the  bone,  made  wherever  the  skin  is- 
boggy  ;  and  warm  boracic  fomentations  applied, 
to  encourage  the  discharge  as  much  as  possible. 
Quinine  and  carbonate  of  ammonia  are  nearly 
always  required  ;  it  is  very  seldom  that  any  food 
can  be  taken  ;  and  in  many  cases  the  condition 
of  the  pulse  is  such  that  stimulants  must  be  given 
freely. 

When  the  pericranium  is  detached  the  risk 
is  greatly  increased.      Necrosis  of  the  outer  table  fio.  283. -Exfoliation  of  a  Triangular  Plate 

■'  •  1        /■  -ill]  „i       u    •_  of  Hone  from  the  Vault  of  a  Skull,  caused 

may    occur    simply    from    its    blood-supply   being  by  denudation,  three  weeks  after  the  injury. 

cut  off ;  more  frequently  it  becomes  va.scular  and 

throws  out  granulations,  minute  red  dots  making  their  appearance  on  the  bare 
white  bone,  and  projecting  more  and  more  as  the  compact  tissue  becomes  ab- 
sorbed, until  they  form  a  perfectly  uniform  layer.  Or  worse  than  this  may  hap- 
pen :  inflammation  may  set  in.  If  this  occurs,  the  whole  thickness  of  the  bone  is 
almost  sure  to  perish,  and  the  mischief  may  extend  to  the  membranes  of  the  brain 
or  into  the  venous  sinuses,  and  cause  either  diffuse  meningitis  or  general  constitu- 
tional infection.  Every  case  of  scalp  wound  in  which  the  bone  is  exposed  requires 
to  be  watched  with  the  greatest  care, 
41 


634    niSEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Fractures  of  the  Skull. 

These  are  divided  into  fractures  of  the  vault  and  fractures  of  the  base. 
They  are  nearly  always  the  result  of  direct  violence.  If  the  area  on  which  the 
blow  falls  is  limited,  the  injury  is  limited  too  ;  and  naturally  this  is  more  common 
on  the  vault.  If,  on  the  other  hand,  the  force  is  diffused  over  a  wider  area,  the 
cranium  is  comi)ressed,  the  most  inelastic  and  unyielding  part  gives  way,  and 
a  fissure  is  produced  which  generally  runs  across  the  base  and  part  of  the  vault 
as  well.  The  distinction,  therefore,  is  not  perfect,  but  it  is  found  to  work  con- 
veniently. 

I.  Fracture  of  the  Vault. 

Owing  to  its  arched  shape,  its  elasticity  even  in  adults,  and  the  presence  of 
sutures  breaking  up  and  softening  the  force  of  blows,  this  escapes  more  frequently 
than  might  be  expected.  In  infants  it  is  sometimes  bent  in  like  a  piece  of  tin, 
without  any  actual  tearing,  but  in  many  of  these  cases  the  inner  table  gives  way, 
as  in  greenstick  fracture. 

The  fracture  may  take  the  form  of  a  simple  fissure,  or  it  may  be  stellate  or 
comminuted.     Occasionally  the  outer  table  only  is  hurt,  and  a  few  rare  cases  are 


/  '\-,.    -  v.. 


c 


Figs.  284  and  285. —  Fracture  of  Vault  of  Skull  Caused  by  the  Impact  of  a  Blunt  Instrument  (a  hammer),  showing  the 
greater  area  and  more  extensive  splintering  on  the  inner  surface. 

recorded  in  which  this  has  escaped,  and  the  inner  only  has  given  way,  but  nearly 
always  it  extends  through  the  whole  thickness.  If  the  bone  is  driven  in,  the  frac- 
ture is  sa4d  to  be  depressed  ;  in  most  instances  the  whole  substance  is  forced  in, 
but  over  the  frontal  sinuses,  and  in  contusions,  the  inner  table  may  not  be  affected  ; 
generally  it  is  splintered  a  great  deal  more  than  the  outer.  In  children,  owing  to 
the  elasticity  of  the  bones,  depression  may  take  place  without  fracture,  especially 
if  the  area  is  extensive,  but  probably  in  many  of  these  there  is  really  some  tearing 
of  the  inner  layer.  Elevated  fractures,  caused  by  oblique  cuts,  are  rare  in  civil 
life,  and  can  only  occur  while  the  bones  are  still  capable  of  yielding.  Punctured 
fractures,  which  are  produced  by  the  impact  of  some  sharp  body,  such  as  a  nail, 
are  particularly  serious,  owing  to  the  amount  of  injury  inflicted  on  the  inner  table. 
There  may  be  only  a  small,  round  hole  in  the  outer,  while  the  inner  is  fringed  all 
round  with  a  row  of  spikes,  projecting  at  right  angles  from  the  surface  into  the  dura 
mater.  The  inner  table,  as  a  rule,  splinters  more  readily  than  the  outer,  partly 
because  it  is  thinner  and  more  brittle,  and  forms  j^art  of  a  smaller  circle,  but 
mainlv  because,  in  all  ordinary  accidents,  the  blow  falls  ui)on  the  outer  first,  so 
that  the  force,  in  traveling  through  the  diploe,  becomes  distributed  over  a  wider 
area  (Figs.  284  and  285).  If  a  bullet  passes  through  the  cranium  from  within 
outward  the  reverse  is  the  case. 


FRACTURES  OF  THE   SKULL.  635 

{a)  Simple  Fractures. 

Of  themselves,  simple  fractures  of  the  vault  are  of  little  or  no  consequence; 
contusions,  fissures,  and  fractures  without  displacement  do  not  admit  of  proof,  and 
even  when  the  bone  is  comminuted  and  the  depression  considerable,  the  diagnosis 
is  often  only  a  conjecture,  owing  to  the  amount  of  blood  extravasated.  Their 
gravity  arises  from  the  fact  that  serious  injury  to  important  structures  is  so  often 
associated  with  them.  Concussion  or  contusion  of  the  brain,  hemorrhage  between 
the  membranes,  or,  especially  if  the  course  of  the  fissure  traverses  the  middle 
meningeal  artery,  between  the  dura  mater  and  the  bone,  rupture  of  the  venous 
sinuses  and  laceration  of  the  membranes  are  of  frequent  occurrence  after  simple 
fractures  ;  more  rarely  the  contents  of  the  cranium  (the  cerebrospinal  fluid  at  least) 
find  their  way  out,  and  form  a  soft,  fluctuating  and  pulsating  swelling  underneath 
the  aponeurosis — cephalhydrocele. 

Later,  especially  in  cases  in  which  the  bone  is  severely  contused,  inflamma- 
tion may  set  in,  though  it  is  very  rare  in  comparison  with  compound  fractures.  It 
may  be  either  acute  or  chronic.  In  the  former  case  the  whole  thickness  of  the 
bone  perishes,  lymph  is  poured  out  beneath  the  pericranium,  the  scalp  becomes 
boggy  and  oidematous  (Pott's  puff'y  tumor),  and  suppuration  follows  and  spreads 
to  the  inner  surface  of  the  cranium.  A  few  cases  are  on  record  in  which  the 
abscess  resulting  from  this  hks  been  merely  local,  between  the  bone  and  the  dura 
mater  ;  much  more  frequently  the  inflammation  rapidly  involves  the  venous  sinuses, 
and  ends  in  either  diffuse  suppurative  meningitis  or  pyaemia. 

Chronic  inflammation  is  even  more  uncommon,  but  an  extraordinary  thicken- 
ing of  the  bone  is  said  to  have  occurred  after  simple  fracture.  The  whole  skull 
may  be  affected,  or  irregular  nodules  may  grow  out  and  cause  constant  wearing 
pain  and  neuralgia.  Loss  of  power,  partial  paralysis,  and  even  insanity  or  epi- 
lepsy have  been  known  to  follow. 

{b)  Compound  ( Open)  Fractures. 

In  the  majority  of  instances  the  nature  of  the  injury  can  be  seen  at  once. 
There  is  a  fissure,  appearing  as  a  thin,  red  line,  out  of  which  blood  continues  to 
ooze,  contrasting  with  the  white  bone  around,  or  the  bone  is  plainly  comminuted 
and  driven  in,  or  the  broken  edge  of  a  knife  or  other  foreign  body  can  be  seen 
upon  the  surface.  But  this  is  not  enough  ;  the  wound  must  be  carefully  and  thor- 
oughly explored  with  the  finger,  the  mere  diagnosis  is  not  suiificient ;  its  extent  and 
the  depth  and  character  of  the  displacement  must  be  made  out  as  accurately  as 
possible,  especially  in  the  case  of  punctured  wounds.  There  are  many  sources  of 
fallacy  ;  a  suture  can  be  easily  mistaken  for  a  fracture,  or  the  edge  of  a  pericranium, 
if  it  is  cut  and  one  side  is  adherent  to  the  bone,  may  feel  like  a  fissure,  especially 
if  a  probe  is  used.  The  temporal  aponeurosis  has  before  now  given  rise  to  diffi- 
culty :  a  foreign  body  may  be  broken  off  flush  with  the  surface  so  that  it  can 
scarcely  be  detected,  or,  as  in  the  case  of  the  frontal  sinuses  in  men,  though 
the  outward  depression  is  very  considerable  the  inner  table  may  not  be  injured 
at  all. 

Serious  complications  are  much  mare  common  in  compound  fractures.  In  the 
first  place,  the  force  is  often  greater,  and  nearly  always  is  concentrated  in  one  small 
spot,  so  that  the  inner  table  is  driven  inward  and  extensively  sijlintered.  The 
more  nearly  a.  fracture  approaches  the  punctured  form  the  more  dangerous  it 
becomes  ;  it  does  not  matter  so  much  if  the  depression  is  wide  and  extensive, 
or  if,  owing  to  the  softness  and  elasticity  of  the  bones  there  is  little  or  no 
splintering ;  the  dura  mater  is  not  injured,  and  symptoms  of  compression,  merely 
from  displaced  bone,  are  exceedingly  rare ;  but  where  the  inner  opening  is 
fringed  with  a  circle  of  little  spikes  projecting  vertically  inward,  and  tearing 
and  irritating  the  membranes  and  the  brain,  inflammation  is  almost  certain  (Fig. 
286).      In    addition,    compound    fractures   are   always    exposed    to    the    risk   of 


636    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

decomposition.  Blood  is  extravasated  into  the  diploe,  and  between  the  dura 
mater  and  the  bone ;  the  fracture  is  often  comminuted  ;  there 
are  numerous  little  spaces  and  fissures  between  the  fragments 
which  cannot  drain,  and  the  wound  is  frequently  filled  with 
dirt  and  other  foreign  substances.  Under  these  circumstances, 
unless  steps  are  taken  to  prevent  it,  inflammation  must  break 
out,  and  though  fortunately  it  often  remains  limited  to  the 
wound,  and  merely  causes  necrosis  of  the  broken  fragments,  it 
mav  at  any  moment  spread  into  the  surrounding  bone,  or, 
especially  if  the  dura  mater  has  been  pricked,  into  the  mem- 
branes of  the  brain,  and  set  up  fatal  meningitis. 

Treatment. — (a)  In  Simple  Fractures. — So  far  as  the 
bone  itself  is  concerned,  injury  to  the  vault  of  the  skull  rarely 
requires  anything.  Unless  there  are  definite  symptoms  of 
'""Fra^reofSkuu"*  compression.  either  growing  worse  or  refusing  to  clear  up, 
nothing  should  be  done.  But  it  is  so  often  associated  with 
concussion  and  contusion  of  the  brain,  and  the  e.vtent  of  the  injury  is  so  entirely 
unknown,  that  in  any  case  in  which  there  is  the  least  ground  for  suspicion  the 
utmost  precautions  must  be  taken.  The  patient  must  be  placed  in  a  darkened 
room  with  the  head  shaved,  and  an  ice-bag,  or,  better,  Leiter's  coil  applied  ; 
every  source  of  irritation  or  excitement  should  be  ex'cluded,  the  bowels  should  be 
opened,  preferably  with  a  calomel  purge,  and  nothing  but  the  simplest  diet 
allowed.  Rest  in  bed  must  be  strictly  enforced  for  at  least  three  weeks,  and  the 
patient  must  be  carefully  watched  for  months.  The  great  fear  during  the  first 
few  days  is  that  hyjjeraemia  and  inflammation  of  the  brain  may  occur;  after  that 
the  chief  risk  comes  from  the  bone,  which  may  inflame  and  cause  necrosis, 
meningitis,  or  pyaemia ;  still  later,  even  years  after,  symptoms  of  cerebral 
irritation  may  make  their  appearance,  sometimes  merely  undue  e.xcitability  or  fits 
of  temper,  especially  if  there  is  any  indiscretion  in  diet  or  abuse  of  stimulants  ; 
occasionally,  but  fortunately  very  rarely,  more  serious  trouble,  such  as  epilepsy 
and  even  insanity. 

{b)  In  compound  fractures  the  wound  in  the  soft  parts  and  the  injury  to  the 
bone  require  something  further.  The  former  should  be  treated  as  already  described  ; 
the  hair  should  be  shaved  off,  the  scalp  well-washed,  the  hemorrhage  stopped,  for- 
eign matter  and  dirt  carefully  removed,  and  then  all  the  part  that  has  been  exposed 
thoroughly  washed  out  with  corrosive  sublimate  or  some  other  antiseptic.  It  should 
then  be  well  dried,  the  edges  dusted  over  with  iodoform  and  brought  together  with 
sutures  (catgut  is  especially  useful  where  there  is  no  tension),  leaving  suitable  open- 
ings for  the  escape  of  the  lymph,  and  if  neces.sary  one  or  two  tubes  may  be  inserted. 
Then  it  should  be  carefully  covered  over  with  a  thick  layer  of  some  dressing  suffi- 
ciently absorbent  to  soak  up  any  discharge  at  once,  and  bandaged  to  avoid  dis- 
placement and  secure  rest. 

Simple  linear  fissures,  not  depressed  and  not  caused  by  the  impact  of  a 
sharp  weapon,  may  be  covered  in  at  once,  the  pericranium  being  replaced  if  it  is 
torn  off.  There  is  no  splintering  in  such  a  case,  no  fear  of  spicules  irritating  the 
dura  mater  and  the  brain,  and  the  sooner  the  fracture  is  converted  into  a  simple 
one  the  less  the  risk  of  decomposition  and  suppuration.  Punctured  fractures,  on 
the  other  hand,  should  always  be  trephined,  the  wound  in  the  outer  table  being 
included  in  the  circle  of  the  instrument.  It  is  impossible  to  ascertain  the  condi- 
tion of  the  inner  table  :  in  nearly  every  case  it  is  starred  and  the  splinters  driven 
inward  :  the  operation  adds  nothing  to  the  gravity  of  the  case,  and  deep  punc- 
tured wounds  passing  through  strata  of  different  consistence  cannot  either  be 
cleaned  or  drained. 

In  compound  depressed  fractures,  portions  of  bone  that  are  detached  or 
loose  or  driven  into  the  substance  of  the  dura  mater,  must  be  carefully  picked  out. 
If  there  are  symptoms  of  compression,  or  if  the  size  and  depth  of  the  wound 
make  it  probable  that  the  inner  table  is  splintered,  the  bone  must   be  elevated. 


FRACTURES  OF  THE   SKULL.  637 

and,  if  necessary,  part  of  a  circle  removed  with  the  trejjhine,  the  pin  resting  on 
the  uninjured  margin.  No  pains  must  be  spared  to  make  the  elevation  effectual,  and 
to  exclude  the  possibility  of  splinters  being  left  under  the  overhanging  edges.  It 
is  true  that  a  large  proportion  of  patients  never  suffer  in  any  way  ;  that  fragments 
of  bone  and  even  foreign  bodies  have  remained  embedded  in  the  substance  of  the 
brain  itself  for  years,  without  its  being  known  ;  but  they  are  never  safe.  So  many 
ca.ses  are  recorded  of  disturbances  of  the  most  varied  character — motor,  sensory, 
and  psychic — being  caused  by  the  presence  of  a  depressed  fracture,  and  being  cured 
by  its  elevation,  that  unless  the  depression  is  smooth  and  even,  as  it  nearly  always 
is  in  children  (fractures  of  the  skull  in  them  rarely  require  much  interference), 
it  is  better  to  raise  it  at  once.  The  operation  does  not  increase  the  patient's  risk  ; 
trephining,  when  done  as  a  precaution  and  not  as  a  last  resource  for  a  disease  that 
has  almost  proved  fatal  already,  is  very  rarely  followed  by  any  ill  result;  and  in 
many  cases  in  which  the  wound,  filled  with  extravasated  blood,  has  been  exposed 
to  the  air,  and  perhaps  ground  in  with  dirt,  the  cleansing  process  cannot  be  thor- 
oughly carried  out,  or  the  risk  of  decomposition  and  inflammation  avoided,  with- 
out its  being  done. 

Sometimes  it  is  merely  necessary  to  introduce  the  point  of  an  elevator  under 
one  of  the  edges  of  a  depressed  fragment,  and  gradually  lever  it  up  until  it  is  on 
a  level  with  the  rest.  Very  often,  however,  the  fragments  are  so  locked  together 
that  this  cannot  be  done  without  first  removing  a  portion  of  bone  ;  or  it  is  found 
that  the  injury  is  much  more  extensive  than  it  appeared  to  be  at  first  sight,  and 
that  the  splintering  extends  a  long  way  under  the  edge  of  the  outer  table.  Then  it 
becomes  necessary  either  to  remove  some  of  the  overhanging  edge  with  Hofmann's 
gouge-forceps  (or  Keene's  vongeur),  or  to  apply  the  trephine  on  the  margin.  In 
any  case  great  care  must  be  taken  to  pre.serve  the  pericranium  and  to  avoid  detach- 
ing any  adherent  fragments.  The  wound  must  be  dressed  in  the  ordinary  way. 
The  portion  of  bone  that  has  been  removed  may  be  replaced,  and  in  some  cases 
it  retains  sufficient  vitality  to  form  fresh  adhesions  ;  more  often  it  gradually  becomes 
absorbed,  or,  if  suppuration  sets  in,  perishes  and  is  thrown  off  as  a  foreign  body. 
It  very  rarely  happens  that  there  is  any  reproduction  of  bone  ;  the  edges  of  the 
opening  become  rounded  and  smooth,  and  a  dense  fibrous  cicatrix  forms  upon  the 
surface  of  the  dura  mater,  strong  enough  of  itself  to  act  as  a  protection  to  the 
brain,  unless  the  opening  is  very  large. 

2.   Fracture  of  the  Base. 

Fracture  of  the  base  of  the  skull  is  sometimes  the  result  of  direct  violence — 
when,  for  example,  a  revolver  is  discharged  into  the  mouth,  or  a  stick  is  forced 
through  the  roof  of  the  orbit,  or  the  condyle  of  the  jaw  is  driven  through  the 
glenoid  fossa.  More  often  it  is  caused  by  a  fissure  extending  from  the  vault.  The 
fracture  starts  from  the  point  that  is  struck,  and  generally  passes  across  the  base  of 
the  corresponding  fossa,  sometimes  when  the  force  is  great  involving  more  than 
one.  The  middle  suffers  the  most  frequently,  as  might  have  been  expected,  and  a 
very  common  course  for  the  fissure  to  take  is  across  the  petrous  portion  of  the  tem- 
poral bone  and  the  internal  auditory  meatus.  Occasionally  it  is  produced  in  other 
ways.  The  skull,  for  example,  may  be  driven  down  on  to  the  vertebral  column, 
just  as  a  hammer-head  is  forced  on  to  the  shaft,  with  such  violence  as  to  break  the 
bone  round  the  foramen  magnum  ;  or,  as  it  falls  upon  the  head,  the  vertebral 
column  may  be  driven  against  the  skull.  In  fracture  by  contre-coup  the  injury  is 
on  the  opposite  side  of  the  head,  at  the  other  end  of  the  diameter.  The  orbital 
plate  of  the  frontal  bone,  for  example,  is  sometimes  fissured  from  a  fall  upon  the 
occipital  region.  The  skull  is  suddenly  shortened  in  its  antero-posterior  diameter, 
and  correspondingly  widened  in  its  lateral  and  vertical  ones  ;  both  the  frontal  and 
the  occipital  regions  are  flattened  out ;  but  the  former,  being  the  thinner,  more 
brittle  and  less  regular  in  its  elasticity,  gives  way  first.  It  must  not  be  forgotten 
that  fractures  extending  into  the  ear,  nose,  and  pharynx  are  really  compound. 


638     niSEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

The  diagnosis  of  fracture  of  the  l>ase  of  the  skull  can  only  be  made  either 
from  an  escape  of  some  of  the  contents  of  the  cranium,  or  from  injury  to  some  of 
the  structures  that  pass  out  through  it.  It  may  be  suspected  whenever  there  is 
evidence  of  serious  injury  to  the  brain  after  a  severe  blow  upon  the  head  but  it 
can  only  be  proved  by  one  of  these.  I^rol)al)ly  it  is  present  in  many  of  the  cases 
of  severe  contusion  to  the  brain,  in  which  the  patient,  after  lying  in  a  state  of 
semi-unconsciousness  for  days  and  even  weeks,  slowly  recovers.  If  it  is  compound 
It  adds  very  distinctly  to  the  danger  of  the  case. 


v»-.~ 


X  ■?: 


Fig.  287.-B.->se  of  Skull  showing  the  most  frequent  Lines  of  Fracture  (<i)  across  the  petrous  portion  of  the  Temnoral 
I  nm '.K^  r^  ^'  '""=■■"'"'  ^'"''"'/y  '::'-f"^  i"  'WO,  (/»  passing  between  the  Foram.na  medfa  and  (.)  r^diaUni 
from  the  Foramen  magnum  uito  the  thin  bone  of  the  Occipital  Fossa.  '  "'''^""S 

The  brain  substance  /Av/^ rarely  escapes,  except  in  gunshot  injuries  and  com- 
pound fractures  through  the  ethmoid,  when,  for  exami)le,  there  is  a  violent  blow 
at  the  root  of  the  nose  breaking  up  the  cribriform  plate  and  lacerating  the  dura 
mater.  1  he  ordinary  signs  that  are  looked  for  are  the  escape  of  cerebro-spinal 
fluid  and  hemorrhage. 

Escape  of  Cerebro-Spinal  Fluid.— 'Wm'?,  mav  take  place,  as  already  mentioned 
on  the  vertex,  coming  from  the  ventricles  of  the  brain,  and  forming  if  the  frac- 
ture is  a  simple  one,  a  soft,  fluctuating,  and  pulsating  swelling,  which  causes  symp- 
toms of  compression  when  it  is  reduced  ;  or  it  may  escape  from  the  ear,  the  nose,  or 


FRACTURES    OF   THE  SKULL.  639 

the  roof  of  the  pharynx.  Owing  to  the  frequency  with  which  fractures  of  the  middle 
fossa  of  the  skull  pass  across  the  internal  auditory  meatus  and  tear  open  the  pro- 
longation of  the  arachnoid  along  the  auditory  nerve,  the  ear  is  by  far  the  most  com- 
mon of  the  three.  If  the  tympanic  membrane  is  torn  across,  it  pours  out  from  the 
external  meatus  ;  if  it  is  not,  it  trickles  down  the  P^ustachian  tube  into  the  pharynx 
and  probably  escapes  notice  altogether.  In  the  case  of  the  nose  and  pharynx  it 
must  come  from  the  great  sub-arachnoid  sac  at  the  base  of  the  brain,  possibly  along 
the  course  of  the  olfactory  nerves.  In  one  or  two  instances  the  fissure  in  the 
petrous  portion  of  the  temporal  bone  has  been  so  fine  that  it  could  only  be  detected 
after  maceration. 

The  nature  of  the  fluid  may  be  recognized  partly  by  its  quantity,  partly  by 
its  chemical  comjjosition.  The  escape  of  a-  teaspoonful  of  moderately  clear  fluid 
from  the  ear,  a  day  or  two  after  a  severe  blow  on  the  head,  cannot  be  regarded 
as  proof  of  fracture  of  the  base  of  the  skull.  If  the  tympanic  membrane  is  torn 
across,  there  is  often,  especially  in  men,  a  certain  amount  of  secretion  of  a  watery 
fluid  from  the  mucous  membrane  lining  the  mastoid  cells ;  but  this  does  not  come 
on  immediately  after  the  accident,  and,  like  catarrhal  secretion  generally,  is  al- 
ways more  or  less  turbid.  It  is  possible  the  .same  thing  may  occur  in  connection 
with  the  frontal  sinuses.  Cerebro-spinal  fluid  begins  to  escape  either  at  once  or 
immediately  after  the  hemorrhage  has  ceased,  and  as  much  as  a  pint  may  flow  out 
in  twenty-four  hours.  Usually  it  continues  for  several  days  and  then  ceases  of  itself. 
That  it  comes  from  the  interior  of  the  cranium  may  be  shown  by  making  the 
patient  blow  his  nose  hard,  compressing  it  at  the  same  time  ;  the  intra-cranial  pres- 
sure rises  rapidly  and  the  fluid  pours  out ;  but  the  experiment  is  not  advisable.  Its 
chemical  composition  agrees  perfectly  with  that  of  cerebro-spinal  fluid  ;  there  is 
an  appreciable  amount  of  chloride  of  sodium  present ;  a  trace  of  sugar  can  some- 
times be  found  ;  but  the  amount  of  albumin  is  much  too  small  to  give  any  reaction 
with  nitric  acid,  or  acetic  acid  and  ferrocyanide  of  potassium,  even  when  the  fluid 
has  been  concentrated  at  a  low  temperature. 

Hemo7'rhage  naturally  is  more  ambiguous.  The  mere  escape  of  blood  after 
a  severe  injury  to  the  head  cannot  be  regarded  as  a  diagnostic  sign  of  any  value, 
unless  there  are  special  features  in  connection  with  it.  Every  case  of  hemorrhage 
from  the  ear,  for  example,  must  be  looked  upon  with  grave  suspicion,  unless  it  can 
be  traced  to  some  small  laceration  ;  but  it  can  only  be  regarded  as  a  proof  of 
fracture  when  it  is  immediate,  copious,  and  long  continued.  The  same  thing  may 
be  said  of  hemorrhage  into  the  tissue  of  the  orbit.  If  the  stain  does  not  make 
its  appearance  under  the  conjunctiva  for  some  time  after  the  accident,  and  if  it 
gradually  creeps  forward  toward  the  cornea  (not,  as  in  an  ordinary  black  eye,  from 
direct  injury,  diminishing  as  it  recedes),  it  is  proof  that  the  hemorrhage  comes 
from  behind,  possibly  from  fracture  of  the  orbital  plate  of  the  frontal  bone  ;  and 
if  it  slowly  soaks  forward  into  the  eyelids,  the  lower  first,  until  they  are  both  jet 
black,  without  any  staining  of  the  cheek  or  forehead  around,  or  if  the  eyeball 
is  protruded,  it  becomes  much  more  definite.  But  it  is  only  certain  when  the  na- 
ture of  the  accident  is  such  as  to  preclude  the  possibility  of  any  direct  injury  to 
the  structures  in  the  orbit  itself.  Under  such  conditions,  serious  hemorrhage 
coming  from  behind  can  only  arise  from  a  fissure  traversing  the  orbital  plate  of  the 
frontal  bone  or  part  of  the  sphenoid,  and  opening  up,  perhaps,  the  anterior  ex- 
tremity of  the  cavernous  sinus. 

Hemorrhage  into  the  nose  or  mouth,  or  into  the  tissues  at  the  back  of  the 
neck,  and  vomiting  of  blood  after  any  severe  injury  to  the  head,  in  the  same  way 
must  be  regarded  as  very  suspicious,  and  any  case  in  which  they  occur  must  be 
given  the  benefit  of  the  doubt,  and  treated  as  if  it  w^ere  certain  that  there  were  a 
fracture  of  the  base  ;  but  they  cannot  be  regarded  as  proof,  unless  the  presence  of 
all  other  injuries  can  be  excluded. 

The  cranial  nerves  may  be  injured  in  fractures  of  the  base  of  the  skull ; 
either  torn,  when  the  effect  is  immediate  and  usually  permanent,  or  merely  com- 
pressed by  blood  extravasated  into  the  sheath  or  into  one  of  the  bony  canals. 


640     DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

Sometimes  this  is  followed  by  neuritis,  coming  on  after  an  interval  of  two  or  three 
weeks,  and  gradually  disappearing  again.  The  seventh  nerve  suffers  the  most  fre- 
(juently,  causing  deviation  of  the  soft  palate,  as  well  as  facial  paralysis ;  but 
atrojjhy  of  the  optic  disc,  from  rupture  of  the  optic  nerve,  has  been  found  after 
fractures  of  the  anterior  fossa,  and  occasionally  the  fifth  and  the  motor  nerves  of 
the  eye  are  involved. 

Fractures  of  the  base  of  the  skull  must  be  treated  in  the  .same  way  as  fracture 
of  the  vault  ;  the  brain  is  always  severely  injured,  and  the  greatest  care  must  be 
taken  to  ward  off  any  source  of  irritation.  If  the  cribriform  plate  of  the  ethmoid 
is  comminuted,  an  attemjjt  should  be  made  to  remove  the  fragments,  either  through 
the  orbit  or  the  nose,  for  fear  of  the  dura  mater  being  injured,  and  to  insure  more 
perfect  drainage.  The  discharge  is  certain  to  become  purulent  [unless  drained 
and  antiseptically  irrigated],  and  is  usually  exceedingly  offensive,  especially  if  the 
injury  is  followed  by  necrosis.  In  the  case  of  the  ear,  the  meatus  should  be  gently 
syringed  out  with  an  antiseptic,  and  then  covered  with  a  large  pad  of  absorbent 
cotton,  renewed  as  often  as  required.  The  fracture  is  compound,  but  meningitis 
rarely  follows. 

Callus  is  scarcely  ever  thrown  out,  the  parts  lie  absolutely  quiet,  and  there  is 
no  irritation  ;  in  many  cases  union  is  by  fibrous  tissue  only  ;  and  the  edges  of  the 
fracture  become  smoothed  down  and  absorbed  to  some  extent,  so  that  the  fissure, 
when  the  skull  is  macerated,  appears  much  larger  than  it  really  was. 


INJURIES  OF  THE  BRAIN. 

The  brain  may  be  injured  by  concussion,  contusion,  or  compression  ;  blood 
may  be  extravasated  between  the  membranes  or  in  the  substance  of  the  brain  itself, 
and  the  cranial  nerves  may  be  torn  or  crushed  at  their  origin.  The  symptoms  and 
diagnosis  of  these  affections  must  be  considered  separately.  The  treatment  may  be 
dealt  with  as  a  whole. 

Concussion. 

Concussion  is  the  effect  produced  by  a  blow  upon  the  head  sufficiently  severe 
to  affect  the  functions  of  the  brain,  without  causing  any  considerable  alteration 
in  its  structure.  There  may  be  merely  a  temporary  sensation  of  giddiness ;  or 
the  patient  may  lie  for  hours  in  a  state  of  semi-unconsciousness ;  or,  rarely,  the 
depression  may  prove  fatal,  without  reaction  ever  setting  in. 

Opportunities  for  examining  the  condition  of  the  brain  are  so  rare  that  very 
little  is  known  about  the  pathology  of  concussion.  Minute  ecchymoses  and  small 
points  of  contusion  are  found  in  the  majority  of  instances ;  but,  as  the  symptoms 
subside  long  before  these  disappear,  they  can  scarcely  be  regarded  as  the  cause. 
A  certain  amount  of  congestion  is  nearly  always  present,  arising  from  paralysis  of 
the  walls  of  the  vessels  ;  and  in  all  probability  this  is  the  immediate  source  of  the 
functional  depression.  The  rapidity  with  which  recovery  takes  ]jlace  as  .soon  as 
reaction  sets  in,  and  the  peculiar  irritability  that  follows,  jwint  distinctly  to  some 
altered  condition  of  the  circulation.  It  has  been  shown  experimentally  that  vio- 
lent vibration,  or  even  a  slight  degree,  provided  it  is  long  continued,  is  capable 
of  suspending  more  or  less  completely  the  activity  of  nerve-cells.  If  the  cortex 
only  is  affected,  the  depre.ssion  is  merely  transient  and  the  symptoms  soon 
disappear ;  but  if,  in  addition  to  this,  the  ganglia  at  the  base  of  the  brain  are 
involved,  particularly  the  vaso-motor  and  the  cardiac  centres,  the  effect  is  more 
general  and  more  lasting.  The  walls  of  the  vessels  everywhere,  those  of  the  cortex 
included,  are  relaxed  ;  the  blood-pressure  falls ;  the  blood  lies  stagnant  in  the  great 
veins  of  the  abdomen  ;  the  surface  becomes  cold  and  white  ;  the  temperature  of 
the  skin  is  lowered  ;  and  the  pulse  is  rapid  and  feel)le.  In  .short,  all  the  symptoms 
of  severe  shock  are  i)resent,  with  the  cerebral  ones  strongly  accentuated. 

Symptoms. — In  the  .slighter  cases  there  is  merely  a  little  transient  giddiness 


INJURIES   OF  THE   BRAIN— CONTUSION.  641 

or  confusion  ;  when  the  injury  is  severe,  the  symptoms  may  be  divided  into  four 
stages — collapse,  rallying,  reaction,  and  convalescence. 

The  first  is  characterized  by  depression,  general  and  extreme,  beginning  at 
once  and  sometimes  proving  fatal,  as  the  action  of  the  heart  becomes  more  and 
more  feeble.  The  patient  lies  without  moving,  but  the  attitude  is  not  that  of 
utter  helplessness;  consciousness  is  not  lost,  though  no  notice  is  taken  of  any- 
thing; he  can  easily  be  aroused  so  as  to  speak,  and  move  his  limbs,  but  only  for 
a  moment ;  the  skin  is  cold,  pale,  and  clammy  ;  the  temperature  low  ;  the  pulse 
feeble  and  rapid,  sometimes  intermittent,  or  so  faint  that  it  can  scarcely  be  felt ; 
the  respiration  shallow,  with  occasional  sighing ;  the  eyes  glassy  and  devoid  of 
expression;  the  pupils  either  contracted  or  dilated;  the  sphincters  relaxed,  and 
reflex  excitability  almost  abolished.  Then,  after  an  interval  that  varies  from  a 
few  minutes  to  several  hours,  the  second  stage  begins  ;  the  heart  begins  to  recover  ; 
the  cardiac  and  vaso-motor  centres  regain  their  power  ;  the  pulse  becomes  fuller  and 
stronger  ;  the  surface  grows  warmer ;  the  brain  is  better  supplied  with  blood,  and 
sensibility  rapidly  returns.  Very  often  at  the  same  time  there  is  vomiting,  partly 
due  to  the  fact  that  digestion  has  been  interrupted,  partly  to  the  recovery  of  the 
pneumogastric  centre  ;  and  the  reaction  is  assisted  by  the  compression  of  the 
abdominal  veins  driving  the  blood  into  the  circulation. 

The  third  stage,  that  of  reaction,  is  scarcely  noticeable  in  slight  cases,  espe- 
cially in  children  ;  there  is  merel)'  a  little  restlessness  or  irritability,  often  put 
down  to  temper.  In  the  more  severe  ones,  however,  after  twenty-four  or  forty- 
eight  hours  the  symptoms  change  their  character  completely.  The  circulation 
becomes  quickened  ;  the  amount  of  blood  that  flows  through  the  brain  is  immensely 
increased  ;  the  head  begins  to  ache  and  throb  ;  the  carotids  beat  so  that  they  can 
be  seen  ;  the  face  is  flushed  ;  the  skin  becomes  hot  and  dry ;  the  eyes  cannot  face 
the  light ;  there  are  noises  in  the  ears  ;  sometimes  there  is  extreme  drowsiness,  so 
that  the  patient  lies  for  hours  in  a  semi-torpid  condition,  curled  up  in  bed  away 
from  the  light ;  sometimes  there  is  great  irritability  or  even  wandering.  In  short, 
there  are  all  the  symptoms  of  hyperemia  of  the  brain,  such  as  are  met  with  in  the 
early  days  of  inflammation. 

Gradually,  in  the  course  of  a  few  hours,  this  begins  to  subside  and  convales- 
cence sets  in  ;  very  rarely,  considering  how  common  concussion  is,  it  runs  on  to 
inflammation,  but  it  is  often  months  before  the  cerebral  circulation  is  thoroughly 
under  control  and  is  able  again  to  regulate  itself;  for  a  long  time  it  continues  un- 
duly excitable,  responding  to  the  slightest  stimulus  with  disproportionate  energy. 
The  memory  is  defective;  often,  curiously  enough,  the  accident  itself  and  the 
events  of  a  few  hours  before  are  completely  forgotten  ;  the  patient  is  liable  to  un- 
reasonable outbreaks  of  temper  ;  headache  and  sli'ght  attacks  of  giddiness  are  not 
uncommon  ;  there  is  a  peculiar  susceptibility  to  the  effects  of  alcohol,  and  any  little 
mental  emotion  or  anxiety  causes  an  excessive  amount  of  disturbance.  Sometimes 
this  condition  persists  for  the  rest  of  life ;  the  patient  loses  his  aptitude  for  busi- 
ness or  work,  and  is  said  by  his  friends  never  to  have  been  himself  again. 

Contusion  of  the  Brain. 

This  may  or  may  not  be  attended  by  concussion,  according  to  the  extent  of 
surface  that  receives  the  injury  and  the  amount  of  general  shock,  and  it  may  either 
cause  a  definite  train  of  symptoms  of  its  own,  or  it  may  be  so  confused  with  con- 
cussion, compression,  or  hyperaemia  as  to  be  almost  unrecognizable. 

Laceration  of  the  brain  may  occur  without  any  wound  of  the  soft  parts  or 
fracture  of  the  bone  ;  probably  it  is  present  in  all  cases  of  severe  injury  to  the 
head — certainly  if  there  is  a  fracture,  and  it  is  produced  either  by  the  sudden 
alteration  in  shape  when  a  violent  blow  falls  upon  the  skull,  or  by  fragments  of 
bone  or  foreign  bodies  that  are  driven  in.  In  the  latter  case  the  dura  mater  is 
torn  ;  there  may  be  hemorrhage  from  the  meningeal  arteries,  and  the  injury  may 
be  compound.     The  brain  is  bruised  either  immediately  under  the  seat  of  injury, 


642     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

or  exactly  at  the  opposite  side,  at  the  other  end  of  the  diameter  ;  the  sudden  arrest 
of  the  momentum  when  the  head  strikes  the  ground  dashes  it  against  the  opjiosite 
side  of  the  skull,  and,  especially  if  the  surface  is  uneven  or  irregular,  bruises  it 
against  the  bone.  If  the  force  is  at  all  severe,  it  is  hurt  in  both  places.  This 
injury  by  contre-coup  (as  it  is  called)  may  occur  at  any  point,  but  is  met  with  most 
fre(|uently  at  the  ai)e.K  of  the  temi)oro-s})henoidal  lobe,  or  on  the  under  surface  of 
the  frontal,  partly  because  of  the  frequency  of  falls  upon  the  occiput.  Multiple 
ecchymoses,  arising  from  the  rupture  of  small  vessels,  deep  in  the  substance  of  the 
brain,  and  even  in  the  floor  of  the  fourth  ventricle,  are  often  fcnind  in  i)ost-mortem 
examinations  of  fatal  cases,  in  addition  to  the  superficial  injuries.  It  is  possible 
that  they  are  often  present,  but,  unless  they  involve  some  ])art  the  function  of 
which  is  definite  and  known  there  is  no  means  of  making  a  diagnosis. 

The  extent  of  injury  may  vary  from  a  mere  superficial  bruise,  with  a  few  points 
of  extravasation  on  the  surface  or  in  the  substance  of  the  gray  matter,  to  complete 
disintegration.  When  it  is  severe,  the  hemorrhage  may  plow  up  the  cortex  in 
all  directions,  extending  deep  into  the  white  substance  and  spreading  in  the  sub- 
arachnoid space  over  the  greater  portion  of  one  hemisphere.  It  very  rarely  breaks 
into  the  ventricles,  but  it  not  unfrequently  extends  into  the  subdural  space  as  well 
as  into  the  subarachnoid.  The  subsequent  changes  are  the  same  as  those  that 
occur  elsewhere :  as  soon  as  the  hemorrhage  ceases  the  vessels  round  the  seat  of 
injury  begin  to  dilate,  the  circulation  becomes  more  rapid,  lymph  pours  out,  in- 
filtrating the  clot  and  the  structures  around,  so  that  the  pia  mater  becomes  thick 
and  milky,  and  all  the  neighboring  brain  substance  becomes  so  soft  that  it  can  be 
washed  away  by  a  stream  of  water.  Then,  if  the  part  injured  is  not  a  vital  one, 
if  the  hemorrhage  is  not  sufficient  to  cause  compression,  and  if  there  is  no  further 
cause  of  irritation,  no  bone-spicules  driven  in,  and  no  septic  decomposition,  the 
blood-clot  slowly  breaks  down,  the  ha^mogloljin  soaks  into  and  stains  the  tissues 
around,  the  fibrin  and  corjniscles  are  absorbed,  the  torn  and  lacerated  brain  sub- 
stance undergoes  fatty  degeneration,  the  damaged  portions  are  removed  or  repaired, 
and  gradually  the  injured  space  becomes  filled  with  lymph,  which  organizes  and 
forms  a  depressed  cicatrix,  firmly  adherent  to  the  membranes,  and  discolored  from 
deposits  of  hematoidin.  Blood  extravasated  into  the  subarachnoid  space  is  usually 
absorbed  ;  when  there  is  an  extensive  collection  in  the  subdural  it  may  become 
organized  and  form  a  tough  brownish-colored  membrane  on  the  under  surface  of 
the  dura  mater  ;  or  it  may  lose  its  color  completely  and  gradually  become  con- 
verted into  a  thin-walled,  transparent  cyst,  generally  adherent,  either  to  the  dura 
mater  or  the  arachnoid,  but  sometimes  cjuite  free,  resting  in  a  depression  on  the 
surface  of  the  cortex. 

The  termination,  however,  is  not  always  so  fortunate;  in  many  cases  the 
amount  of  blood  poured  out  is  so  great  as  to  cause  compression  of  the  brain,  and 
death  ensues  in  the  course  of  a  few  hours  from  coma  and  paralysis,  or  the  hyper- 
emia and  tension  continue  to  increase  until,  after  the  lapse  of  two  or  three  days, 
inflammation  .sets  in.  This  may  happen  even  when  there  is  no  external  wound  ; 
but  in  comi)ound  fractures,  when  spicule  of  bone  are  driven  into  the  dura  mater, 
there  is  everything  to  favor  it.  An  injury  of  this  kind  is  always  the  result  of  direct 
violence  ;  everything  is  bruised  ;  the  deeper  parts  suffer  in  particular,  owing  to  their 
delicate  structure  ;  the  wound  is  of  such  a  shaj^e  and  depth  that  it  can  rarely  be 
drained  effectually  ;  it  is  filled  with  broken  down  blood  clot  ready  to  decompose 
at  once,  and  is  often  covered  with  dirt  and  foreign  matter.  At  a  later  period,  after 
months,  or  even  years,  when  these  dangers  are  long  since  past,  others  are  some- 
times met  with.  Occasionally  the  softening  and  degeneration  of  the  brain  in  the 
immediate  neighborhood  of  the  injury  spread  to  the  parts  around,  so  that  large 
areas  are  destroyed,  or  chronic  inflammation  sets  in,  and  an  abscess  forms  in  the 
substance  of  the  brain,  or  the  cortex  becomes  atroi)hied  from  j)ressure.  and  sclerosed 
tracts  make  their  appearance  in  the  anterior  and  lateral  columns  of  the  cord. 

Symptoms. — The  symptoms  of  contusion  of  the  brain  depend  upon  the 
locality  of  the  injury.      In  many  cases  they  are  entirely  wanting ;  in  all  ca.ses  of 


INJURIES   OF   THE  BRAIN— CONTUSION.  643 

concussion,  for  example,  a  certain  amount  of  bruising  is  ijresent,  but  unless  the 
injury  is  extensive,  or  some  special  centre  is  involved  (such,  for  instance,  as  that 
which  controls  the  function  of  speech  or  the  movements  of  the  arm),  there  is  no 
evidence  of  it.  'I'he  occipital,  temporo-sphenoidal,  and  part  of  the  frontal  lobes 
may  be  very  seriously  injured  without  there  being  any  symptoms  of  it,  though 
there  may  be  every  reason  to  suspect  it. 

In  other  cases  symptoms  are  present  similar  to  those  of  concussion  ;  at  first 
there  is  extreme  depression,  the  j^atient  lies  almost  unconscious  in  a  state  of  pro- 
found shock  ;  then,  when  this  passes  off  and  the  circulation  through  the  brain 
begins  to  recover,  a  period  of  reaction  sets  in  ;  the  temjjerature  rises,  the  face 
becomes  flushed,  the  patient  becomes  excited  and  irritable,  and,  perhaps,  if  the 
hyper;x;mia  extends  to  the  motor  area,  spasmodic  contractions  of  groups  of  muscles, 
and  even  general  convulsions,  occur.  But  though  the  symptoms  may  be  of  the 
same  class  in  concussion  and  in  contusion,  there  is  a  striking  difference  in  the 
length  of  time  they  last.  In  the  former  the  hyperemia  is  transient,  and  either 
subsides  or  passes  on  into  inflammation  within  forty-eight  hours  ;  in  the  latter  it 
may  persist  for  weeks.  In  the  one  case  there  has  been  temporary  paralysis  of  the 
walls  of  the  vessels,  and,  as  in  a  limb  when  Esmarch's  bandage  is  removed,  this  is 
followed  by  a  transient  hypersemia  as  soon  as  the  circulation  recovers  ;  in  the 
other  the  brain  substance  is  crushed  and  torn,  and,  just  as  the  skin  over  a  severe 
bruise  remains  hot  and  tender  until  the  injury  is  completely  repaired,  so  there 
may  be  hyperemia  and  increased  excitability  of  the  nerve  tissue  for  a  variable 
distance  around  the  bruising  in  the  brain  for  a  proportionate  length  of  time. 

Such  cases  are  often  met  with  after  severe  injuries  to  the  head,  as,  for  example, 
fracture  of  the  base  of  the  skull ;  and  the  prognosis  is  always  very  grave,  for, 
though  a  large  proportion  recover,  further  hemorrhage  or  inflammation  of  the 
brain  may  occur  at  any  time.  There  are  the  same  symptoms  as  in  the  later  stages 
of  concussion,  but  they  are  much  more  strongly  marked.  The  patient  lies  curled 
up  in  bed,  with  every  joint  flexed  and  his  head  turned  away  from  the  light ;  he  is 
conscious,  but  pays  no  attention  to  anything  ;  if  spoken  to,  he  does  not  reply, 
and  if  roused,  or  if  an  attempt  is  made  to  move  him,  he  often  becomes  violent  or 
abusive,  and  tosses  himself  restlessly  from  side  to  side  until  the  old  position  is 
regained.  The  head  is  hot  and  aches  violently ;  the  face  is  flushed,  the  pupils 
contracted,  and  the  temperature  generally  slightly  above  normal.  In  severe  cases, 
the  patient  often  passes  faeces  and  urine  in  the  bed  ;  sometimes,  but  not  often, 
there  is  retention.  Then,  gradually,  at  the  end  of  perhaps  three  or  four  weeks, 
when  the  circulation  through  the  brain  is  again  becoming  normal,  the  irritability 
begins  to  subside,  the  other  symptoms  disappear,  and  often  the  patient  will  declare 
that  he  has  absolutely  forgotten,  not  only  all  that  has  happened  during  his  illness, 
but  the  accident  itself  and  the  events  that  immediately  preceded  it. 

In  the  third  class  of  cases  there  are  local  symptoms,  either  by  themselves,  or 
in  addition  to  these.  The  injury  has  affected  a  portion  of  the  brain  which  is  con- 
cerned with  carrying  out  some  special  work,  and  the  effect  depends  upon  the 
degree  to  which  the  nerve  tissue  suffers.  If  it  is  disorganized,  the  function  of  the 
part,  whatever  it  may  be,  is  abolished  ;  later  on  it  may  recover,  or  some  other 
portion  of  the  brain  may  perform  its  duties  more  or  less  well ;  but  for  the  time 
being  its  action  is  completely  lost.  This,  when  it  involves  a  group  of  muscles,  is 
known  as  monoplegia.  If,  on  the  other  hand,  the  injury  is  not  so  severe,  if  it  is 
merely  sufficient  to  excite  and  increase  the  irritability  of  the  cortex  without 
destroying  it,  there  may  be  spasmodic  contraction  of  groups  of  muscles  {7110710- 
spas77is)  or  of  a  limb,  or  even  general  convulsions  affecting  the  whole  body.  The 
occurrence  of  either  of  these  symptoms  is  of  the  greatest  significance;  if  they  are 
local,  and  if  they  occur  within  twelve  hours  of  an  injury  to  the  head,  they  point 
definitely  to  some  laceration  of  the  brain  or  to  progressing  hemorrhage  involving 
the  cortex  of  the  medulla. 

{a)  Co7-tical  Lesio/is. — The  symptoms  to  which  these  give  rise  are  always 
manifested  on  the  opposite  side  of  the  body.      It  must  be  remembered,  however, 


644    DISEASES  AND  INJURIES  01  SPECIAL  STRUCTURES. 

that  as  injury  to  the  brain  by  contre-coup  is  very  common,  this  may  be  on  the 
same  side  as  the  injury  to  the  head. 

A  blow  upon  the  right  side  of  the  occiput  is  frequently  followed  (in  right- 
handed  people)  by  aphasia.  This  may  be  accompanied  by  si)asm  or  by  paralysis 
of  the  muscles  of  the  lower  part  of  the  face  on  the  right  side,  or  either  of  the.se 
may  make  its  appearance  later,  as  the  hemorrhage  extends.  The  patient,  on 
coming  round  from  the  concussion,  is  entirely  unable  to  s])eak,  or  can  only  make 
use  of  a  limited  number  of  words,  or  constantly  uses  wrong  ones,  and  is  conscious 
that  he  does  so.  The  centre  for  speech  is  situated  in  the  posterior  part  of  the  third 
left  frontal  convolution,  and  immediately  behind  it,  at  the  lower  end  of  the  ascend- 
ing frontal  one,  is  the  centre  that  controls  the  movements  of  the  lips  and  mouth 
associated  with  it.  In  a  fall  upon  the  right  side  of  the  back  part  of  the  head  this 
portion  of  the  brain  is  dashed  violently  against  the  edge  of  the  anterior  fossa  of 
the  skull.  If  the  bruising  is  severe  there  is  com)>lete  loss  of  function,  if  slight,  it 
is  only  partial,  and  if  the  bleeding  continues,  the  effect  spreads  in  order  to  the 
neighboring  centres,  first  irritating  them  and  causing  monospasms,  then  compress- 
ing or  destroying  them,  so  that  monoplegia  sets  in. 

Spasmodic  contraction  or  paralysis  of  the  upper  part  of  the  face  and  eyelids, 
after  a  severe  blow  upon  the  head,  is  due  to  injury  of  centres  that  lie  a  little  higher 
up  in  the  ascending  frontal  convolution.  The  lower  i)art  of  the  face  and  the 
platysma  are  affected  when  it  extends  to  the  ascending  parietal  on  the  same  level. 
Brachial  monospasm  or  monoplegia  is  the  result  of  irritation  or  compression  of  the 
middle  portion  of  the  same  two  convolutions,  the  centre  for  the  movements  of  the 
arm,  like  those  of  the  muscles  of  the  face,  lying  on  both  sides  of  the  fissure  of 
Rolando.  If  the  stimulus  continues  to  spread  upward  (as,  for  instance,  in  hemor- 
rhage from  the  middle  meningeal)  the  associated  movements  of  the  leg  and  arm 
become  involved,  and  if  it  extends  so  far  backward  that  it  reaches  the  superior 
parietal  lobule,  those  confined  to  the  leg  alone.  The  muscles  of  the  trunk  appear 
to  be  under  the  control  of  centres  that  lie  on  the  inner  side  of  the  hemisphere  facing 
the  falx  cerebri. 

1.  Cortical  Paralysis. — If  the  bruising  is  severe,  this  is  immediate  ;  if  not 
quite  so  bad,  it  comes  on  gradually,  some  hours,  perhaps,  after  the  accident,  and, 
as  the  hemorrhage  extends,  spreads  by  degrees  from  one  group  of  muscles  to  another. 
Often,  especially  if  there  is  hemorrhage  into  the  subarachnoid  space,  the  paralysis 
is  preceded  by  convulsions,  which  may  involve  the  same  muscles,  or  may  be  gen- 
eral, or  may  even  affect  the  opposite  side  of  the  body  ;  the  blood,  as  it  spreads 
over  the  surface  of  the  cortex,  stimulates  it  first,  and  then  compresses  it,  until, 
perhaps,  the  whole  of  one  hemisphere  is  covered  in.  As  a  rule,  the  paralysis  of 
simple  contusion  (without  compression)  stops  short  of  complete  hemiplegia.  If  it 
makes  its  first  appearance  after  the  lapse  of  several  days,  or  if  it  continues  to 
extend,  it  is  a  sign  either  that  the  softening  is  spreading,  or  that  there  is  the  com- 
mencement of  a  cerebral  abscess. 

2.  Cortical  Spasm. — In  some  cases  this  is  immediate,  caused  by  the  irritation 
of  the  laceration  or  by  the  blood  as  it  spreads  over  the  surface  of  the  brain  ;  in 
others  it  does  not  make  its  appearance  for  some  time.  If  the  interval  is  only  a 
few  days,  it  is  probably  due  to  the  hyperaemia  that  sets  in  around  the  injured  area  ; 
either  the  sensitiveness  of  the  cortex  increases  so  that  repeated  discharges  of  nerve 
force  take  place  without  any  apparent  stimulus,  or  the  circle  of  hyperaemia  is 
spreading  and  now  for  the  first  time  involves  the  motor  area  ;  whichever  it  may 
be,  the  prognosis  is  very  grave,  for  though  such  injuries  may  end  favorably,  inflam- 
mation and  suppuration  sometimes  occur,  even  when  there  is  no  fracture.  If  the 
first  appearance  is  still  fiirther  delayed,  not  perhaps  until  a  month  has  passed,  the 
suspicion  of  cerebral  abscess  at  once  arises. 

The  convulsions  are  always  sudden,  occurring  without  any  warning  ;  and  they 
may  either  ht  purely  local,  or,  especially  if  they  are  repeated,  they  may  spread 
from  one  centre  to  another,  always  extending  in  a  definite  and  intelligible  order 
until  they  become  general  and  involve  the  whole  body.     The  fits  may  be  momen- 


INJURIES  OF  THE   BRAIN— COMPRESSION.  645 

tary,  or  they  may  last  half  an  hour  or  more  ;  consciousness  is  not  lost,  as  a  rule, 
unless  they  occur  in  rapid  succession  or  become  general ;  and  they  may  either 
subside  or  end  in  paralysis.  If  the  hemorrhage  is  extending,  each  outbreak 
may  be  followed  by  a  further  diminution  of  consciousness  and  an  increase  in  the 
area  of  loss  of  power,  until  at  length  coma  and  general  paralysis  occur  together. 
General  convulsions,  resembling  an  epileptic  fit,  coming  on  immediately  after  an 
injury,  may  be  the  result  either  of  powerful  stimulation  of  one  part  of  the  cortex 
only,  or  of  raj^idly  increasing  compre.ssion  and  anaemia.  In  the  latter  case  they 
are  followed  by  profound  coma. 

ij))  Medullary  Lesions. — Much  less  is  known  with  regard  to  the  symptoms  and 
localization  of  these.  Multiple  contusions  are  not  uncommon  in  the  white  sub- 
stance of  the  hemispheres,  and  if  they  interrupt  the  course  of  the  fibres  from  the 
cortex,  the  general  effect  is  the  same  as  if  the  centres  themselves  were  destroyed  ; 
but  unless  the  blood  makes  it  way  into  one  of  the  lateral  ventricles  (which  as  the 
result  of  injury  is  very  rare)  and  sets  up  compression,  the  extent  of  the  hemor- 
rhage is  never  great.  In  fatal  cases  of  concussion  minute  points  of  contusion  are 
usually  found,  but  it  seldom  happens  that  there  are  any  very  definite  signs  of  their 
presence  during  life.  Sometimes,  however,  there  are  symptoms  which  point  to 
injury  about  the  floor  of  the  fourth  ventricle  ;  there  may  be  persistent  vomiting, 
possibly  due  to  some  irritation  about  the  root  of  the  vagus ;  or  the  pulse  rate 
may  remain  abnormally  slow,  perhaps  for  the  same  reason  ;  or  there  may  be  dis- 
turbances in  the  region  of  the  vasomotor  centre,  giving  rise  to  diabetes,  polyuria, 
albuminuria,  or  haematuria. 

Compression, 

In  its  most  typical  form,  apoplexy,  for  example,  compression  of  the  brain 
presents  a  striking  contrast  to  concussion  ;  but  very  often  one  can  scarcely  be 
distinguished  from  the  other,  and  if,  as  not  unfrequently  happens,  compression 
follows  concussion  before  the  rallying  stage  sets  in,  it  may  be  impossible  to  say 
when  the  addition  takes  place. 

Causes. — It  may  arise  from  injury,  inflammation,  or  the  presence  of  new 
growths.  Extravasation  of  blood  and  inflammation  are  the  most  common  causes. 
The  former  occurs  either  immediately  after  an  accident,  or  within  a  very  {q\\  hours, 
and  may  lie  between  the  dura  mater  and  the  bone,  in  the  subdural  or  subarach- 
noid space,  in  the  substance  of  the  brain,  or  in  the  cavity  of  the  ventricles. 
Compression  when  due  to  inflammation  does  not  appear  until  later.  If  the 
brain  is  involved  primarily,  as  sometimes  happens  after  concussion,  there  may 
be  some  indication  of  it  within  the  first  three  or  four  days  ;  if  it  is  secondary, 
consequent  on  meningitis  or  acute  suppurative  osteitis,  it  rarely  occurs  for  a  week 
or  more  ;  and  when  there  are  no  definite  signs  of  it  for  weeks  or  months,  it  is 
probably  the  result  of  chronic  abscess  in  the  substance  of  the  brain.  Whether 
depressed  bone  by  itself  can  ever  give  rise  to  general  compression  is  very  doubtful ; 
when  there  is  a  tumor  it  is  often  present  toward  the  end,  especially  if  it  is  a 
rapidly  growing  one,  or  if  there  are  hemorrhages  in  connection  with  it. 

The  effect  of  pressure  upon  the  nerve  centres  depends  to  a  great  extent  on 
the  rapidity  with  which  it  acts.  If  it  is  sudden,  convulsions  and  even  an  epileptic 
fit  may  occur  before  the  function  of  the  cortex  is  abolished  ;  but  this  is  more 
common  in  animals  than  in  man.  If  it  takes  place  slowly,  the  brain  accom- 
modates itself  to  the  change  so  far  as  it  can.  In  some  cases  as  much  as  eight 
ounces  of  blood  has  been  found,  but  probably  the  amount  necessary  to  produce 
fatal  compression  varies  very  much  in  different  individuals.  The  cerebrospinal 
fluid  first  makes  way  by  flowing  down  the  spinal  sheath  ;  then  the  smaller  vessels 
in  the  brain  become  compressed ;  the  stream  becomes  slower  and  slower,  until  it 
stops  altogether.  At  first  the  effect  is  local,  and  limited  to  the  region  of  the 
cause;  but  gradually  it  spreads  to  other  parts  that  are  to  some  extent  protected 
by  the  falx  and  the  tentorium  ;  finally,  the  base  of  the  brain  becomes  bloodless, 
convulsions  perhaps  set  in,  and  life  becomes  extinct.      Unless  there  is  hemorrhage 


646    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

into  one  of  the  lateral  ventricles,  compression  is  nearly  always  gradual,  and  leads 
steadily  from  impairment  of  function  to  complete  loss,  the  higher  centres  suffering 
first  ;  but  in  inflammation  or  abscess  of  the  brain,  the  last  stages  maybe  relatively 
very  rapid.  The  chief  difficulty  arises  from  the  fact  that  compression  is  seldom 
met  with  unmixed  ;  nearly  always  it  is  associated  with  concussion,  contusion,  or 
hyperi-emia,  not  unfrequently  with  all  three  at  the  same  time. 

Symptoms. —  {a)  \\'hen  the  compression  is  general  they  are  very  much  the 
same,  whatever  the  cause  may  be.  The  patient  lies  in  a  state  of  complete  coma ; 
voluntary  movement  and  reflex  excitability  are  both  abolished  ;  the  limbs  lie 
absolutely  helpless,  just  as  they  are  placed,  and  nothing  that  is  said  or  done 
produces  the  least  effect.  The  surface  of  the  body  may  be  cool,  or  bathed 
in  i>erspiration  ;  in  some  cases  extreme  high  temperature  has  been  noted.  The 
breathing  is  slow  and  labored,  often  stertorous  from  jiaralysis  of  the  soft  palate, 
and  accompanied  by  a  peculiar  puffing  in  and  out  of  the  cheeks ;  the  pulse  is  full 
and  strong  ;  the  vasomotor  and  the  cardiac  centres  in  the  medulla  are  both 
affected  ;  the  pupils  are  fixed  and  generally  dilated,  or  one  of  them  is  dilated 
(generally  the  one  on  the  side  of  the  compression)  and  the  other  contracted  ;  the 
urine  is  retained  until  the  bladder  becomes  full,  and  the  faeces  are  passed  involun- 
tarily. Convulsions  are  very  rarely  present  unless  the  compression  takes  place 
suddenly,  and  then  they  are  soon  followed  by  coma  and  complete  paralysis. 

{b)  In  local  compression,  on  the  other  hand,  the  symptoms  depend  upon  the 
nature  and  position  of  the  exciting  cause,  and  consciousness  is  not  lost.  If  the 
pons  or  medulla  is  involved,  the  effect,  as  may  be  imagined,  is  of  the  most  serious 
character,  threatening  life  from  interference  either  with  the  nerve  centres  them- 
selves, or  with  the  trunks  on  their  way  through  the  skull.  The  anterior  part  of 
the  brain,  on  the  other  hand,  may  be  almost  destroyed  without  any  definite  local 
evidence,  unless  the  third  left  frontal  convolution  is  involved  at  its  posterior 
extremity.  Pressure  upon  the  motor  area  of  the  cortex  is  the  best  defined, 
causing  paralysis  of  the  opposite  side  of  the  body,  either  of  certain  movements 
only,  or  of  one  limb,  or  of  the  whole  side,  according  to  the  extent  of  the  injury.* 
When  the  sensory  zone  is  affected  there  is  rarely  any  local  evidence,  although,  as 
MacEwen  has  shown,  a  depressed  spiculum  from  the  inner  table,  driven  into  the 
anterior  portion  of  the  angular  gyrus  on  the  left  side,  may  cause  typical  mind- 
blindness.  In  addition  to  these  symptoms,  which  are  directly  dependent  on  the 
brain,  there  may  be  pain  from  the  stretching  to  which  the  dura  mater  is  subjected  ; 
or  there  may  be  evidence  of  pressure  upon  the  nerves  inside  the  cranium,  choked 
disc,  facial  paralysis,  or  neuralgia  corresponding  to  the  fifth,  or  even  the  blood- 
vessels may  afford  some  indication — the  cavernous  sinus,  for  example,  may  be 
compressed  so  that  the  eyeball  is  protruded  and  the  veins  of  the  orbit  distended. 

Diagnosis. — No  absolute  distinction  can  be  drawn  between  conci/ssioti  and 
compression.  It  is  true  the  former  is  immediate,  while  the  latter,  as  a  rule,  comes 
on  gradually,  and  that  loss  of  consciousness  is  rarely  complete  in  the  one,  while 
coma  is  a  symptom  of  the  other  ;  but  when  there  is  a  condition  of  profound  shock, 
such  as  often  occurs  after  severe  head  injuries,  it  may  be  imjjossible  to  make  an 
exact  diagnosis,  especially  as  one  is  not  seldom  only  a  prelude  to  the  other.  The 
same  may  be  said  of  contusion.  The  effect  on  a  centre  in  the  cortex  is  much  the 
same,  whether  it  is  crushed  by  an  extravasation  between  the  dura  mater  and  the 
bone,  or  by  one  in  its  own  substance  ;  only  in  contusion  monoplegia  is  either  im- 
mediate or  is  preceded  by  monospasm,  and  extensive  paralysis,  especially  hemi- 
plegia, is  uncommon  ;  while  in  compression,  pure  and  simple,  there  is  usually  an 

*  In  one  case  under  my  care,  in  which  the  whole  of  the  left  side  of  the  I^ody  was  paralyzed,  more 
or  less,  consequent  on  a  severe  blow  immedistely  in  front  of  and  above  tlie  right  jjarietal  eminence, 
there  was  a  decided  fall  of  temperature  on  the  affected  side.  The  patient  w.ts  a  cliiUl  six  years  old  ; 
concussion  was  well  marked,  but  passed  off;  symptoms  of  local  compression  followed  and  became 
more  and  more  intense  for  forty-eight  hours,  aft'ecting  the  face  and  tongue  (very  .slightly),  the  arm 
(almost  completely),  and  the  leg.  Twenty-four  hours  later  the  loss  of  power  began  gradually  to 
disappear. 


WOUNDS  OF   THE  BRAIN.  647 

interval  of  a  few  minutes,  or  even  of  some  hours,  and  the  paralysis,  if  the  symptoms 
are  not  masked  by  concussion,  commences  imperceptibly.  Convulsions  only 
occur  in  compression  when  it  is  rapid,  and  this  rarely  happens,  for  hemorrhage 
into  the  lateral  ventricles  is  not  common  as  the  result  of  injury;  depression  of 
bone  is  hardly  ever  sufficient,  and  bleeding  on  the  surface  or  in  the  substance  of 
the  brain  is  nearly  always  gradual. 

Alcoholic  cojiia,  especially  that  which  is  induced  by  rapid  spirit  poisoning,  is 
sometimes  mistaken  for  comi)ression,  particularly  if  there  is  an  injury  to  the  head 
at  the  same  time  ;  more  often  the  converse  happens.  There  is  nothing  in  the  tem- 
])erature,  or  the  pulse,  or  the  respiration,  that  can  be  relied  upon.  MacEwen,  how- 
ever, has  shown  that  in  alcoholic  coma  the  pupils,  which  are  contracted  to  a  pin's 
point,  very  slowly  dilate  when  an  attempt  is  made  to  rouse  the  patient,  and  then, 
if  he  is  left  undisturbed,  gradually  begin  to  contract  again,  until  in  ten  or  twenty 
minutes  they  have  resumed  their  former  size.  If  there  is  any  doubt  the  urine 
should  be  drawn  off  and  examined  for  alcohol,  which  is  often  present  in  large 
quantities  in  these  cases  ;  but  it  must  always  be  remembered  that  the  two  condi- 
tions may  very  easily  occur  together. 

Opium  coma,  in  the  absence  of  history,  is  sometimes  a  little  difficult  to  dis- 
tinguish, though  the  diagnosis  may  be  suspected  from  the  peculiar  character  of  the 
pulse  and  respiration  and  the  fixed  contracted  condition  of  the  pupils,  unless  they 
have  become  dilated  again-,  and  they  do  toward  the  end.  In  the  case  of  laudanum 
the  odor  or  the  stomach-pump  may  make  the  question  certain  ;  but  this  fails  com- 
pletely with  morphia,  especially  if  it  is  injected  subcutaneously.  In  urcemia  the 
coma  is  not  so  continuous,  there  are  epileptiform  convulsions,  the  breathing  is 
quiet,  not  stertorous,  and  there  is  no  paralysis. 

When  compression  occurs  immediately  after  an  accident,  without  any  interval, 
it  can  only  be  the  result  either  of  very  extensive  depression  of  bone,  or  of  extrava- 
sation of  blood,  either  into  the  cavity  of  the  lateral  ventricles  or  at  the  base  of 
the  brain.  If  it  is  more  gradual,  if  it  does  not  make  its  appearance  for  some  min- 
utes, or  even  for  some  hours,  the  extravasation  is  either  between  the  bone  and  the 
"dura  mater,  in  the  subdural  space,  or  in  the  substance  of  the  brain.  Of  these  the 
two  former  cannot  be  distinguished  from  each  other  ;  the  last  may  be  suspected  if 
there  are  signs  of  cerebral  irritation  in  addition  to  those  of  compression,  or  if  the 
patient  does  not  regain  consciousness  after  the  accident. 

Compression  following  inflammation  of  the  meninges  is  always  general;  that 
due  to  cerebral  abscess  or  tumor  may  be  local  at  first ;  in  either  case  the  diagnosis 
must  be  based  upon  the  previous  symptoms. 

Wounds  of  the  Brain. 

Incised,  punctured,  and  contused  wounds  of  the  dura  mater  and  the  brain  are 
not  uncommonly  met  with  in  conjunction  with  fracture  of  the  skull.  They  may 
be  produced  by  cutting  instruments,  such  as  knives  and  sabres,  penetrating  the 
bones,  or  even  slicing  off  a  portion  of  the  skull  and  the  brain  beneath  it ;  or  by 
blunt  weapons,  such  as  sticks  or  slate-pencils,  driven  throvvgb  either  the  roof  of  the 
orbit  or  the  cribriform  plate  of  the  ethmoid,  often  without  any  apparent  external 
injury;  more  often  still  by  fragments  of  bone  driven  inward;  or  as  a  result  of 
gunshot  injuries.  These  last  are,  generally  speaking,  fatal  at  once  ;  but  instances 
in  which  small  revolver  bullets  have  entered  the  skull  and  have  remained  lodged 
in  the  substance  of  the  brain  for  years  are  not  uncommon. 

The  cortex  is  the  part  that  is  usually  affected  ;  the  base  rarely  suffers  except 
in  gunshot  injuries  through  the  mouth  ;  and  the  immediate  symptoms  depend  upon 
the  extent  and  locality  of  the  injury.  As  a  rule  there  is  no  difficulty  in  the  diag- 
nosis, but  in  some  cases  of  depressed  and  punctured  fractures  the  rent  in  the  dura 
mater  may  lie  concealed  beneath  an  overhanging  margin  of  bone,  and  be  over- 
looked if  this"  is  not  elevated.  The  prognosis  is  always  grave,  even  when  the  in- 
jury is  so  slight   that  there  is  no  immediate  risk  to  life  ;   foreign  substances  are 


648    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

often  carried  inward — bullets,  fragments  of  bone,  hair,  even  portions  of  a  hat  ;  the 
wound  is  exceedingly  difficult  to  clean  thoroughly  :  in  many  cases — as,  for  exam- 
ple, gunshot  injuries — no  attemjjt  can  be  made;  it  is,  generally  speaking,  more 
or  less  valvular,  that  is  to  say,  there  is  a  small  ojjening  in  a  tough,  unyielding  mem- 
brane leading  into  a  space  fdled  with  broken  down  brain  substance  and  extrava- 
sated  blood,  and  inflammation  of  the  membranes  or  of  the  brain  and  hernia 
cerebri  are  proportionately  likely  to  occur. 

Intracranial   Hemorrhage. 

This  may  take  place,  as  already  mentioned,  between  the  dura  mater  and  the 
bone  ;  in  the  subdural  or  the  subarachnoid  space  ;  in  the  substance  of  the  brain 
itself;  or  in  the  cavity  of  the  ventricles  ;  and  it  may  occur  rapidly  when  there  is 
a  large  space  for  it  to  collect  in  or  when  a  large  vessel  is  torn  across  ;  more  often 
it  takes  place  slowly  and  continues  until  either  the  tension  and  the  coagulation  are 
sufficient  to  close  the  vessels  or  fatal  compression  is  induced. 

1 .  Hemorrhage  between  the  dura  mater  and  the  bone  may  occur  from  injury 
to  one  of  the  venous  sinuses,  but  it  is  rarely  of  any  surgical  importance  unless  it  is 
caused  by  rupture  of  the  middle  meningeal  artery  or  its  anterior  branch  ;  then  it 
gives  rise  to  a  series  of  symptoms  which  may  be  taken  as  the  type  of  those  of 
compression. 

It  may  be  produced  either  by  direct  violence  or  by  a  fissure  extending  from  the 
vertex  ;  sometimes  the  force  of  the  blow  is  exceedingly  slight,  and  there  is  no 
concussion,  or  only  a  transient  sense  of  giddiness  ;  and  it  is  said  to  have  occurred 
without  fracture  of  any  kind  being  detected.  Generally  speaking,  the  extravasation 
takes  place  on  the  same  side  as  the  injury  ;  but  the  opposite  artery  may  be  torn  if 
the  fissure  extends  across  the  base  of  the  skull,  and  possibly  in  fracture  by  contre- 
coup.  In  a  characteristic  case  the  patient  is  stunned  for  a  time  and  gradually  re- 
gains consciousness.  Then  after  an  interval  sometimes  of  half  an  hour,  some- 
times of  a  day,  symptoms  of  compression  begin  to  set  in.  The  patient  becomes 
drowsy  ;  the  muscles  on  the  opposite  side  of  the  body  begin  to  lose  power,  those 
of  the  face  perhaps  first,  then  those  of  the  neck  and  arm,  and  finally  the  leg  and 
trunk;  the  pulse  becomes  slow  and  full;  the  drowsiness  deepens  into  coma  ;  the 
respiration  becomes  stertorous  and  the  compression  complete.  Convulsions  are 
not  generally  present,  though  I  have  known  them  to  be  brought  on,  in  a  case  of 
comminuted  fracture  associated  with  only  meningeal  hemorrhage,  by  i)ressure  with 
the  finger  over  the  seat  of  injury.  The  eyeball  on  the  injured  side  is  sometimes 
protruded,  probably  from  pressure  upon  the  cavernous  sinus,  causing  congestion  of 
the  orbit ;  and,  what  is  of  very  great  significance,  the  pupil  on  the  same  side  (op- 
posite to  the  hemiplegia)  is  dilated.  It  is  said  that  this  is  due  to  pressure  upon  the 
trunk  of  the  third  nerve,  and  that  it  may  be  preceded  by  a  transient  contraction, 
pressure  when  it  is  slight  first  acting  as  a  stimulus,  and  then  as  it  increases  de- 
stroying the  conducting  power  ;  but  it  may  certainly  occur  when  the  extravasa- 
tion is  nowhere  near  the  course  of  the  nerve.  The  diagnosis  can  only  be  certain 
when  there  is  a  distinct  interval  after  the  concussion,  and  when  the  compression 
begins  locally  and  spreads  gradually  without  there  being  any  evidence  of  cerebral 
contusion  or  irritation.  If  the  latter  is  present  the  subcranial  hemorrhage  is 
probably  associated  with  cortical  or  subarachnoid,  or  these  may  be  i)resent  alone. 

Subcranial  extravasation,  due  to  rupture  of  the  middle  meningeal  artery,  forms 
a  black  granular  clot  of  peculiar  solidity  and  hardness  between  the  dura  mater  and 
the  bone.  It  is  usually  disc-shaped,  three  and  even  four  inches  across,  thickest  at 
the  centre,  sometimes  as  much  as  an  inch,  and  thinning  off  toward  the  margin. 
There  is  a  cup-shaped  depression  to  correspond  on  the  surface  of  the  brain,  and 
all  the  convulsions  are  flattened  down.  If  not  so  large  as  to  cause  fatal  com- 
pression, the  coagulum  may  become  absorbed,  but  only  after  a  long  time. 

2.  Subdural  hemorrhage  is  rarely  met  with  by  itself  and  cannot  be  distin- 
guished from  other  forms.      Nearly  always  it  is  secondary  to  cortical  and  subarach- 


INTRACRANIAL   HEMORRHAGE. 


649 


^^--;::" 


Fig. 


3. — Hemorrhage 


m  tnt 
Artery. 


^Nliddle  Meningeal 


noid  extravasation,  and  adds  the  element  of  gradually  spreading  compression  to 
the  other  symptoms.  The  blood  comes  either  from  the  vessels  of  the  pia  mater  or 
cortex,  the  arachnoid  being  torn  across,  or  from  the  large  veins  on  the  upper  sur- 
face of  the  brain,  which  sometimes  give 
way  just  where  they  enter  the  superior 
longitudinal  sinus.  More  rarely  the  dura 
mater  is  wounded,  and  the  bleeding  pro- 
ceeds from  the  meningeal  arteries  or  the 
venous  sinuses.  When  it  occurs  by  itself, 
the  blood  gradually  extends  over  the  sur- 
face of  the  hemisphere  and  does  not  re- 
main localized  or  become  hard  and  dense, 
as  in  the  subcranial  form.  The  vessels  are 
smaller  and  the  tension  of  the  extravasa- 
tion not  so  great.  The  symptoms  are  the 
same  as  those  of  subcranial  hemorrhage, 
and,  like  them,  come  on  slowly  and  gradu- 
ally, but  they  are  more  vague,  the  com- 
pression is  incomplete ;  there  is  stupor, 
lasting  perhaps  for  days  or  even  weeks, 
but  not  necessarily  coma  ;  there  may  be 
loss  of  power  over  certain  muscles,  or 
even  over  one  side  of  the  body,  but  there 
is  no  well-defined  paralysis.  If  the  patient 
survives,  cerebral  hypereemia  and  irri- 
tation are  almost  sure  to  set  in  ;  head- 
ache, irritability,  spasmodic  contraction  of 
the  muscles,  even  general  convulsions  may 
occur ;    and    there    is   always   a    certain 

degree  of  fever  and  some  risk  of  inflammation.  Recovery  in  these  cases  is  always 
very  slow  and  often  remains  imperfect;  the  blood  may  be  absorbed  completely, 
but  it  often  forms  a  false  membrane  adherent  to  the  dura  mater  or  arachnoid,  at 
first  soft  and  vascular,  later  becoming  tough  and  hard  ;  or  it  becomes  organized 
into  a  cyst,  which  at  length  loses  its  color  completely,  l)ecoming  transparent,  and 
floats  free  in  the  arachnoid  space.  Memory  often  remains  defective  ;  or  the  patient 
becomes  liable  to  violent  outbreaks  of  passion,  or  there  may  be  complete  loss  of 
self-control ;  and  even  insanity  and  epilepsy  have  been  known  to  declare  them- 
selves at  length. 

3.  Subarachnoid  hemorrhage  is  practically  always  associated  with  severe  in- 
jury to  the  cortex,  and  is  secondary  to  it  ;  often  it  extends  into  the  subdural  space 
as  well.  The  blood,  if  the  arachnoid  does  not  give  way,  pours  down  into  the 
sulci  and  over  the  convolutions,  until  it  may  reach  the  big  subarachnoid  space  at 
the  base  of  the  brain.  There  are  no  symptoms  which  are  peculiar  to  it ;  if,  how- 
ever, after  an  accident  there  is  evidence  of  severe  contusion  to  one  part  of  the 
brain,  and  if  the  symptoms,  local  at  first,  rapidly  become  general,  involving  one 
centre  after  another  in  quick  succession,  causing  first  convulsions  and  then 
paralysis,  it  m^y  be  conjectured  that  extravasation  into  the  subarachnoid  space  is 
part  at  least  of  the  injury  present. 

4.  Cerebral  hemorrhage  when  slight  rarely  admits  of  diagnosis.  There  is 
little  doubt  that  minute  extravasations  are  present  in  all  cases  of  concussion,  but, 
as  a  rule,  they  give  rise  to  no  special  symptoms.  When  they  are  extensive — 
when,  for  example,  a  diseased  artery  gives  way  under  a  sudden  .shock  and  the  ex- 
travasation bursts  into  one  of  the  ventricles,  causing  an  apoplectic  fit — the  symp- 
toms are  altogether  general  ;  there  is  no  local  indication  of  any  kind. 

42 


650    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

Injuries  of  Nerves. 

The  cranial  nerves  may  be  injured  either  at  their  deep  origin  or  in  their 
course  through  the  cranium.  They  may  be  torn  across  in  fractures  of  the  skull,  or 
conii)ressed  by  an  e.xtravasation  of  blood  around  them  or  in  their  sheath  ;  or  later 
on  they  may  be  aftected  by  a  neuritis,  which  commences  gradually,  lasts  a  few 
weeks,  and  gradually  disappears  again. 

The  olfactory  may  be  injured  in  fractures  of  the  anterior  fossa  ;  sometimes 
complete  anosmia  occurs  without  any  evidence  of  injury  to  the  bone,  jjossibly 
caused  by  momentary  separation  of  the  bulbs,  tearing  across  the  nerves  at  their 
origin. 

The  optic  is  frequently  affected.  If  the  tract  is  injured,  there  is  loss  of  sight 
in  the  corresjionding  half  of  the  field  of  vision  of  both  eyes — lateral  hemiopia;  if 
the  chiasma  itself,  either  the  inner  or  the  outer  side  of  both  retinse  is  blind,  ac- 
cording to  the  position  of  the  lesion.  The  trunk  of  the  nerve  may  be  torn  across 
at  the  optic  foramen,  or  crushed  by  a  splinter  of  bone,  leading  to  simple  atrophy 
and  complete  blindness ;  or  hemorrhage  may  take  place  into  the  sheath,  so  that 
compression  of  the  nerves  and  choked  disc  are  produced  at  once  ;  or,  later,  if 
meningitis  or  cerebral  abscess  occurs,  double  optic  neuritis  may  set  in. 

Paralysis  of  the  third  nerve  gives  rise  to  ptosis,  immobility  of  the  eyeball  in 
the  position  of  external  strabismus,  dilation  of  the  pupil,  and  loss  of  power  of 
accommodation.  Sometimes  the  eyeball  appears  slightly  too  prominent.  If  the 
injury  is  in  the  crus  there  is  coincident  hemiplegia  of  the  opposite  side.  Paralysis 
of  the  fourth  merely  affects  the  superior  oblique,  so  that  there  is  diplopia  or  look- 
ing downward  ;  giddiness,  when  going  down  stairs,  is  often  the  first  thing  noticed. 
The  sixth,  which  supplies  the  external  rectus  only,  is  injured  more  frequently  than 
any  other  of  the  orbital  nerves.  Injury  to  the  fifth  nerve  at  its  origin,  with  com- 
plete anaesthesia  of  that  side  of  the  face,  may  occur  in  gunshot  injuries  through 
the  mouth  ;  but  the  lesion  generally  proves  fatal  in  a  few  hours.  When  the  sen- 
sory divisions  are  affected  after  their  separation,  there  may  l)e  intense  neuralgia 
from  irritation  of  the  fibres  or  complete  anaesthesia.  If  the  latter  persists  the  skin 
on  that  side  of  the  face  becomes  cold  and  purple  ;  the  conjunctiva  loses  its  sensi- 
bility and  becomes  inflamed  ;  the  lachrymal  and  salivary  glands  cease  secreting; 
and  there  is  complete  loss  of  smell  and  taste  on  that  side,  from  the  dryness  of  the 
mucous  membrane.  The  anjesthesia  and  trophic  influences  are  more  marked  when 
the  injury  is  peripheral  than  when  the  origin  of  the  nerve  is  involved.  Paralysis 
from  injury  to  the  motor  portion  is  rare,  but  may  be  diagnosed  from  the  irregular 
character  of  the  movements  of  the  lower  jaw. 

The  facial,  which  is  frequently  involved  in  fractures  through  the  middle  fossa 
of  the  skull,  may  be  injured  at  its  origin,  in  the  meatus,  or  in  its  course  through 
the  aqueduct.  In  the  first  case  the  sixth  usually  suffers  as  well,  and  there  is  hemi- 
plegia of  the  opposite  side  of  the  body  ;  in  the  meatus  the  auditory  nerve  is  either 
torn  or  compressed  at  the  same  time,  so  that  there  is  deafness  on  that  side  ;  in  the 
aqueduct  the  paralysis  is  limited  to  the  muscles  of  expression,  and  if  the  petrosal 
nerves  are  injured,  to  those  of  the  soft  palate.  Deviation  of  the  velum,  however, 
may  occur  in  paralysis  of  the  fifth,  the  glosso-pharyngeal,  and  even,  it  is  said,  the 
hypoglossal.  Loss  of  the  sense  of  taste  is  usually  present  wh^n  the  chorda 
tympani  is  injured.  If  the  nerve  is  only  compressed  by  extravasation  or  exudation, 
the  symptoms  are  not  immediate  ;  they  come  on  by  degrees  and  gradually  disap- 
pear again.      In  a  few  cases  neuritis  sets  in  afterward. 

The  other  cranial  nerves  are  rarely  hurt  in  fractures  of  the  skull  unless  the 
injury  is  of  extreme  severity  ;  but  it  is  not  improbable  that  some  of  the  instances 
of  remarkably  slow  pulse,  of  constant  vomiting,  of  peculiar  respiratory  rhythm, 
and  of  such  vasomotor  disturbances  as  diabetes,  or  polyuria,  may  be  due  to  deep- 
seated  extravasation  nuclei  of  their  near  origin. 


TREATMENT  OF  INJURIES  OF   THE   BRAIN.  651 

General  Treatment  of  Injuries  of  the  Brain. 

Injuries  of  the  brain  may  either  prove  fatal  at  once,  from  the  extent  or  the 
situation  of  the  laceration,  or  death  may  ensue  in  the  course  of  a  {e\v  hours  or 
days,  from  shock,  inflammation,  or  compression  ;  or  at  a  much  later  period 
secondary  complications  may  set  in — softening,  cerebral  abscess,  or  epilepsy — and 
lead  at  length  to  the  same  result.  No  injury  of  the  brain,  no  matter  how  trivial  it 
appears  to  be,  even  if  it  is  only  attended  by  a  transient  giddiness,  should  be 
neglected. 

Coneussion. — The  collapse  of  the  first  stage  of  concussion  may  be  merely 
momentary,  or  may  last  for  hours.  In  exceptional  cases  it  may  terminate  fatally, 
either  at  once  or  after  a  couple  of  days,  without  the  patient  ever  having  rallied. 
The  state  of  the  pulse,  therefore,  requires  to  be  very  carefully  watched.  In  most 
instances  stimulants  are  not  only  unnecessary,  but  absolutely  injurious  :  the  danger 
is  that  the  symptoms  of  reaction  and  the  hypercemia  that  attends  it  may  run  on  to 
inflammation,  or  that  the  bleeding  may  continue,  and  undoubtedly  they  would 
encourage  this  ;  but  every  now  and  then  cases  are  met  with  in  which  they  seem 
indispensable  ;  the  heart  will  fail  without ;  and  it  must  not  be  forgotten  that  the 
mere  prolongation  of  the  period  of  collapse  is  in  itself  a  source  of  danger,  and 
tends  to  aggravate  the  intensity  of  the  reaction  when  it  once  begins. 

The  patient  should  be  placed  in  bed  with  the  head  low,  wrapped  up  in  warm 
blankets,  and  surrounded  with  hot-water  bottles  ;  then,  as  soon  as  he  can  swallow, 
a  small  quantity  of  hot  tea  or  coffee  maybe  given.  In  the  vast  majority  of  cases 
the  collapse  passes  off  of  itself  without  anything  further  being  required;  if  the 
condition  of  the  pulse  becomes  alarming,  some  good  may  result  from  the  rectal 
injection  of  hot  water,  or  the  hypodermic  injection  of  atropin  (yi^  grain)  ;  if  it 
distinctly  begins  to  fail,  ether  or  ammonia  must  be  given  at  once  ;  and  if  these 
do  not  succeed,  brandy  must  be  injected  subcutaneously.  Cases  of  this  kind,  how- 
ever, in  which  the  collapse  is  so  intense,  are  fortunately  very  rare. 

As  soon  as  reaction  commences  every  effort  must  be  made  to  keep  the  hyper- 
aemia  within  bounds.  The  room  must  be  darkened,  all  noise  prevented,  conversa- 
tion absolutely  forbidden,  and  complete  rest  in  the  recumbent  position  insisted  on. 
In  severe  cases  the  head  should  be  shaved,  Leiter's  coils  applied,  and  if  there  is 
much  aching,  or  if  the  temperature  rises  more  than  a  degree,  leeches  should  be 
placed  behind  the  ears.  Milk  and  beef-tea  only  should  be  allowed,  and  in  small 
quantities  ;  and  the  bowels  should  be  opened  as  soon  as  possible,  either  with  five 
grains  of  calomel  or  with  a  minim  of  croton  oil.  The  former  may  have  some 
influence  on  inflammatory  exudation,  but  in  addition  it  is  no  slight  advantage  that 
it  may  be  placed  upon  the  tongue  of  a  person  who  is  insensible  with  perfect  safety, 
and  that  there  is  little  risk  of  its  being  vomited.  If  this  does  not  succeed,  if  the 
temperature  continues  to  rise,  and  particularly  if  the  head  begins  to  throb  and 
beat,  there  should  be  no  hesitation  in  making  use  of  venesection,  and  withdrawing 
six  or  even  ten  ounces  of  blood.  Whatever  may  be  the  way  in  which  this  acts, 
there  is  no  doubt  that  it  sometimes  stops  incipient  delirium  at  once. 

[Fluid  extract  of  ergot  has  extreme  value  in  reducing  cerebral  hypersemia,  and 
it  will  be  found  useful  in  all  varieties  of  cerebral  injuries  where  hyperaemia  is 
manifested  by  the  symptoms.  A  teaspoonful  to  a  dessertspoonful  will  be  required, 
to  be  repeated  according  to  the  urgency  of  the  case.] 

In  the  case  of  children  with  slight  concussion  it  is  very  difficult  to  keep  them 
in  bed  more  than  two  or  three  days ;  in  more  severe  cases,  especially  adults,  and 
where,  from  the  continuance  of  the  symptoms,  it  is  morally  certain  that  there  has 
been  some  considerable  contusion  of  the  brain,  and  that  it  has  been  followed,  as 
contusions  are  in  every  part  of  the  body,  by  hyperaemia  and  exudation,  rest  in  bed 
must  be  insisted  upon,  until  every  sign  of  the  mischief  has  disappeared.  This 
rarely  happens  under  a  fortnight,  in  many  cases  not  for  three  or  four  weeks  ;  and 
until  then  no  precaution  must  be  relaxed. 

Compression. — The  treatment  of  compression  of  the  brain  depends  upon  what 


652    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

can  be  found  out  from  the  history  and  the  symptoms  with   regard  to  the  locality 
and  nature  of  the  cause. 

1.  Where  it  is  either  general  from  the  first,  or  where  there  is  no  definite 
evidence  of  local  origin,  surgical  interference  is  out  of  the  question.  If  it  is 
recent,  within  a  few  hours  of  an  accident,  and  therefore  probably  due  to  hemor- 
rhage, means  must  be  taken  to  render  the  return  of  venous  blood  from  the  head 
as  easy  as  possible  by  position,  and  possibly  by  venesection  (though  this  is  not 
of  such  service  here  as  it  is  in  controlling  the  commencement  of  inflammation), 
to  favor  the  absorption  of  cerebro-s|)inal  fluid  by  free  purgation,  and  to  diminish 
the  amount  of  blood  going  to  the  head  as  much  as  possil)le  by  the  application 
of  cold.  If  some  days  have  passed  since  the  accident,  and  symptoms  of  inHam- 
mation  are  already  present,  the  same  remedies  may  be  employed,  with,  in  addition, 
the  free  use  of  mercury,  but  with  very  little  hope.  The  compression  in  either  case 
is  only  a  late  symptom  of  an  injury  over  which  we  have  at  present  little  or  no 
control. 

2.  Where,  on  the  other  hand,  the  signs  point  to  some  local  cause,  and  where 
the  nature  of  the  case  is  such  (as  it  nearly  always  is  when  the  compression  is  the 
result  of  accident)  that  there  is  but  slight  prospect  of  spontaneous  improvement, 
means  must  be  taken  as  soon  as  possible  to  relieve  the  brain. 

(rt)  If  the  symptoms  are  immediate  they  may  be  due  to  depression  of  bone. 
Mayo  Robson  has  recorded  a  case  in  which  l)rachial  monospasm  and  monoplegia 
were  caused  by  this,  and  relieved  almost  at  once  by  trephining,  ten  days  after  the 
accident.  The  dura  mater  was  intact  and  there  was  no  evidence  of  subdural 
hemorrhage  or  of  cortical  bruising.  Whenever  anything  of  this  kind  can  be 
ascertained,  the  depression  must  be  elevated,  and  the  sooner  the  better  ;  the  longer 
the  case  is  left  the  greater  the  risk  of  inflammation  breaking  out,  or  of  a  discharg- 
ing lesion  being  set  up  in  the  cortex,  so  that,  after  the  original  cause  has  been 
removed,  epileptiform  convulsions  continue. 

(/;)  If  the  symptoms  do  not  set  in  at  once,  if  there  is  a  distinct  interval  of 
partial  or  complete  return  of  consciousness,  without  any  evidence  of  cereljral  irrita- 
tion, there  is  probably  sul)cranial  hemorrhage,  with,  excei)tionally,  subdural  in 
addition.  It  may  come  from  the  anterior  division  or  the  trunk  of  the  middle 
meningeal  ;  more  rarely  from  its  posterior  division  or  the  lateral  sinus  ;  very  rarely 
from  any  other  vessels. 

Hemorrhage  from  the  middle  meningeal  is  not  necessarily  fatal,  from  the 
anterior  division  at  any  rate  ;  but  it  is  so  in  the  great  majority  of  instances,  and 
consecjuently,  if  the  diagnosis  is  clear  and  the  symptoms  show  that  the  extravasa- 
tion is  extending,  an  attempt  should  be  made  to  check  it  either  by  ligature  of  the 
external  carotid  artery,  or  by  trephining.  The  former  operation  has  not  been 
tried  sufficiently  often  to  justify  its  recommendation  ;  the  latter  may  be  carried  out 
without  much  difficulty,  so  long  as  the  case  is  recent.  If  there  is  an  external 
wound  this  should  be  made  use  of;  if  there  is  not,  the  artery  maybe  found  mid- 
way between  the  auditory  meatus  and  the  external  angular  process  of  the  frontal 
bone,  an  inch  or  an  inch  and  a  half  above  the  level  of  the  zygoma.  A  triangular 
flap,  comprising  the  skin,  the  temporal  aponeurosis,  the  muscle,  and  the  periosteum, 
is  reflected  downward  from  off  the  bone,  and  the  surface  of  the  greater  wing  of 
the  sphenoid  and  the  inferior  angle  of  the  parietal  examined.  If  there  is  a  fissure, 
the  point  of  the  trephine  is  applied  over  the  spot  where  the  fracture  and  the  line  of 
the  vessel  intersect  each  other.  As  soon  the  circle  is  removed  a  dense,  almost 
black,  coagulum  presents  itself  in  the  opening.  This  has  to  be  literally  scraped 
out,  and  often  it  is  necessary  to  enlarge  the  opening  in  one  or  other  direction  by 
means  of  Hoffmann's  forceps  in  order  that  this  may  be  done  eff"ectually.  A 
greater  difficulty  is  to  secure  the  bleeding  point.  The  artery  is  superficial  only 
where  it  occupies  the  canal  in  the  parietal  bone  ;  for  the  rest  of  its  course  it  lies  in 
the  dura  mater,  and  this,  with  the  brain,  is  pushed  away  from  the  skull  by  the 
coagulum.  In  recent  cases  the  brain  may  rise  up  again  as  soon  as  the  clot  is 
removed,  but  this  is  not  invariable,  especially  if  the  injury  is  of  some  days'  stand- 


TREATMENT  OE  INJURIES  OF  THE   BRAIN.  653 

ing  :  or  the  trephine  opening  may  not  have  exposed  the  wound  in  the  vessel  ;  or 
the  cavity  fills  up  again  with  blood  as  fast  as  it  is  emptied,  so  that  the  bleeding 
spot  cannot  be  seen.  Ice-cold  water,  and  pressure  upon  the  carotid,  are  usually 
sufficient  to  check  the  hemorrhage  for  the  time  ;  but  if  the  bleeding  jjoint  is  not 
exposed,  it  is  better  to  enlarge  tiie  trephine  oj^ening  until  it  can  be  found  and 
ligatured.  If  this  is  not  done,  the  bleeding  is  very  likely  to  return  as  soon  as  the 
parts  are  restored  to  their  position  and  the  normal  temijerature  is  regained.  After- 
ward the  wound  must  be  well  washed  out  with  corrosive  sublimate  or  some  other 
antiseptic,  the  whole  of  the  clot  removed,  and  free  drainage  provided  for  from  the 
posterior  extremity.  If  the  cavity  is  a  large  one,  it  is  advisal)le  to  make  a  second 
opening  in  the  bone. 

If  instead  of  the  clot  presenting  in  the  wound  the  dura  mater  is  dark  purple 
in  color,  and  is  forced  up  into  the  opening  without  the  normal  pulsation  being  per- 
ceptible, it  is  probable  there  is  subdural  hemorrhage.  This,  if  the  pressure  symp- 
toms are  so  severe  as  to  threaten  life,  must  be  treated  in  the  same  way  as  subcranial  ; 
the  opening  in  the  bone  must  be  enlarged  to  a  sufficient  extent,  the  dura  mater  in- 
cised and  reflected  in  a  flap  so  arranged  as  not  to  injure  its  own  vessels,  the  clot 
washed  away,  or,  if  the  arachnoid  is  injured,  carefully  picked  off,  and  then  the 
membrane,  the  bone  so  far  as  possible,  the  pericranium  and  the  skin,  carefully  re- 
placed and  sutured  to  their  corresponding  parts,  one  by  one,  an  opening  for  a 
drainage-tube  being  left  at  the  spot  that  is  most  dependent  when  the  patient  is 
lying  down. 

Even  when  there  are  symptoms  of  cerebral  irritation  and  laceration  in  ad- 
dition to  those  of  compression,  the  treatment  must  be  conducted  on  the  same 
principles  so  long  as  there  is  evidence  that  the  injury  is  local.  If  it  is  general, 
nothing  can  be  done  ;  but  if  local  convulsions  occur,  and  if  they  spread  and  involve 
other  groups  of  muscles  in  definite  order,  and  particularly  if  every  convulsive  fit  is 
followed  by  an  increase  in  the  area  of  paralysis  and  a  further  diminution  of  con- 
sciousness, so  that  it  is  almost  certain,  not  only  that  there  is  an  extravasation  of 
blood  involving  a  particular  portion  of  the  cortex  of  the  brain,  but  that  it  is  spread- 
ing and  that  it  will  inevitably  result  in  fatal  compression,  the  question  arises  whether 
it  is  not  advisable  to  trephine  and  explore.  Cold,  bleeding,  first  local  and  then 
general,  profuse  purging  with  calomel,  or,  if  there  is  no  time  for  that  to  act,  w-ith 
croton  oil,  and  internal  remedies  that  assist  in  causing  hsmostasis,  may  be  tried  ; 
but  if  the  symptoms  persist,  and  particularly  if  the  compression  is  extending,  there 
can  be  little  doubt  as  to  the  ultimate  result  if  the  case  is  left  to  itself.  Everything 
depends  upon  an  exact  diagnosis  of  the  locality  ;  and,  of  course,  this  is  only  practi- 
cable when  certain  portions  of  the  brain  are  involved,  and  when  there  has  been  an 
interval  of  at  least  partial  consciousness  since  the  accident.  The  history  is  of  the 
utmost  importance  ;  the  condition  of  the  scalp  and  skull  must  be  thoroughly  ex- 
amined, as  well  on  the  sound  side  as  on  the  injured  one,  and  the  closest  attention 
must  be  paid  to  the  course  the  symptoms  take.  In  such  a  case,  where  everything 
points  to  an  injury  that  is  local  at  first,  and  where  the  prognosis  admits  of  little 
doubt,  the  scalp  should  be  reflected,  bringing  the  pericranium  with  it ;  a  large  open- 
ing should  be  made  wnth  the  trephine,  unless,  as  probably  happens,  the  bone  is 
already  comminuted,  and  if  the  dura  mater  bulges  into  the  wound  or  appears  pur- 
ple in  color  from  the  extravasation  beneath,  or  if  when  it  is  touched  spasmodic 
contractions  make  their  appearance  in  any  of  the  muscles,  it  must  be  reflected  as 
well,  the  clot  turned  out  from  beneath,  and  the  seat  of  hemorrhage  exposed.  Such 
cases  must  always  be  rare,  for  unless  consciousness  returns,  for  a  time  at  least,  it  is 
scarcely  possible  to  prove  that  one  portion  of  the  cortex  has  been  involved  ;  and 
it  is  absolutely  beyond  our  power  to  show  that  there  are  no  deeper  lesions. 


654    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Traumatic  E  filers  v. 

Injuries  of  the  head  are  occasionally  followed  by  epilepsy.  CJenerally  it  does 
not  make  its  appearance  for  some  time  after  the  accident ;  and  at  first  the  fits  are 
slight  and  infrequent,  not  attended  by  loss  of  consciousness  ;  but  as  time  passes 
the  fretpiency  and  intensity  increase,  until  at  length  they  end  in  permanent  im- 
pairment. 

The  severity  of  the  accident  does  not  appear  to  have  anything  to  do  with  it  ; 
and  in  many  cases  the  immediate  cause  seems  rather  to  be  an  injury  to  the  cover- 
ings of  the  brain  than  to  the  brain  itself.  In  some  cases  the  cicatri.x  on  the  scalp 
is  tender  and  sensitive,  with  a  constant  sense  of  burning  ;  pressure  on  it  may  cause 
a  fit  ;  or  an  aura  may  start  from  it.  In  others  some  injury  to  the  bone  seems  to  be 
the  exciting  cause  ;  it  may  be  thickened  or  hardened  ;  or  there  may  be  irregular 
nodules  on  its  inner  surface  ;  or  there  may  have  been  inflammation,  leaving  a  se- 
iiuestrum.  In  others  again  the  stimulus  proceeds  from  some  affection  of  the  mem- 
branes ;  the  dura  mater  has  been  found  thickened  and  yellow  :  sometimes  it  is 
adherent  to  the  cortex  ;  or  it  has  undergone  calcareous  degeneration  ;  or  there  is  a 
cyst,  possibly  developed  from  a  blood-clot,  upon  its  inner  surface. 

In  another  class  no  lesion  can  be  found  in  any  of  the  structures  that  cover  in 
the  brain.  The  exciting  cause  is  in  the  cortex  itself;  and  if  the  affected  part  lies 
in  the  motor  area,  if  the  spasm  always  starts  in  certain  muscles,  or  extends  in  a 
certain  order,  the  exact  spot  may  be  defined  without  reference  to  the  injury.  There 
may  be  no  gross  lesion  perceptible  in  the  brain  ;  but  that  the  disease  is  dependent 
upon  some  alteration  in  this  particular  part  is  clear  from  the  fact  that  excision  of  it 
is  followed  by  complete  and,  in  some  cases  at  least,  permanent  cessation  of  the  fits. 

Treatment. — If  it  can  be  shown  that  the  convulsions  are  excited  by  a  local 
irritation  anywhere,  the  part  should  be  excised  without  delay.  In  the  case  of  injury 
the  superficial  scar  should  be  removed  altogether,  the  bone  beneath  carefiilly  ex- 
amined, and,  if  there  is  the  least  suspicion  of  any  alteration,  trephined.  Where 
it  is  thickened  or  otherwise  affected,  and  where  the  dura  mater  appears  healthy  be- 
neath, this  may  suffice  ;  but  if  the  membrane  is  marked  with  scar  ti.ssue,  or  if  it  is 
yellow,  or  if  it  is  fixed  down  to  the  cortex,  it  should  be  cut  away  from  under  the 
trephine  opening  and  the  adherent  portion  of  brain  removed  with  it.  It  is  true 
that  when  the  motor  area  of  the  cortex  is  excised  loss  of  jjower  in  the  correspond- 
ing muscles  follows  ;  but  as  a  rule  this  is  only  temporary,  and  even  if  it  were  per- 
manent the  cost  would  be  slight.  Hughlings  Jackson  and  Ferrier  have  shown,  in 
non-traumatic  ca.ses,  that  the  removal  of  an  epileptogenous  focus  in  the  cortex  of 
the  brain  (if  it  can  be  localized)  is  not  only  justifiable,  but  called  for,  whether  any 
gross  lesion,  such  as  scar  tissue  or  tumor,  can  be  found  or  not  ;  and  when  there  is  in 
addition  the  evidence  of  injury  to  assist  in  the  diagnosis  of  the  situation,  there 
should  be  no  hesitation.  One  or  two  convulsive  spasms  not  unfrecjuently  occur 
after  the  operation,  but  in  many  cases  the  improvement  has  not  only  been  marked, 
but  has  persisted. 

This  operation  must  be  clearly  distinguished  from  that  ])erformed  by  Arcilza, 
who,  in  a  case  of  true  epilepsy,  commencing  with  convulsive  movements  of  the  left 
arm,  extirpated  the  whole  of  the  brachial  motor  area  on  the  right  side.  Paralysis 
followed,  and  as  this  passed  off  the  convulsions  returned  as  badly  as  ever. 

Traumatic  Insanity. 

This  does  not  occur  so  frequently  as  epilepsy,  but  there  are  several  cases  re- 
corded in  which  it  has  followed  injuries  of  the  head.  Byrd  has  reported  four  in 
which  the  operation  of  trephining  was  jierformed  :  one  died,  one  improved  for  a 
time,  and  two  are  stated  to  have  entirely  recovered. 


DISEASES  OF   THE  SCALP.  655 


SECTION  111.— DISEASES   AND  INJURIES  OF  THE  HEAD. 
SURGICAL  DISEASES  OF  THE  SCALP. 

Erysipelas. 

This  is  frequently  met  with  as  a  complication  of  wounds  ;  even  in  the  so- 
called  idiopathic  cases  it  is  probable  that  there  is  some  scratch  or  abrasion 
[through  which  the  pathogenic  germ  gains  entrance].  It  does  not  differ  in  any 
essential  respect  from  the  same  affection  in  other  parts  of  the  body,  but,  owing 
to  the  anatomical  structure  of  the  scalp,  the  local  signs,  the  swelling  and  redness, 
are  generally  ill-defined,  while  the  constitutional  ones,  especially  those  which, 
like  the  headache,  wandering,  and  drowsiness,  may  be  referred  to  the  disorder  in 
the  subjacent  structures,  are  unusually  prominent.  The  prognosis  is  always  grave, 
owing  to  the  possibility  of  cerebral  complications. 

SUPPUR.A.TION. 

This  may  be  either  diffuse  or  circumscribed.  The  former  is  exceedingly  grave, 
owing  to  the  rapidity  with  which  it  spreads  through  the  loose  subaponeurotic  layer. 
The  inflammatory  products,  unable  to  escape,  make  their  way  in  all  directions 
under  the  tendon  of  the  occipito-frontalis,  spreading  down  into  the  eyebrows  in 
front,  to  the  superior  curved  line  of  the  occipital  bone  behind,  and  as  low  as  the 
zygoma  at  the  sides.  The  whole  surface  of  the  head  becomes  swollen  and  puffy. 
The  skin  is  hot  and  exceedingly  painful  ;  at  first,  owing  to  the  dense  aponeurosis 
between  it  and  the  seat  of  inflammation,  it  is  white  and  tense  ;  later,  if  left,  it 
becomes  soft  and  boggy  ;  red  patches  form  in  the  temporal  and  mastoid  regions, 
and,  finally,  it  gives  way,  allowing  the  escape  of  an  immense  amount  of  pus,  mixed 
with  shreds  and  sloughs.  The  constitutional  symptoms  are  most  severe  :  the  head- 
ache is  intense,  the  temperature  many  degrees  above  normal,  and  wandering  and 
delirium  are  rarely  absent.  If  left  to  itself,  the  whole  of  the  cellular  tissue  beneath 
the  aponeurosis  may  gradually  come  away,  and  after  a  prolonged  illness,  the  oppos- 
ing surfaces  may  grow  together,  or  the  skin  and  the  pericranium  may  slough,  leaving 
large  districts  of  the  cranial  bones  deprived  of  their  blood  supply,  or  the  inflam- 
mation may  spread  along  the  emissary  veins  into  the  diploe,  causing  osteophlebitis, 
or  meningitis,  thrombosis  of  the  sinuses,  and  pyaemia  may  follow. 

The  cause  is  nearly  always  the  sealing  up  of  an  imperfectly  cleansed  wound. 
There  is  no  harm  in  sutures  if  the  injured  surface  is  thoroughly  washed  out  and  a 
loophole  left  at  the  most  dependent  angle  for  drainage  ;  but  at  the  first  sign,  if 
there  is  any  rise  of  temperature,  or  the  least  tenderness  by  the  side  of  the  wound, 
one  or  two  of  the  stitches  should  be  cut,  and  the  edges  gently  separated  with  a 
probe.  Probably  a  small  bead  of  pus  will  escape,  and  all  will  be  well.  If  this 
stage  is  past  and  the  inflammation  is  already  diffuse,  the  whole  wound  should  be 
reopened,  incisions  parallel  to  the  main  vessels  made  wherever  there  is  the  least 
sensation  of  bogginess,  and  warm  boracic  fomentations  applied  to  encourage  the 
discharge.  If  the  vitality  of  the  tissues  is  not  already  broken  down,  they  will 
begin  at  once  to  throw  off  the  poison  and  protect  themselves  with  a  layer  of  vascular 
granulations.  Convalescence,  however,  is  always  very  protracted ;  drainage 
requires  careful  watching  ;  the  scalp  itself  may  need  to  be  fixed  by  strapping  ;  the 
sloughs  often  take  a  long  time  separating  ;  and,  as  a  rule,  the  patient's  constitu- 
tion is  not  of  the  best. 

Circumscribed  suppuration  may  occur  in  the  skin  and  subcutaneous  tissue  ; 
deeper,  in  the  subaponeurotic  layer,  or  between  the  pericranium  and  the  bone. 


656    DISEASES  A. YD  INJUR  IE  S  OF  SPECIAL  STRUCTURES. 

Abscesses  that  form  in  the  loose  celUilar  tissue  may  be  of  considerable  size  ;  the 
others  are  smaller,  but  are  much  more  painful. 

Suppuration  beneath  the  deep  temporal  fascia  is  difficult  of  diagnosis,  owing 
to  the  tenseness  of  the  membrane  over  it ;  and  sometimes,  for  the  same  reason, 
the  constitutional  symptoms  are  very  severe.  The  pus  usually  tends  to  gravitate 
downward  beneath  the  zygoma,  but  the  opening  should  be  made  above  it  as  soon 
as  there  is  any  feeling  of  l)ogginess  or  of  deep-seated  fluctuation.  [The  sudden 
ri.se  in  temperature  is  the  usual  guide  to  the  formation  of  pus.] 

[Here,  as  elsewhere,  the  cause  of  the  disease  must  be  destroyed.  Tincture  of 
iodine  and  strong  solutions  of  bromine,  by  their  anti-bacillary  power,  are  of  much 
value  injected  into  the  wound,  or  into  pus  cavities  ;  they  soon  destroy  the  strepto- 
coccus, and,  although  irritating  locally,  they  produce  no  general  toxic  effect. 
Even  the  j)ainting  of  the  shaved  scalp  with  tincture  iodine  has  considerable  value.] 


Tumors  of  the  Scalp. 

I.  Congenital. 

Ncevi  are  exceedingly  common,  both  the  cutaneous  and  venous  form,  but 
they  do  not  require  any  special  treatment. 

Dennoid  cysts,  containing  fine  hairs  as  well  as  sebaceous  matter,  frequently 
occur  at  the  outer  angle  of  the  orbit,  and  sometimes  are  found  elsewhere  along 
the  lines  of  union.  For  the  most  part  they  are  small,  seldom  exceeding  half  an 
inch  in  diameter ;  but  they  may  be  deeply  seated,  lying  in  little  recesses  in  the 
bone,  or  even  in  perforations  extending  right  through,  so  that  they  are  in  contact 
with  the  dura  mater.     As  a  rule,  they  are  better  left  alone. 

2.  Acquired. 

Sebaceous  cysts,  developed  in  connection  with  the  hair  follicles,  and  showing 
their  origin  by  the  small  black  dot  upon  their  surface,  are  very  common  after  adult 


Fig.  289. — Sebaceous  Tumors  in  Sc.ilp,  and  Horn. 


life,  and  not  unfrequently  are  multiple.  They  lie  just  beneath  the  skin,  to  which 
they  are  closely  adherent.  The  small  ones  are  firm  and  den.se  ;  as  they  grow  larger 
and  project  further  above  the  level,  the  contents  become  softer  and  the  skin  that 
covers  them  thinner,  so  that  the  hair  follicles  waste  away  and  the  hairs  fall  off;  and 
sometimes  at  length  they  rupture  and  discharge  a  thin  fluid  mixed  with  sebaceous 


DISEASES  OF   THE   BONES   OF  THE  SKULL.  657 

matter  and  crystals  of  cholesterin,  often  of  a  peculiarly  offensive  odor.  This  is 
especially  likely  to  occur  if  they  are  injured  or  if  they  become  inflamed  ;  and  then 
the  interior  begins  to  throw  out  granulations  and  forms  a  fungating  vascular  mass, 
which,  in  appearance,  closely  resembles  einthelioma,  and  possibly  may  in  some 
cases  pass  into  it. 

These  cysts  should  always  be  removed  before  they  become  inflamed.  The 
simi)lest  way  is  to  make  a  linear  incision  through  the  skin  over  them,  down  to,  but 
not  into  the  cyst  wall,  and  then  quickly  isolate  them  by  separating  the  soft  cellular 
tissue  on  either  side  with  the  handle  of  the  scalpel.  The  larger  ones,  however, 
and  these  which  have  been  inflamed  must  be  transfixed,  emptied  by  stpieezing,  and 
then  dissected  out,  the  edge  of  the  wall,  where  it  has  been  divided,  being  firmly 
grasped  with  a  pair  of  forceps.  In  no  case  may  any  portion  of  the  cyst  be  left 
behind,  or  union  will  not  take  place. 

Hornv  excrescences  are  occasionally  produced  from  sebaceous  cysts  that  have 
ruptured  or  been  oijened.  The  sebaceous  material  on  the  outside  dries  up  and 
shrinks  into  a  kind  of  horny  layer,  while  a  fresh  production  is  continually  going 
on  at  the  ba.se.      In  some  cases  they  attain  a  length  of  .several  inches. 

Other  varieties  of  tumor  are  rare  in  comparison.  Cirsoid  aiieurysm  may 
occur  ;  circumscribed //^r^;//«!  is  occasionally  found,  and  there  are  a  few  instances 
on  record  of  an  enormous  diffuse  grow.th  of  fibrous  tissue,  forming  great  pendulous 
masses  (^pachydermatocele).  Probably  it  is  akin  to  elephantiasis,  and  may  be  con- 
genital. Epithelioma  and  7'odent  ulcer  are  sometimes  met  with,  but  sarcoma,  with 
the  exception  of  those  forms  which  originate  in  the  bone  or  dura  mater  beneath 
and  involve  the  scalp  secondarily,  is  very  uncommon. 


DISEASES  OF  THE  BONES  OF  THE  SKULL. 
Hypertrophy. 

In  osteitis  deformans  the  vault  of  the  cranium  is  usually  immensely  thickened. 
The  inner  surface  becomes  irregular  and  is  marked  all  over  by  arborescent  grooves  ; 
the  outer  remains  smooth  and  even  ;  the  diploe  disappears,  and  on  section  the  bone 
is  hard  and  dense,  like  ivory.  Beyond  a  gradual  increase  in  the  circumference  of 
the  head,  it  does  not  appear  to  give  rise  to  any  symptoms  ;  and  no  treatment  is  of 
any  avail.      Other  forms  of  enlargement  are  described  under  Diseases  of  the  Bones. 

Rickets. 

A  peculiar  form  of  atrophy  of  the  inner  table,  known  as  craniotabes,  is  occa- 
sionally met  with  in  infants  suffering  from  rickets.  It  aff'ects  especially  the  poste- 
rior inferior  angles  of  the  parietal  bones  and  the  tabular  part  of  the  occipital, 
probably  because  of  the  recumbent  position  of  the  child,  for  a  certain  flattening  of 
that  part  of  the  head  is  not  unfrequently  noticed  at  the  same  time,  and  in  one  or 
two  instances,  in  which  the  disease  existed  before  birth,  a  similar  change  has  been 
found  on  the  inner  surface  of  the  vertex.  The  sulci  for  the  cerebral  convolutions 
are  unusually  plain,  and  here  and  there  are  marked  in  their  course  by  little  conical 
pits,  which,  in  some  places,  are  so  deep  that  nothing  but  a  parchment-like  layer  of 
dura  mater  and  pericranium  is  left ;  the  whole  thickness  of  the  bone  is  absorbed. 
Sometimes  in  addition  there  is  a  granular  deposit  of  new  bone  under  the  pericra- 
nium on  the  outer  surface,  and  occasionally  a  very  considerable  amount  round  the 
fontanelles  and  along  the  sutures,  sufficiently  to  be  felt  plainly  through  the  scalp. 

In  all  probability  it  is  due  to  the  effect  of  continued  pressure  acting  on  soft- 
ened hyper-vascular  bone.  It  certainly  may  occur  independently  of  hereditary 
syphilis,  although  it  is  often  associated  with  it  {e.  g..  Parrot's  nodes),  and  a  few 
instances  are  recorded  in  which  other  evidence  of  rickets  was  unusually  slight. 

The  diagnosis  can  only  be  made  in  well-marked  cases  by  the  peculiar  parch- 
ment-like yielding  on  pressure  with  the  fingers.     No  special  treatment  is  required. 


658    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Inflammation. 

Inflammation  of  the  bones  of  the  cranium  may  be  caused  by  mechanical  in- 
jury, by  the  products  of  septic  decomj^osition,  and  pyogenic  micrococci  ;  and  by 
syphilis,  tubercle,  and  occasionally  other  specific  diseases. 

{a)  Simple  inflammation  {rarcfyin^i^osfcitis)  may  result  from  mechanical  injury, 
if  it  is  sufficiently  i)ersistent  in  its  action,  but  naturally  such  conditions  are  rare  in 
connection  with  the  cranium.  It  may,  however,  occasionally  be  seen  when  a 
portion  of  bone  which  has  been  killed  by  external  violence  is  quietly  removed  and 
detached  without  suppuration.  The  tissues  around  become  soft,  vascular,  and 
filled  with  lymph  ;  the  bone  immediately  adjacent  to  the  portion  that  is  dead  is 
absorbed  and  replaced  by  a  layer  of  granulations,  and  at  length  the  sequestrum  is 
loosened,  and,  as  soon  as  the  condition  of  the  scalp  will  allow  it,  thrown  off. 
Suppuration  is  usually  present  in  these  cases,  but  it  is  an  addition  and  not  in  any 
way  essential. 

The  i)ortions  of  bone  that  are  reimi)lanted  after  trephining  sometimes  behave 
in  the  same  way.  In  many  instances  they  contract  adhesions  to  the  structures 
around  ;  in  some  they  appear  to  become  welded  together  by  masses  of  new  bone, 
although  this  is  not  quite  certain  ;  but  in  others  they  cause  a  certain  degree  of 
irritation  ;  vascular  granulation  tissue  is  forijied  around  them  ;  if  the  constitution 
is  sound  and  the  tissues  healthy,  they  are  absorbed  ;  if,  on  the  other  hand,  the 
irritation  is  too  great  for  the  tissues  to  bear,  pyogenic  micrococci  find  their  way  in 
and  cause  suppuration,  exactly  as  they  do  round  buried  sutures  and  old  sequestra. 

{!>)  Suppurative  osteitis  is  rarely  met  with  except  in  compound  fractures  and 
the  later  stages  of  tubercular  or  syphilitic  caries,  after  pyogenic  organisms  have 
gained  entrance  as  well  as  specific  ones.  Exceptionally  it  may  follow  a  simple 
contusion,  the  pyogenic  germs  being  carried  to  the  injured  spot  by  the  blood 
stream  (as  in  Pott's  puffy  tumor),  singly,  or,  as  in  pyaemia,  in  the  form  of  emboli. 
In  any  case,  there  is  very  grave  risk  of  extension  to  the  meninges  on  the  one  hand 
and  the  emissary  veins  and  venous  sinuses  on  the  other. 

{c)  Tubercular  caries  of  the  vault  of  the  skull  is  rare,  even  in  childhood,  and 
is  seldom  recognized  until  the  skin  has  given  way  and  left  a  tuberculous  ulcer,  the 
floor  of  which  is  formed  of  softened  carious  bone. 

((/)  Syphilitic  osteitis  is  exceedingly  common  in  all  stages  of  the  disease. 

Intensely  painful  periosteal  nodes  are  often  present  during  the  secondary 
period.  There  is  very  little  swelling,  but  the  most  extreme  tenderness,  so  that  the 
patient  will  not  allow  a  finger  to  come  near.  Possibly  the  severe  local  headache 
that  occurs  sometimes  about  the  same  period  may  be  due  to  a  similar  affection  of 
the  dura  mater. 

Gummatous  deposits,  leading  to  caries  and  necrosis,  are  even  more  common 
in  the  tertiary  and  late  hereditary  stages.  There  may  be  merely  a  soft  and  tender 
swelling  on  the  scalp,  or  an  ulcer  with  a  base  of  carious  bone  and  undermined 
overhanging  edges  ;  or  half  the  frontal  bone  may  be  bare,  black,  and  dead,  even 
through  its  whole  thickness,  while  the  skin  around  is  thickened  and  curled  inward, 
as  if  it  had  shrunk  away  from  the  centre  as  soon  as  the  tension  on  it  had  yielded. 
Immense  portions  of  bone  may  be  lost  in  this  way,  and  it  may  be  years  before  the 
sequestra  separate.  No  new  bone  is  ever  formed,  and  deep  radiating  cicatrices, 
through  which  sometimes  the  pulsation  of  the  brain  can  be  felt,  are  left,  causing 
the  most  hideous  and  characteristic  deformity. 

In  other  cases,  corresponding  to  the  diffuse  gummatous  infiltration  of  other 
organs,  the  diploe  becomes  completely  obliterated,  so  that  the  bone  on  section  is 
solid  throughout  and  exceedingly  dense  and  hard  ;  and  occasionally,  in  addition, 
great  bosses  are  developed  from  the  inner  surface,  especially  over  the  frontal 
region,  so  that  the  grooves  for  the  sinuses  and  meningeal  arteries  become  deep 
channels. 

Parrot's  nodes,  periosteal  thickenings  of  soft  vascular  new  bone,  arranged  in 
lamellae,  are  characteristic  of  the  hereditary  form.     They  occur  round  the  anterior 


TUMORS  OF  THE  CRANIUM. 


659 


fontanelle,  one  on  each  parietal  bone,  and  one  on  each  half  of  the  frontal,  seldom 
invading  the  normal  centres  of  ossification,  and  leave  a  cruciform  sulcus  in  between, 
the  so-called  natiform  skull.  Occasionally  this  is  associated  with  wasting  or  gela- 
tiniform  degeneration  affecting  the  posterior  portion  of  the  skull,  but  distinguished 
from  craniotabes  by  its  occurring 
on  the  outer  surface.  For  a 
further  description  see  Syphilitic 
Diseases  of  Bone. 

Treatment.— The  consti- 
tutional treatment  varies  natu- 
rally according  to  the  cause.  The 
local  is  much  more  simple.  Free 
exit  must  be  given  to  all  dis- 
charges ;  secjuestra  removed  as 
soon  as  they  are  loose  ;  and  de- 
composition prevented  by  proper 
drainage  and  antiseptics.  Tu- 
bercular caries  can  sometimes  be 
greatly  benefited  by  free  scraping  •       ,  u      u 

and  the  application  of  iodoform.  Sometimes  exfoliation  may  be  assisted  by  the 
use  of  strong  sulphuric  acid  ;  and  occasionally  trephining  is  necessary,  either  to 
drain  an  extra-dural  collection  of  pus,  or  to  release  a  fragment  that  is  locked  in, 
owing  to  its  peculiar  shape. 


Fig.  290.— Syphilitic  Necrosis  of  the  Frontal  Bone. 


Tumors  of   the  Cranium. 

Osteomata  and  sarcomata  are  the  most  common.  Carcinoma  only  occurs  as 
a  secondary  deposit  by  extension.  Hydatid  cysts  and  angeiomata  have  occasion- 
ally been  described. 

Osteomata.— i:\\o'&Q  growing  from  the  outer  table  are  sometimes  called 
exostoses ;  those  from  the  inner  and  diploe,  enostoses.  Most  of  the  latter  are, 
however,  inflammatory  and  probably  syphilitic. 

Cancellous  exostoses  upon  the  cranium  are  rare  ;  ivory  ones  are  more  common, 
growing  chiefly  from  the  frontal  bone  and  in  the  external  auditory  meatus.  Some- 
times they  are  multiple  and  symmetrical.  As  a  rule  they  are  of  very  slow  growth 
and  should  be  left  alone ;  but  when  they  grow  in  the  frontal  sinus  they  may  cause 
the  most  fearful  disfigurement  from  displacement  of  the  eyeball,  or  even  more 
serious  symptoms  from  pressure  upon  the  brain  ;  while  in  the  ear  they  may  lead 
to  deafness  and  ultimately  to  complete  obstruction  of  the  meatus,  with  its  con- 
sequences (acute  suppurative  osteitis  and  meningitis)  if  the  secretion  collects  behind 
and  decomposes. 

Fortunately,  it  frequently  happens  that  the  necks  of  these  growths  are  much 
more  slender  than  would  be  imagined  from  their  size,  so  that  they  have  even 
been  known  to  break  off".  As  a  rule,  they  can  be  detached  with  a  drill  fitted  to  a 
surgical  engine,  but  very  great  care  is  required  in  the  selection  of  proper  instru- 
ments. In  one  or  two  instances  the  growths  have  detached  themselves,  like  the 
anders  of  a  stag,  the  vascular  canals  in  the  neck  gradually  becoming  smaller  and 
smaller  until  at  length  the  blood  supply  is  altogether  cut  off". 

^arr^wa/^.— Spindle-celled  and  myeloid  sarcomata  occasionally  grow  from 
the  diploe  and  cause  expansion  of  the  outer  table.  In  some  cases  the  two  tables 
are  widely  separated  from  each  other,  and  the  intervening  space  traversed  by  a 
complex  arrangement  of  radially  arranged  trabeculae.  Occasionally  the  bone 
gives  way  and  the  growth  spreads  rapidly  under  the  skin,  or  compresses  the  dura 
mater  and  the  brain  according  to  the  direction  it  takes.  There  is  usually  a  good 
deal  of  pain  at  the  first,  and  the  symptoms  may  be  masked  to  a  considerable  extent 
by  the  inflammation  around. 

Sarcoma  of  the  dura  mater  (and  more  rarely  of  the  other  membranes)  some- 


66o    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

times  perforates  the  cranium  and  spreads  rapidly  underneath  the  scalj)  (fungus  of 
the  dura  mater).  This  may  he  distinguished  from  the  preceding  by  its  pulsation 
(which  is  communicated  from  the  brain  beneath),  reducibility  (so  long  as  it  is 
small),  and  by  the  sharp  opening  in  the  skull  through  which  it  jirotrudes.  Some- 
times, also,  the  attempt  at  reduction  gives  rise  to  characteristic  cerebral  symptoms. 
Excision  is  the  jjroper  treatment  for  both,  if  the  diagnosis  is  made  in  time, 
but  as  a  rule  the  disease  is  much  too  far  advanced  to  justify  an  operation  of  such  a 
serious  nature. 


DISEASES  OF   THE  BRAIN  AND  MENINGES. 
Inflammation. 

Inflammation  may  begin  in  the  brain  (cerebritis)  or  the  membranes  (menin- 
gitis) ;  or  it  may  spread  to  them  from  structures  around,  the  bones,  the  scalp,  the 
mucous  lining  of  the  tympanum,  or  the  eye.  It  may  be  acute,  or  chronic  from 
the  beginning,  and  it  may  end  in  resolution,  or  persist  in  a  milder  form  ;  or,  if 
pyogenic  organisms  gain  entrance,  lead  to  diffuse  or  circumscribed  suppuration. 

{ci)  Simple  Acute  Inflammation. 

Cerebritis. — Inflammation  of  the  brain  may  follow  the  reactionary  stage  of 
concussion,  or  may  be  caused  by  the  intense  hypera^mia  that  attends  prolonged 
over-excitement.  It  is  common  after  severe  contusions,  a  zone  of  red  softening, 
formed  partly  of  l)roken  down  brain  substance,  ])artly  of  inflammatory  exudation, 
developing  around  the  injured  area;  and  it  is  always  found  around  al)scesses  (with 
the  excei)tion  of  the  most  chronic),  in  acute  suppurative  arachnitis,  and  to  a  less 
extent  around  rapidly  growing  tumors.  When  it  follows  concussion  or  is  due  to 
over-excitement,  it  is  diffuse  and  involves  the  whole  cortex  of  the  brain  ;  under 
other  circumstances  it  is  usually  local,  although  it  may  be  multiple  and,  sometimes 
at  least,  involve  a  very  large  area. 

Meningitis. — Simple  acute  inflammation  of  the  dura  or  pia  mater  is  rare  as  a 
primary  affection  ;  it  may,  however,  occur  in  com]:)ound  fractures  of  the  skull, 
caused  by  septic  decomposition  of  extravasated  blood  (arachnitis,  for  example, 
may  start  from  a  fissured  fracture  of  the  petrous  portion  of  the  temporal  bone, 
laying  open  the  cavity  of  the  tympanum  and  the  prolongation  of  the  arachnoid 
in  the  internal  auditory  meatus),  and  then  it  nearly  always  ends  in  suppuration. 
On  the  other  hand,  consecutive  meningitis,  due  to  extension  from  neighboring 
structures,  is  by  no  means  uncommon.  The  infection  may  travel  along  the  blood- 
vessels or  lymphatics,  by  progressive  thrombrosis  (as  in  orbital  cellulitis  and  diffuse 
inflammation  of  the  scalp),  or  by  embolism  (as  in  i)yffimia)  ;  or  it  may  s])read 
into  the  membranes  directly  from  the  adjacent  structures,  either  the  bones  (most 
of  the  cases  of  acute  suppurative  meningitis  after  compound  fractures  are  caused 
in  this  way)  or  the  brain.  In  the  one  case  the  dura  mater  is  attacked  the  first,  in 
the  other  the  pia;  but  although  the  pathological  changes,  hypera^mia,  softening, 
exudation,  and  extravasation,  may  be  more  marked  in  the  one  than  in  the  other, 
it  rarely  hai)pens  that  the  inflammation  is  limited. 

Morbid  Appearances. — In  the  early  stages  of  the  attack,  and  when  the 
whole  brain  is  affected,  these  are  only  slightly  marked.  The  venous  sinuses  are 
full ;  the  vessels  of  the  pia  and  the  plexuses  engorged  ;  the  meshes  of  the  arachnoid 
opaque  and  milky  ;  the  ventricles  distended  with  turbid  fluid  ;  and  the  brain  itself 
infiltrated,  oedematous,  and  studded  with  minute  red  points  like  hemorrhages.  In 
cases  of  longer  standing,  and  when  the  mischief  is  limited,  the  affected  part  appears 
swollen  and  pulpy  ;  if  it  is  cut  across  the  surface  rises  above  the  surrounding  level ; 
and  the  color  is  most  conspicuous.       Later  still  it  becomes  so  soft  that  a  gentle 


INFLAMMATION  OF  THE  BRAIN.  66 r 

stream  of  water  washes  it  away,  leaving  an  irregular  excavation  with  ragged, 
ctdematous,  and  softened  walls,  breaking  down  at  the  slightest  touch. 

Symptoms. — The  constitutional  ones  are  merely  those  of  acute  pyrexia. 
There  is  rarely  a  rigor;  that  is  the  signal  for  pyremia  or  suppuration,  but  the 
temperature  rises  rapidly  until  sometimes  it  attains  an  extraordinary  height;  the 
pulse  becomes  full,  quick,  and  bounding  ;  the  respiration  hurried  and  shallow  ;  the 
bowels  confined,  and  the  appetite  lost.  The  local  ones,  on  the  other  hand,  those 
that  depend  upon  the  organ  involved,  exhibit  a  greater  variety.  Headache  is 
always  present,  and  usually  is  described  as  agonizing.  At  first  there  is  general 
hvperffisthesia ;  the  least  noise  causes  intolerable  suffering ;  the  eyes  cannot  face 
the  light;  the  pupils  are  contracted  to  pin's  points;  and  even  the  skin  may  be 
exceedingly  tender.  Vomiting  and  delirium  are  rarely  absent ;  sometimes  there 
is  merely  a  certain  amount  of  wandering  at  night,  but  not  unfrequently  there  is  a 
condition  approaching  that  of  furious  mania.  Then,  by  degrees,  as  the  disorder 
of  the  cortex  becomes  greater,  the  abnormal  state  of  excitement  passes  into  a  con- 
dition of  insensibility  ;  the  pupils  dilate  ;  the  eyes  remain  staring  widely  open  ; 
the  breathing  becomes  stertorous ;  consciousness  is  lost,  and  stupor  and  coma  set 
in. 

The  character  and  extent  of  the  cerebral  symptoms  vary  with  the  seat  of  the 
disease.  In  some  cases  there  is  weakness  of  the  limbs  on  the  of)posite  side  of  the 
body  ;  in  others  there  are  general  convulsions.  Occasionally,  when,  for  example, 
the  inflammation  spreads  from  a  contusion  in  or  near  the  motor  area,  the  spas- 
modic contraction  is  local  at  the  first,  and  gradually  extends  from  one  group  of 
muscles  to  another  in  definite  order.  On  the  other  hand,  when  the  attack  com- 
mences in  the  bones,  as  in  syphilitic  osteitis,  and  spreads  from  them  to  the  dura 
mater,  it  may  be  some  time  before  any  symptoms  that  are  definitely  cerebral  make 
their  appearance.  There  is  no  delirium  or  wandering  in  such  a  case  ;  convulsions 
are  not  present  until  sometimes  quite  late ;  there  is  no  intolerance  of  light  or 
sound  ;  but  there  is  the  most  acute  tenderness  all  over  the  inflamed  bone,  espe- 
cially on  percussion  ;  the  pain  is  intense,  particularly  at  night ;  and  if  the  base  of 
the  skull  is  involved  optic  neuritis  and  affections  of  the  other  cranial  nerves, 
paralysis  or  neuralgia,  are  often  present.  Cases  of  this  kind,  in  which  the  inflam- 
mation is  local  at  the  beginning  and  remains  so  for  some  considerable  time,  are 
naturally  much  less  severe  than  those  in  which  the  pia  mater  and  the  cortex  of  the 
brain  are  involved  from  the  first. 

The  course  and  termination  depend  chiefly  upon  the  intensity  and  persistence 
of  the  exciting  cause. 

1.  Resolution  may  take  place  if  the  irritant  is  mechanical  and  transient,  an 
extravasation,  for  example,  that  becomes  absorbed.  Every  severe  contusion  of 
the  brain  that  does  not  prove  fatal  at  once  is  surrrounded  by  a  considerable  area 
of  red  softening ;  and  it  is  not  uncommon  for  patients  who  have  sustained  injuries 
of  this  character  to  remain  for  two  or  three  weeks  in  a  very  critical  condition, 
feverish,  exceedingly  irritable,  with  photophobia,  intense  headache,  quickened 
pulse,  hot,  dry  skin,  and  often  a  certain  degree  of  delirium.  Then,  at  the  end  of 
that  time,  the  temperature  gradually  falls  and  convalescence  begins,  although  the 
least  excitement  or  over-indulgence  is  sufhcient  to  bring  on  a  relapse. 

2.  Death  may  ensue,  either  because  of  the  extent  or  importance  of  the  part 
of  the  brain  affected  ;  or  from  exhaustion  and  the  intensity  of  the  fever. 

3.  The  inflammation  may  become  chronic  if  the  irritant  (without  being 
pyogenic)  is  a  persistent  one.  It  may  be  a  depressed  plate  of  bone,  or  a  foreign 
body  driven  in,  or  a  cyst  or  patch  of  dense  fibrous  tissue  developed  from  an  old 
extravasation  ;  or  it  may  be  a  specific  organism,  such  as  that  of  syphilis,  tubercle, 
or  actinomycosis,  sufficiently  irritating  to  cause  the  production  of  a  mass  of  granu- 
lation tissue,  but  not,  at  first  at  any  rate,  lowering  the  vitality  of  the  surrounding 
structures  so  far  that  they  become  unable  to  withstand  the  action  of  pyogenic 
organisms. 


662    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

4.  Suppuration  may  follow,  whether  other  germs  are  present  or  not.  If  the 
vitality  of  the  tissues  is  very  feeble,  or  if  the  action  of  the  pyogenic  micro-organ- 
isms is  assisted  by  septic  decomposition  and  tension,  it  will  be  diffuse  and  rapidly 
fatal.  \{  the  conditions  are  not  so  unfavorable,  a  limiting  wall  of  granulation 
tissue  may  be  developed,  forming  a  cerebral  or  meningeal  abscess ;  and  this, 
according  to  the  rapidity  with  which  it  extends,  may  be  acute,  chronic,  or  even 
latent,  remaining  concealed  perhaps  for  years.  It  takes,  however,  three  weeks, 
or  at  least  a  fortnight,  for  the  surrounding  brain  tissue  to  protect  itself  in  this 
way  ;  and,  consequently,  circumscribed  suppuration  is  rarely  met  with  after  com- 
pound fractures,  and  never  until  some  considerable  time  after  the  receipt  of  the 
injury. 

The  organisms  may  gain  access  directly  through  a  wound  ;  or  indirectly  by 
e.xtension  along  the  veins  (thrombosis,  which  is  usually  retrograde)  ;  by  sudden 
embolism,  as  in  pyaemia ;  or  by  continuity  through  the  adjacent  tissues.  What- 
ever the  way,  unless  everything  is  perfectly  healthy  and  well  nourished  (when 
probably  the  germs,  like  those  of  putrefaction,  are  soon  destroyed),  they  begin 
their  work  at  once  ;  the  leucocytes  perish  and  become  pus-corpuscles  ;  the  plasma 
and  formed  tissues  melt  away  ;  and  suppuration  begins,  diffuse  or  circumscribed, 
according  to  the  ability  of  the  surrounding  tissues  to  repel  the  assault. 


{p)    Chronic  Inflammation. 

Chronic  inflammation  of  the  brain  or  its  membranes  may  be  the  relic  of  an 
acute  attack,  resolution  having  been  imperfect ;  or  it  may  be  chronic  from  the 
beginning.  In  either  case  the  immediate  cause  is  the  presence  of  some  persisting 
irritant,  which  may  be  mechanical,  chemical,  or  a  living  organism.  The  inflam- 
mation may  begin  in  the  brain  or  the  membranes;  but  unless  a  definite  exciting 
cause,  such  as  a  depressed  spiculum  of  bone,  is  known  to  be  present,  it  is  rarely 
possible  to  distinguish  one  form  from  the  other. 

Causes. — Fracture  of  the  skull  not  uncommonly  leaves  behind  it  symptoms 
of  chronic  irritation  of  the  brain,  arising,  certainly  in  many  cases,  from  the  per- 
sistence of  some  gross  lesion.  Starring  of  the  inner  table  ;  angular  depressions 
(smooth  extensive  ones,  such  as  occur  in  children,  are  not  so  serious)  ;  detached 
spiculae  of  bone  ;  and  even  foreign  bodies  (fragments  of  knife  blades)  have  been 
known  to  occasion  it.  Intra-meningeal  extravasation  is  more  rare,  but  sometimes 
it  leaves  a  dense,  hard  layer  of  organized  blood  clot,  or  a  cyst,  pressing  upon  the 
cortex.  (Subcranial  hemorrhage  between  the  bone  and  the  dura  mater,  whether 
occurring  at  birth  or  later,  rarely  gives  rise  to  symptoms  of  irritation.  Like 
smooth  dei)ressions  of  the  cranial  bones,  it  may  cause  spastic  paralysis,  or  some 
form  of  birth  palsy,  if  it  does  not  of  itself  prove  fatal;  but  the  symptoms  are 
nearly  always  referable  rather  to  atrophy  than  anything  else).  In  other  cases  a 
dense,  sclerosed  condition  of  the  bone,  with  nodes  projecting  from  its  inner  sur- 
face, may  be  found  ;  or  a  thickened  and  partially  ossified  plate  in  the  dura  mater  ; 
or  a  spot  in  which  all  the  membranes  are  so  fused  with  each  other  and  with  the 
cortex  that  there  is  nothing  left  but  a  fibrous  ma.ss  with  a  few  shriveled  or  calcified 
ganglion  cells  in  its  substance. 

Syphilis,  as  it  affects  the  membranes  and  the  cortex  of  the  brain  more  often 
than  other  parts,  is  a  frequent  cause.  Osseous  nodes  may  grow  out  from  the  inner 
surface  of  the  bones  (the  frontal  in  particular,  on  either  side  of  the  longitudinal 
sinus)  ;  or  gummatous  deposits  may  occur  in  the  dura  or  pia  mater,  or  in  the 
substance  of  the  brain,  leaving,  after  they  have  been  absorbed,  dense  rigid  cica- 
trices which  perpetuate,  or  even,  by  their  contraction,  intensify  the  mischief 
already  done.  The  coats  of  the  arteries  may  be  diseased,  so  that  either  the  lumen 
is  blocked  and  softening  ensues,  or  their  walls  give  way  and  aneurysms  or  hemor- 
rhages follow;  or,  again,  slowly  extending  ])atches  of  sclerosis  may  develop,  and 
by  degrees  involve  one  part  after  another.      Tubercle,  when  it  begins  in  the  mem- 


INFLAMMATION  OF  THE  BRAIN.  663 

branes,  usually  runs  an  acute  course,  and  ends  in  a  speedily  fatal  form  of  menin- 
gitis ;  when,  however,  it  takes  the  shape  of  a  caseous  mass ;  deeply  buried  in  the 
substance  of  the  brain,  the  chief  symptom,  until  compression  sets  in,  is  the  chronic 
irritation  of  all  the  surrounding  parts.  Slowly  growing  tumors  and  cysts,  whether 
originating  in  the  brain  itself  or  springing  from  the  bones,  act  in  the  same  way. 
The  persistent  abuse  of  alcohol  is  said  to  cause  the  same  result,  leading  to  chronic 
inflammation  and  induration  of  the  membranes  and  surface  of  the  brain,  especially 
on  the  vertex;  and  sometimes  there  are  other  causes,  some  acting  directly,  others 
giving  rise  to  reflex  irritation,  and  others  again  affecting  the  circulation  chiefly,  if 
not  entirely,  so  that,  post-mortem,  no  local  pathological  lesion  can  be  found. 

Symptoms  of  chronic  irritation  of  the  brain,  whether  sufficiently  severe  to 
excite  visible  inflammatory  changes  or  not,  are  of  the  most  varied  character.  In 
many  instances  they  are  entirely  general,  without  the  least  indication  of  any  local 
lesion.  A  peculiar  condition  of  general  irritability,  for  example,  is  often  left  after 
severe  contusions.  Recovery  does  not  appear  to  be  complete  ;  there  is  a  great  ten- 
dency to  headache,  especially  after  any  mental  exertion  or  excitement ;  the  patient 
is  irritable,  giving  way  to  fits  of  passion  without  any  apparent  reason  ;  memory  is 
defective,  sometimes  generally,  sometimes  only  for  certain  special  things  ;  the 
power  of  mental  concentration  is  impaired,  and  the  patient  is  quite  unable  to  do 
what  he  used  to  do  without  effort  before.  It  seems  as  if  the  circulation  through 
the  brain  does  not  easily  regain  its  power  of  self-control ;  for  a  long  time  the  least 
mental  excitement  or  over-exertion  is  enough  to  throw  it  into  disorder,  and  to 
bring  back,  temporarily,  the  condition  of  hyperaemia  and  congestion  that  followed 
immediately  upon  the  receipt  of  the  injury.  As  a  rule  this  passes  off;  but  some-" 
times,  if  the  part  is  not  kept  at  rest,  it  becomes  permanent,  and  a  lasting  condi- 
tion of  cerebral  incapacity  is  left. 

The  symptoms  are  the  same  when  the  irritant  is  a  persisent  one,  but  they  are 
usually  more  intense.  Headache  is  never  absent,  sometimes  it  is  general,  sometimes 
local  ;  but  wherever  it  is,  it  is  always  made  worse  by  excitement,  or  by  hanging  the 
head  down,  or  by  the  use  of  alcoholic  stimulants.  Vomiting,  such  as  is  met  with 
in  cerebral  affections,  apparently  purposeless  in  character,  is  not  infrequent.  Ver- 
tigo may  occur,  especially  when  suddenly  rising  up.  Optic  neuritis  is  nearly  always 
present,  especially  when  the  membranes  at  the  base  are  concerned  ;  and  in  many 
cases  there  are  other  affections — neuralgia,  for  example,  or  paralysis  of  the  other 
cranial  nerves. 

Some  form  of  mental  disturbance  is  rarely  absent.  It  may  be  merely  irrita- 
bility and  wakefulness,  with  an  uncertain  temper  ;  or  there  may  be  loss  of  memory 
and  power  of  concentration  with  want  of  mental  vigor,  and  in  extreme  cases  de- 
mentia. The  local  symptoms  are  no  less  variable.  Spasmodic  convulsions  may 
occur  if  the  irritant  affects  the  motor  portion  of  the  cortex,  and  without  occasion- 
ing any  loss  of  consciousness,  may  spread  from  one  centre  to  another.  Traumatic 
epilepsy  may  follow,  the  discharging  lesion  from  constant  repetition  becoming  per- 
manent. Or  paralysis  may  occur,  but  this  is  less  frequent,  as  lesions  that  cause 
chronic  irritation  or  inflammation  are  usually  connected  with  the  membranes  or  the 
surface  of  the  brain,  and  slow  destruction  of  the  cortical  motor  centres  in  one 
hemisphere  admits  very  largely  of  compensation. 

Valuable  information,  both  as  to  the  site  and  nature  of  the  lesion,  may  fre- 
quently be  obtained  in  other  ways.  In  traumatic  cases,  for  instance,  there  may  be 
a  depression  or  irregularity  on  the  surface  of  the  skull.  Pressure  may  be  exceed- 
ingly painful  at  one  particular  spot ;  or  the  whole  bone  may  be  tender  on  percus- 
sion. The  pain  may  be  altogether  of  a  different  character,  dull  and  heavy,  infin- 
itely worse  at  night,  due  chiefly  to  the  osteitis.  The  temperature  of  the  part  may 
be  higher  than  that  of  the  corresponding  point.  The  skin  may  be  puffy  or  raised  ; 
or  there  may  be  evidence  of  obstruction  to,  or  pressure  upon,  structures  passing 
out  through  canals  in  the  bone ;  and  these  symptoms  of  course  vary  in  every  casei 


664    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

SL'I'PURA'IION. 

Acute  inflammation  of  the  brain  and  its  membranes  may  terminate  in  sup- 
puration. The  pus  may  form  between  the  bone  and  the  chira  mater  (subcranial), 
probably  always  extending  inward  from  the  bone;  between  the  meninges  (sub- 
dural) ;  or  in  the  substance  of  the  brain.  In  this  last  situation  the  ab-scess  may 
be  separated  from  the  external  focus  of  disease  from  which  it  started  by  a  layer  of 
healthy  brain  ti.ssue,  and  even  by  intact  and  unaffected  membranes,  the  infection 
having  traveled  inward  along  one  of  the  veins  or  in  its  perivascular  sheath. 

Suppuration  is  limited  or  not,  according  to  the  relative  vigor  of  the  tissues  on 
the  one  hand  and  the  irritants  on  the  other.  If  the  latter  are  much  the  stronger, 
it  will  be  diffuse  and  set  in  acutely  \  if  the  difference  is  not  so  great,  it  may  be  cir- 
ciimscrihcd,  two  or  three  weeks  being  recjuired  for  the  development  of  the  limiting 
wall  of  granulation  tissue  ;  and  if  the  balance  is  only  just  in  their  favor,  it  may  be 
chronic  and  even  latent,  remaining  concealed  perhaps  for  some  years. 

Cause. — Intracranial  suppuration  may  originate  in  three  different  ways  : — 

(i)  It  may  break  out  after  contusion  or  concussion  of  the  brain,  even  though 
the  skin  has  not  been  injured  or  the  bone  fractured,  the  pyogenic  organisms  being 
carried  by  the  blood,  but  not  causing  embolism.  Fortunately  it  is  very  rare.  It 
may  be  either  diffuse,  acute  cerebritis  running  on  to  sup])uration,  and  proving  fatal 
within  a  few  days,  or  circumscribed,  the  area  of  red  softening  round  the  contusion 
gradually  growing  more  and  more  liquid  in  the  centre  until  it  simply  becomes  a 
collection  of  pus.  Abscesses  caused  in  this  way  are  nearly  always  single  and  in 
the  substance  of  the  brain.  Not  unfrequently  they  are  situated  on  the  side  oppo- 
site to  the  injury — in  the  right  frontal  or  temporo-sphenoidal  lobes,  for  example, 
when  the  blow  has  fallen  upon  the  left  side  of  the  occiput,  owing  to  the  fact  that 
in  such  cases  this  is  the  part  of  the  brain  that  usually  suffers  most. 

(2)  It  may  be  due  topycemia  consequent  upon  the  impaction  of  infected  emboli 
from  some  distant  focus  of  suppuration  (usually  in  the  lungs).  If  it  occurs  in  con- 
nection with  the  membranes  it  is  always  diffu.se  ;  if  it  is  in  the  brain  it  is  nearly 
always  multiple  and  generally  in  the  course  of  the  middle  cerebral  artery. 

(3)  It  may  be  due  to  extension  from  suppuration  near.  This,  which  is  by 
far  the  most  common  and  the  most  important  variety,  may  be  the  result  either  of 
injury  or  disease. 

{a)  After  Injury. — Acute  suppurative  meningitis  may  be  caused  either  by  the 
organisms  entering  through  the  wound  directly,  or  by  extension  inward  as  a  result 
of  suppuration  in  the  diploe. 

In  the  former  case  the  inflammation  breaks  out  within  a  day  or  two  after  the 
injury.  It  usually  occurs  after  small  punctured  fractures,  not  when  the  bone  has 
been  extensively  comminuted  and  all  the  loose  fragments  have  been  removed.  In 
these  cases  a  considerable  amount  of  blood  is  often  extravasated  ;  it  collects  in 
the  wound  exposed  to  the  air,  and  so  long  as  the  fragments  remain  impacted  is 
unal)le  to  escape.  If  septic  decomposition  is  allowed  to  take  place,  the  i)roducts 
soak  into  the  bruised  and  damaged  tissues  around,  and  lower  their  vitality  to  such 
an  extent  that  suppuration  follows  at  once,  and  is  always  diffuse.  The  meshes  of 
the  pia  mater  are  filled  with  exudation,  which  surrounds  the  veins,  dips  into  the 
sulci,  and  covers  the  convolutions,  until  it  can  be  stripped  off  like  a  cast  of  yel- 
lowish-green wax,  bringing  with  it  the  surface  of  the  softened  and  infiltrated 
cortex. 

In  the  latter  case,  when  the  meningitis  is  secondary  to  acute  suppurative 
osteitis,  the  apjjearances  and  the  result  are  generally  the  same,  although  it  may  be 
several  days  before  the  di.sease  is  so  far  advanced.  Sometimes,  however,  when  the 
dura  mater  is  not  torn,  the  course  is  more  protracted,  and  subcranial  (extra-dural) 
suppuration  occurs,  and  persists  for  some  little  time  before  the  inflammation  gains 
the  subdural  space  and  becomes  diffuse  ;  and,  occasionally,  even  when  the  dura 
mater  has  been  punctured  and  spicules  of  bone  driven  into  the  substance  of  the 
brain,  there  is   no  definite  evidence  of  the  formation  of  pus,  though  weeks  may 


INTRACRANIAL   SUPPURATION.  665 

have  passed  since  the  receipt  of  the  injury.  Probably  in  this  latter  case  there  has 
been  no  septic  decomposition,  and  the  pyogenic  organisms,  with  only  a  limited 
area  of  damaged  tissue  at  the  seat  of  injury,  without  the  assistance  of  the 
poisonous  i)roducts  of  putrefaction,  have  only  been  able  to  cause  the  minimum  of 
destruction. 

In  exceptional  instances  intracranial  suppuration  may  follow  a  simple  contu- 
sion of  the  cranial  bones,  sui)purative  osteitis  breaking  out  at  the  seat  of  injury  and 
extending  inward.  A  severe  blow  is  received  upon  the  head  ;  blood  is  extrava- 
sated  into  the  veins  of  the  diploe  and  under  the  pericranium  ;  usually  it  becomes 
absorbed  ;  occasionally  days  or  weeks  after  the  injury  suppuration  breaks  out,  the 
organisms  having  entered  from  some  already  existing  focus  of  suppuration,  through 
a  wound,  or  through  the  mucous  membranes.  At  once  the  inflammation  becomes 
much  more  severe  ;  the  pericranium  is  detached  from  the  bone  on  one  side  and 
the  dura  mater  on  the  other ;  the  exudation  pours  out  into  all  the  tissues  around, 
lifting  up  the  skin  (Pott's  puffy  tumor)  and  glueing  together  the  membranes  ; 
acute  osteophlebitis  sets  in,  and  the  pus  spreads  rapidly  through  the  softened  and 
inflamed  tissues.  Suppurative  osteitis  of  this  character  is  so  often  associated  with 
liysmia.  sometimes  as  its  cause,  that  when  the  pus  does  burst  through  the  bone 
it  rarely  remains  limited;  nearly  always,  however  early  an  incision  is  made,  the 
pericranium  is  already  stripped  up,  the  bone  is  bare,  rough,  and  brown,  and  if  a 
trephine  is  applied,  pus  wells  out  from  the  groove  mixed  with  the  bone-dust.  When 
the  disc  is  lifted  out,  instead  of  a  circumscribed  abscess,  the  dura  mater  is  already 
perforated  and  the  arachnoid  and  sub-arachnoid  spaces  are  filled  with  a  thick  layer 
of  yellowish-green  pus. 

{b')  As  a  Reszdt  of  Disease. — Intracranial  suppuration  is  frequently  caused  by 
extension  inward  from  a  purulent  focus  in  the  surrounding  tissues,  without  fracture 
or  other  injury.  The  pathological  process  is  essentially  the  same  as  when  it  follows 
an  open  wound  or  a  compound  fracture  ;  the  route,  that  is  to  say,  may  be  direct,  the 
micro-organisms  simply  invading  one  part  after  another  and  forming  a  continuous 
track  of  suppuration  ;  or  the  inflammation  may  spread  along  the  veins  or  lym- 
phatics without  leaving  in  the  intervening  tissues  any  evidence  of  its  passage  through 
.them ;  but  the  difficulty  of  localization  is  so  great,  and  the  onset  of  the  disease  in 
the  majority  of  cases  so  insidious,  that  a  separate  description  is  advisable. 

As  in  the  case  of  compound  fractures,  the  suppuration  may  be  either  diffuse, 
involving  the  membranes,  or  circumscribed,  and  usually  in  the  substance  of  the 
brain  (cerebral  abscess)  ;  but  the  relative  frequency  of  the  two  is  very  different. 

The  former,  which  is  by  far  the  most  common  after  injury,  is  rarely  met 
with  unless  there  is  acute  extra-cranial  inflammation,  such  as  orbital  cellulitis, 
facial  carbuncle,  diffuse  inflammation  of  the  cellular  tissue  of  the  scalp,  the 
so-called  phlegmonous  erysipelas,  or  acute  suppuration  in  connection  with  the 
ear.  In  all  probability  the  infection  extends  along  the  veins  or  their  sheaths, 
the  ophthalmic  for  example,  or  the  mastoid,  or  those  that  pass  back  through  the 
sphenoidal  fissure,  for  the  meningitis  is  nearly  always  associated  with  thrombosis 
of  the  sinuses  and  general  pyaemia.  So  far  as  the  pathological  appearances  are 
concerned,  it  does  not  diff"er  in  any  material  respect  from  the  diffuse  suppurative 
meningitis  that  occurs  after  compound  fractures. 

The  latter  {cerebral  abscess)  results  almost  always  from  chronic  suppurative 
disease,  and  is  usually  consecutive  to  caries  of  the  ethmoid,  or  especially  the 
petrous  portion  of  the  temporal  bone. 

Catarrhal  inflammation  of  the  middle  ear  is  exceedingly  common  after  the 
exanthemata  (particularly  scarlatina  and  measles),  and  may  occur  whenever  the 
mucous  membrane  of  the  throat  becomes  inflamed.  In  most  cases  it  subsides 
without  any  ill  consequence ;  but  if  it  runs  on  to  suppuration  it  may  lead  to  per- 
foration of  the  membrana  tympani  and  destruction  of  the  auditory  ossicles  ;  or  it 
may  become  chronic,  spread  from  the  mucous  membrane  to  the  periosteum  and 
the  bone  beneath,  and  give  rise  to  caries  and  necrosis.  When  this  takes  place 
there  is  always  imminent  danger  that  it  may  extend  further  still. 
43 


666    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Extension  may  take  place  while  the  inflammation  is  acute,  or  later  when  it  has 
become  chronic,  and  there  is  nothing  to  attract  attention  l)ut  the  loss  of  hearing 
and  a  little  purulent  discharge  from  time  to  time.  In  the  former  case,  as  in 
traumatic  intracranial  suppuration,  it  is  usually  diffuse  ;  if  the  conditions  are  so 
favorable  that  the  jjyogenic  germs  can  si)read  without  difficulty  tlirough  the 
petrous  portion  of  the  temporal  bone  to  the  meninges,  they  are  not  likely  to 
remain  localized  and  confined  there.  In  the  latter  case  it  is  nearly  always 
circumscribed.  So  long  as  the  exit  is  free  and  the  discharge  is  not  allowed  to 
accumulate  and  decompose,  the  danger  is  not  great,  although  suppuration  does 
sometimes  occur  even  under  these  conditions,  the  abscess  remaining  latent  in 
the  brain.  If,  however,  the  outlet  becomes  blocked,  whether  this  is  due  to  dried- 
up  discharge  or  to  the  growth  of  polypoid  granulations,  the  pus  that  is  retained 
begins  to  decompose,  the  tension  becomes  higher  and  higher,  and  extension  of 
the  inflammation  is  the  natural  consecpience.  It  depends  chiefly  ujjon  the 
accidental  anatomical  relations  of  the  focus  of  disease,  whether  the  pyogenic 
organisms  spread  to  the  dura  mater  (causing  subcranial  abscess  or  diffuse  menin- 
gitis), to  the  brain  (fmding  a  route  by  direct  continuity  of  structure,  or  along 
the  veins  or  lymphatics),  or  to  the  blood-vessels  in  the  diploe,  giving  rise  to 
osteophlebitis,  thrombosis  of  the  lateral  sinus,  or  pyaemia. 

These  relations,  and  particularly  the  development  of  the  mastoid  cells,  vary  at 
different  jieriods  of  life.  In  a  child  two  years  of  age,  there  is  only  a  small  air 
space  lying  immediately  behind  the  tympanum  ;  the  cells  that  occupy  the  mastoid 
process  have  as  yet  no  existence,  and  the  lamina  of  bone  which  forms  the  roof  of 
the  tympanum  and  helps  to  separate  the  external  meatus  from  the  middle  fossa  is 
exceedingly  thin.  On  the  other  hand,  in  adults,  the  mastoid  i>rocess  may  be 
excavated  by  great  hollows  quite  up  to  the  lateral  sinus  and  the  mastoid  vein 
(especially  when  the  sinus  curves  rather  more  forward  than  usual,  for  its  position 
is  very  variable).  Suppuration,  therefore,  in  connection  with 
the  mastoid  cells  would  tend  to  spread  more  easily  toward 
the  middle  fossa  in  the  child,  toward  the  sinus  in  the  adult ; 
but  further  evidence  is  wanted  to  establish  this  as  a  fact. 

In  many  cases,  the  inflammation  spreads  by  direct 
continuity  of  structure  ;  the  bone  becomes  inflamed,  and 
necroses ;  the  dura  mater  over  it  sloughs,  and  either  the 
pus  spreads  into  and  through  the  arachnoid  space  at  once, 
or  the  membranes  become  glued  to  each  other  and  to  the 
cortex  by  inflammatory  exudation  before  this  can  occur. 
There  are,  however,  many  other  routes  almost  as  direct, 
along  which  the  infection  may  travel.  It  may  spread,  for 
Fig.  29.. -Section  (slightly  example,  dowu  the  internal  auditory  meatus,  or  through  the 
oblique)  through  the  mas-  hiatus  Falloijii,  or  the  aciueductus  vestibuli,  or  it  may  extend 

toid  process  and   the  lat-  r    .1  11  •  /  1  .,  \^A 

erai  sinus,  showing  the  along  some  of  the  numcrous  small  veins  (each  surrounded 
ofherTnEd.tu'""''''  L)y  a  perivascular  lymi)h  sheath;  which  run  between  the  in- 
ternal and  middle  ear  on  the  one  hand  and  the  dura  and 
pia  mater  on  the  other.  Some  of  these  pass  directly  from  the  tem])oro- 
sphenoidal  lobe  of  the  brain  to  the  dura  mater,  covering  the  petrous  portion 
of  the  temporal  bone ;  others  run  through  the  squamo-petrosal  suture,  and 
through  the  slit  for  the  dura  mater  that  lies  by  the  side  of  the  aqueductus 
vestibuli ;  others,  again,  lie  in  small  canals  (immediately  behind  the  superior 
semicircular  canal)  which  connects  the  middle  ear  directly  with  the  middle  fossa 
of  the  skull  ;  and  not  a  few  communicate  with  the  middle  meningeal  veins  and 
the  superior  petrosal  and  lateral  sinuses. 

In  most  cases  of  disease  in  the  middle  ear  the  abscess  is  in  the  temporo-sphe- 
noidal  lobe  ;  sometimes  the  dura  mater  covering  the  anterior  surface  of  the  petrous 
portion  is  unaffected  ;  generally  it  is  sloughing,  or  at  least  inflamed.  The  abscess 
is  usually  of  large  size  (an  inch  and  a  half  or  two  inches  in  diameter)  ;  its  walls 
may  be  very  thick  (occasionally  acute  suppuration  develops  round  an  old  encysted 


INTRACRANIAL   SUPPURATION.  667 

abscess)  ;  and  it  may  lie  in  the  substance  of  the  lobe,  covered  over  by  a  layer  of 
apparently  healthy  cortex  a  (juarter  of  an  inch  in  thickness,  or  communicate  with 
the  suppurating  focus  in  the  bone  through  a  sinuous  channel.  The  pus  is  generally 
exceedingly  fcetid.  The  abscess  if  left  to  itself  may  remain  latent  for  years  ;  or 
acute  symptoms  may  suddenly  develop  from  some  comparatively  trivial  cause, 
exposure  to  cold  for  example,  or  a  blow  upon  the  ear  :  usually  it  terminates  sooner 
or  later  by  rupturing  into  the  lateral  ventricle  or  the  subarachnoid  space. 

Cerebellar  abscess  is  less  frecjuently  met  with.  There  is  a  certain  amount  of 
evidence  that  it  is  more  common,  comparatively,  in  children  than  in  adults  and 
when  the  mastoid  cells  are  inflamed.  Thrombosis  of  the  lateral  sinus  is  associated 
with  it  in  many  instances. 

Abscesses  in  many  localities  are  more  rare  :  but  they  are  sometimes  found 
between  the  dura  mater  and  the  bone  (extra-dural)  ;  in  the  centrum  ovale  ;  even 
on  the  opposite  side  of  the  head  (probably  py?emic,  or  at  least  thrombotic  ;  and 
in  the  pons.  It  is  said  that  the  last  is  consecutive  to  disease  of  the  internal  rather 
than  of  the  middle  ear. 

In  comparison  with  this,  intracranial  suppuration  consequent  on  disease  of 
bone  elsewhere,  is  seldom  met  with.  Both  forms,  however,  the  diffuse  and  the 
circumscribed,  may  occur  in  the  region  of  the  frontal  lobes  from  caries  of  the 
ethmoid  and  ozsena  ;  and  one  or  two  instances  are  recorded  in  which  the  same 
thing  has  happened  in  connection  with  the  orbit. 

Symptoms. — i.  Diffuse  Suppuration. — It  is  rarely  possible  to  tell  when  sup- 
puration begins  in  a  case  of  acute  inflammation  of  the  brain.  Sometimes  there  is 
a  rigor,  but  it  is  by  no  means  invariable,  and  if  it  does  occur  it  more  frequently 
indicates  the  commencement  of  pyaemia.  The  constitutional  symptoms  simply 
grow  more  and  more  severe,  the  temperature  in  particular  rising  to  an  exceptional 
height,  while  the  local  ones  gradually  merge  into  those  of  compression.  The  cortex 
becomes  more  and  more  disordered  ;  convulsions,  excitement,  and  delirium  give 
way  to  paralysis,  loss  of  consciousness,  and  coma ;  the  pupils  dilate  ;  the  eyes 
remain  widely  open  ;  the  face  becomes  flushed  and  dusky  :  the  pulse  slow  and 
full ;  and  respiration  labored  and  stertorous. 

2.  Intracranial  Abscess. — The  symptoms  depend  upon  the  rapidity  with 
which  it  is  formed,  the  rate  at  which  it  extends  and  the  locality  in  which  it  occurs. 
In  rare  instances  intracranial  abscesses  are  acute,  ushered  in  with  a  rigor  and  high 
fever.  Much  more  often  they  are  chronic  and  even  latent,  without  any  elevation 
of  temperature  ;  sometimes  there  is  an  actual  fall,  so  that,  for  a  time  at  least,  it  is 
subnormal.  Occasionally,  after  existing  without  a  symptom  for  an  indefinite 
period,  an  abscess  suddenly  becomes  acute,  spreads  rapidly,  and  breaks  into  the 
ventricular  or  subarachnoid  space.  The  local  symptoms  are  those  of  pressure 
upon  or  irritation  of  the  structures  that  lie  around  it. 

The  most  important  varieties  are  the  traumatic  and  that  which  is  secondary 
to  disease  of  the  middle  ear.  Others  are  more  rare  and  seldom  admit  of  diag- 
nosis. 

(«)  Traumatic  Intracranial  Abscess. — The  symptoms  are  partly  general,  in- 
dicative of  disturbance  of  the  whole  nervous  system  ;  partly  local,  arising  from 
aff"ections  of  special  portions  of  the  brain,  or  the  nerves,  or  the  bones  and  mem- 
branes covering  them  in. 

There  is  always  a  latent  period  after  the  accident,  at  least  a  fortnight,  gener- 
ally much  longer,  sometimes  years.  At  the  time  there  may  have  been  concussion, 
or  evidence  of  contusion  of  the  brain  ;  but  in  a  typical  example  this  has  passed 
away.  Recovery,  however,  is  not  perfect ;  the  patient  grows  thinner,  or  loses  his 
memory  ;  perhaps  he  becomes  irritable,  or  there  is  general  failure  of  power,  bodily 
as  well  as  mental.  Sometimes  these  signs  are  so  marked  that  the  friends  notice 
them  and  become  anxious  ;  sometimes  they  are  scarcely  perceptible.  The  tem- 
perature is  usually  subnormal,  although  slight  chills  may  occur,  the  pulse  is  quick 
and  irritable  at  first,  very  slow  toward  the  end.  Pain  is  rarely  absent ;  in  most 
cases  it  is  very  severe  ;  usually  it  is  general,  affecting  the  whole  head  ;  sometimes 


668    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

it  is  local,  and  associated  with  great  tenderness  on  pressure  or  percussion.  (Jptic 
neuritis  is  present  in  nearly  every  case,  and  irregularity  of  the  pupils  is  often  noted, 
the  one  that  is  more  dilated  and  fixed  corresponding  to  the  affected  side.  Very 
often  local  signs  are  entirely  wanting  ;  there  is  merely  headache  followed  by 
drowsiness,  paralysis,  and  at  length  coma,  without  its  being  possible  to  say  from 
the  brain  symptoms  more  than  that  it  is  a  ca.se  of  gradual  compression. 

Valuable  information  is  often  gained  from  the  condition  of  the  skin  or  the 
bone.  Sometimes  there  is  a  scar  or  an  irregularity  on  the  surface  of  the  cranium 
from  depression  of  a  portion  of  bone.  In  many  instances  there  has  been  a  history 
of  purulent  discharge  following  fracture,  and  of  very  protracted  healing.  Occa- 
sionally the  discharge  has  stopped,  collected,  and  begun  again  more  than  once 
before  the  symptoms  l)ecame  serious,  although  each  time  there  may  have  been  a 
certain  degree  of  headache  and  feverishness.  Tenderness  on  percussion  over  the 
affected  bone  is  not  uncommon.  Sometimes  there  is  a  dull,  aching  pain,  espe- 
cially severe  at  night.  In  a  few  cases  there  is  a  soft  puffy  swelling  on  the  scalp, 
due  to  effusion  under  the  pericranium  (Pott's  puffy  tumor),  and  pointing  to  com- 
mencing suppuration  in  the  dii)loe. 

Intense  neuralgia  in  all  the  three  branches  of  the  fifth  pair  has  been  noted 
once  or  twice.  Paresis  from  j^rcssure,  occasionally  passing  into  paralysis,  is  more 
common,  affecting  especially  the  motor  nerves  of  the  eyeball. 

Cerebral  symptoms,  monospasm  and  monoplegia,  gradually  extending  over  a 
wider  area,  are  rare.  They  only  occur  when  the  motor  area  is  involved,  and  are 
not  always  present  then.  When  cerebral  abscess  is  caused  by  cont re-coup  they  are 
the  only  local  signs  that  are  present. 

Diagnosis. — Diffuse  suppurative  menini::;itis  usually  runs  a  much  more  rapid 
course  ;  it  begins  within  a  short  time  of  the  injury,  almost  always  in  the  first  week, 
sometimes  in  forty-eight  hours,  and  is  associated  with  high  fever,  headache, 
delirium,  and  other  signs  of  rapidly-spreading  destruction  of  the  cortex. 

Chronic  tneningitis  is  often  present  as  a  complication  in  cerebral  abscess  ;  by 
itself  it  does  not  give  rise  to  symptoms  of  compression. 

Py(2mia  is  the  most  difficult,  especially  when  it  commences  as  osteophlebitis 
in  the  injured  portion  of  the  cranium.  The  difference  is  merely  in  the  method  of 
extension.  Each  commences,  in  many  cases  at  any  rate,  as  a  purulent  osteitis, 
with  a  soft,  puffy,  and  exceedingly  tender  swelling  upon  the  scalp.  In  the  one, 
the  suppuration  spreads  through  the  contiguous  structures  to  the  membranes  and 
the  brain  beneath,  until  an  abscess  is  formed.  In  the  other  the  veins  of  the  diploe 
and  the  sinuses  are  thrombosed,  and  the  infective  emboli  carried  off  to  cause 
abscesses  elsewhere.  The  local  signs  are  the  same  ;  the  early  constitutional  ones 
present  no  material  difference ;  a  single  rigor  may  occur  in  either  ;  indeed  it  is 
not  until  pyaemia  has  shown  its  presence  by  local  indications  in  other  parts  of  the 
body,  or  by  repeated  shivering  fits,  that  the  diagnosis  is  certain.  The  difficulty 
is  not  so  great  when  cerebral  abscesses  are  dependent  upon  other  causes  than 
disease  of  bone,  but  then,  not  unfrecjuently,  all  l)ut  the  most  general  symptoms 
are  wanting  altogether. 

{b)  Intracranial  Abscess  Due  to  Disease  of  the  Middle  or  Internal  Ear. — 
Nearly  three-fourths  of  these  are  situated  in  the  temporo-sphenoidal  lobe,  and 
many  are  associated  with  a  sloughing  condition  of  the  dura  mater.  The  rest  occur 
in  the  cerebellum,  between  the  dura  and  the  bone,  in  the  pons,  and  occasionally 
in  distant  parts  of  the  brain.  They  never  appear  while  the  inflammation  is  acute  ; 
there  is  always  a  history  of  chronic  purulent  discharge  lasting  for  years,  and  often 
of  its  having  stopped  on  some  previous  occasion  which  was  marked  by  severe  head- 
ache, vomiting,  and  perhaj)S  other  symptoms. 

In  most  instances  two  stages  can  be  distinguished  ;  the  first,  while  the  abscess 
is  slowly  forming,  of  very  indefinite  length  ;  the  second,  that  of  rapid  extension, 
rarely  lasting  more  than  a  week.  The  transition  may  be  gradual,  but  more  often 
it  is  sudden,  caused  by  some  comparatively  trivial  accident,  such  as  a  blow  upon 
the  ear  or  exposure  to  cold  and  wet.      Many  apparently  unaccountable  cases  of 


INTRACRANIAL   SUPPURATION.  669 

fatal  coma  are  explained  in  this  way  ;  an  old  cerebral  abscess,  which  has  already 
lasted  weeks  or  months  without  giving  rise  to  any  definite  symptoms,  suddenly 
giving  way  and  bursting  into  the  ventricular  or  subarachnoid  space. 

The  symptoms  in  the  early  stage  are  vague  and  ill-defined.  There  is  always 
headache,  sometimes  very  severe,  and,  not  unfretiuently,  vomiting  without  any 
apparent  reason,  as  is  usual  in  cerebral  affections  ;  but  in  many,  the  only  sign  is  a 
dull,  sluggish  state  of  mind,  sometimes  uniformly  lethargic,  sometimes,  on  the 
other  hand,  diversified  by  strange  fits  of  irritability,  and,  in  rare  cases,  delirium 
and  convulsions.      Rigors,  pyrexia,  and  optic  neuritis  seldom  occur. 

In  the  acute  stage,  the  symi)toms  present  the  same  general  characters  but  they 
are  infinitely  more  severe.  The  headache  is  of  the  most  intense  description, 
radiating  from  the  ear  and  causing  such  fearful  agony  that  the  patient  can  do 
nothing  but  scream  or  rock  himself  from  side  to  side,  clasping  his  head  in  his 
hands  or  burying  it  in  the  j^illow.  The  lethargy  rapidly  deepens  into  stupor  ; 
there  may  be  an  attack  of  vomiting  or  a  single  rigor,  but  this  is  more  commonly 
associated  with  subdural  abscess  and  thrombosis  of  the  lateral  sinus  ;  the  face  be- 
comes dark  and  cyanosed,  the  respiration  labored  and  stertorous,  and  coma,  with 
or  without  convulsions,  quickly  follows.  Death  usually  takes  place  within  the 
week,  sometimes  within  a  few  hours. 

Diagnosis. — An  accumulation  of  decomposing ///j-, /dv// ///  //;  the  mastoid 
antrum,  may  cause  many  of  the  symptoms  of  cerebral  abscess,  including,  accord- 
ing to  Barker,  double  optic  neuritis.  In  any  case  of  doubt  a  preliminary  explor- 
ation should  be  made,  a  trephine  or  gouge  applied  to  the  outer  wall  half  an  inch 
behind  and  above  the  centre  of  the  external  meatus,  the  cavity  thoroughly  opened 
and  washed  out.  This  difficulty  of  course  only  occurs  in  the  early  period  of  the 
disease,  before  there  are  any  symptoms  of  compression. 

ThfoDibosis  of  the  Lateral  Sinus. — According  to  Pott,  this  is  usually  due  to 
direct  extension  from  the  bone  on  the  posterior  surface  of  the  petrous  part ;  more 
rarely  from  the  mastoid  cells  along  the  vein  of  the  cochlea.  The  clotting  mav  be 
local  or  extend  into  the  other  sinuses  and  down  into  the  jugular  vein.  When  due 
to  osteitis  it  nearly  always  proves  fatal  from  pyaemia.  The  symptoms  resemble  to 
some  extent  those  of  cerebral  abscess,  but  there  is  usually  a  rigor,  or  at  least  a 
very  irregular  temperature  ;  the  pain  is  more  local ;  there  is  a  tendency  to  retract 
the  head  ;  the  neck  is  stiff;  and  occasionally  subcutaneous  oedema  may  be  noted 
over  the  mastoid,  or  the  internal  jugular  vein  can  be  felt  as  a  hardened  cord  in 
the  neck.  Optic  neuritis,  vomiting,  headache,  giddiness,  and  even  coma  may  be 
present  in  these  cases  before  any  clearly  pysemic  symptoms  make  their  appearance. 
Hitherto  these  cases  have  been  regarded  as  practically  hopeless  :  it  has,  however, 
been  shown  by  Ballance  and  others  that  recovery  is  possible  even  after  pyaemic 
symptoms  have  made  their  appearance  in  distant  parts  of  the  body,  if  only  the 
disease  is  treated  thoroughly.  The  mastoid  antrum  must  be  cleared  out  first :  if 
nothing  is  found  in  it  to  account  for  the  symptoms,  or  if,  in  spite  of  this  having 
been  done,  the  pyrexia  and  irregular  temperature  continue,  the  orifice  of  the 
mastoid  vein  (an  inch  and  a  quarter  behind  the  meatus)  should  be  exposed,  and  if 
it  is  thrombosed  a  further  operation  undertaken.  The  jugular  vein  must  be  liga- 
tured in  the  neck ;  the  whole  of  the  dead  bone  between  the  meatus  and  the  wall 
of  the  lateral  sinus  cut  away,  so  that  there  may  be  free  exit  for  the  pus  that  lies 
between  the  membranes  and  the  bone  ;  and  the  cavity  that  is  left,  the  sinus  itself, 
and  the  upper  part  of  the  vein  thoroughly  syringed  out  with  a  solution  of  corrosive 
sublimate. 

Subdural  abscess  may  form  on  the  posterior  surface  of  the  petrous  portion  of 
the  temporal  bone,  or  over  the  roof  of  the  tympanum  close  to  the  squamoso- 
petrosal  suture.  In  the  former  locality  it  is  nearly  always  associated  with  throm- 
bosis of  the  lateral  sinus,  the  pus  spreading  between  the  dura  mater  and  the  bone 
until  it  reaches  the  fibrous  wall  and  so  alters  the  endothelium  that  a  clot  forms 
upon  it.  In  the  latter,  it  may  occur  independently  by  itself.  It  is  very  doubtful, 
w^hen  it  exists  by  itself,  whether  it  can  be  distinguished  from  cerebral  abscess ; 


670    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

rigors  api)ear  to  be  more  common  ;  percussion  over  the  temporal  bone  is  more 
jjainfuland  the  cerebral  symptoms  are  less  distinct  ;  but  the  two  maybe  associated 
together.  The  diagnosis  is  not  perha]js  of  so  much  importance,  as  in  any  case  in 
which  the  symptoms  continued  after  the  mastoid  cells  had  been  cleared  explora- 
tion must  be  continued  in  the  same  direction  :  behind  the  mastoid  process  if  there 
is  any  evidence  of  sinus  throml)Osis,  above  and  slightly  in  front  (so  as  to  expose 
the  anterior  surface  of  the  petrous  part)  if  there  is  not. 

The  diagnosis  of  tlic  locality  of  cerebral  abscess,  when  consecutive  to  osteitis, 
is  equally  difficult.  The  majority  are  situated  in  the  tem])oro-si>henoidal  lobe, 
especially  in  the  case  of  adults  ;  of  the  rest,  most  are  in  the  lateral  lobe  of  the 
cerebellum,  the  others  are  practically  inaccessiljle. 

An  abscess  in  the  temporo-sphenoidal  lobe  does  not  cause  any  localizing 
symptoms  until  it  has  attained  a  very  considerable  size.  As  it  increases,  the  third 
nerve  on  the  same  side  becomes  compressed,  so  that  ptosis,  fixed  mydriasis,  and 
paresis  of  the  ocular  muscles  ensue ;  and  then  the  lower  part  of  the  ascending 
frontal  and  i)arietal  convolutions,  so  that  the  facial  muscles  on  the  opposite  side 
of  the  body  become  paralyzed  (retaining,  however,  some  jjower  of  emotional  ex- 
pression), and  then,  later,  those  of  the  arm.  The  leg  is  never  affected  ;  and 
.sensibility  remains  unimpaired. 

Cerebellar  abscess  is  still  more  indefinite.  It  appears  to  be  relatively  more 
common  in  the  young,  and  there  is  no  doubt  that  it  is  often  associated  with  throm- 
bosis of  the  lateral  sinus.  Severe  occipital  pain,  persistent  vomiting,  and  retraction 
of  the  head  are  suggestive  of  its  presence  ;  but  unless  there  is  definite  evidence  of 
disease  of  the  posterior  surface  of  the  petrous  portion,  exploration  for  cerebellar 
abscess  should  never  be  made  until  the  existence  of  a  temporo-sphenoidal  one  has 
been  excluded. 

Prognosis. — Intra-cranial  suppuration,  whether  traumatic  or  consecutive,  if 
left  to  itself  is  practically  ho])eless.  A  few  cases  have  recovered,  the  former  by  the 
cicatrix  giving  way  so  that  the  pus  was  discharged  externally,  the  latter  owing  to 
the  abscess  becoming  surrounded  by  a  dense  capsule ;  but  the  number  is  very 
small.  Death  may  be  caused  by  compression,  or  by  the  abscess  rupturing  suddenly 
into  the  ventricles.  Occasionally  a  condition  of  marasmus  sets  in  and  proves  fatal 
without  any  definite  reason  ;  and  sometimes  sudden  death  occurs,  as  in  the  case  of 
cerebral  tumors. 

General  Treatment  of  Inflammation  of  the  Brain.  —  i.  Preventive. — If  there 
is  a  wound  no  effort  should  be  spared  to  free  the  surface  from  all  possible  sources 
of  irritation,  whether  mechanical,  such  as  depressed  fragments  of  bone,  or  chemical, 
such  as  the  products  of  decomposition  ;  and  to  secure  perfect  drainage,  so  that 
there  may  be  no  retention  of  lymph  and  no  tension.  In  the  same  way,  if  there  is 
suppuration  in  connection  with  the  middle  ear,  and  the  membrana  tympani  is 
bulged  outward  by  a  quantity  of  opacjue  white  pus,  it  should  be  incised  from  top 
to  bottom  behind  the  malleus,  and  transversely  below  it,  and  the  cavity  thoroughly 
drained.  Still  more  is  this  necessary  if  the  disease  has  already  involved  the  bone, 
so  that  a  foul  collection  of  decomposing  jjus  lies  buried  behind  the  meatus. 

If  there  is  no  wound,  but  merely  a  history  of  a  severe  blow  upon  the  head, 
followed  perhaps  by  symjttoms  of  concussion  or  contusion  of  the  brain,  absolute 
rest  must  be  enforced.  Everything  that  causes  hyperemia  of  the  brain — mental 
exertion,  excitement,  want  of  rest,  stimulants,  even  conversation — is  injurious,  and 
tends  to  delay  recovery.  The  head  should  be  shaved,  cold  applied,  the  room 
darkened,  the  bowels  thoroughly  opened  (preferably  with  calomel)  and  only  the 
lightest  diet  allowed  ;  nor  should  any  precaution  be  omitted  until  a  sufficient  time 
has  elapsed  for  the  extravasated  blood  to  become  absorbed  and  the  damaged  tissue 
repaired.  In  other  jjarts  of  the  body  this  often  takes  a  fortnight  or  three  weeks  : 
and  there  is  no  proof  that  a  shorter  time  is  required  in  the  case  of  the  brain. 

2.  Curative. — {a)  Acute  Inflammation. — If,  in  spite  of  this,  the  symjjtoms  of 
acute  inflammation,  the  headache,  pyrexia,  and  delirium,  grow  wor.se,  leeches  may 
be  applied  behind  the  ears  ;  venesection  may  be  tried  ;  the  calomel  may  be  repeated 


INTRACRANIAL   SUPPURATION.  671 

so  as  to  produce  copious  evacuation,  and  if  there  is  great  excitement  small  doses 
of  opium,  or,  better,  bromide  of  potassium  and  chloral,  may  be  given  ;  but  if  the 
inflammation  is  general,  if  no  local  cause  can  be  found  and  removed,  there  is  very 
little  hope  ;  it  is  almost  sure  to  run  on  to  diffuse  suppuration. 

{b)  Chronic  Intlainiiiation. — The  treatment  clei)ends  upon  whether  a  local 
cause  can  be  found  or  not.  If  there  is  a  tender  spot  on  the  bone  corresponding 
to  an  old  injury,  or  a  depression,  or  a  suspicion  of  some  alteration  on  the  inner 
surface,  such  as  splintering  of  the  inner  table,  thickening  of  the  dura  mater,  or 
the  formation  of  a  cyst  in  the  arachnoid,  the  cicatrix  should  be  reopened,  the  peri- 
osteum reflected,  and  a  circle  of  bone  removed  with  the  trephine.  If  nothing  is 
found  to  account  for  the  symptoms,  the  dura  mater  should  be  examined  too  and 
incised  ;  and  if  the  brain  projects  upward  into  the  wound,  indicating  a  certain 
amount  of  pressure,  it  should  be  explored  with  a  grooved  needle  or  a  fine  trocar 
and  cannula.  Possibly  there  may  be  a  chronic  abscess  or  a  cyst.  If  nothing  is 
discovered,  the  dura  mater  should  be  readjusted,  sutured  or  not,  according  to  the 
size  of  the  opening,  and  the  bone,  provided  it  is  not  thickened  or  sclerosed,  re- 
placed again. 

Where  there  are  no  local  symptoms,  but  merely,  instead  of  perfect  conva- 
lescence, a  condition  of  irritability,  excitement,  or  headache,  great  relief  may  be 
obtained  by  counter-irritation,  blisters,  and  even  setons.  Mercury  pushed  to 
salivation  has  been  strongly  recommended  ;  iodide  of  potash  is  also  said  to  have 
been  of  service  ;  but  probably  most  reliance  must  be  placed  upon  the  effect  of 
time  and  perfect  rest.  Change  of  air  and  scene,  and  the  avoidance  of  everything 
that  can  cause  cerebral  hyperc'emia,  naturally  suggest  themselves,  and,  of  course, 
special  attention  should  be  paid  to  the  presence  of  any  diathesis,  such  as  syphilis 
or  gout. 

{c)  Iiitracranial  suppuration  can  only  be  treated  by  operation.  The  diffuse 
form  in  which  the  whole  surface  of  one  hemisphere  is  covered  over  with  a  layer  of 
pus,  dipping  down  into  the  sulci  and  sheathing  all  the  vessels,  is  practically  beyond 
reach.     The  localized  one  requires  trephining. 

///  traumatic  cases  there  can  be  no  question.  Except  in  those  rare  instances 
in  which  the  abscess  has  developed  as  a  result  of  contre-coup  (and  they  rarely 
admit  of  diagnosis),  an  exploratory  operation  should  be  performed  at  the  seat  of 
injury  ;  and  when  the  brain  is  exposed,  if  the  cause  still  remains  undiscovered,  a 
grooved  needle  should  be  thrust  into  it  in  all  directions.  Many  cases  have  been 
relieved  in  this  way,  some  temporarily,  the  immediate  symptoms  of  compression 
passing  away,  so  that  the  patient  recovered  consciousness  and  the  pulse  regained 
its  vigor  (I  have,  on  several  occasions,  seen  all  the  vessels  in  the  scalp  begin  to 
spirt  as  soon  as  the  tension  was  relieved)  ;  others  permanently,  recovery  having 
been  complete. 

The  same  thing  holds  good  with  regard  to  cases  that  are  consecutive  to  middle 
ear  disease,  but  the  difficulty  is  much  greater.  Other  affections,  especially  throm- 
bosis of  the  lateral  sinus  and  pyaemia,  are  caused  in  the  same  way  and  give  rise 
to  very  much  the  same  symptoms  ;  and  even  when  these  are  excluded  there  is 
often  no  definite  evidence  as  to  locality.  In  all  such  the  mastoid  antrum  should 
be  thoroughly  explored  first,  and  a  free  communication  established  between  it  and 
the  external  auditory  meatus  ;  in  many  instances  relief  is  obtained  at  once  by  this, 
the  incipient  meningitis,  which  is  probably  the  cause  of  the  cerebral  symptoms, 
subsiding  as  soon  as  the  cause  is  removed.  If  this  does  not  succeed,  or  if  no 
evidence  of  accumulated  pus  is  found,  the  exploration  must  be  carried  further. 
Whether  it  should  be  made  half  an  inch  above  and  slightly  in  front  of  the  meatus, 
so  as  to  expose  the  anterior  surface  of  the  petrous  portion,  or  behind  and  on  the 
same  level,  must  be  guided  by  what  is  known  of  the  condition  of  the  sinus.  In 
either  case,  the  exit  must  be  as  free  as  possible,  not  only  for  the  pus  in  the  brain, 
but  for  all  the  gangrenous  shreds  of  dura  mater. 

In  all  cases  the  orifice  of  the  mastoid  vein  must  be  exposed  first.  If  this 
gives  no  evidence  of  thrombosis,  and  there  is  no  other  sign,  the  anterior  operation 


672     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

should  be  selected,  the  under  surface  of  the  temporo-sphenoidal  lobe  exposed,  and, 
if  there  is  no  extra-dural  collection  of  pus,  thorouglily  explored  with  a  grooved 
needle.  If,  on  the  other  hand,  there  is  any  symptom  pointing  to  the  sinus,  the 
bone  should  be  removed  from  l)ehind  the  meatus  ;  and  if  an  extra-dural  abscess 
and  septic  thrombosis  are  found,  the  jugular  vein  shoukl  be  ligatured  too.  The 
only  hope  lies  in  thoroughly  clearing  out  the  clot  and  removing  the  whole  focus 
of  disea.se. 

If  no  abscess  is  found  in  the  anterior  operation,  either  between  the  dura 
mater  and  the  bone,  or  in  the  substance  of  the  brain,  and  there  is  no  evidence  of 
thrombosis,  even  when  the  mastoid  vein  is  exposed,  the  periosteum  and  the  muscular 
attachments  must  be  separated  from  the  occipital  bone  beneath  the  superior  curved 
line,  and  the  lateral  lol)e  of  the  cerel)ellum  explored.  In  many  cases  of  cerebellar 
abscess,  however,  there  is  sinus  thrombosis  as  well,  and  there  must  always  be  con- 
siderable danger  of  one  of  the  two  being  overlooked  if  the  other  is  found. 


Hernia  Cerebri. 

Hernia  cerebri  is  a  protru.sion  through  an  opening  in  the  cranium  of  brain 
substance  that  has  been  softened  by  inflammation  ;  and  it  is  caused  by  the  differ- 
ence between  the  external  and  the  internal  pressure. 

When  a  portion  of  the  brain  is  excised  the  cavity  fills  almost  at  once,  and 
the  edges  of  the  incision  become  everted.  If  the  seal])  is  laid  down  again,  and 
union  takes  place  by  the  first  intention  (protection  being  afforded  in  the  meantime 
by  the  dressings),  the  outside  tension  is  restored  and  there  is  merely  a  slight  sink- 
ing inward,  corresponding  to  the  amount  of  tissue  removed.  (Sometimes,  when, 
for  example,  the  loss  has  been  very  great,  and  the  walls  cannot  fall  in,  a  serous 
cyst  forms  to  fill  up.)  If,  on  the  other  hand,  inflammation  sets  in  instead  of 
repair,  the  brain  tissue  becomes  softened,  the  intracranial  tension  rises  higher  and 
higher,  and  either  symptoms  of  compression  follow,  or  the  pulpy  brain  substance 
is  s(]ueezed  out  through  the  opening. 

The  defect  in  the  cranial  walls  may  be  caused  by  injury  (compound  fractures 
wounding  the  membranes),  or  by  necrosis,  syphilitic  or  otherwise,  causing  gradual 
softening  of  the  dura  mater. 

The  inflammation  of  the  brain  may  be  produced  by  any  of  the  causes  already 
mentioned  (the  area  of  red  softening,  for  example,  that  exists  round  a  rapidly 
growing  tumor  might  lead  to  the  development  of  a  hernia  after  excision)  ;  but 
inasmuch  as  nearly  all  the  ca.ses  of  inflammation  that  coexist  with  an  opening  in 

the  cranium  are  due  to  decomposition 
of  the  extravasated  blood  and  end  in 
suppuration,  hernia  cerebri  is  almost 
always  regarded  as  the  product  of  sup- 
jjurative  meningitis.  The  protrusion, 
in  cases  of  injury,  consists  at  first  of 
extrava.sated  blood  mixed  with  inflam- 
matory exudation  ;  later  of  the  latter 
with  a  varying  proi)ortion  of  softened 
and  broken  down  brain  tissue.  In 
cases  of  necrosis  the  first  layer  natu- 
rally is  wanting.  .Xs  the  tension  in- 
creases and  the  process  of  softening 
extends,  more  and  more  of  the  under- 
lying brain  tissue  is  forced  out,  until 
sometimes,  if  the  i)rotrusion  is  sliced 
off,  the  cavity  of  one  of  the  ventricles 
is  laid  open. 
It  is  more  frequent  in  the  young  than  in  the  old  ;  in  the  frontal  than  in  the 
parietal  region  ;  and  it  is  more  likely  to   occur  when  the  opening  is  small  than 


Fig.  292. — Hernia  Cerebri. 


INTRACRANIAL   TUMORS.  673 

when  the  cranial  bones  are  extensively  comminuted.  The  appearance  is  unmis- 
takable. 'Inhere  is  a  soft,  dark-brown  mass,  covered  over  with  lymph  or  pus, 
bleeding  at  the  slightest  touch,  and  ])ulsating  synchronously  with  the  brain.  It 
may  grow  rapidly,  becoming  more  and  more  oedematous  as  it  protrudes  from  a 
narrow  opening,  or  the  increase  may  be  very  slow;  and  after  a  time  it  may  cease 
altogether,  shrink  back  of  itself,  and  skin  over.  Recovery  may  take  place  even 
after  large  mas.ses  have  sloughed  away,  the  space  left  in  the  cranium  being  filled 
with  clear  serous  fluid  ;   more  frequently  the  meningitis  proves  fatal. 

Hernia  cerebri  is  always  the  result  of  inflammation  ;  if  this  is  local  and  cir- 
cumscribed, and  the  products  can  escape  freely,  the  hernia  gradually  sinks  back 
and  skins  over  ;  if  it  is  diffuse,  nothing  is  of  much  avail.  An  ice-bag  must  be 
laid  upon  the  head,  and  the  ordinary  treatment  adopted  for  inflammation  of  the 
brain.  The  protrusion  itself  must  be  kept  perfectly  clean  ;  it  is  no  use  either 
applying  pressure  or  shaving  it  off.   The  prognosis  depends  upon  the  inflammation. 

Intracranial  Tumors. 

In  1884,  relying  entirely  upon  the  clinical  evidence  of  a  focal  lesion,  Godlee 
exposed  the  surface  of  the  brain  and  removed  a  tumor  from  beneath  the  cortex. 
Since  then  the  same  operation  has  been  performed  on  many  occasions  by  MacEwen, 
Horsley,  and  others  with  very  considerable  success.  Unhappily  the  conditions  are 
so  stringent  that  the  proportion  of  cases  in  which  relief  by  operation  is  possible  is 
very  small.  Localization  must  be  exact ;  the  site  must  be  accessible  ;  the  size  of 
the  tumor  must  not  be  too  great,  or  the  lesion  left  may  be  practically  as  bad  ;  and 
there  must  be  no  other  growth  or  disease.  Success  is  naturally  more  probable 
when  the  tumor  is  surrounded  by  a  capsule  than  when  it  is  of  an  infiltrating  nature, 
but  this  it  is  rarely  possible  to  determine  beforehand. 

The  tumors  that  are  grouped  together  under  this  class  may  grow  from  the 
bones,  the  membranes,  or  the  brain.  Some  are  primary,  others  secondary,  the 
original  lesion  occurring  elsewhere. 

{a)  In  Connection  with  the  Bones. — Tumors  (other  than  syphilitic  or  inflam- 
matory outgrowths)  springing  from  the  inner  surface  of  the  inner  table  of  the 
skull  are  very  rare.  Myeloid  sarcoma  is  not  uncommon  in  the  diploe,  and  ivory 
exostoses  may  grow  from  the  frontal  or  other  sinuses  ;  and  both  of  these  may  cause 
a  very  serious  inward  projection  of  the  bone  ;  but  they  usually  admit  of  speedy 
recognition  from  the  exterior,  and  in  any  case  require  to  be  dealt  with  on  their 
own  merits. 

(J))  In  Connection  with  the  Membranes . — Fibromata  have  been  described  in 
connection  with  the  dura  mater.  Sarcomata  are  rather  more  common,  sometimes 
causing  absorption  of  the  bone  lying  over  them  (the  so-called  fungus  of  the  dura 
mater),  and  seriously  compressing,  but  not  invading,  the  brain  beneath.  Cysts, 
possibly  originating  in  old  extravasations,  are  met  with  from  time  to  time  in  the 
arachnoid  cavity,  sometimes  free,  sometimes  attached  ;  hydatids  have  been  known 
to  occur ;  and  occasionally  other  tumors,  plexiform  angeio-sarcoma  or  endothe- 
lioma (in  which  the  walls  of  the  vessels  appear  as  if  they  were  converted  into 
sarcoma  tissue),  psammoma,  cholesteatoma,  etc.,  of  little  clinical  importance. 

{c)  In  the  Brain. — Three-fourths  of  the  tumors  that  occur  in  the  substance  of 
the  brain  are  either  gummata  or  caseous  masses  of  tuberculous  material.  The 
former,  which  nearly  always  occur  in  connection  with  the  membranes  or  the  vessels 
as  they  dip  through  the  cortex,  are  very  irregular  in  shape  and  size,  and  usually 
present  on  section  surface  marked  by  spots  of  caseation  separated  from  each  other 
by  firmer  tracts  of  fibrous  tissue.  So  long  as  they  are  spreading,  the  surrounding 
brain-tissue  is  softened  and  hyperaemic  ;  after  absorption  there  is  merely  a  dense, 
indurated,  star-like  cicatrix,  tying  the  brain  down  to  the  membranes,  and  spread- 
ing in  its  substance  in  all  directions. 

Tubercular  masses,  on  the  other  hand,  are  usually  rounded  and  uniform  in 
shape,  and  opaque  and  cheesy  on  section.     Around  them,  so  long  as  they  are 


674     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

spreading  (and  they  may  attain  the  size  of  a  pigeon's  egg)  is  a  zone  of  gray  granula- 
tions, spreading  along  the  vessels  ;  later  they  may  soften  and  form  a  caseous 
abscess,  or  develop  into  fibrous  tissue,  or  dry  up  and  undergo  calcification. 
Naturally  they  are  more  common  in  the  young,  while  gummata  are  generally  met 
with  in  adult  life.  In  many  cases  they  are  multiple  (more  than  half,  according  to 
Gowers),  and  not  unfrecpiently  are  associated  with  tubercular  disease  of  the  mem- 
branes and  other  organs. 

Gliomata  are  the  next  most  common.  They  are  composed  of  tissue  resem- 
bling to  some  extent  the  neuroglia  of  the  brain,  but  they  vary  very  much  in 
consistence,  and  the  softer  ones  are  often  stained  with  old  and  recent  extravasa- 
tions. They  differ  from  the  former  and  from  other  kinds  of  sarcomata  in  their 
infiltrating  character,  spreading  among  the  nerve  elements  without  any  defined 
outline. 

Other  forms  of  sarcoma  are  more  rare.  Carcinoma  has  been  described  as  a 
primary  affection  of  the  brain,  and  occasionally  other  tumors  and  deposits  of 
actinomycosis. 

Dermoid  cysts  have  been  known  to  occur,  sometimes  projecting  on  the 
exterior  of  the  cranium  through  the  bone.  Hydatids  and  cysticerci  are  occa- 
sionally found  both  in  connection  with  the  membranes  and  the  brain.  Most  of 
the  serous  cysts  that  have  been  described  have  originated  in  all  probability  either 
in  the  interior  of  sarcomata  or  in  connection  with  old  injuries  and  extravasations. 

Symptoms. — Some  of  these  are  general,  occurring  more  or  less  with  all 
tumors,  whatever  position  they  occupy  inside  the  cranium  ;  others  are  localizing 
and  are  only  present  when  certain  parts  are  involved. 

{a)  Headache,  due  in  great  measure  to  the  tension  upon  the  fibrous  struc- 
tures;  vomiting,  apparently  without  cause  or  object,  and  especially  on  waking; 
vertigo  on  suddenly  rising  up  ;  optic  neuritis  ;  mental  dullness,  and  lethargy  are 
the  most  prominent  and  the  most  constant  among  the  former.  For  a  full  account, 
special  works,  such  as  those  by  Gowers  and  Bramwell,  must  be  consulted. 

{b)  These  may  be  due  to  interference  with  the  cortex,  the  conducting  paths, 
the  nerves,  or  the  walls.  The  more  rapid  the  growth  and  the  greater  the  amount 
of  irritation  and  inflammation  it  causes  in  the  tissues  around  it,  the  more  distinct 
they  are. 

Lesions  of  the  cortex  may  lead  to  perversion  or  abolition  of  its  function.  If 
the  part  involved  is  motor  there  may  be  localized  epileptiform  convulsions  (the 
most  valuable  sign  of  all),  followed  by  loss  of  power  in  the  muscles  most  concerned, 
without  any  loss  of  consciousness.  Nearly  always  this  is  due  to  some  coarse  lesion, 
and  most  often  a  tumor.  Greater  pressure  causes  paralysis  at  once,  extending  in 
a  definite  order.  When  the  part  is  not  a  motor  one,  the  indications  are  much  less 
distinct  ;  but  as  mind-blindness  has  been  caused  by  a  spicule  of  bone  driven  into 
the  angular  gyrus  and  has  been  cured  by  its  removal,  it  is  possible  that  similar 
evidence  may  be  obtained  of  the  growth  of  a  tumor.  The  presence  of  a  visual 
aura  at  the  same  time  would  render  this  much  more  probable. 

Lesions  of  the  conducting  paths  are  attended  in  the  same  way  by  abolition  or 
perversion  of  function  ;  but  in  this  case  the  former  (manifested  as  paralysis  or  an- 
aesthesia, according  to  the  part  involved,  without  any  sign  of  irritation)  is  much 
the  more  prominent.  If  the  internal  capsule  is  concerned  there  may  be 
hemianaesthesia  or  hemiplegia  ;  if  the  lesion  is  lower,  mixed  or  irregular  forms,  the 
muscles  that  are  paralyzed  on  the  same  side  as  the  lesion  becoming  atrophied  and 
exhibiting  the  reactions  of  degeneration.  If  the  paralysis  is  incomplete,  and  jjar- 
ticularly  if  it  is  variable,  there  may  be  only  pressure  on  the  fibres  without  destruc- 
tion ;  but  unless  this  can  be  clearly  proved  to  be  the  case,  it  is  very  improbable 
that  the  lesion  is  within  reach,  or  if  it  is,  that  it  is  not  too  large. 

Pres.sure  upon  the  cranial  nerves  is  often  of  great  value  in  localization  :  neu- 
ralgia of  all  the  branches  of  the  fifth  pair  upon  one  side,  for  example,  or  anaesthesia 
limited  to  the  same  region,  pointing  definitely  to  intracanial  pressure  upon  the 
trunk  before  its  division. 


INTRACRANIAL   TUMORS.  675 

Affections  of  the  walls  have  been  already  mentioned  ;  they  are  rarely  present 
when  the  growth  originates  in  the  brain,  until,  that  is  to  say,  it  has  attained  a  size 
that  precludes  interference. 

Diagnosis. — Bright's  disease  and  advanced  forms  of  lead  i>oisoning  may  both 
be  attendctl  hv  ojitic  neuritis,  vomiting,  headache,  and  convulsions.  Anaemia  and 
hypermetropia  occurring  together  may  occasion  a  momentary  difficulty,  a  slight 
degree  ofoi)tic  neuritis  and  sometimes  other  symptoms  being  met  with  under  these 
conditions  ;  but  the  presence  of  a  disorder  connected  with  vision  and  the  absence 
of  localizing  symptoms  are  usually  sufficient.  It  is  not  so  easy  with  paroxysmal 
hemicrania,  especially  when  it  is  associated  with  hysteria,  for  the  pre.sence  of  one 
disease  is  not  absolute  proof  that  there  is  no  other.  Cerebral  or  cerebellar  abscess 
very  rarely  occurs  without  a  history  of  injury  or  evidence  of  diseased  bone. 
Localized  meningitis  cannot  always  be  distinguished,  as  it  is  present  in  many  forms 
of  tumor,  especially  syphilitic  and  tubercular  ones,  and  furnishes  some  of  the 
symptoms  upon  which  the  diagnosis  rests. 

The  diagnosis  of  the  kind  of  tumor  is  much  more  difficult.  Age,  as  already 
mentioned,  is  of  importance,  but  at  the  best  it  only  indicates  a  slight  degree  of 
probability.  Definite  evidence,  either  from  the  history  or  from  lesions  in  other 
parts  of  the  body,  of  a  syphilitic  or  tubercular  diathesis  is  very  significant,  and 
should  influence  the  line  of  treatment  very  materially,  but  it  cannot  be  regarded  as 
conclusive.  Pseudo-apoplectic  attacks  are  more  common  in  connection  with  glio- 
mata  and  gummata  than  with  other  forms.  A  positive  diagnosis,  however, 
especially  in  the  early  stages,  is  very  often  out  of  the  question. 

Prognosis. — Syphilitic  gummata  may  be  absorbed,  and  all  the  symptoms 
disappear,  if  only  the  treatment  is  commenced  sufficiently  soon  and  carried  out 
consistently.  If  they  have  already  caused  extensive  destruction  of  the  nerve-tissue 
around,  that  of  course  cannot  be  replaced  ;  and  it  is  possible  that  the  cicatrix  left, 
dragging  upon  the  brain  and  anchoring  it  to  the  membrane,  may  sometimes  of 
itself  lead  to  serious  after  trouble.  It  is  probable,  too,  that  tubercular  masses  are 
sometimes  absorbed  or  dried  up  ;  certainly  they  not  unfrequently  remain  latent  for 
long  periods,  but  there  is  not  nearly  the  same  degree  of  control  over  them.  Other 
tumors  pursue  their  course  relentlessly,  sometimes  leading  to  coma  and  compression, 
or  destroying  life  by  the  intensity  of  the  pain  that  accompanies  them,  sometimes 
leading  to  a  condition  of  marasmus,  or  suddenly  causing  death  by  interfering  with 
the  respiratory  centre  in  the  medulla. 

Treatment. — From  what  has  been  already  said  it  is  clear  that,  except  in  the 
case  of  gummata  and  some  tuberculous  masses,  there  is  little  or  no  hope  for 
diseases  of  this  class  except  in  operation  ;  and  that  even  then  the  proportion  in 
Avhich  this  is  practicable  is  a  very  small  one.  Nor  is  there  much  prospect  that, 
with  only  our  present  methods  of  investigation,  it  will  be  materially  increased  ;  for 
the  difficulty  does  not  arise  so  much  from  the  size  of  the  tumor  (although  this  has 
occurred)  as  from  the  impossibility  either  of  localizing  it  or  of  gaining  access  to  it. 
If  the  conditions  are  favorable,  and  it  is  decided  to  make  the  attempt,  the  direc- 
tions given  by  Horsley  should  be  followed. 

The  head  should  be  shaved,  washed  with  soft  soap  and  ether,  and  thoroughly 
purified  wdth  an  antiseptic,  the  site  of  the  lesion  having  first  been  ascertained  by 
measurement  and  definitely  marked.  A  quarter  of  a  grain  of  morphia  is  given 
before  the  operation,  and  the  anaesthetic  used  is  chloroform.  This  has  the  great 
advantage  of  causing  contraction  of  the  cerebral  arterioles  and  so  diminishing  the 
amount  of  bleeding ;  but  very  great  care  is  required  in  the  management  of  the 
anaesthetic,  and  a  very  small  quantity  should.be  given. 

The  flap  reflected  must  be  of  sufficient  size,  carried  right  down  to  the  bone  at 
once,  so  as  to  bring  the  periosteum  with  it,  and  so  arranged  that  while  its  main 
blood-vessels  are  kept  intact,  dependent  openings  are  left  for  drainage.  The  bone 
is  most  easily  removed  by  taking  out  an  inch  disc  with  a  trephine  to  learn  the 
thickness,  and  then  cutting  out  the  piece  required  with  a  circular  saw  mounted  on 
a  surgical  engine,  the  separation  being  completed  with  bone-forceps  •  or  two  tre- 


676    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


])hine  openings  may  be  made,  one  at  each  end  of  the  exposed  area,  and  the  inter- 
vening tissues  divided  with  Hey's  saw.  All  the  fragments  should  be  carefully  jjre- 
served  between  warm  carbolic  sponges  or  in  a  warm  dilute  carbolic  solution,  for 
reimplantation. 

[The  osteo-plastic  resection  is  preferable  in  most  cases,  because  by  this 
method  the  bone  disc  is  preserved.] 

The  natural  color  of  the  healthy  dura  mater 
is  difficult  to  describe.  The  fibres  of  which  it  is 
composed  run  in  coarse  interlacing  bundles,  so 
that  its  surface  is  irregularly  fasciculated  ;  and 
showing  up  through  them  more  or  less  distinctly 
is  the  purplish  tint  of  the  vascular  brain.  In 
cases  of  tumor  it  is  sometimes  reddened  and  vas- 
cular itself,  at  others  adherent  to  the  growth  be- 
neath and  more  yellow.  The  line  of  incision 
should  run  round  four-fifths  of  the  circumference 
of  the  area  exposed,  at  one-eighth  inch  distance 
from  the  margin  of  the  bone,  so  that  the  edges 
can  be  stitched  together  afterward.  The  main 
branches  of  the  meningeal  artery,  if  they  lie  in  the 
line  of  the  incision,  should  be  secured  by  ligature 
before  division.  Adherent  portions  of  the  dura 
mater  must  be  removed. 

In  cases  of  cerebral  tumor,  in  which  there  is 
F.G.  293.-Osteopiastic  Resection,  showing  i^^^^^^^d  intracranial  tension,  the  brain  protrudes 
Scalp  with  Bone  Flap.   (After  Esmarch.)  into  the  wound  as  soon  as  the  dura  is  divided.    If 

the  growth  does  not  occupy  the  surface,  an  attempt 
must  be  made  to  ascertain  its  position  by  the  difference  in  color  or  consistence  of 
the  parts  of  the  cortex  exposed.  Horsley  suggests  that  particular  attention  should 
be  paid  to  the  presence  of  any  white  i)atches  along  the  course  of  the  cerebral 
vessels,  as  indicating  old  mischief.  In  several  cases  an  exploratory  incision  into 
the  substance  of  the  cortex  has  been  necessary. 

The  arteries  that  supply  the  brain  are  terminal,  so  that,  where  it  is  jjossible, 
every  main  vessel  should  be  left  intact;  but,  as  Horsley  points  out,  they  can  some- 
times be  raised  from  the  surface  of  the  brain  and  even  drawn  out  of  the  sulci 
without  inflicting  irreparable  damage  upon  them. 

The  incisions  through  the  cortex  must  be  exactly  vertical,  directed  into 
the  corona  radiata,  avoiding,  as  far  as  possible,  any  injury  to  other  fibres,  those, 
for  example,  running  toward  the  internal  capsule.  The  gaj)  left  by  removal 
of  a  portion  of  brain  fills  up  at  once,  the  corona  radiata  bulging  ujiward  and 
the  cut  edges  becoming  slightly  everted  ;  so  that,  owing  to  the  mechanical  rela- 
tions between  the  brain  and  the  skull,  there  is  normally  a  tendency  to  hernia 
cerebri. 

The  edges  of  the  dura  mater  are  accurately  secured  by  silk  and  horsehair 
sutures.  In  his  earlier  operations,  Horsley  used  a  drainage-tube  for  twenty-four 
hours  :  later,  he  discarded  this,  and  merely  leaves  one  inch,  unsecured,  at  the  most 
dependent  part. 

The  fragments  of  bone  should  be  replaced  ///  situ  in  a  kind  of  mosaic  :  tjiere 
is  no  question  as  to  their  vitality  being  retained  or  their  power  of  contracting  ad- 
hesions to  the  pericranium  above  and  the  dura  mater  below  ;  and  so  far  there  is  no 
doubt  they  add  greatly  to  the  security  of  the  flap  ;  but  it  is  not  certain  how  far 
there  is  any  production  of  new  bone. 

Horsley  follows  Lister's  principles  strictly,  making  use  of  the  carbolic  spray 
and  carbolic  gauze.  At  the  end  of  five  or  six  days  the  wound  is  covered  with 
powdered  boracic  acid,  cotton-wool,  and  collodion.  The  scalp  usually  tends  to 
fall  in  a  little  at  the  seat  of  the  operation,  but  the  cicatrix  becomes  exceedingly 
strong. 


TREPHINING. 


G-n 


Trephining. 

Trephining  is  performed  either  as  a  precaution  to  prevent  irritation  and  in- 
flammation of  the  dura  mater  by  fragments  of  bone  and  to  secure  thorough 
cleansing,  or  to  procure  relief  from  symptoms  that  are  already  ])resent.  In  the 
former  case,  the  prognosis,  so  far  as  the  operation  is  concerned,  is  exceedingly 
good  ;  in  the  latter,  it  can  scarcely  be  said  to  add  very  much  to  the  risk.  If,  for 
example,  there  is  compression  of  the  brain,  whether  it  arises  from  extravasation 
of  blood,  from  pus,  or  from  the  presence  of  a  new  growth,  or  if  a  bullet  has 
traversed  the  l)rain,  and  fissured  the  opposite  side  of  the  skull,  or  if  insanity  or 
ei)ilepsy  follows  an  injury  to  the  head,  trephining  may  be  the  only  chance  of  afford- 
ing relief;  but  when  done  under  such  circumstances  as  these,  for  the  removal  of  a 
condition  that  has  almost  proved  fatal  already,  it  ought  not  to  receive  the  whole 
blame  of  the  result. 

The  bone  is  exposed  either  by  enlarging  the  original  wound  or  by  reflecting 
a  flap  of  skin  in  such  a  direction  as  to  secure  a  dependent  opening  for  drainage 
(when  the  patient  is  lying  down)  without  endangering  the  blood-supply.  The 
pericranium  is  best  preserved  by  reflecting  it  in  the  flap,  laying  the  bone  bare  at 
once.  In  most  cases  where  mere  elevation  is  required,  enough  may  be  accom- 
plished by  sawing  off  a  projecting  angle  or  cutting  a  channel  with  Hoffman's 
gouge-forceps  without  actually  using  the  trephine.  If,  however,  the  original  open- 
ing in  the  bone  is  not  large  enough  for  this,  a  portion  must  be  removed  to  begin 
with.  The  centre  pin  of  the  instrument  is  screwed  tight  so  as  to  project  a  little 
below  the  edge  of  the  crown,  and  placed  upon  the  centre  of  the  part  that  is  to  be 
cut  away.  Then  it  is  worked,  with  alternate  pronation  and  supination,  until  a 
groove  is  cut  in  the  bone  sufficiently  deep  to  prevent  slipping.  As  soon  as  this  is 
done,  the  pin  is  withdrawn  to  avoid  injury  to  the  membranes.  The  external  table 
is  exceedingly  hard  to  saw  ;  the  diploe,  o-n  the  other  hand,  gives  way  with  ease, 
and  as  soon  as  this  is  reached  the  groove  becomes  filled  with  soft  debris  mixed 
with  blood.  The  inner  table,  again,  is  harder,  but  it  is  generally  possible,  when 
this  is  partially  sawn  through,  to  detach  the  circle  by  gently  rocking  the  trephine 
from  side  to  side,  or  by  means  of  an  elevator.  It  must,  of  course,  be  recollected 
that  the  skull  is  not  of  the  same  thickness  all  over  ;  that  in  some  places  the  di];Ioe 
is  wanting,  and  also  that,  owing  to  the  curves  of  the 
vault,  one  part  is  usually  sawn  through  before  another. 
It  is  advisable,  therefore,  to  test  the  depth  of  the 
groove  from  time  to  time  with  the  flat  end  of  a  probe 
or  with  a  toothpick,  so  as  to  be  sure  of  the  progress 
made  ;  and  unless  it  is  done  intentionally,  the  region 
of  the  sinuses  and  the  course  of  the  middle  meningeal 
artery  should  be  avoided.  If  larger  portions  of  bone 
have  to  be  removed,  so  as  to  expose  a  considerable 
surface  of  the  cortex,  a  trephine  fixed  to  a  carpen- 
ter's brace,  or  to  a  surgical  engine,  may  be  em- 
ployed. When  the  first  opening  has  been  made,  it 
can  be  enlarged  in  any  required  direction,  either  by 
means  of  Hey's  saws  or  by  the  gouge-forceps. 

The  bone  removed  should  be  kept  warm  in  a  weak 
solution  of  carbolic  acid  and  replaced,  either  bodily 
or  after  being  broken  up.  In  many  instances,  where 
the  periosteum  has  been  laid  over  it  again  and  the 
dura  mater  is  not  sunken  down,  the  vitality  of  the 
bones  has  been  retained,  and  it  has  contracted  adhe- 
sions to  the  parts  near. 

When  it  is  a  mere  question  of  removing  splinters,  and  the  dura  mater  has 
not  been  cut,  the  flaps  are  replaced  and  the  wound  sewn  up  (after  being 
thoroughly  washed    out  with   corrosive  sublimate    solution)   except  at  its   most 


Fig.  294. 


678    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

dependent  i)art.  (ieiierally  a  drainage-tube  is  unnecessary,  unless  there  has  been 
a  great  deal  of  bruising,  or  the  cavity  of  an  abscess  has  been  laid  open,  so  that 
union  by  the  first  intention  is  improbable.  If  the  dura  mater  is  incised  to  any 
extent,  it  should  be  thrown  downward  in  a  flap,  as  recommended  by  Horsley, 
rather  smaller  than  the  opening  in  the  bone,  in  order  that,  when  rej^Iaced,  it  may 
be  readily  fixed  by  sutures,  and  thus  helj)  to  maintain  the  cerebral  pressure  until 
union  is  complete,  and  avoid  the  risk  of  hernia  cerebri. 

[Prof.  Senn,  in  common  with  most  German  surgeons,  prefers  the  chisel  and 
mallet  to  the  trephine.] 

Cerebral   Localiz.ation. 

An  elaborate  description  of  the  relation  between  the  surface  of  the  scalp  and 
the  cerebral  convolutions  would  be  out  of  place  in  a  work  of  this  kind  ;  a  fiiU  ac- 
count may  be  found  in  the  papers  by  Reid,  Hare,  Anderson,  Makins,  and  others  ; 
still,  a  few  general  statements  are  almost  necessary.  It  must  be  premised  that 
anything  like  mathematical  accuracy  is  utterly  out   of  the  question  ;   to  say  noth- 


FiG.  295. — The  Relation  of  the  Sutures  and  the  Chief  Points  on  the  Skull  to  the  Cerebral  Convolutions. 
The  vertical  depth  of  the  teniporo-sphenoidal  lobe  is  unusually  great  for  an  adult. 


ing  of  the  differences  at  different  ages  and  in  different  types,  the  same  rules  often 
will  not  hold  good  in  more  than  a  general  way  for  the  two  sides  of  the  same 
head. 

The  fixed  points  of  chief  value  are  the  glal)ella,  the  inion,  the  external  angle 
of  the  orbit,  the  external  auditory  meatus,  and  the  parietal  eminence.  The  last 
mentioned,  which  at  first  sight  ap])ears  to  be  particularly  vague,  is  really  of  very 
great  value,  as  it  bears  a  certain  relation  to  the  general  development  of  the  skull 
and  is  nearly  always  in  close  correspondence  with  the  supramarginal  gyrus. 

The  most  important  boundary  lines  for  the  brain  are  the  fissures  of  Sylvius 
and  Rolando  and  the  tentorium.  Of  these  the  last  is  easily  marked  by  the  superior 
curved  line  ;   the  two  former  are  more  difficult. 

The  upper  end  of  the  fissure  of  Rolando  is  most  easily  defined  by  the  measure- 
ment originally  given  by  Thane,  half  an  inch  behind  the  mid-])oint  between  the 
glabella  and  the  inion.  supposing,  of  course,  the  fissure  were  continued  quite  into 
the  great  longitudinal  division. 

The  lower  does  not  really  admit  of  definition.     The  easiest  way  to  arrive  at  it 


CEREBRAL   LOCALIZATION. 


679 


is  by  means  of  ^\'ilsc)n's  cyrtonieter.  A  strip  of  metal  (graduated  according  to 
Hare's  measnrenients  to  suit  skulls  of  different  shapes)  is  caiTied  along  the  sagittal 
suture  from  the  glabella  to  the  inion  ;  on  this  glides  a  metal  rod,  about  three  and  a 
half  inches  long,  forming  with  the  sagittal  band  a  fixed  angle  of  67°.  This  when 
l)lace(,l  in  position  corresi)onds  api)roximately  in  length  and  direction  to  the  fissure 
of  Rolando  as  measured  ujjon  the  scalp.  The  angle  is  more  ojjen  in  some  brains 
than  in  others  ;  possibly  67°  is  slightly  more  than  the  average,  which  other 
measurements  place  at  65°,  but  it  is  sufficiently  near  for  practical  purposes;  nine 
times  out  of  ten,  it  will  allow  a  required  point  to  be  exposed  with  a  trephine  an 
inch  and  a  quarter  in  diameter. 


Fig.  296. — Wilson's  Cyrtometer  in  situ.  G,  glabella ;    E  A  P,  external  angular  process;  R,  fissure  of 
Rolando — its  position  and  direction  marked  by  the  lateral  strip  of  metal.     {After  Bram-uwll.') 


The  direction  of  the  fissure  of  Sylvius  is  equally  difficult.  Hare  takes  a  base 
line  from  the  external  angle  of  the  orbit  to  the  inion  ;  this  passes  rather  above  the 
external  auditory  meatus.  The  beginning  of  the  fissure  of  Sylvius  lies  on  this 
rather  more  than  an  inch  from  its  commencement,  and  runs  directly  upward  and 
backward  from  it  to  the  parietal  eminence.  Practically  the  same  line  may  be 
obtained  by  starting  from  the  middle  of  the  outer  border  of  the  orbit  (the  ex- 
ternal canthus  or  the  sharp  margin  of  bone  that  lies  beneath  it)  and  ending  at  the 
same  point.  The  point  of  bifiircation  is  approximately  three-eighths  of  the  dis- 
tance from  the  edge  of  the  orbit. 


68o    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  VIII. 

INJURIES  AND  DISEASES  OF  THE  BACK. 

SECTION  I.— iMALFORMATlONS, 

Spina  Bifida. 

In  the  strict  sense  of  the  term  spina  bifida  refers  to  the  condition  of  the  spinal 
column  ;  but  it  is  usually  understood  to  mean  a  congenital  tumor  projecting  through 
the  ununited  laminae  of  the  vertebrae,  and  formed  of  the  cord  or  its  membranes, 
or  of  both  together. 

It  is  nearly  always  on  the  back  ;  cases  are  reported  in  which  the  protrusion 
has  taken  place  on  the  anterior  aspect  of  the  vertebrae  through  the  bodies,  but  they 
are  very  rare,  and  are  generally  associated  with  other  deformities.  Three-fourths 
of  the  whole  number  are  found  in  the  lumbo-sacral  region,  where  the  medullary 
groove  is  open  latest ;  of  the  rest,  the  majority  occur  in  the  neck,  but  they  may 
protrude  through  any  part,  from  the  occiput  downward,  or  may  even  involve  the 
whole  length  of  the  column. 

Symptoms  and  Diagnosis. — Spina  bifida  usually  occurs  in  the  form  of  a 
rounded,  sessile  (sometimes  pedunculated)  tumor,  projecting  in  the  middle  line  of 
the  body,  over  the  spine,  with  which  it  is  closely  connected.  It  may  be  of  any 
size,  larger  even  than  the  child's  head.  In  some  instances  the  skin  over  it  is 
natural  ;  in  most  it  is  reddened,  devoid  of  hair,  and  e.xceedingly  thin  :  in  a  few 
it  is  vascular,  like  a  naevus,  and  velvety,  so  far  at  least  as  the  most  prominent  part 
is  concerned,  and  occasionally  there  is  a  great  growth  of  hair  all  round  it,  con- 
verging in  a  spiral  fashion  toward  the  central  point.  The  swelling  may  be  perfectly 
uniform  in  shape,  or  there  may  be  a  longitudinal  groove  running  vertically  down- 
ward over  it  in  the  middle  line,  beginning  and  ending  with  a  little  pit-like  depres- 
sion, and  sometimes  in  addition  two  lateral  grooves  can  be  made  out,  wide  apart 
at  the  centre,  but  converging  at  their  extremities  toward  the  same  small  pits. 

The  sac  is  very  often  translucent,  and  the  nerve  cords  can  be  traced  by  trans- 
mitted light  running  obliquely  across  it.  Fluctuation  is  distinct,  and  when  the 
neck  is  wide  the  wave  can  be  felt  even  at  the  anterior  fontanelle.  The  tension 
varies  according  to  the  quantity  of  fluid  present,  increasing  if  the  child  cries  or 
if  the  pelvis  is  allowed  to  hang  down.  Some  of  the  contents  can  often  be  reduced 
by  steadily  compressing  the  sac,  so  that  the  edges  of  the  cleft  can  be  felt ;  but  the 
proceeding  is  a  dangerous  one,  likely  to  cause  convulsions. 

Complications  are  often  present.  Talipes,  parajjlegia,  and  atony  of  the  e.xter- 
nal  sphincter  are  due,  in  all  probability,  to  the  condition  of  the  sacral  ple.xus,  and 
point  to  the  fact  that  the  spinal  cord,  or  the  nerves  coming  from  it,  are  involved 
in  the  sac  ;  meningocele,  ectojjia  of  the  viscera,  and  other  malformations  result 
from  a  similar  arrest  of  development  in  other  j^arts  of  the  body. 

The  diagnosis  rarely  presents  any  difficulty.  The  position  of  the  tumor,  its 
congenital  origin,  and  its  varying  tension  are  sufficient  to  distinguish  it  from  every- 
thing but  naevus.  Every  now  and  then,  however,  other  forms  of  congenital  tumor 
closely  resembling  it  are  met  with  in  this  region.  False  spina  bifida  is  the  most 
deceptive.  Strictly  speaking,  it  is  a  single  cyst  in  communication  with  the  spinal 
canal,  but  not  with  the  membranes  or  the  cord,  and  probably  it  originates  from 
the  sac  of  a  true  spina  bifida,  the  neck  of  which  has  become  occluded.  Kut  con- 
genital lipomata,  and  even  myo-lipomata,  are  known  to  occur,  springing  from  the 
interior  of  the  spinal  canal  and  spreading  out,  either  between  the  arches,  or  through 
an  opening  left  by  their  imperfect  growth,  until  they  form  large  masses  sessile  upon 


SPINA    BIFIDA.  68 1 

the  backbone.  The  true  multilocular  sacro-coccygeal  tumors  are,  as  a  rule,  in 
connection  with  a  part  of  the  sjjinal  cohunn  which  is  not  the  seat  of  spina  bifida. 

Pathology. —  There  are  three  chief  varieties  of  sjjina  bifida,  of  which  the 
second  is  by  lar  the  most  common. 

{a)  Meningocele. — Protrusion  of  the  membranes  only;  the  skin  covering  it 
may  be  thinned  and  reddened,  but  in  other  respects  it  is  perfectly  natural.  'I'he 
cord  lies  in  its  proper  situation,  and  there  are  no  nerves  in  the  .sac. 

(/^)  Ale ningo myelocele. — Protrusion  of  the  cord  with  its  nerves  and  membranes. 
The  skin  around  the  neck  of  the  tumor  is  natural  ;  over  the  most  prominent  part 
it  is  replaced  by  a  thin,  vascular  layer,  which  shows  no  trace  of  corium,  hairs,  or 
sweat  glands,  and  the  line  of  transition  is  sharply  marked.  This  layer  is  the  flat- 
tened out  spinal  cord  itself,  which,  in  the  most  typical  examples,  leaves  the  spinal 
canal  at  the  ujjper  angle  of  the  cleft,  ])asses  backward  acro.ss  the  sac  until  it  meets 
and  fu.ses  with  its  posterior  wall,  and  then  leaving  it  after  a  variable  distance, 
regains  the  canal  below.  In  some  instances  the  cord  is  structurally  complete,  and 
although  the  normal  arrangement  of  w^hite  and  gray  substance  is  somewhat  inter- 


%^-^ 


Fig.  297. — Meningomyelocele  Laid  Open.  The  centre  is  marked  by  a  pit  leading  down  to  the  spinal  canal. 
Below  this  is  a  trifid  groove.  The  whole  of  the  posterior  surface  is  composed  of  flattened-out  spinal 
cord,  the  line  at  which  the  true  skin  stops  being  clearly  marked  off.  In  the  interior  the  ligamentum 
denticulatum  and  some  of  the  roots  are  stretched  across  from  back  to  front. 

fered  with,  the  central  canal  can  still  be  recognized  in  transverse  microscopic 
sections.  In  others  the  cord  itself  is  flattened  out  from  in  front ;  the  posterior 
fissure  has  never  been  closed,  and  the  central  canal  forms  the  median  groove  already 
mentioned,  ending  in  a  pit  above  and  below,  where  it  resumes  its  normal  situation. 
Finally,  in  a  few  the  pressure  of  the  fluid  in  front  of  the  cord  has  been  so  great 
that  the  anterior  columns  are  separated,  and  between  them  there  is  a  vascular, 
velvety  protrusion  of  pia  mater.  The  position  of  the  nerves  is,  of  course,  con- 
siderably modified  :  the  anterior  roots  spring  from  the  concavity  of  the  roof  of  the 
sac  near  the  middle  line  ;  the  posterior  ones  arise  from  it  further  down  the  sides, 
with  between  them  an  enormously  elongated  ligamentum  denticulatum.  Sooner 
or  later  the  roots  fuse  together  to  form  a  trunk,  which,  running  partly  in  the  wall 
of  the  sac,  partly  across  its  interior,  passes  between  the  margins  of  the  cleft  into 
the  spinal  canal,  in  order  to  gain  its  proper  intervertebral  foramen.  The  dura 
mater  lies  on  the  posterior  surface  of  the  bodies  of  the  vertebrae,  and  can  be 
traced  into  the  wall  of  the  sac  as  far  as  the  covering  of  the  true  skin,  never 
further.  The  sac,  in  other  words,  is  an  immensely  distended  subarachnoid  space. 
44 


682    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

(r)  Syrifigoccle. — The  central  canal  of  the  spinal  cord  is  dilated,  forming  the 
cavity  of  the  sac  ;  the  posterior  wall  is  formed  of  skin,  as  a  rule,  with  the  expanded 
posterior  columns  of  the  cord,  and  perhaps  the  dura  mater. 

In  all  of  these  there  is  a  defect  in  the  arches  and  laminae  of  tbe  vertebrae  (spina 
bifida)  ;  much  rarer  deformities  are  sometimes  met  with,  chiefly  in  association 
with  syringocele,  itself  \ery  rare  ;  defective  development  of  the  bodies  of  the 
vertebrje,  for  example,  so  that  they  are  either  cleft  vertically,  or  that  one-half  is 
wanting;  growth  of  a  Ijony  process  backward  through  the  substance  of  the  spinal 
cord  and  even  complete  division  of  the  spinal  cord  into  two  for  more  or  less  of  its 
length. 

From  the  fact  that  in  sacral  spina  bifida  the  cord  is  found  still  occupying  the 
sacral  region  (the  nerves  coming  off  horizontally  without  forming  a  cauda  equina), 
while  at  birth  it  has  normally  receded  far  up  the  lumbar  part,  it  is  clear  this  defor- 
mity originates  at  the  very  earliest  period,  when  the  spinal  cord  and  the  vertebral 
column  are  practically  of  the  same  length.  The  defect  is  in  the  formation  of  the 
medullary  canal. 

Spinal  meningocele  is  the  most  simple.     In  this  the  neural  canal  has  closed, 


FiG.^298. — Meningomyelocele, showing  ihe  vascular 
Pia  Mater  in  the  centre,  the  flattened  cord  on 
either  side,  and,  above,  the  pit  leading  to  the 
central  canal  (diagrammatic). 


Fig.  299  —Cured  Spina  Bifida,  taken  from 
a  man  xt.  26. 


SO  that  the  cord  itself  is  well  formed  ;  but  the  mesoblastic  elements  which  should 
grow  around  it  and  enclose  it  on  the  dorsal  surface  are  imperfectly  developed  ;  the 
bony  laminre,  the  muscles  and  the  substance  of  the  true  skin  are  deficient  in  various 
degrees  (according  to  Recklinghausen,  the  dura  mater  is  wanting  in  this  as  well  as 
in  the  other  forms)  :  and  the  protrusion  is  due  to  passive  distention  :  fluid  is 
secreted  in  the  sac  under  the  i)ressure  of  the  blood,  and  the  wall  is  too  thin  and 
weak  to  resist. 

In  meningomyelocele  the  fluid  collects  in  the  .subarachnoid  space  in  front  of 
the  cord  ;  if  the  neural  canal  is  closed  already,  the  cord  itself  is  gradually  flattened 
from  before  backward  and  pushed  out  from  the  cleft,  until  it  joins  and  fuses  with 
the  epidermic  covering  developed  from  the  epiblast,  the  sole  trace  of  all  the  struc- 
tures that  should  protect  the  spinal  cord  behind.  In  this  case  a  transverse  section 
through  the  posterior  wall  of  the  sac  reveals,  on  microscopic  examination,  the  flat- 
tened out  central  canal,  and  there  is  no  median  groove  or  pit.  In  the  other  form 
the  defect  occurs  at  an  earlier  period  still,  l)efore  the  medullary  groove  is  closed  to 
form  the  cord  and  tlie  layer  of  elementary  nerve  tissue  is  first  flattened  out,  and 
then  becomes  convex  backward,  until  at  length  it  projects  as   the  covering  of  a 


SPINA   BIFIDA.  683 

thin-walled  cyst.  In  the  most  extreme  cases  the  anterior  columns  are  so  far  sepa- 
rated from  each  other  by  the  pressure  that  a  strip  of  pia  mater,  that  which  should 
line  the  bottom  of  the  anterior  fissure,  forms  a  longitudinal  velvety  band  on  the 
most  convex  portion  of  the  sac. 

The  other  malformations  are  due  to  the  fluid  collecting  in  the  central  canal, 
and  to  inequality  of  growth  of  various  parts  of  the  vertebral  column.  The  bifur- 
cation of  the  spinal  cord  is  probably  an  indication  of  the  enormous  power  of  re- 
production and  repair  posse.ssed  by  the  embryo  at  the  earliest  period.  If  the  neural 
canal  is  prevented  from  closing  into  a  tube,  each  half  may  in  some  instances  be 
capable  at  that  time  of  life  of  forming  one  for  itself. 

Treatment. — If  the  protrusion  is  small,  covered  over  with  healthy  skin,  and 
not  inclined  to  enlarge,  it  should  be  carefully  protected  with  cotton-wool  and 
collodion  in  sufficient  thickness  to  form  a  fairly  rigid  covering,  or  with  a  gutta- 
percha cap.  There  is  a  possibility  of  its  gradually  shrinking  up.  In  most  cases, 
however,  the  sac  is  increasing  rapidly  and  threatens  to  give  way  sooner  or  later  if 
left  to  itself.  If  the  skin  is  already  ulcerated  or  the  wall  is  actually  broken,  it 
should  be  dusted  over  with  iodoform  and  carefully  packed  with  iodoform  gauze  or 
salicylic  wool,  in  the  hope  that  meningitis  will  not  follow,  and  that  the  wound 
will  cicatrize  under  the  protection. 

The  only  treatment  that  has  met  with  any  success  is  the  injection  of  Morton's 
fluid:  this  consists  of  iodine- gr.  x,  pot.  iod.  gr.  xxx  and  glycerine  5J.  A  punc- 
ture is  made  with  a  fine  trocar  and  cannula  through  the  healthy  skin  near  the 
bottom  of  the  sac,  and  a  certain  quantity  of  the  fluid,  not  more  than  half,  allowed 
to  escape.  Then  half  a  drachm  to  two  drachms  of  the  solution  is  injected,  taking 
care  that  none  escapes  by  the  side  in  the  cellular  tissue,  and  the  puncture  sealed 
with  collodion.  The  opening  may  be  made  valvular  to  prevent  the  contents  drain- 
ing away.  Afterward  the  sac  must  be  carefully  packed  in  cotton-wool  with  a 
sHght  amount  of  pressure,  and  the  child  kept  as  quiet  as  possible,  so  that  the  in- 
jection may  not  diffuse  itself  too  rapidly.  In  successful  cases  the  sac  soon  begins 
to  diminish  in  size,  and  at  length  shrivels  up  into  a  rounded  solid  excrescence ; 
but  very  often  several  injections  are  required,  and  it  not  unfrequently  happens  that 
after  a  while  the  skin  becomes  red  and  the  opening  begins  to  leak,  or  the  child 
is  attacked  by  convulsions  and  meningitis  sets  in.* 

Excision  of  the  sac  has  been  practiced  successfully  in  cases  of  simple  menin- 
gocele, but  as  it  is  impossible  to  prove  that  the  spinal  cord  is  not  involved  in  the 
sac,  this  operation  should  very  rarely  be  undertaken. 

The  prognosis  is  rarely  favorabk.  Even  in  simple  cases  the  child  is  seldom 
well  nourished  \  in  the  more  severe  ones — when,  for  example,  there  is  a  large  thin- 
walled  sac — it  is  nearly  always  small  and  puny  ;  and  in  many  there  is  clear  evidence 
from  the  first  of  paralysis  or  other  nerve  lesions.  Growth,  especially  of  the  lower 
limbs,  is  usually  stunted  ;  areas  of  anaesthesia  persist ;  some  of  the  muscles  of  the 
lower  extremity  continue  in  a  state  of  spastic  rigidity,  so  as  to  limit  the  action  of 
the  joints  ;  and  handling  the  cicatrix  left  may  in  some  instances  give  rise  to  evi- 
dence of  nerve  irritation,  passage  of  urine,  defecation,  and  sexual  emissions. 

[*Prof.  Brainard,  the  originator  of  this  method  of  treament  of  spina  bifida,  used  the  Lugol  solu- 
tion.    The  solution  used  by  him  consisted  of  iodini  .03,  potass,  i.jdidi  .10,  aquce  destiliat   c.c.  -^t^. 

The  rules  laid  down  by  Brainard  for  performing  the  operation  were:  First,  to  make  the  punc 
ture  subcutaneously  in  the  sound  skin,  by  tlie  side  of  the  tumor  ;  secondly,  to  draw  off  no  mure 
serum  than  the  quantity  of  fluid  about  to  be  injected  ;  thirdly,  to  evacuate  the  contents  of  the  sac,  if 
symptoms  of  irritation  supervene,  and  to  replace  them  imme  liately  with  distilled  water.  The  patient 
should  lie  on  his  side  or  face  after  the  operation,  and  if  there  be  much  heat,  warm,  evaporating 
lotions  should  be  applied  to  the  part  on  head.  As  sojn  as  the  tumor  becomes  flaccid  it  should  be 
covered  with  collodion,  or  supported  by  pressure  continued  for  some  weeks  after  the  cure  has  been 
perfected;  and  lastly,  the  injection  should  be  repeated  ai  often  as  may  be  n.cessary, care  being  taken 
that  the  previous  irritation  has  completely  subsided. 

The   operation  is  performed  with  a  very  delicate  trocar,  the  puncture  being  accurately  closed 
with  adhesive  strips.] 


684    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


Congenital  Sacral  Tumors. 

A  great  variety  of  congenital  tumors  is  met  with  in  connection  with  the 
sacro-coccygeal  region,  and  the  origin  of  many  is  still  involved  in  doubt. 

(^a)  Spina  bifida  (true  and  false)  may  occur  on  the  back  of  the  sacrum.  Its 
diagnosis  and  treatment  have  already  been  discussed. 

(Ji)  Congenital  liponiata  and  niyo-lipomata  are  also  met  with,  springing  from 
the  interior  of  the  spinal  canal  and  protruding  through  an  opening  in  its  wall. 
Similar  growths,  due  in  all  probability  to  the  accidental  transference  of  tissue  germs 
at  a  very  early  period  of  embryonic  life,  are  also  met  with  higher  up  in  the  column. 
When  small  their  diagnosis  from  spina  bifida  is  almost  impossible  without  a  punc- 
ture.    They  have  been  excised  with  success. 

(r)  Congenital  sacral tiivior,  in  the  limited  sense  of  the  term,  is  applied  to  a 
mass,  often  of  enormous  size,  developed  in  the  region  of  the  coccyx,  in  front,  dis- 
placing it ;  or  behind  ;  or  hanging  from  it  by  a  neck.  It  is  made  up  of  cysts  of 
all  sizes,  from  that  of  a  pea  to  a  horse-chestnut,  communicating  more  or  less  freely 
with  each  other,  and  filled  with  a  thick  gelatinous  material.  When  small  the 
epithelium  lining  them  is  columnar,  resting  upon  flatter  cubical  cells.  In  between 
is  a  variable  amount  of  fibrous  tissue  with  fat,  hyaline  cartilage,  and  sometimes 
even  bone.  It  seems  probable  that  this  growth  originates  from  Luschka's  gland, 
which  in  its  turn  (according  to  Bland  Sutton)  is  the  rudiment  of  the  post-anal  gut 
of  the  embryo.  Excision  is  the  only  line  of  treatment  possible,  but  very  careful 
examination  is  necessary,  as  not  unfrequently  the  growth  extends  much  further  up 
the  pelvis  or  the  spinal  canal  than  would  be  imagined  from  external  appearances, 

{d')  Dermoid  cysts,  containing  the  ordinary  mixture  of  sebaceous  material, 
hair,  etc.,  are  not  uncommon.  Sometimes  they  communicate  with  the  rectum  or 
bladder,  and  occasionally  they  are  of  very  large  size,  extending  long  distances  up 

the  pelvis.  As  Bland  Sutton  has 
pointed  out,  there  is  an  especial  ten- 
dency to  the  production  of  these 
growths  in  those  localities  in  which 
fusion  of  the  germinal  layers  takes 
place  in  the  embryo. 

{/)  Finally,  attached  foetuses  oi 
all  grades  of  development  may  be 
met  with.  There  may  be  merely  a 
shapeless,  formless  mass  of  skin, 
containing  fibrous  tissue,  bone,  and 
fat,  all  mixed  up  together ;  or  a 
well-formed  limb ;  or  even  larger 
portions  still.  Excision  is  the  only 
treatment  practicable,  flaps  being 
formed  from  the  part  removed  for 
the  purpose  of  covering  in  the  stump  ;  but  full  examination  of  the  connections 
should  be  made  in  every  case,  as  it  is  impossible  to  say  how  far  growths  of  this 
kind  may  be  incorporated  with  the  bearer  of  them. 


Fif;s.  3C0  and  301. — Congenit.-il  Coccygeal  Tumors. 


SPRAINS  OF  THE  BACK.  685 


SECTION  II.— INJURIES. 

INJURIES  OF  THE  BACK. 

Injuries  of  the  back,  like  those  of  the  head,  derive  much  of  their  importance 
from  the  danger  to  which  the  great  nerve  centres  are  exposed.  Independently  of 
this,  the  structure  of  the  spinal  column  is  so  complex,  its  position  as  the  axis  of 
support  for  the  trunk  and  the  chief  base  for  the  movements  of  the  body  so  im- 
portant, that  no  injury,  however  slight,  can  be  inflicted  upon  it  without  produc- 
ing a  serious,  and  often  a  widely  felt,  effect. 

Sprains  and  Wrenches. 

These  are  very  common,  especially  in  the  flexible  parts,  the  cervical  and 
lumbar  regions  ;  sometimes  they  are  chiefly  muscular,  as  in  cases  of  overwork — 
lifting  heavy  weights,  for  example — or  in  sudden  awkward  twists  ;  sometimes, 
when  due  to  external  violence,  they  involve  the  fibrous  textures,  the  ligaments, 
fascise,  and  synovial  membranes  as  well,  the  muscles  either  being  caught  unawares 
by  the  unexpected  jerk  or  being  overpowered.  The  worst  of  all  occur  in  rail- 
way collisions,  when  suddenly  and  without  any  warning,  before  a  single  muscle 
can  contract,  the  body  is  wrenched  and  twisted,  or  thrown  with  overpowering 
force  from  one  side  of  the  carriage  to  the  other,  until  every  muscle  or  ligament 
that  has  an  attachment  to  the  spine  is  strained  or  hurt. 

For  various  reasons,  the  spinal  cord  itself  escapes  more  frequently  than  might 
be  expected  ;  it  lies  in  the  central  axis,  so  that  in  all  movements  it  occupies  neu- 
tral ground  ;  it  is  separated  by  some  distance  from  the  walls  ;  around  it  there  is  a 
water-bed,  probably  always  filled  with  fluid  ;  and  in  the  lumbar  region,  where  the 
range  of  movement  is  as  great,  perhaps  greater,  than  anywhere  else,  its  place  is 
taken  by  the  cauda  equina. 

The  extent  of  injury  in  these  cases  is  very  variable.  No  structure  is  always 
exempt,  but  probably  the  muscles  and  fibrous  tissue  are  the  greatest  sufferers.  The 
former  may  be  thrown  into  a  state  of  cramp  ;  they  may  be  torn  or  wrenched  away 
from  the  bone ;  there  may  be  hemorrhage  into  the  sheath  that  invests  them  ;  this 
may  be  torn  and  the  muscular  substance  forced  through  the  rent  like  a  hernia;  or, 
especially  in  the  neck,  where  the  long  slender  slips  lie  closely  packed  together  side 
by  side,  there  may  be  a  real  dislocation.  The  latter  may  be  still  more  damaged  ; 
the  broad  sheets  that  extend  on  either  side  of  the  spine  may  be  overstretched,  or 
the  loose  cellular  tissue  that  fills  up  the  irregular  spaces  around  and  between  the 
bones  crushed,  and  bruised  ;  or,  what  is  much  more  serious,  some  of  the  ligaments 
that  connect  the  vertebrae  may  be  strained  until  they  yield.  This  is  especially 
dangerous,  not  only  from  the  proximity  of  the  membranes  and  the  cord  and  the 
risk  of  their  being  injured  at  the  same  time,  but  from  the  danger  of  hemorrhage 
and  inflammation.  A  certain  amount  of  extravasation  must  always  occur,  causing 
an  ill-defined  swelling  and  tenderness,  and  giving  rise  to  pain  and  inconvenience 
when  any  attempt  at  movement  is  made;  but  if  the  posterior  ligaments,  especially 
the  ligamenta  subflava,  are  torn,  the  bleeding  may  be  very  severe,  owing  to  the 
size  of  the  veins  that  surround  them,  and  the  blood  may  pour  down  the  spinal 
canal. 

In  other  cases,  the  spinal  nerves  are  hurt,  stretched  possibly  as  they  pass  out 
through  the  foramina,  or  compressed  by  extravasation,  so  that  the  effects  are  re- 
ferred to  distant  parts  of  the  body.  Even  the  bones  and  joints  do  not  escape,  for, 
though  it  is  rarely  possible  to  prove  the  existence  of  definite  injury  at  the  time,  it 
is  certain  that  inflammation  may  break  out  in  them  afterward. 


686    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

The  complications  that  follow  these  injuries  depend  largely  upon  the  state  of 
the  patient's  health.  Stiff  neck,  lumbago,  and  chronic  rheumatism  occur  in  some, 
particularly  after  middle  life  ;  synovitis  and  osteo-arthritis,  leaving  the  spine  rigid, 
ankylosed,  and  i)erhai)s  distorted,  occur  in  others  ;  caries  is  exceedingly  common, 
especially  in  children  and  young  adults;  and,  what  is  still  more  serious,  if  the 
ligaments  have  been  torn  and  hemorrhage  has  taken  place  in  the  vertebral  canal, 
inflammation  of  the  membranes  or  of  the  cord  itself  may  follow.  In  most  cases 
this  is  very  insidious  ;  softening  sets  in  slowly,  and  steadily  grows  worse  and 
worse  ;  in  a  few  rare  instances  it  is  acute,  suppuration  commencing  externally  in 
the  broken-down  blood-clot  or  in  the  joints,  and  spreading  through  a  rent  in  the 
membranes  or  along  the  lymphatics,  until  the  dura  matral  sheath  is  involved. 
This  is  not  so  frecpient  as  in  the  skull,  owing  to  the  wide  separation  between  the 
dura  mater  and  periosteum,  and  the  lower  vascularity  of  the  former  in  the  spinal 
canal ;  but  it  has  proved  fatal  in  many  cases  of  latent  fracture. 

Sprains  of  the  back  have  accpiired  a  peculiar  significance  from  their  frequency 
in  railway  collisions,  and  attempts  have  been  made  to  distinguish  them,  when  they 
occur  under  these  conditions,  from  others.  Except,  however,  for  their  severity 
and  for  the  fact  that  they  are  always  associated  with  a  very  grave  degree  of  shock, 
which  is  certainly  not  without  influence  upon  the  subsequent  progress  of  the  case, 
there  is  no  reason  for  such  a  step. 

Symptoms. — The  chief  ones  are  pain  and  stiffness  ;  these  are  never  absent. 
The  former  may  be  immediate  and  severe,  as  when  the  head  is  twisted  round  to 
look  in  some  awkward  direction,  and  a  muscle  or  tendon  is  caught  or  disj^laced  ; 
or  it  may  be  dull  and  aching,  not  coming  on  for  hours.  The  least  attempt  at 
movement  makes  it  tenfold  \vorse.  Very  often  it  is  especially  severe  at  night, 
when  the  patient  is  getting  warm  in  bed  ;  and  usually  the  skin  over  the  painful 
part  is  exceedingly  tender,  as  it  always  is  over  muscles  that  have  been  overstrained 
or  overworked.  If  the  nerves  are  injured  in  the  foramina  the  pain  runs  round 
the  trunk  like  a  girdle,  or  extends  into  the  limbs  ;  sometimes  it  is  attended  by  for- 
mication. In  one  case,  in  which  the  lumbar  region  was  severely  wrenched,  a 
l)atient  described  it  as  shooting  like  lightning  down  the  legs,  and  very  often  it  is 
referred  to  the  distribution  of  the  nerves — to  the  pubic  region,  for  instance,  when 
the  injury  is  at  the  junction  of  the  dorsal  and  lumbar  vertebrae.  The  stiffness  is 
to  a  great  extent  the  result  of  this  ;  the  neck  and  back  are  held  perfectly  rigid, 
and  if  the  patient  is  asked  to  pick  u])  anything  from  the  floor,  the  knees  and  hips 
are  flexed,  and  he  lowers  himself  carefully  down.  Very  often  patients  imagine 
they  are  paralyzed,  mistaking  the  difficulty  of  movement  arising  from  the  pain  for 
actual  loss  of  power ;  and  this  may  be  very  misleading.  I  have  recorded  else- 
where a  case  in  which,  after  a  muscular  strain  of  the  neck,  the  patient  believed 
that  he  could  neither  hold  his  head  upright,  without  supi)orting  it  with  his  hands, 
nor  open  his  mouth  ;  and  it  is  not  uncommon  to  find  after  a  strain  of  the  loins 
that  defecation  and  micturition  are  attended  with  difficulty,  not  because  the  spinal 
cord  has  been  injured  (though  it  must  never  be  forgotten  that  this  may  be  the  case), 
but  because  these  actions  depend  so  largely  upon  the  integrity  of  the  muscles  that 
support  the  back.  The  same  thing  occurs  in  lumbago,  when  it  is  due  to  cold, 
without  there  being  any  suspicion  of  injury  ;  but  it  cannot  be  denied  that,  espe- 
cially after  railway  accidents,  it  is  a  very  disquieting  symptom. 

Swelling  is  not  common  in  accidents  of  this  kind,  unless  there  is  a  consider- 
able extrava.sation  ;  it  may  follow  the  outline  of  the  muscles,  as  in  the  neck,  or 
simply  from  a  smooth,  rounded  elevation.  The  skin,  as  already  mentioned,  is 
often  very  tender,  but,  as  a  rule,  firm  pressure  gives  relief.  Redness  is  hardly  ever 
seen,  and  it  rarely  happens  that  the  temjjerature  is  raised. 

Htematuria  is  not  an  uncommon  occurrence  after  s])rains  of  the  lumbar 
region  ;  the  urine  is  bright  red  for  a  day  or  two,  and  sometimes  there  is  sufficient 
blood  to  form  a  clot  in  the  ureter  ;  then  it  gradually  becomes  smoky,  until,  as  a 
rule,  the  whole  has  disai)peared  in  about  a  week.  It  is  seldom  sej-ious,  but  I  have 
known  it  fatal,  probably  from  one  of  the  larger  arteries  having  given  way. 


FRACTURE  OF  THE  SPINE.  687 

Treatment. — As  in  the  case  of  sprains  elsewhere,  rest  is  the  first  considera- 
tion, to  limit  the  amount  of  extravasation  and  hyi)era;mia  that  follows,  and  then 
gentle  passive  movement  to  assist  in  absorjttion  and  to  restore  the  function  and 
nutrition  of  the  part.  If  there  is  one  spot  especially  tender,  or  one  particular 
movement  that  causes  i)ain,  immediate  relief  may  sometimes  be  obtained  by  sud- 
denly throwing  the  muscles  concerned  into  vigorous  action.  Subcutaneous  injec- 
tions of  morphia  must  generally  be  used,  as  the  pain  is  often  so  severe  that  the 
patient  has  not  the  power  to  make  the  effort.  In  twists  and  ricks  of  the  neck  and 
loins  this  plan  may  be  tried  at  once.  Where  the  aching,  stiffness,  and  pain  on 
movement  are  more  general,  and  it  is  clear  that  the  symptoms  are  due  to  chronic 
changes  in  the  joints  and  muscles,  and  that  the  spinal  cord  is  not  involved,  counter- 
irritants,  may  be  employed.  Hot  baths,  shampooing,  friction  with  stimulating 
liniments,  ironing,  blisters,  acupuncture,  and  galvanism  with  slow  interruptions  of 
the  current,  are  of  the  greatest  value,  but  constitutional  treatment  must  not  be 
neglected,  especially  if  there  is  any  evidence  of  gout  or  rheumatism.  Muscles  and 
joints  are  intended  for  work  ;  if  they  are  injured  they  require  rest,  it  is  true  ;  but 
as  soon  as  the  damage  is  repaired  they  become  stiff  and  waste  unless  they  are  used  ; 
and  the  longer  they  remain  at  rest  the  worse  they  become. 

In  cases  of  more  severe  injury,  when  there  is  either  shock  or  excitement,  the 
patient  should  be  placed  in  bed,  and  kept  warm  and  as  quiet  as  possible  until  it  has 
entirely  passed  away.  The  urine  may  have  to  be  drawn  off,  especially  after  rail- 
way accidents,  or  other  severe  injuries  ;  the  bowels  are  almost  sure  to  be  constipated, 
and  should  be  opened  by  a  calomel  purge ;  stimulants,  unless  the  pulse  is  very 
feeble  or  actually  failing,  do  more  harm  than  good.  Then,  as  soon  as  the  acute 
symptoms  have  subsided,  when  the  patient  begins  voluntarily  to  change  his  position 
in  bed,  gentle  passive  motion,  bending  the  spine  backward  and  forward,  and 
massage,  may  be  commenced,  to  prevent  the  muscles  becoming  rigid.  If  the 
depression  continues,  or  if  some  weeks  after  the  accident  the  patient  does  not 
begin  to  rally,  the  prognosis  becomes  very  grave.  There  is  evidence  then  that  the 
nervous  system  has  been  seriously  affected  ;  and  in  patients  of  a  neurotic  temper- 
ament, or  where  there  is  any  hereditary  taint,  it  is  impossible  to  predict  what  may 
happen.  Perfect  rest  for  mind  as  well  as  body  is  essential  ;  everything  that  can 
worry  or  annoy  must  be  carefully  kept  away,  and  the  attention  must  be  diverted 
as  much  as  possible  by  change  of  scene  or  occupation.  Good  food,  fresh  air,  and 
a  moderate  amount  of  such  exercise  as  the  patient  can  be  induced  to  take  are  the 
best  remedies ;  stimulants  should  be  avoided.  The  only  drugs  of  any  service  are 
those  that  improve  the  appetite  and  help  to  keep  up  nutrition  ;  bromide  of  potas- 
sium and  sedatives  or  narcotics  usually  do  harm. 


Fractures  and  Dislocations  of  the  Spine. 

Fracture. 

The  vertebral  column  may  be  broken  either  by  direct  or  indirect  violence. 
The  former  is  the  most  rare,  at  least  in  civil  practice  :  but  a  violent  blow,  or  a 
fall,  striking  the  back  against  a  projection,  may  crush  it  in  at  any  point.  The 
extent  of  the  injury  is  very  variable  ;  if  the  force  is  slight,  one  of  the  processes 
only  is  broken  off ;  more  frequently  the  laminae  are  driven  in  ;  sometimes  the  bone 
is  completely  broken  up.  Fracture  by  indirect  violence  is  generally  the  result  of 
extreme  flexion  ;  the  head,  for  example,  is  caught  in  driving  under  an  arch  and 
forced  down  upon  the  sternum  (sometimes  breaking  it)  ;  or  the  neck  is  fractured 
by  diving  head  foremost  into  too  shallow  water ;  more  rarely  it  is  caused  by  over- 
extension. When  the  fracture  is  the  result  of  flexion  the  spine  usually  gives  way 
either  just  above  or  just  below  the  dorsal  region,  the  seat  of  junction  of  the  more 
movable  parts  with  the  more  rigid  ;  and  the  injury  is  always  very  extensive.  The 
muscles  are  torn  ;   the  spinous  processes  are  dragged  asunder  ;    the  ligamenta  sub- 


6S8     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

flava  are  pulled  away  from  their  attachments  ;  the  body  is  wrenched  off  the  adja- 
cent disc  and  crushed  in  ;  blood  pours  down  the  spinal  canal,  or  is  extravasated 
into  the  sheath  ;  and  the  upjjer  part  of  the  spine  carrying  the  head  is  displaced 
forward,  so  that  the  edge  of  the  vertebra  below  pins  the  spinal  cord  against  the 
arches  ;  or,  what  is  worse  still,  a  triangular  piece  of  bone  is  broken  out  of  one  of 
the  bodies  and  driven  backward  like  a  wedge  across  the  spinal  canal  (Fig.  302). 

Dislocation. 

True  dislocation,  without  fracture,  is  met  with  in  several  parts  of  the  verte- 
bral column.  In  children  it  may  occur  between  the  atlas  and  axis,  from  lifting 
them  up  by  the  head.  In  hanging  there  is  usually  a  fracture  running  through  the 
base  of  the  odontoid  ])rocess.  Dislocation  is  most  frequent  in  the  lower  part  of 
the  cervical  region,  especially  between  the  fifth  and  sixth  :  here  the  articular  pro- 
cesses look  backward  and  forward,  and  are  easily  separated  from  each  other  by 
extreme  flexion  without  any  fracture  taking  place.     Sometimes  when  the  force  is 


Fig.  302. — Fracture  of  Spine.  Part  of  the  body  of 
the  upper  of  the  two  vertebrae  is  driven  back- 
ward into  the  spinal  canal,  causing  hopeless 
disorganization. 


Fig.  303. — Dislocation  of 
the  Spine. 


spent,  they  fallback  into  position  again,  so  that,  though  the  spinal  cord  may  have 
been  completely  disorganized,  there  is  no  permanent  deformity  ;  in  other  cases 
they  are  caught  and  fixed,  and  then,  generally  speaking,  the  body  of  the  vertebra 
is  displaced  as  well  (Fig.  303).  The  same  thing  has  been  known  to  happen  be- 
tween the  two  last  dorsal  vertebrae,  and  also  between  the  twelfth  dorsal  and  the 
first  lumbar  ;  in  other  parts  it  is  very  rare. 

Unilateral  dislocation  can  be  produced  in  the  cervical  region  by  rotation.  If 
the  head  is  suddenly  twisted  round  while  the  neck  is  partially  flexed,  the  movement 
may  be  carried  a  little  too  far  and  one  articular  process  displaced  from  another. 
It  may  be  the  result  of  muscular  action  only,  or  of  direct  violence  applied  to  the 
side  of  the  head.  The  symptoms  are  usually  characteristic  ;  the  face  looks  down- 
ward and  is  inclined  to  one  side  ;  the  neck  is  slightly  bent ;  the  muscles  on  the 
convexity  are  in  a  state  of  spasmodic  contraction,  in  the  concavity  they  are  quite 
relaxed  ;  the  spines  are  not  irregular,  but  some  projection  can  be  felt  to  one  side 
of  the  middle  line  ;  and  the  least  attempt  at  movement  causes  the  most  intense 
pain.     Sometimes  there  is  difficulty  in  swallowing,  and  a  projection  can  be  felt  in 


FRACTURE  OF  THE  SPINE.  689 

the  pharynx  with  the  finger.  Nervous  symptoms  may  be  altogether  wanting  ; 
more  frequently  there  is  intense  pain,  formication,  or  anaesthesia,  corresponding  to 
one  or  more  of  the  roots  of  the  cervical  or  brachial  plexus  ;  in  most  there  is 
evidence  of  i)ressure  upon  the  cord,  difficulty  of  respiration,  weakness  or  paralysis 
of  the  extremities  ;  and  even  when  these  symptoms  are  not  present  at  first,  they 
generally  make  their  api)earance  later  on,  if  the  dislocation  is  not  reduced, 
caused  in  all  i)robability  either  by  hemorrhage  or  by  inflammation  and  softening. 

In  the  majority  of  cases  of  fracture,  or  of  complete  dislocation  of  the  spine, 
the  injury  inflicted  upon  the  cord  is  beyond  repair.  The  dura  mater,  when  the 
canal  is  laid  open,  may  appear  to  have  escaped,  but  only  too  frequently  everything 
inside  it  is  reduced  to  pulp.  In  exceptional  cases  the  chances  are  better;  if,  for 
instance,  a  spinous  process  only  is  broken  off,  or  an  articular  one  displaced,  there 
may  be  merely  bruising  or  comjjression  from  hemorrhage  into  the  sheath  of  the 
cord  or  into  the  spinal  canal ;  but  if  the  fracture  involves  the  laminae,  or  if  the 
ligamenta  subflava  are  torn,  the  effect  is  rarely  limited  to  this.  In  the  lumbar 
region  there  is  better  hope:  the  cord  occupies  a  smaller  space  in  the  spinal  canal ; 
the  displacement  is  less,  owing  to  the  greater  size  of  the  bodies ;  and  the  cauda 
equina,  formed  of  nerves  which  are  tough  and  firm,  escapes  more  easily.  In  pure 
dislocation  the  prospect  is  a  little  better  than  it  is  in  fracture,  for  though  the  dis- 
])lacement  may  be  no  less,  the  risk  of  fragments  being  driven  into  the  substance 
of  the  cord  is  certainly  not  .so  great. 

If  the  patient  survives  the  immediate  injury  there  is  always  the  danger  of 
diffuse  spinal  meningitis  and  red  softening  of  the  cord.  The  former  is  more 
common  after  gunshot  injuries,  but  even  in  simple  fractures  it  sometimes  begins 
around  the  bones  and  joints  ;  the  latter  is  nearly  always  present  in  greater  or  less 
degree  in  cases  that  prove  fatal  after  a  few  days  or  weeks,  starting  from  the  seat 
of  injury  and  extending  upward  as  well  as  downward.  It  is  more  likely  to  happen 
after  severe  injuries,  but  none  are  exempt. 

Symptoms, — {a)  Those  that  Depend  upon  the  Injury  Sustained  by  the  Bones 
and  Ligaments. — Undue  mobility  ;  deformity,  and  crepitus  are  present  in  fractures 
of  the  spine  as  in  most  others  :  but,  so  far  at  least  as  the  first  and  last  are  con- 
cerned, no  attempt  should  ever  be  made  to  elicit  them.  They  are  not  required 
for  purposes  of  diagnosis,  and  might,  probably  would  in  many  cases,  inflict  still 
further  injury  upon  the  cord.  With  deformity  it  is  different :  the  hand  should  in 
all  cases  be  carried  gently  down  the  back,  feeling  each  spinous  process  in  turn 
without  disturbing  the  patient,  so  as  to  ascertain  if  there  is  any  irregularity.  It 
may  be  necessary  to  reduce  it  at  once.  In  addition,  pain  is  always  present,  and  is 
made  worse  by  movement  or  by  pressure.  Generally  it  is  limited,  but  sometimes 
it  spreads  down  an  arm  or  leg  or  round  the  trunk,  owing  to  one  of  the  nerves 
being  caught  at  the  seat  of  fracture. 

In  a  few  cases  these  are  the  only  signs  ;  the  fracture  may  be  latent,  especially 
in  the  lumbar  region.  One  or  two  vertebrae  are  exceedingly  tender ;  there  is  a 
sense  of  weakness  or  want  of  support  when  standing  up;  lying  down,  the  patient 
can  move  his  limbs  with  such  freedom  that  I  have  known  it  necessary  to  put  a  cer- 
tain amount  of  restraint  upon  their  action  ;  but  there  may  be  no  other  sign. 
Sudden  displacement,  however,  may  occur  at  any  moment ;  hemorrhage  may 
spread  into  the  canal  ;  meningitis  or  myelitis  may  set  in  ;  even  suppuration  may 
follow  and  extend  along  the  cord  or  lead  to  caries  or  necrosis  of  the  bones.  In  the 
neck  latent  fracture  is  more  rare,  but  a  {q\n  instances  are  recorded  in  which  patients 
have  continued  to  get  about  even  for  days  without  its  being  suspected.  Weakness 
of  the  extremities  ;  a  sense  of  insecurity  in  the  movements  of  the  head,  so  that  it 
must  be  supported  by  the  hands  ;  pain  along  the  course  of  the  occipital  nerves  ; 
even  slight  deformity  may  be  present ;  and  yet  the  patient  be  unaware  of  the  risk 
that  he  is  running.  In  a  few  of  these  cases  the  symptoms  have  gradually  sub- 
sided, a  certain  amount  of  stiffness  only  has  been  left,  and  the  patient  has  re- 
covered ;  in  one  a  portion  of  bone,  recognized  as  the  odontoid  process,  was  dis- 


690     DISEASES  AND   INJURIES    OF  SPECIAL   STRUCTURES. 

charged  througli  an  abscess  :  more  fre([uently  death  occurs  either  instantaneously 
from  sudden  displacement,  or  gradually  from  myelitis. 

{b)  Those  Due  to  Injury  of  the  Spinal  Cord  or  Nerves. — In  most  cases,  even 
when  no  displacement  is  apparent,  the  cord  is  completely  crushed  and  the  power 
of  conduction  and  reflex  action  lost.  The  former  never  returns  ;  a  clean  division 
of  the  spinal  cord  might  i)ossibly  be  repaired,  even  in  man  ;  hemisection  certainly 
may  ;  but  the  injury  sustained  in  accidents  of  this  kind  is  much  too  grave.  The 
latter,  if  the  patient  survives,  returns  to  some  extent  as  the  shock  wears  off,  and 
may  in  some  cases  become  exaggerated.  Recently  l^owll)y  has  pointed  out  that, 
so  far  as  men  are  concerned,  there  is  a  material  difference  in  this  respect  between 
the  behavior  of  the  superficial  and  deep  reflexes  ;  the  former  may  return,  whether 
the  cord  is  crushed  completely  or  not ;  the  latter  never  do  unless  some  part  still 
remains  unhurt.  If  this  is  substantiated  it  must  become  a  factor  of  very  great 
importance  both  as  regards  prognosis  and  treatment. 

Another  sign  of  great  significance  has  been  pointed  out  by  Thorburn  ;  when 
the  violence  is  extreme,  the  roots  of  the  si)inal  nerves  are  crushed  and  torn  as 
badly  as  the  cord  itself,  and  the  area  of  anaesthesia  corresponds  anatomically  with 
the  seat  of  the  lesion.  If,  however,  the  force  is  not  so  great,  the  nerve-roots  lying 
by  the  side  of  the  cord  may  escape,  even  though  the  cord  itself  is  crushed,  and 
thus  give  rise  to  an  apparent  discrepancy,  especially  in  the  lower  dorsal  and  lumbar 
regions.  The  prognosis  in  the  former  case  is  certainly  much  worse,  and  if  ever 
surgical  interference  is  justifiable,  it  can  only  be  in  the  case  of  the  latter. 

If  the  injury  is  not  so  severe,  as  for  instance  happens  occasionally  in  the 
lumbar  region,  motion  is  always  more  affected  than  sensation,  and  although  perfect 
recovery  is  rare,  a  certain  amount  of  repair  may  take  place,  leaving  more  or  less 
anresthesia  and  spastic  rigidity.  When  due  to  hemorrhage  the  symptoms,  as  a 
rule,  begin  gradually  ;  there  is  an  interval  of  a  few  minutes,  or  even  of  some  hours  ; 
and,  as  Horsley  has  pointed  out  in  the  ca.se  of  tumors  pressing  upon  the  spinal 
cord,  the  paralysis  of  motion  spreads  from  above  downward,  the  anaesthesia  in  the 
opposite  direction.  In  the  slighter  cases,  when  the  blood  is  absorbed,  the  symp- 
toms begin  to  disappear  again,  following  the  reverse  order;  but  perfect  recovery 
is  uncommon,  and  not  unfrequently  after  temporary  improvement  red  softening 
sets  in. 

Occasionally  the  symptoms  occur  in  such  a  peculiar  manner  that  it  is  difficult 
to  believe  they  can  be  due  merely  to  suspension  of  the  activity  of  the  cord.  Lim- 
ited hyj)eriesthesia,  for  examjjle,  is  very  common  ;  sometimes  it  becomes  general, 
and  is  so  intense  that  the  slightest  touch  causes  agony  ;  mu.scular  wasting  is  the 
rule  ;  but  every  now  and  then  cases  are  met  with  in  which  it  is  so  rapid  that  it  is 
difficult  to  believe  that  it  is  only  the  result  of  disuse.  The  most  striking  examples, 
however,  are  sloughing  of  the  skin,  and  inflammation  of  the  urinary  organs. 
Both  of  these  are  common  results  of  fracture  of  the  spine,  and  in  nearly  every 
case  admit  of  a  local  explanation  ;  but  occasionally  they  are  so  intense,  so  rapid, 
and  attended,  with  such  an  amount  of  congestion  and  extravasation  that  it  has 
been  suggested  they  must  be  the  result  of  irritation  of  the  cord.  Symmetrical 
patches  of  skin  on  the  inner  sides  of  the  thighs,  for  example,  where  there  can  be 
no  pressure,  have  sloughed  and  beco;-',ie  gangrenous  in  a  few  days  ;  suppurative 
nephritis  has  set  in  within  forty-eight  hours  ;  and  weeks  after  the  accident  the 
most  intense  cystitis  has  suddenly  broken  out  and  proved  fatal  without  the  slightest 
evidence  of  any  local  cause.  Moreover,  in  one  or  two  cases,  these  lesions  have 
occurred  when  there  has  been  no  fracture  at  all,  but  merely  hemorrhage  into  the 
gray  substance  of  the  cord  and  red  softening. 

The  nature  of  the  symptoms  and  the  i)rognosis  depend  upon  the  seat  of  injury  ; 
loss  of  sensation,  for  example,  extending  as  high  as  the  umbilicus,  points  to 
injury  of  the  seventh  dorsal  vertebra;  if  it  extends  to  the  ensiform  cartilage, 
above  the  sixth.  The  superficial  origin  of  the  nerves  only  corresponds  to  the  point 
of  exit  from  the  canal  in  a  very  few  instances;  and,  as  Reid  has  shown,  varies, 


FRACTURE  OF  THE  SPINE.  691 

immensely  with  regard  to  the  spinous  processes.  The  first  dorsal,  for  instance, 
which  passes  out  below  the  first  dorsal  vertebra  and  helps  to  form  the  ulnar,  is 
nearly  always  destroyed  in  fracture  of  the  seventh  cervical ;  the  second,  third,  and 
fourth  lumbar  are  at  their  origin  opposite  the  eleventh  dorsal  ;  while  the  whole  of 
the  sacral  plexus  corresponds  roughly  to  the  ujjper  border  of  the  first  lumbar. 
Further,  owing  to  the  softening  of  the  cord  that  follows  injuries,  it  generally 
happens  that  a  day  or  two  after  the  accident  the  paralysis  and  loss  of  motion 
extend  upward  toward  the  head. 


Injuries  of  the   Upper  Cervical  Vertebm. 

Dislocation  of  the  head  from  the  atlas  is  very  rare,  but  can  be  produced  by  a 
violent  blow  upon  the  occiput  while  the  patient  is  stooping  forward.  Fracture 
of  the  atlas  is  nearly  as  rare ;  dislocation  from  the  axis  with  fracture  of  the 
odontoid  process  is  the  common  form.  The  check  ligaments  are  stronger  than 
the  bone,  so  that  this  gives  way  either  at  the  base,  or  more  frecjuently  below, 
through  the  body  of  the  axis.  Dislocation  without  fracture  is  seldom  met  with, 
but  may  occur  in  children,  owing  to  the  smaller  size  of  the  odontoid  process,  and, 
possibly  in  adults  when  the  injury  is  the  result  of  violent  rotation,  the  check 
ligaments,  as  it  were,  being  torn  across  in  detail. 

Injuries  of  this  character,  are,  of  course,  usually  fatal  at  once  ;  the  lower  end 
of  the  medulla  and  the  upper  part  of  the  cord  are  destroyed  by  the  odontoid 
process  being  driven  in.  In  a  very  few  instances,  however,  life  has  been  pro- 
longed, owing  to  the  large  size  of  the  ring  of  the  atlas  and  the  thickness  and 
toughness  of  the  attachment  of  the  dura  mater  to  the  margin  of  the  foramen' 
magnum.  Sometimes,  in  these  cases,  sudden  displacement  has  taken  place  after 
hours,  and  even  after  days. 

Fracture  immediately  below  this  is  equally  fatal,  owing  to  the  phrenic  nerve. 
The  main  root  comes  out  with  the  fourth  cervical.  If  the  centre  is  destroyed 
death  is  practically  instantaneous,  as  diaphragmatic  and  intercostal  respiration  are 
both  interrupted. 

Injuries  of  the  Lower   Cervical  Vertebrae. 

The  most  common  seat  of  fracture  as  well  as  dislocation  lies  between  the  fifth 
cervical  and  the  first  dorsal  ;  and,  as  a  rule,  the  cord  is  completely  crushed. 
Motion  and  sensation  are  entirely  lost  in  the  trunk  aud  lower  part  of  the  body. 
In  a  few  cases  there  is  a  want  of  symmetry  at  first ;  the  paralysis  may  extend  one 
or  even  two  nerves  higher  on  one  side  than  on  the  other  ;  but  as  softening  sets  in 
this  .soon  disappears.  Immediately  above  the  paralyzed  region  there  is  a  zone  of 
hyperesthesia ;  when  this  is  immediate  it  can  only  be  explained  by  the  mechanical 
irritation  of  the  nerves  above  the  seat  of  injury  ;  more  frequently  it  does  not  make 
its  appearance  for  some  hours,  not  until  the  circulation  in  the  parts  round  the 
injured  area  has  become  more  active.  Owing  to  the  shock,  reflex  action  is  at 
first  entirely  suspended  ;  the  cutaneous  reflexes  give  no  response  ;  irritation  at 
the  neck  of  the  bladder,  or  at  the  anus  has  no  effect ;  the  function  of  the  part  of 
the  cord  below  is,  for  the  time  being,  practically  abolished  ;  the  vaso-motor  nerves 
are  paralyzed,  the  blood-pressure  falls,  the  secretion  of  nrine  is  diminished,  the 
heart  beats  very  feebly,  and  the  pulse  is  rapid,  small,  and  soft. 

In  injuries  through  this  region  the  fibres  of  the  sympathetic  that  supply  the 
dilator  pupillse  must  be  paralyzed,  so  that  dilatation  of  the  pupil  cannot  take 
place.  It  is,  however,  difficult  to  estimate,  as  it  occurs  on  both  sides,  not  on  one 
only,  as  when  the  brachial  ])lexus  is  torn  away  from  the  cord,  and  the  degree  of 
contraction  is  not  very  marked. 

The  actual  distribution  of  paralysis  and  anaesthesia  depends  naturally  upon 
the  seat  of  the  lesion,  but  there  is  considerable  difficulty  in  ascertaining  the  exact 
centre  and  nerve-root  for  individual  muscles,  and  without  this,  of  course,  perfect 


692    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

localization  is  impossible.      [The  following;  table,  founded  almost  entirely  upon 
clinical  data,  is  taken  from  Thorburn,  doubtful  muscles  being  excluded  : — 

Supraspinatus, "1    ,-       ,  .     , 

-r  ^       ^ ■       ,^^  \  rourlh  cervical  nerve, 

leres  minor  (?), J 


f  l^icejjs,    ..... 
\  Brachialis  anticus,  . 

Deltoid, 

(  Supinator  longus    . 
\  Supinator  brevis  (?), 


Fifth  cervical  nerve. 


Subscapularis, ~| 

Pronators, 

Teres  major, 

Latissimus  dorsi, j-  Sixth  cervical  nerve. 

Pecloralis  major, 

/  Triceps, | 

\  Serratus  magnus, J 

Extensors  of  the  wrist, Seventh  cervical  nerve. 

Flexors  of  the  wrist,      Eighth  cervical  nerve. 

Interossei, )    t-    .  j        1 

^-..i       •  .  •      „  1        r  ti     1,      1  1   i'lrst  dorsal  nerve. 

Other  intrinsic  muscles  of  the  hand,    .    .    .    .    j 

— From  Thorburn^ 

These,  of  course,  as  Thorburn  points  out,  are  only  the  chief  points  of  origin, 
minor  connections  not  being  regarded.  Thus,  if  the  injury  is  above  the  sixth 
•cervical,  the  elbow  is  flexed  and  supinated,  the  arm  abducted,  and  the  wrist  and 
fingers  motionless — a  most  characteristic  attitude  ;  if  below  this,  abduction  and 
supination  are  better  performed,  and  a  certain  degeee  of  extension  and  adduction 
is  possible,  but  there  is  still  no  power  over  the  lower  joints. 

The  level  of  the  anesthesia  is  not  so  difficult ;  the  fifth  root,  the  first  of  the 
series  supj)lying  the  fore  limb,  is  distributed  to  the  region  of  the  deltoid  and  the 
outer  aspect  of  the  arm  and  forearm  as  far  as  the  base  of  the  thumb  ;  the  eighth 
and  first  dorsal  supply  the  inner  side  of  the  arm,  forearm,  hand,  and  little  finger  ; 
the  sixth  and  seventh  are  distributed  to  the  intervening  spaces  on  the  anterior  and 
posterior  surfaces. 

Respiration  is  embarrassed  from  the  first.  All  the  muscles  that  raise  the  ribs 
and  help  to  enlarge  the  thorax  are  paralyzed  ;  only  the  diaphragm  is  left.  Inspira- 
tion is  carried  on  with  difficulty  ;  instead  of  the  chest  expanding  when  the 
diaphragm  contracts,  so  that  at  the  end  of  the  act  it  is  distended  in  all  directions, 
it  collapses  and  sinks  in,  and  the  work  of  the  diaphragm  is  in  great  measure  lost. 
Expiration  is  worse  still ;  at  the  commencement,  when  the  chest  ought  to  be  dilated 
to  its  utmost,  ready  to  recoil  from  the  elasticity  of  its  walls  as  soon  as  the  muscles 
relax,  it  is  already  contracted,  and  every  expiratory  muscle  is  paralyzed.  The 
only  forces  left  are  the  elasticity  of  the  partially-distended  lungs  and  the  weight 
of  the  abdominal  viscera  which  have  been  pushed  downward  and  forward. 
Coughing  is  impossible;  fiill  expansion  of  the  lungs  cannot  take  place;  the 
bronchi  become  plugged  with  mucus,  and  the  blood  gradually  stagnates  at  the 
lower  and  back  part  of  the  lobes  until,  the  respiration  growing  worse  and  worse 
each  moment,  and  the  action  of  the  heart  becoming  feebler,  hypostatic  congestion 
or  pneumonia  sets  in.     Generally  this  proves  fatal  in  the  course  of  a  few  days. 

As  the  shock  passes  off,  the  character  of  the  symptoms  begins  to  change. 
The  loss  of  motion  and  sensation  remains  unaltered,  or  possibly  extends  a  short 
distance  higher  up,  but  the  su])erficial  reflexes  gradually  return.  If  their  recovery 
is  long  delayed,  or  if,  having  once  returned,  they  begin  to  fail  again,  the  prog- 
nosis is  very  grave;  in  one  case  it  points  to  injury  so  serious  that  it  may  prove 
fatal  before  reaction  can  set  in  ;   in  the  other  to  progressive  softening  of  the  cord. 

The  first  sign  is  the  recovery  of  the  circulation  :  the  heart  begins  to  beat  more 
firmly,  the  skin  becomes  warm,  and  the  state  of  extreme  prostration  passes  off.     In 


FRACTURE  OF  THE  SPINE.  693 

fracture  through  this  region,  liowever,  strange  variations  are  not  uncgmmon.  In 
some  cases,  the  pulse  becomes  aljnormally  full,  slow,  and  deliberate  ;  in  others  the 
temperature  falls  immediately  after  the  accident,  and,  in  spite  of  the  shock  passing 
off,  continues  to  drop  until  in  one  instance  it  is  said  to  have  reached  80°  6'  F. 
More  frecjuently  it  rises  rapidly  ;  I  have  known  it  to  ascend  from  93°  F.  to  109° 
F.  within  thirty-six  hours  ;  and  higher  temjjeratures  than  this,  persisting  and 
sometimes  even  rising  after  death,  have  been  recorded  on  many  occasions.  It  is 
impossible  to  avoid  comparing  this  with  the  results  of  curare-poisoning,  but  it 
cannot  be  said  to  explain  in  any  way.  As  has  been  shown  by  Hutchinson,  high 
temperatures  are  always  associated  with  vigorous  action  of  the  heart  and  full, 
throbbing  pulse. 

The  secretion  of  urine  is  but  little  altered ;  the  quantity  is  scanty  at  first, 
owing  to  the  general  fall  in  the  blood  pressure ;  but  as  the  shock  passes  off  it  in- 
creases again.  Sometimes  there  is  haematuria  without  any  direct  injury  to  the 
lumbar  region,  possibly  from  extreme  distention  of  the  capillaries;  and  it  is  said 
that  the  urine,  as  secreted  by  the  kidney,  is  not  unfrequently  alkaline  in  reaction. 

Micturition  is  always  affected.  At  first  there  is  complete  retention  ;  the  lum- 
bar portion  of  the  spinal  cord,  has,  for  the  time  being,  completely  lost  its  power, 
and  the  urine  simply  accumulates  in  the  bladder.  If  this  is  not  relieved  the  result 
is  merely  a  question  of  relative  pressure  ;  the  bladder  becomes  more  and  more  dis- 
tended, until,  if  left  sufficiently  long,  its  muscle  passes  into  a  state  of  atony,  the 
elastic  resistance  of  the  sphincter  gives  way,  and  the  urine  flows  out  drop  by  drop, 
leaving  the  bladder  as  full  as  it  can  be. 

If  the  patient  survive,  the  subsequent  condition  is  not  always  the  same.  Some- 
times, as  the  cord  regains  its  power,  micturition  takes  place  involuntarily  at  regular 
intervals  :  the  bladder  becomes  distended,  a  drop  of  urine  flows  into  the  neck,  the 
stimulus  passes  up  to  the  lumbar  centre  in  the  cord,  and  as  the  influence  of  the 
brain  is  not  there  to  strengthen  the  sphincter,  the  muscles  of  the  bladder  contract 
and  empty  the  cavity  more  or  less  completely.  This  appears  to  be  the  rule  in  the 
lower  animals,  but  such  perfect  recovery  of  function  is  rarely  met  with  in  man  ; 
either  from  atony  of  the  wall  of  the  bladder  (arising  from  its  over-distention),  or 
from  the  spinal  centre  never  regaining  its  full  power  of  reflex  action,  a  catheter 
has  generally  to  be  passed  at  regular  intervals,  or  the  bladder  must  be  emptied  by 
pressure  over  the  pubes. 

Cystitis  is  exceedingly  common  ;  in  some  few  cases  it  may  be  caused,  like 
bed-sores,  by  irritation  of  the  cord — extreme  congestion,  followed  by  intense, 
inflammation,  suppurating  and  sloughing  setting  in  without  any  local  cause,  and 
attacking  kidneys,  ureters,  and  bladder  together — but  such  must  be  very  rare  ;  in 
by  far  the  majority  it  is  due  to  the  extreme  difficulty  of  taking  proper  precautions 
for  such  a  length  of  time.  There  is  everything  to  favor  its  occurrence  ;  the 
bladder  and  urethra  are  absolutely  insensitive  ;  their  walls,  deprived  of  all  oppor- 
tunity of  working,  are  badly  nourished  and  therefore  prone  to  inflammation  ;  the 
cavity  is  never  properly  and  naturally  emptied ;  the  mucus  which  is  secreted  and 
which  lines  the  urethra  is  not  washed  out,  but  remains  as  a  tenacious  alkaline 
coating ;  the  constant  introduction  of  a  catheter,  even  when  it  is  perfectly  clean, 
acts  as  an  irritant ;  the  amount  of  mucus  increases  ;  and  the  acidity  of  the  urine 
diminishes  until  every  condition  that  favors  the  growth  of  the  specific  urea  fer- 
ment is  present.  If,  in  such  circumstances,  it  finds  its  way  in,  whether  by  means 
of  the  catheter  (which  is  usually  the  case)  or  along  the  mucus  of  the  urethra,  or 
through  the  kidney,  decomposition  immediately  begins,  the  urine  becomes  am- 
moniacal,  every  drop  as  it  falls  into  the  bladder  becomes  an  intense  irritant,  and 
the  most  severe  cystitis,  so  bad  as  to  cause  sloughing  of  the  mucous  membrane, 
or  perivesical  suppuration,  is  sure  to  follow.  In  a  large  number  of  the  cases  in 
which  the  patient  escapes  hypostatic  congestion,  this  proves  fatal,  either  directly 
or  through  the  secondary  inflammation,  suppurative  pyelo-nephritis. 

Priapism  is  common  in  fractures  above  the  mid-dorsal  region  ;  sometimes  it 
is  immediate ;  more  frequently  reflex,  not  beginning  until  a  catheter  is  passed  or 


694    DISEASES  AND  INJURIES   OF  SPECIAL  STRUCTURES. 

the  bladder  becomes  distended.  It  is  rarely  marked  in  degree  ;  and,  if  the  patient 
survives,  usually  passes  off  of  itself;  occasionally,  however,  it  is  extreme  and  it 
may  be  followed  by  extravasation  into  the  erectile  tissue. 

.As  a  rule  in  these  fractures  the  alimentary  canal  suffers  very  little  ;  obstinate 
vomiting  has  occasionally  been  noticed  in  injuries  of  the  cervical  region,  and 
tympanites  may  occur,  possibly  from  absence  of  the  natural  support  to  the  intes- 
tines after  the  muscles  of  the  abdominal  wall  are  paralyzed.  Wherever  the  fracture 
takes  place  constipation  is  the  rule,  so  long  as  the  motions  are  solid  ;  the  peristaltic 
action  of  the  intestine  is  in  abeyance  for  some  time,  then  it  gradually  recovers, 
and  at  long  intervals  passes  on  the  contents  into  the  rectum  ;  the  sphincter  is  com- 
pletely paralyzed,  and  as  soon  as  the  lower  part  of  the  bowel  is  reached  evacuation 
takes  place  involuntarily.  Liquid  motions,  as  when  there  is  diarrhoea,  flow  away 
continuously  without  control.  In  those  instances  in  which  the  patients  recover 
the  bowels  usually  act  once  or  twice  a  week,  the  motions  being  very  copious  and 
solid  ;  and  after  a  time  the  patient  becomes  aware,  from  the  feeling  of  headache, 
or  oppression,  or  from  flushing  of  the  face,  when  an  evacuation  is  going  to  take 
place. 

In  by  far  the  majority,  fracture  of  the  lower  cervical  spine  is  fatal  within  the 
first  four  days  :  few  last  out  the  week  ;  a  very  small  number  is  recorded  as  having 
survived  for  longer  periods.  Still  it  is  possible  for  life  to  be  prolonged  for  months 
and  even  for  years,  in  spite  of  paralysis  of  the  trunk  and  legs,  and  in  one  or  two 
instances  of  the  arms  as  well.  The  nutrition  of  the  paralyzed  part  is  very  feeble  ; 
bed-sores  are  liable  to  form  upon  the  sacrum,  the  ischial  tuberosities,  and  the 
trochanters.  If  they  occur  within  the  first  few  hours,  they  may  be  the  direct 
result  of  irritation  of  the  cord,  but  much  more  often  they  do  not  make  their 
appearance  until  three  or  four  days  have  passed,  and  are  due  entirely  to  local 
causes.  The  body  lies  absolutely  motionless,  hour  after  hour,  pressing  upon  the 
same  points,  without  intermission  of  any  kind  or  sense  of  discomfort;  the  skin 
becomes  red  ;  the  epidermis  is  detached,  the  cutis  exposed,  and  a  slough  soon 
forms,  spreading  perhaps  until  the  bone  beneath  becomes  necrosed,  or  even  the 
spinal  canal  is  opened.  If  the  parts  are  allowed  to  become  wet  or  sodden  from 
faeces  or  urine,  this  is  sure  to  occur,  and  the  inflammation  is  verv  likelv  to  end 
fatally. 

All  over  the  paralyzed  part  the  skin  becomes  harsh  and  branny,  covered  with 
desquamating  scales  ;  the  rounded  outline  of  the  limb  disappears,  the  bones  be- 
.come  prominent,  the  muscles  waste  and  become  hard  and  unyielding,  and  the 
limbs  are  either  fixed  in  a  condition  of  permanent  flexion,  or  are  subject  to  con- 
stant twitchings,  which  may  be  so  violent  as  to  shake  the  whole  body.  As  may 
be  ipiagined,  the  health  soon  begins  to  fail,  though  in  fractures  through  the  dorsal 
region  the  nutrition  of  the  rest  of  the  body  is  sometimes  maintained  surprisingly 
well ;  and  even  if  the  patient  escapes  the  immediate  consequences  of  the  injury, 
he  is  very  likely  to  succumb  to  the  first  trivial  accident  with  which  he  meets,  even 
a  mere  cold,  especially  if  it  attacks  the  lungs. 

Injuries  of  the  Dorsal  Region. 

The  symptoms  of  fracture  below  the  first  dorsal  vertebra  are  practically  the 
same,  making  allowance  for  the  difference  in  position  and  number  of  the  muscles 
that  are  paralyzed.  Owing  to  the  small  size  of  the  canal,  the  cord  is  generally 
crushed  completely;  there  is  the  same  risk  of  cystitis  and  bed-sores;  priapism, 
however,  does  not  occur  unless  the  injury  is  high  up  ;  the  temperature  is  rarely 
phenomenal ;  and  respiration  is  not  so  much  interfered  with.  The  extent  to  which 
this  takes  place  depends  upon  the  number  of  intercostals  paralyzed.  Temporary 
recovery  is  not  unfrequent,  but  death  follows  sooner  or  later  from  bladder  or  renal 
trouble,  from  bed-sores,  exhaustion,  or  from  degeneration  and  softening  extending 
further  up  the  cord. 


FRACTURE  OF  THE  SPINE.  695 

Injuries  of  the  Lumbar  Region. 

The  lower  the  injury  the  better  the  prognosis :  the  shock  is  not  so  great,  the 
respiratory  muscles  escajje,  and  owing  to  the  flexibility  and  toughness  of  the  nerves 
that  form  the  cauda  equina,  the  loss  of  motion  and  sensation  in  the  parts  below  is 
often  incomplete.  In  fractures  through  the  last  dorsal  or  first  lumbar  vertebra, 
the  centre  that  governs  the  act  of  micturition  is  destroyed,  and  the  effect  on  the 
bladder  is  the  same  as  if  all  the  nerves  going  to  it  were  cut  across.  At  first  there 
is  retention  of  urine,  and,  unless  relief  is  given,  overflow,  just  as  when  the  cervical 
cord  is  hurt  ;  but  in  a  short  time  the  muscles  begin  to  degenerate  and  contract ; 
they  become  hard  and  lose  their  elasticity  ;  the  capacity  of  the  bladder  diminishes 
until  its  cavity  is  almost  obliterated  ;  and  a  condition  of  true  incontinence  is 
produced,  the  urine  flowing  out  from  the  urethra  as  it  passes  down  the  ureters. 
The  eff"ect  on  defecation  is  not  so  marked,  as  the  action  of  the  intestine  is  to  a 
much  greater  extent  independent  of  the  spinal  cord 

When  the  fracture  occurs  below  the  second  lumbar  the  symptoms  are  often 
obscure.  The  cord  itself,  of  course,  escapes,  being  above  the  seat  of  injury  ;  so  may 
the  long  flexible  roots  of  the  cauda  equina,  which  slip  to  one  side  or  the  other  out 
of  the  way  ;  and  there  may  be  either  no  nervous  symptoms  of  any  kind,  or  partial 
loss  of  motion  and  sensation,  with  violent  pain  shooting  down  the  limbs,  owing 
to  some  of  the  nerves  being  crushed  or  torn  by  the  broken  fragments  of  bone. 
If  the  fourth  sacral  is  injured,  there  is  true  incontinence,  as  when  the  micturition 
centre  is  destroyed.  These  cases  of  latent  fracture  not  unfrequently  escape 
diagnosis;  there  is  no  crepitus  or  undue  mobility,  nor  of  necessity  is  there  any 
deformity  ;  merely  local  pain  and  tenderness,  and  a  great  sense  of  weakness  and 
insecurity  when  an. attempt  is  made  to  stand  or  move.  The  prognosis  of  course, 
is  much  more  favorable  ;  but,  as  in  fracture  of  the  spine  elsewhere,  there  is  always 
the  risk  of  chronic  inflammation  setting  in  and  extending  along  the  membranes 
until  the  cord  becomes  affected. 

Treatment  — In  many  cases  the  cord  is  completely  crushed  at  once,  beyond 
all  hope  of  recovery  ;  sometimes  the  injury  is  made  very  much  worse  by  the  ill- 
advised  efforts  of  assistants.  If  therefore  there  is  the  barest  suspicion  of  such  an 
accident,  the  patient  should  merely  be  laid  perfectly  straight  upon  his  back  on  level 
ground  and  not  raised  or  moved  until  there  is  some  one  to  superintend  his  being 
placed  upon  a  stretcher.  A  water  or  air-cushion,  circular  or  horseshoe-shaped  for 
choice,  is  essential  for  the  sacrum,  and  is  better  than  a  water-bed  ;  and  the  mattress 
and  draw-sheets  must  be  arranged  so  that  the  bed-pan  may  be  used  without  dis- 
turbing the  patient.  The  outer  clothes  and  boots  may  be  removed  while  the  patient 
is  on  the  stretcher  ;  the  others  should  be  left  until  he  is  lifted  on  to  the  bed  and 
everything  is  ready  for  a  complete  examination. 

Active  treatment  is  impossible  in  the  majority  of  instances  ;  if,  however,  defi- 
nite displacement  can  be  made  out,  if  there  is  a  distinct  irregularity  in  the  spines, 
or  a  projection  where  there  ought  to  be  a  hollow,  and  if  the  patient's  condition 
admits  of  it,  reduction  should  certainly  be  attempted,  and  as  soon  as  possible; 
delay  only  increases  the  risk  of  hemorrhage  and  softening  of  the  cord  from  pres- 
sure ;  but,  particularly  in  the  cervical  region,  it  should  be  explained  to  the  friends 
that  the  proceedings  may  prove  immediately  fatal. 

In  unilateral  dislocations  of  the  neck,  when  one  articular  process  only  is  dis- 
placed, and  when  the  accident  is  the  result  of  sudden  twist,  reduction  is  often 
attended  with  conspicuous  success.  The  patient  should  be  cautiously  placed  under 
an  anaesthetic,  so  as  to  relax  the  muscles  ;  the  head,  which  already  inclines  toward 
the  opposite  shoulder,  bent  over  as  far  as  can  be  to  disengage  the  processes  ;  and 
then  rotated  so  as  to  carry  the  under  side  forward.  Slow  extension  with  rotation 
has  succeeded  even  without  an  anaesthetic,  the  patient  being  seated  and  the 
operator  standing  behind,  grasping  the  head  while  the  shoulders  are  fixed  ;  some- 
times a  sudden  snap  has  been  heard ;  more  often  the  improvement  is  gradual. 

Bilateral  dislocations  are  very  much  more  serious,  owing  to  the  displacement 


696    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

of  the  body  ;  but  even  here  a  sufificient  degree  of  success  has  occurred  to  warrant 
the  proceeding.  Hiiter  recommends  the  same  method  as  in  the  unilateral  form, 
one  side  being  reduced  first,  and  then  the  other,  on  the  ground  that  extension 
when  all  the  ligaments  are  so  much  torn  would  expose  the  cord  to  undue  risk  ;  and 
in  one  case  out  of  three  he  succeeded  in  saving  life.  Ashhurst,  however,  gives  par- 
ticulars of  several  in  which  permanent  improvement  followed  gentle  extension 
combined  with  rotation,  and  in  one  instance  with  pressure  upon  the  displaced  body 
from  the  interior  of  the  pharynx.  When  the  displacement  is  not  reduced,  the 
result  is  almost  sure  to  be  fatal  within  the  week.  It  must  always  be  rememl^ered 
in  manipulating  that  the  upper  fragment  is  displaced  forward,  and  that  if  it  is 
carried  ever  so  little  further  in  this  direction  the  cord  must  be  crushed.  As  soon 
as  the  displacement  is  rectified,  the  head  must  be  fixed  by  weight-extension,  and 
the  arch  of  the  neck  supported  from  below,  either  by  a  sand-bag  (others  being  used 
to  prevent  lateral  bending)  or  a  collar  made  from  softened  mill-board,  or,  better, 
from  sheets  of  absorbent  cotton  dipped  in  thin  plaster-cream. 

Extension  under  anaesthetics,  combined  with  pressure,  has  also  been  successful 
in  injuries  of  the  lower  dorsal  and  lumbar  regions  ;  but  the  displacement  is  seldom 
com])letely  rectified,  owing  to  the  i)resence  of  fracture  and  to  the  locking  of  the 
articular  i)rocesses.  Crepitus  has  been  felt  on  several  occasions  while  it  was  being 
done.  Weight-extension  should  be  applied  to  the  legs  before  the  patient  comes 
round,  in  order  to  prevent  any  recurrence. 

Where  there  are  no  nerve  symi)toms  the  trunk  may  be  encased  at  once  in 
plaster-of-Paris,  as  the  best  method  for  ensuring  rest  and  guarding  against  injury 
to  the  cord ;  and  the  same  plan  has  been  adopted  with  great  benefit  in  injuries  of 
the  lumbar  region  in  which  the  displacement  has  been  rectified.  Berkeley  Hill 
has  done  it  within  thirty  hours  of  the  accident ;  in  most  of  the  other  cases  two  to 
four  days  have  been  allowed  to  elapse. 

In  the  earlier  cases  the  vertical  position  was  tried,  the  patient  either  being 
supported  under  the  arms,  or,  better,  laid  upon  a  table  swinging  upon  a  central  axis 
like  a  toilet  glass,  and  then  carefully  slung  up  from  Sayre's  tripod.  In  the  more 
recent  ones  the  jacket  has  been  applied  with  the  patient  lying  down.  A  bed  is 
prepared  with  folded  blankets  and  a  mackintosh,  and  two  bandages  are  laid  upon  it, 
crossing  at  right  angles  to  mark  the  ground  plan  :  one  must  be  long  enough  to 
reach  from  the  occiput  to  within  an  inch  of  the  trochanters  ;  the  other  must  be 
one-fourth  more  than  the  girth  of  the  patient's  chest.  On  these  are  placed,  first, 
a  many-tailed  bandage  made  of  coarse  house-flannel  to  go  on  the  outside  of  all  ; 
then  a  layer  of  crinoline  bandages,  three-fold  thick,  soaked  in  mucilage  and  plaster 
(the  proportions  are  generally  an  ounce  of  mucilage  to  a  pound  of  plaster).  The 
upper  strijjs  must  be  laid  in  position  first,  and  each  must  overlap  the  one  above  it 
at  least  two-thirds.  Then,  over  this  in  a  similar  manner,  a  second  and  a  third 
layer,  the  ends  of  the  strips  being  prevented  from  sticking  to  those  above  and  below 
by  laying  a  piece  of  ordinary  bandage  over  these  down  each  side.  Overall  is  laid 
a  sheet  of  absorbent  wool,  especially  thick  on  either  side  of  the  spine,  so  as  to  pro- 
tect the  processes  as  far  as  possible  ;  and  a  small  water  or  air-cushion  may  be  fixed 
opposite  the  sacrum,  so  that  when  the  jacket  is  set  its  contents  may  be  let  out,  and 
may  be  withdrawn  without  disturbing  the  rest.  If  the  jacket  issufticiently  long  to 
come  well  over  the  gluteal  region,  and  clasp  the  crests  of  the  ilia,  it  will  hold  the 
trunk  firmly  enough. 

The  patient  must  be  lifted  up  from  either  side,  carried  over  the  foot  of  the 
bed  while  extension  is  still  being  kept  up,  and  laid  gently  down  in  the  exact  posi- 
tion that  has  been  prepared  for  him  ;  and  then  commencing  from  below,  each  strip 
must  be  carefully  folded  round,  crossed  over,  and  smoothed  down  as  rapidly  as 
possible. 

In  a  very  large  proportion  of  cases  all  that  can  be  done  is  to  protect  the  patient 
from  the  various  complications  that  may  set  in.  The  effect  of  the  pressure  on  the 
back  must  be  avoided  as  far  as  can  be  by  water-cushions  and  ])illows,  and  by  pads 
of  elephant  plaster.     The  skin  must  be  kept  as  dry  as  possible,  and  whenever  there 


INJURIES  OF  THE  SPINAL  CORD.  697 

is  an  opportunity,  should  be  sponged  over  with  spirit  to  harden  it  ;  Ijut  care  must 
be  taken  that  the  shoulders  are  not  rolled  over  first,  to  dry  that  part  of  the  back, 
and  the  hips  afterward.  Even  the  position  of  the  extremities  must  be  carefully 
watched,  and  the  weight  of  the  bed-clothes  preventetl  from  pressing  them  down, 
or  sores  may  form  upon  the  external  malleoli  and  elsewhere.  The  bladder  must  be 
emptied  by  means  of  a  catheter  three  times  a  day  ;  of  course  the  greatest  gentle- 
ness must  be  used,  especially  as  the  part  is  absolutely  insensitive  ;  but  this  is  not 
enough,  the  catheter  must  be  of  the  softest  description,  and  must  be  kept  in  a 
solution  of  carbolic  acid  ;  it  is  not  enough  to  dip  it  in  before  using.  If  there  is  the 
least  sign  of  cystitis,  gr.  xv  of  benzoate  of  ammonia  should  be  given  three  times  a 
day,  to  try  and  keej)  the  urine  acid  ;  the  bladder  should  be  very  carefully  washed 
out  with  Condy's  fluid,  boracic  acid,  or  a  very  dilute  acid  solution  of  corrosive 
sublimate  ;  and  a  grain  of  sulphate  of  quinine  dissolved  in  an  ounce  of  water  may 
be  injected  afterward  and  left  in.  Phosphatic  calculi  of  enormous  size  have 
formed  in  the  bladder  after  fracture  of  the  spine.  The  bowels  are  better  left 
alone,  at  first,  at  any  rate ;  the  amount  of  food  the  patient  takes  is  generally  very 
small,  and  the  inconvenience  of  constipation  is  not  to  be  compared  with  the  risk 
of  movement  and  the  danger  to  the  skin.  Care,  however,  should  be  taken  that 
the  anus  and  the  parts  around  it  are  kept  dry.  If  the  bowels  do  not  act  of  them- 
selves after  a  few  days,  an  enema  may  be  given. 

Pain  shooting  down  the  nerves  is  sometimes  relieved  by  continuous  extension  ; 
the  hyperesthesia  th^^t  sets  in  on  the  second  day  and  occasionally  extends  over  the 
non-paralyzed  portion  of  the  trunk  is  more  difficult  to  treat.  Probably  it  is  the 
result  of  hypersemia  of  the  cord,  and  points  to  the  commencement  of  red  soften- 
ing or  myelitis.  Iodide  of  potash  in  large  doses  has  been  recommended,  and 
leeches  have  been  applied  with  advantage  when  the  injury  was  in  the  lumbar  region, 
so  that  the  bites  would  not  afterward  be  pressed  upon  ;  but  the  prognosis  when  this 
sets  in  is  very  grave. 

In  cases  of  fracture  by  indirect  violence  the  operation  of  trephining  offers 
little  or  no  hope.  It  is  probable  that  in  the  majority  of  cases  the  cord  is  only 
subjected  to  momentary  compression,  but  yet  it  is  so  reduced  to  pulp  that  recovery 
of  function  very  rarely  follows.  If  it  were  possible  to  diagnose  the  persistence  of 
compression  and  to  relieve  it  by  operation,  the  condition  would  be  no  better  and 
the  probability  of  recovery  not  in  the  least  greater.  This  has  been  confirmed  by 
actual  trial  in  a  sufficient  number  of  instances  ;  in  fractures  of  this  description  the 
injury  to  the  nerve  structures  is  either  so  slight  that  an  operation  of  such  a  nature 
is  not  justifiable,  or  so  severe  that  it  could  do  no  good. 

In  fractures  by  direct  violence,  on  the  other  hand,  the  question  is  altogether 
different.  The  lamina  or  a  spine  may  be  driven  in  with  just  sufficient  violence  to 
compress  the  cord  without  destroying  it ;  and  if  anything  of  the  kind  is  suspected, 
the  operation  should  certainly  be  performed  at  once.  It  has  proved  its  merit. 
Still  more  is  this  the  case  with  cauda  equina.  The  nerves  that  compose  it  may  be 
compressed  by  displaced  bone  or  by  cicatricial  tissue,  and  although  they  possess  a 
power  of  adapting  themselves  altogether  unknown  in  the  spinal  cord,  there  are 
limits  even  to  this ;  and  if  improvement  does  not  take  place,  or  if  in  a  few  weeks 
it  begins  to  flag,  it  is  open  to  argument  whether  it  would  not  be  better  to  expose 
the  seat  of  injury  and,  if  possible,  release  them. 

Injuries  of  the  Spinal  Cord. 

The  spinal  cord  may  be  injured  by  itself  without  the  vertebral  column  being 
hurt.  It  may  be  bruised  from  a  violent  blow  upon  the  back,  or  torn  from  forced 
bending ;  it  may  be  compressed  from  hemorrhage,  from  bone  that  has  been 
driven  in,  or  from  inflammatory  products  thrown  out  by  the  meninges ;  it  may  be 
so  shaken  by  concussion  that  its  activity  is  partially  suspended,  or  it  may  be 
wounded  by  stabs  or  punctures  between  the  arches  of  the  vertebrae.  The  symp- 
toms are  essentially  the  same  as  when  it  is  crushed  in  fractures  of  the  spine ;  and 
45 


698     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

the  same  sequela2,  softening  and  inflammation,  may  set  in,  but  they  differ  con- 
siderably in  their  extent  and  in  the  time  of  their  occurrence. 

Contusion  of  the  Spinal  Cord. — Hamatoinyelia. — Hemorrhage  into  the  sub- 
stance of  the  cord  is  nearly  always  the  result  of  forced  flexion,  and  occurs  naturally 
in  the  region  in  which  fracture  by  indirect  violence  is  most  common.  Sometimes 
the  similarity  of  origin  is  shown  by  their  occurring  together,  but  independently  of 
each  other.  It  is  possible,  however,  that  it  maybe  caused  by  direct  violence  al.so. 
The  hemorrhage  nearly  always  lies  in  the  gray  substance  of  the  cord,  because  this 
is  the  softest  and  the  most  vascular  part ;  and  it  may  occui)y  an  indefinite  length. 
The  effect  is  immediate,  becoming  intensified  later  as  the  hemorrhage  extends. 
Motion  and  sensation  are  lost  over  a  corresponding  area  ;  reflex  action  is  suspended 
for  a  time,  but  rarely  so  completely  as  when  the  cord  is  crushed  ;  and  then  later, 
as  the  circulation  around  the  injured  area  becomes  more  active,  hyperaesthesia  sets 
in  ;  motor  disturbances  are  rare. 

The  subsequent  course  depends  chiefly  upon  the  degree  of  the  primary  injury. 
The  extravasated  blood  may  be  in  great  measure  absorbed,  leaving  a  certain  degree 
of  anaesthesia,  with  paralysis  or  spastic  rigidity  of  the  muscles,  corresj)onding  to 
the  part  of  the  cord  that  has  been  destroyed  ;  or,  on  the  other  hand,  red  softening 
and  ascending  myelitis  may  follow,  the  paralysis  extend  higher,  bed-sores  and 
cystitis  set  in,  and,  if  the  injury  is  in  the  cervical  region,  phenomenal  temperatures, 
just  as  when  there  is  a  fracture.  According  to  Thorburn  it  is  probable  that  cases 
of  hemorrhage  into  the  cord  are  much  more  common  than  is  usually  suspected. 

Wounds  of  the  spinal  cord  are  rare  in  civil  practice,  but  they  may  be  produced 
by  stabs,  the  weapon  passing  between  the  arches  of  the  vertebrae,  possibly  notching 
or  incising  them  as  it  does  so  ;  or  by  gunshot  injuries.  The  symptoms  in  either 
case  depend  upon  the  seat  and  the  extent  of  the  injury,  and  only  differ  from  those 
of  crushing  of  the  spinal  cord  in  fractures  by  their  proneness  to  inflammation  and 
suppuration.  There  are  several  authentic  cases  on  record  in  which  men  have  re- 
covered completely  after  symptoms  that  pointed  to  at  least  partial  division  of  the 
cord  ;  so  that  it  is  probable  that,  though  it  may  not  be  so  perfect  as  it  is  in  animals, 
a  certain  amount  of  repair  may  take  place,  whether  this  consists  in  actual  reunion 
of  the  divided  fibres,  or  in  a  re-arrangement  of  conduction  in  the  cord. 

Compression. — This  is  much  more  rare ;  it  may  be  caused  by  a  lamina  driven 
in,  though  when  this  occurs  the  delicate  nervous  tissue  is  almost  sure  to  be  utterly 
crushed  ;  or  by  hemorrhage,  either  inside  the  theca  or  between  it  and  the  bones  (it 
is  impossible  to  distinguish  one  from  the  other)  ;  or  later  it  may  result  from  inflam- 
mation, as  in  Pott's  disease.  If  due  to  bone  the  symptoms  are  immediate  ;  if  to 
hemorrhage,  there  is  a  distinct  interval  before  they  commence,  and  they  progress 
from  below  upward,  affecting  the  leg  first,  and  then  the  trunk,  until  the  respira- 
tory muscles  are  involved.  The  loss  of  motion  is  more  marked  than  that  of  sen- 
sation, but  it  is  rarely  so  definite  as  in  contusion  ;  pain  along  the  course  of  the 
nerves,  hyperaesthesia  extending  round  the  trunk,  and  muscular  tremors  are  more 
frequent.  In  many  instances  the  blood  is  absorbed  again  and  the  symptoms  sub- 
side ;  occasionally  it  accumulates  to  such  an  extent  as  to  prove  fatal,  either  from 
its  pressure  or  from  secondary  softening  and  degeneration. 

Concussion. — The  position  of  the  spinal  cord,  surrounded  by  a  water-bed  and 
suspended  by  the  nerves  and  the  ligamentum  denticulatum  in  the  centre  of  a  flex- 
ible column  of  bone,  which  nowhere  presents  any  large  surface  exposed  to  injury, 
is  such  that  concussion,  by  itself,  must  be  very  unusual.  If  the  term  is  used  in  the 
same  sense  as  in  speaking  of  the  brain  ;  it  can  only  be  caused  by  direct  violence ; 
the  symptoms  must  be  immediate  ;  there  must  be  no  gross  lesion,  merely  suspension 
of  activity  for  a  time,  and  then,  after  a  itw  minutes  or  some  hours,  gradual  re- 
covery. Practically,  therefore,  it  occurs  under  the  same  conditions  as  contusion, 
and  can  only  be  distinguished  from  it  by  the  symi)toms  being  general,  not  confined 
to  any  one  portion  of  the  spinal  cord,  and  by  their  passing  off  within  a  few  hours. 
Such  cases  do  occur,  though  it  very  rarely  happens  that  there  is  an  opportunity  of 
proving  them.     Gull  (Guy's  Hospital  Reports,  185S)  mentions  one  of  peculiar 


INJURIES  OF  THE  SPINAL   CORD.  699 

interest :  a  man,  40  years  of  age,  fell  on  his  back  from  a  moderate  height  ;  im- 
mediately after  the  accident  there  was  partial  |)aralysis  of  the  upper  and  lower 
extremities  with  collapse,  but  no  insensibility.  Later  in  the  day,- as  reaction  set 
in,  and  the  skin  became  warm  again,  the  paralysis  gradually  disappeared.  The 
next  morning  symptoms  of  injury  to  the  cervical  portion  of  the  cord  came  on  ; 
paralysis  of  upper  and  lower  extremities  ;  anaesthesia  ;  priapism  ;  tympanites  ;  high 
temperature;  and  paralysis  of  the  respiratory  muscles  followed.  He  died  at  the 
end  of  the  third  day.  Post-mortem  the  membranes  of  the  cord  and  the  cord  itself 
api)eared  entirely  uninjured  ;  so  that  the  earlier  symptoms  can  only  have  been  due 
to  concussion  :  outside  the  theca,  caused  by  a  fracture  through  the  body  of  the 
fourth  cervical  vertebra,  was  a  large  extravasation  of  blood  which  had  gradually 
extended  down  the  canal  and  compressed  the  cord.  There  was  slight  displace- 
ment of  the  body  of  the  fractured  vertebra,  but  not  sufficient  to  press  ui)on  the 
membranes. 

Afterward,  when  the  immediate  symptoms  have  disappeared,  hyperaemia  may 
set  in,  as  in  concussion  of  the  brain.  If  there  is  no  contusion  this  may  be  merely 
transient,  and  under  proper  treatment  subside  without  leaving  behind  any  serious 
result  ;  but  if  the  part  is  not  kept  at  rest,  or  if  there  is  severe  contusion,  it  may 
increase,  and  either  run  on  to  inflammation  or  lead  to  softening  and  degeneration. 

Railway  accidents  are  not  unfrequently  followed  by  a  peculiar  train  of 
symptoms  which  have  been -grouped  together  under  a  name,  "railway  spine," 
justly  stigmatized  by  Page  as  absurd. 

The  symptoms  do  not  set  in  immediately  and  are  not  those  of  any  gross  lesion 
of  the  cord,  such  as  contusion  or  inflammation.  As  a  rule  they  do  not  appear  for 
three  or  four  days  ;  then,  after  lasting  some  time,  they  either  begin  to  subside  or 
steadily  grow  worse.  The  chief  difficulty  is  to  distinguish  them  from  locomotor 
ataxy  and  chronic  meningo-myelitis,  both  of  which  may  undoubtedly  follow  injuries 
to  the  back.  If,  however,  sufficient  attention  is  paid  to  objective  symptoms,  to 
the  distribution  of  areas  of  antesthesia,  for  example,  and  the  electric  reactions  of 
muscles,  it  can  usually  be  surmounted. 

Railway  accidents  are  always  accompanied  by  an  extreme  degree  of  shock. 
Sometimes  this  takes  the  ordinary  form  of  profound  collapse  from  the  first ;  more 
frequently  there  is  a  peculiar  phase  of  unconsciousness  associated  with  excitement ; 
pain  is  not  felt ;  an  enormous  amount  of  energy,  often  strangely  misdirected,  is 
displayed  ;  and  then  suddenly,  some  time  later,  the  patient,  as  it  were,  wakes  up 
and  is  entirely  unable  to  account  for  himself,  or  what  he  has  done,  or  explain  how 
he  came  to  be  where  he  is.  This  is  generally  followed  by  violent  reaction,  the 
more  intense  perhaps  for  being  so  long  postponed.  The  temperature  falls  ;  the 
pulse  becomes  small  and  feeble  ;  the  face  is  pale  ;  the  forehead  covered  with  cold 
perspiration  ;  there  is  retention  of  urine  ;  often  the  secretion  is  scanty  ;  in  short, 
the  patient  lies  in  a  state  of  complete  prostration. 

This  may  end  in  various  ways. 

Occasionally,  but  fortunately  not  very  often,  it  grows  worse  and  worse ;  the 
patient  becomes  more  feeble,  and  without  being  able  to  assign  any  definite  reason 
for  it,  or  find  any  gross  lesion,  death  ensues  after  a  few  weeks  or  months,  just  as 
sometimes  happens  after  a  severe  mental  shock. 

More  frequently  there  is  a  certain  amount  of  improvement  for  a  time,  but 
not  perfect  recovery.  The  extreme  depression  passes  off,  but  the  patient  remains 
weak  and  feeble,  unable  to  control  himself  or  to  exercise  deliberate  judgment, 
with  mental  capacity  and  bodily  vigor  alike  impaired.  The  symptoms  are  of  the 
most  varied  character.  Some,  such  as  palpitation,  flushing,  alternate  sensation  of 
heat  and  cold,  and  menorrhagia,  may  be  accounted  for  by  the  disorderly  working 
of  the  vasomotor  system  ;  others,  like  sleeplessness,  dreaming,  headache  (often 
posterior),  irritability  of  temper,  emotional  display,  noises  in  the  ears,  and  failure 
of  sight,  are  due  to  interference  with  the  blood  supply  of  the  brain  and  the  organs 
of  special  sense.  Dyspepsia  is  always  present  and  makes  the  other  symptoms 
worse.     The  breath  is  foul ;  the  bowels  are  constipated  ;  the  bodily  strength  fails  ; 


700    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  j)atient  becomes  worn  and  emaciated  ;  the  cerebral  symptoms  grow  more 
pronounced,  and  at  last  he  becomes  utterly  broken  down  in  health,  feeble  in  mind 
as  well  as  body,  and  aged  before  his  time. 

This  is  not  in  any  way  peculiar  to  railway  accidents.  It  may  be  induced  by 
injuries  of  all  kinds,  especially  those  who  from  heredity  or  for  other  reasons  are  in 
any  way  predisjiosed  to  the  occurrence  of  nervous  disorders.  It  is  not  uncommon, 
for  example,  after  severe  and  prolonged  mental  trouble ;  it  may  even  follow  a 
single  shock  ;  and  I  have  met  with  minor  degrees  of  it  in  several  of  those  who 
were  exposed  to  the  earthcjuake  in  the  Riviera,  and  in  one  person  after  a  dynamite 
explosion.  Occasionally  it  persists  for  the  rest  of  life  ;  as  a  rule,  it  passes  away 
by  degrees  ;  and,  as  Page  has  clearly  shown,  even  when  there  is  no  suspicion  of 
fraud,  there  is  often  rapid  improvement  as  soon  as  the  irritating  question  of  com- 
pensation is  settled.  Too  little  is  known  about  the  working  of  the  central  nervous 
system  to  hazard  a  suggestion  as  to  what  really  happens  in  such  cases  ;  but  there 
can  be  no  doubt  that  the  brain  is  involved  at  least  as  much  as  the  cord,  and  very 
possibly  a  great  deal  more. 

In  another  class  the  symptoms  resemble  those  ordinarily  grouped  together  as 
hysterical.  There  may  be  epileptiform  attacks  from  time  to  time,  with  insanity, 
melancholia,  or  suicidal  impulse.  Aneesthesia  and  hyperesthesia  may  occur, 
affecting  the  special  nerves  as  well  as  those  of  ordinary  sensation.  There  may 
be,  for  instance,  contraction  of  the  field  of  vision,  achromatopsia,  or  hyper- 
gesthesia  at  various  points  ;  one-half  of  the  body  may  be  anaesthetic,  or  one  limb, 
the  line  of  limitation  being  circular,  not  corresponding  to  the  anatomical  distri- 
bution of  the  nerves  ;  and  occasionally  hysterogenic  points,  pressure  upon  which 
causes  epileptiform  spasms,  are  associated  with  these.  In  other  instances  muscular 
paralvsis,  affecting  physiological  groups  rather  than  anatomical  ones,  or  spasmodic 
contraction  is  present,  the  electric  reaction  remaining  unaltered.  Retention  of 
urine  and  aphonia  are  very  common  ;  and  numerous  other  symptoms  are  met  with 
from  time  to  time — pains  in  the  joints,  for  example,  of  the  most  excruciating 
character,  without  any  objective  sign,  dysphagia,  torticollis,  closure  of  the  jaws,  etc. 

Thorburn  has  ingeniously  attemi)ted  to  explain  these  results  by  a  comparison 
with  what  takes  place  by  "  suggestion  "  in  hypnotic  sleep.  There  is  certainly  to 
all  appearance  a  verv  close  resemblance  between  the  condition  of  unconscious 
excitement  that  so  often  occurs  after  these  accidents,  and  some  phases  of  hyj)- 
notism  ;  and  there  is  nothing  impossible  in  the  idea  that  the  violent  shock  and 
emotion  at  the  moment  are  capable  of  producing  either  this  condition  or  one 
closely  similar  to  it.  Now  Charcot  has  shown  that  in  hypnotized  ])ersons  light 
blows  are  often  followed  by  paralysis  and  anaesthesia,  and  it  is  quite  possible  that 
trivial  injuries  in  railway  accidents,  or  even  suggestions  of  them,  when  there  is  this 
condition  of  profound  mental  shock,  are  capable  of  doing  the  same. 

If  in  either  of  these  groups  of  ca.ses  there  is  in  addition  a  severe  sprain  of  the 
muscles  or  ligaments  of  the  neck  and  back,  so  that  every  movement  is  attended 
with  pain,  the  difficulty  of  proving  that  the  whole  mischief  is  limited  to  external 
structures,  and  that  the  spinal  cord  is  not  involved  as  well,  may  be  imagined. 
The  local  symptoms,  the  stiffness,  rigidity,  and  pain,  grow  worse  and  worse  as  time 
goes  on.  U  the  hypnotic  state  continues,  each  suggests  some  further  trouble,  and 
it  is  almost  impossible  to  distinguish  between  the  real  and  the  functional  disorder. 
The  desire  to  get  well  is  often  not  genuine,  even  when  it  is  present,  and  it  is 
impossible  to  obtain  any  assistance  from  the  patient.  If  there  is  even  a  suspicion 
of  chronic  inflammation  of  the  spinal  cord,  it  is  a  serious  matter  to  propose  active 
measures.  And  thus  it  comes  about  that  time  passes  by  ;  the  muscles  become 
more  rigid  from  disuse  ;  the  extravasated  blood  becomes  organized  ;  adhesions 
are  formed  in  all  directions  ;  and  it  ends  in  leaving  a  permanently  crippled 
condition. 

The  diagnosis  from  chronic  inflammation  of  the  spinal  cord  rests  chiefly 
upon  the  absence  of  definite  local  signs.  Stiffness  and  rigidity  of  the  back  are 
not  leading  characteristics  of  chronic  meningitis.     When  this  sets  in  there  are 


DISEASES  OF  THE  SPINAL  COLUMN.  loi 

other  symptoms,  usually  of  an  unmistakable  character  :  there  is  pain  along  the 
course  of  certain  nerves  ;  or  anaesthesia  and  hyperoesthesia  of  definite  regions  ; 
special  groups  of  muscles  are  wasted  or  paralyzed  ;  the  electric  reactions  are 
abnormal  ;  the  cutaneous  reflexes  are  enfeebled  or  lost ;  in  short,  there  is  definite 
evidence  of  injury  to  nerves  or  centres  in  the  cord,  such  as  does  not  occur  in 
sprains  of  the  vertebral  column  alone,  however  severe  the  mental  depression  and 
bodily  weakness  may  be. 


SECTION  111.— DISEASES  OF  THE  BACK. 
DISEASES  OF  THE  SPINAL  COLUMN. 

Osteitis. 

Inflammation  of  the  vertebrae  is  nearly  always  tubercular,  in  children  almost 
without  exception,  although  it  is  not  impossible  that  the  immediate  starting  point 
of  the  disease  is  some  slight  injury  causing  an  extravasation  of  blood  into  the  sub- 
stance of  the  cancellous  tissue.  In  exceptional  cases  it  may  be  due  to  syphilis 
(perhaps  more  frequently  than  is  suspected,  in  the  case  of  adults),  and  late  in  life 
to  rheumatism,  osteo-arthritis,  and  osteitis  deformans. 

Tubercular   Osteitis. 

This  is  essentially  a  disease  of  childhood,  although  it  may  occur  at  any  period 
of  life.  Sometimes  it  is  excited  by  injury  and  affects  one  part  of  the  spine  only  ; 
more  rarely  several  vertebrae  are  involved  together.  Like  tubercular  osteitis  else- 
where, it  nearly  always  begins  in  the  cancellous  tissue,  where  growth  is  most  rapid 
and  the  blood  supply  most  abundant.  The  upper  or  under  surface  of  the  bodies 
of  the  anterior  border  is  the  favorite  seat ;  the  spinous  and  transverse  processes 
are  never  involved  at  the  first,  although  later  they  become  welded  together  as  the 
inflammation  extends  to  them  ;  and  the  articular  processes  only  when,  as  in  disease 
of  the  atlas  and  axis,  synovitis  precedes  osteitis. 

The  most  common  situation  is  at  the  junction  of  the  lumbar  and  dorsal 
regions  ;  here  the  bodies  are  large,  and  strains  are  felt  most  severely.  The  cervi- 
cal vertebrae  enjoy  much  greater  immunity,  and  the  two  highest,  in  children  at 
least,  the  greatest  of  all.  There  is  some  reason  to  think  that  disease  of  the  atlas 
and  axis  is  proportionately  more  common  in  adults. 

Usually  the  intervertebral  discs  are  destroyed  with  the  bones  between  which 
they  lie,  the  granulation  tissue  eating  into  them  and  causing  their  gradual  absorp- 
tion. Sometimes  they  disappear  at  a  very  early  period,  as  if  the  force  of  the 
disease  was  spent  on  them  rather  than  on  the  bodies  ;  very  rarely  they  persist,  as 
when  the  vertebrae  are  absorbed  by  the  pressure  of  an  aneurysm. 

Pathology. — This  does  not  present  any  special  feature.  The  disease  begins 
as  rarefying  osteitis,  the  bone  becoming  softer,  more  open  and  vascular,  and  the 
bone  corpuscles  undergoing  fatty  degeneration.  According  to  the  intensity  and 
number  of  bacilli  on  the  one  hand,  and  the  strength  and  resisting  power  of  the 
tissues  on  the  other,  resolution,  caseation,  or  liquefaction  follows. 

In  the  most  fortunate  everything  is  restored  ;  the  bacilli  are  killed  or  re- 
moved by  the  tissues  and  recovery  is  complete.  In  others  not  so  good  the 
process  steadily  advances  without  any  caseation  (caries  sicca  or  fungosa)  until 
the  solid  structure  of  the  spine  is  replaced  by  masses  of  soft  granulation  tissue, 
which  yield  and  give  way  beneath  the  weight  of  the  trunk.  In  others  again  the 
centre  slowly  degenerates,  caseates,  and  becomes  liquid,  forming  a  so-called 
caseous  abscess,  filled  with  serum,  mixed  with  broken-down  particles  of  bone  and 


70  2    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

cheesy  debris.  Sometimes,  when  the  inflammation  is  severe,  fair-sized  sequestra 
are  found  as  well  (caries  necrotica).  Even  then  recovery  is  jjossible,  with  more 
or  less  deformity.  Part  of  the  debris  is  absorbed,  the  rest  undergoes  calcification  ; 
the  vertebrae  fall  together,  and  ankylosis  occurs  (Fig.  304).  On  the  other  hand, 
however,  the  caseous  focus  may  extend,  grow  larger  and  larger,  until  somewhere 
it  approaches  the  surface,  breaks,  and  unless  due  precautions  are  taken,  becomes 
infected  with  pyogenic  germs  as  well. 

Disease  of  the  upper  two  cervical  vertebrae  nearly  always  commences  as  syno- 
vitis and  extends  from  the  articulation  to  the  bone  beneath,  spreading  along  the 
most  vascular  lines,  and  therefore,  if  it  involves  the  axis,  separating  the  odontoid 
process  from  the  body. 

The  deformity  depends  upon  the  amount  of  destruction.  If  the  caries  is 
superficial,  involving  only  the  anterior  surface  of  the  body,  and  if  repair  begins  at 
once,  it  may  be  entirely  wanting.  If  the  bodies  are  softened  or  destroyed,  even 
if  only  part  of  one,  the  spine  above  sinks  forward,  the  spinous  processes  project 


A 


Fig.  305 — Tubercular  Osteitis  with  Caseation  under  the 
Anterior  Ligament  and  in  the  Bodies  of  the  Vertebrae. 
A  triangular  sequestrum  has  been  driven  back  so  as 
to  compress  the  spinal  cord. 


Fig.  304. — Ankylosis  of  Dorsal  Vertebra,  with  great  De- 
formity Consequent  on  Caries  of  the  Bodies. 


backward,  and  compensatory  curves  in  the  opposite  direction  are  developed  above 
and  below.  This  is  most  distinct  in  the  dorsal  region  ;  the  lower  cervical  rarely 
becomes  convex  backward,  only  a  little  thickening  is  perceptible,  and  the  lower 
lumbar  practically  cannot.  Disease  between  the  axis  and  atlas  is  ]3eculiar  again  in 
this  ;  for,  owing  to  the  shape  of  the  articulation  on  the  former,  the  latter  when  the 
ligaments  are  softened  by  inflammation,  or  the  odontoid  process  is  detached  from 
the  base  on  which  it  rests,  slips  bodily  forward,  carrying  the  head  with  it,  so  that 
when  the  patient  is  looked  at  from  one  side  it  appears  as  if  the  head  were  placed 
in  front  of  the  spine. 

The  eflect  of  this  displacement  (when  it  is  below  the  third  cervical  vertebrae) 
on  the  diameter  of  the  spinal  canal  is  exceedingly  slight ;  often  it  is  actually 
enlarged  ;  exceptionally  a  wedge-shaped  portion  is  driven  backward  (Fig.  305) 
into  the  substance  of  the  cord.  When  the  upper  two,  however,  are  concerned 
the  atlas  slides  forward,  and  the  antero-posterior  mea.surement  opposite  the  odon- 
toid process  may  be  reduced  to  less  than  half  an  inch.  This,  if  it  is  efi"ected 
gradually,   is  not  incompatible  with  life,   and  the  odontoid    process  may  even 


DISEASES  OF  THE   SPINAL   COLUMN.  703 

become  ankylosed  in  its  new  situation  as   much  as  half  an    inch  in  front  of  its 
natural  one  (Fig.  306). 

The  deformity  cannot,  of  course,  remain  limited  to  the  s])ine.  When  the 
cervico-dorsal  region  is  affected,  the  chin  is  brought  down  on  to  the  sternum  so 
that  the  movements  of  the  neck  cannot  l)e  carried  out  ;  and  similarly  when  the 
curvature  is  lower  down  the  thorax  is  crushed  together,  respiration  is  carried  out 
by  the  diaphragm  only,  and  the  heart  and  the  abdominal  viscera  are  placed  at 
great  disadvantage. 

Repair  may  commence  at  any  time  ;  the  ca.seous  material,  if  any  has  formed, 
and  the  debris  being  absorbed,  dried  up,  or  discharged  externally.  The  vertebrae 
above  and  those  below  fall  together  ;  the  spines,  laminae,  and  in  the  dorsal  region 
even  the  ribs,  become  welded  into  a  solid  mass,  the  sinuses  gradually  close  up, 
and  bony  splints  are  thrown  out  around  in  proportion  to  the  degree  of  strength 
required. 

Suppuration  is  visible,  according  to  Oolding  Bird,  in  about  five-and-twenty 
per  cent.  Probably  caseation  and  licjuefaction  are  present  in  many  more,  but 
do  not  come  to  the  surface.  The  fluid  may  make  its  way  into  the  spinal  canal 
and  spread  down  it,  outside  the  theca  vertebralis ;  but  much  more  generally  it 
comes  to  the  front,  under  the  anterior  common  ligament,  and  then  spreads  out- 
ward. If  the  cervical  vertebrae  are  diseased,  the  abscess  may  point  in  the  pharynx 
(retropharyngeal)  ;  in  the  posterior  triangle  of  the  neck  just  above  the  clavicle  ; 
or,  especially  if  the  lower  one  or  two  are  concerned,  it  may  extend  down  into  the 
posterior  mediastinum.  From  the  dorsal  vertebrae  it  usually  makes  its  way  behind 
the  pleura  into  the  sheath  of  the  psoas,  destroying  the  muscle,  dissecting  out  the 
nerves  of  the  lumbar  plexus,  and  pointing  below  Poupart's  ligament,  on  the 
inner  side  of  the  femoral  vessels.  Sometimes,  however,  it  turns  round,  accom- 
panying branches  of  the  intercostal  vessels,  and  passes  between  the  transverse 
processes  to  the  skin  of  the  back.  In  the  case  of  lumbar  vertebrae  it  may  either 
follow  the  same  route  or  work  its  way  into  the  pelvis,  from  which  it  escapes  either 
above  Poupart's  ligament  in  the  iliac  region,  or  along  the  rectum  in  the  ischio- 
rectal fossa,  or  accompanying  some  of  the  branches  of  the  internal  iliac,  out 
through  the  sacro-sciatic  foramen. 

In  the  later  stages,  especially  after  licjuefaction  has  occurred,  the  inflammation 
not  unfrequently  extends  to  the  dura  mater  and  even  to  the  spinal  cord.  Some- 
times a  mass  of  granulations,  developed  from  the  posterior  surface  of  the  vertebrae, 
j)resses  against  the  theca;  more  frequently  meningitis  sets  in,  and  the  membranes 
become  thickened,  caseous,  and  adherent  to  each  other  and  the  cord  beneath  ;  occa- 
sionally the  cord  itself  is  involved,  and  the  degeneration  spreads  upward  and  down- 
ward in  its  substance,  until  it  is  practically  disorganized. 

The  most  common  cause  of  death  is  septicaemia,  hectic,  or  amyloid  disease, 
consequent  on  suppuration  ;  but  it  may  occur  from  tuberculosis,  affecting  the  men- 
inges, or  disseminated  ;  from  pressure  upon  the  cord  itself  (especially  in  atlo- 
axoid  disease)  ;  or  from  the  secondary  consequences  of  paraplegia.  In  other 
cases  it  follows  indirectly  from  the  distortion  of  the  thorax  caused  by  the  angular 
curvature,  long  after  the  disease  itself  has  come  to  an  end. 

Symptoms  and  Diagnosis. —  It  is  of  the  utmost  importance  to  diagnose 
caries  of  the  spine  before  it  has  caused  deformity.  There  is  then  fair  prospect  of 
recovery,  and  if  taken  in  time  repair  may  be  perfect.  Deformity,  once  estab- 
lished, is  irremediable. 

The  most  prominent  symptoms  are  pain,  tenderness  on  pressure,  rigidity  of 
the  back,  and  a  sense  of  weakness  which,  even  when  the  child  cannot  describe  it, 
can  usually  be  recognized  from  its  actions. 

Fain  is  rarely  local  ;  nearly  always  it  is  referred  to  the  distribution  of  the 
spinal  nerves,  not  their  origin  ;  thus,  in  atlo-axoid  disease  it  is  felt  over  the  back 
of  the  head,  or,  when  the  dorso-lumbar  region  is  concerned,  over  the  pubes. 
Sometimes  there  is  a  sense  of  constriction  round  the  thorax,  and  children  often 
describe  it  as  stomach-ache.      Usually  it  is  worse  after  standing  or  any  exertion  ; 


704    DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

lying  down,  it  may  not  be  felt  at  all.  It  is  a  rough  but  a  sure  test  for  the  absence 
of  si)inal  caries  to  stand  a  child  on  the  seat  of  a  chair  and  tell  it  to  jump  down  ; 
if  it  comes  down  readily  and  fairly  on  its  feet  from  a  height  of  only  a  few  inches, 
osteitis  is  out  of  the  question. 

Tenderness  on  percussion  is  very  imjjortant,  especially  in  adults;  a  smart  tap 
with  the  finger  on  the  tip  of  the  spinous  processes  will  generally  show  whether  there 
is  any  inflammation.  Not  unfrequently  the  skin  covering  the  same  region  is  hyper- 
cesthetic,  especially  to  temperature,  owing,  in  all  probability,  to  the  distribution 
of  the  posterior  divisions  of  the  spinal  nerves,  for  the  .same  thing  may  be  noticed 
over  the  insertions  of  strained  and  overworked  muscles. 

Muscular  rigidity  is  highly  characteristic  :  every  movement  of  the  segment  of 
the  back  for  some  distance  al)Ove  and  below  the  seat  of  mischief  is  avoided  with 
the  greatest  care.  If  the  cervical  spine  is  involved,  the  whole  trunk  is  turned 
around  instead  of  the  head  when  the  patient  wishes  to  look  to  one  side,  and  it  is 
done  with  the  utmost  deliberation.  If  it  is  the  back,  and  the  child  is  told  to  pick 
up  anything  from  the  floor,  the  hips  and  knees  are  bent,  the  head  is  thrown  back, 
and  the  si)ine  kept  absolutely  rigid.  Sometimes  it  voluntarily  goes  on  hands  and 
knees.  For  the  same  reason  the  walk  is  very  jjeculiar,  entirely  different  irom  the 
natural  mobile  gait,  and  wry-neck  and  other  distortions  are  not  unfrequently  present. 
Where  children  are  concerned  the  weakness  of  the  back  must  be  judged  of  by 
their  actions.  They  cease  to  play  and  run  about ;  they  wish  to  be  left  alone  quietly  ; 
and  if  they  must  stand,  they  try  to  support  the  weight  of  the  head  and  shoulders 
by  resting  their  hands  upon  the  furniture  or  even  upon  their  knees,  propping  them- 
selves up  in  a  crouching  attitude.  With  adults  it  is  more  easy,  as  they  can 
explain  the  peculiar  difficulty  they  experience  in  holding  themselves  upright'. 

Early  diagnosis  is  often  a  matter  of  real  difficulty,  particularly  in  the  case  of 
children.  In  many  cases  it  is  advi.sable  to  act  upon  the  safe  side  and  confine  them 
to  bed  for  a  few  days.  Wry-neck,  for  example,  arising  from  strains,  inflamed 
glands,  cold,  or  reflex  irritation,  may  simulate  the  beginning  of  cervical  caries  very 
closely  ;  but,  as  a  rule,  a  few  days'  rest  is  sufficient  to  make  the  distinction  clear, 
and  can  do  no  harm.  The  danger  is  that  the  earlier  symptoms  may  be  overlooked 
and  regarded  merely  as  growing  pains  or  stomach-ache. 

With  young  adults,  particularly  girls,  hysteria  is  the  chief  difficulty  ;  and  it 
must  always  be  recollected  that  even  when  some  of  the  symptoms  are  transparently 
exaggerated,  there  may  be  real  disease  behind.  The  projection  of  the  lower  cervi- 
cal vertebras  is  a  frequent  source  of  alarm,  especially  as  it  is  sometimes  greatly  in- 
creased by  muscular  weakness  or  from  some  habitual  faulty  attitude.  Fortunately, 
the  symptoms  generally  exhibit  such  discrepancies  that,  if  not  at  the  first  exami- 
nation, at  least  after  two  or  three,  the  existence  of  caries  may  be  negatived  without 
fear. 

The  diagnosis  is  much  easier  when  deformity  is  present ;  but  the  disease  may 
be  far  advanced  before  it  makes  its  appearance  ;  and,  as  just  mentioned,  care  must 
be  taken  not  to  mistake  natural  projections  for  i)athological  ones  (see  Angular 
Curvature') . 

Caseation  and  liquefaction  may  occur,  even  though  deformity  is  never  present, 
and  no  case  of  spinal  disease  should  be  allowed  to  pass  without  investigating  all 
the  ordinary  situations. 

Retro-piiaryngcal  abscess  usually  first  attracts  attention  by  the  difficulty  it 
causes  in  breathing  and  swallowing.  Generally  it  lies  rather  to  one  side  of  the 
middle  line  and  is  accompanied  by  an  ill-defined  swelling  near  the  angle  of  the 
jaw  ;  in  some  cases  fluctuation  can  be  felt  across  from  one  point  to  the  other.  Left 
to  itself,  it  may  burst  into  the  back  of  the  pharynx  (it  has  been  known  to  cause 
suffocation  from  entering  the  larynx)  ;  or  work  its  way  into  the  mediastinum  ;  or 
point  on  the  side  of  the  neck.  Large  fragments  of  the  atlas  and  axis  have  been 
discharged  through  the  opening  in  the  pharynx  in  many  instances. 

Z><?rj-<7/ (?;'///w/^«r  «/^j'r<f.c.f  forms  a  soft  fluctuating  swelling  on  the  outer  side 
of  the  erector  spinae.     Not  unfrequently  it  is  divided  in  two  by  a  band  of  fascia. 


DISEASES  OF  THE  SPINAL  COLUMN.  705 

and  often  it  is  only  the  superficial  part  of  a  much  larger  cavity  in  the  psoas  and  can 
be  considerably  reduced  in  size  by  steady  pressure.  The  diagnosis  usually  presents 
no  difficulty  ;  but  it  must  be  distinguished  from  subcutaneous  abscesses,  hsema- 
tomata,  suppuration  in  connection  with  the  ribs,  em}jyenia,  nephritic  and  peri- 
nephritic  abscesses,  pyonephrosis,  hydronephrosis,  hydatids,  and  soft  elastic  sar- 
comata originating  in  connection  with  the  bones  or  the  kidney. 

Psoas  abscess,  when  the  abdomen  is  thin,  as  in  a  child,  can  be  felt  under  the 
linea  semilunaris  as  a  soft,  ill-defined  swelling  by  the  side  of  the  spine.  The  hip 
is  flexed,  the  thigh  adducted,  and  not  unfrecpiently  there  is  severe  pain  along  some 
of  the  branches  of  the  lumbar  plexus.  In  other  cases  it  remains  latent  and  even 
unsuspected  throughout.  There  is  no  limit  to  its  size,  and  its  .shape  presents  in- 
finite variety.  It  may  work  its  way  out  under  Poupart's  ligament  behind  the 
vessels  and  point  to  their  inner  side  in  the  adductor  region  ;  or  the  fascia  may  give 
way  in  other  parts  and  offshoots  spread  into  the  iliacus,  down  the  opposite  psoas, 
into  the  pelvis  (coming  out  through  the  perineum  or  the  sacro-sciatic  foramen), 
or  down  the  thigh  on  its  outer  side  near  the  tensor  fasciae  femoris.  It  has  even 
been  known  to  extend  into  the  inguinal  canal  and  down  into  the  leg. 

True  psoas  abscess  may  occur  independently  of  bone  disease,  after  injury 
(though  it  is  not  unlikely  that  many  of  these  cases  are  really  due  to  superfi- 
cial caries)  ;  or  from  inflammation  of  the  hip  joint,  or  of  the  bones  of  the  pelvis. 
Other  abscesses  are  met  with. in  the  same  region  in  connection  with  the  lymphatic 
glands,  the  c^cum,  kidney,  and  even  the  pleura  ;  and  sometimes  pelvic  cellulitis 
works  its  way  upward  as  well.  In  addition  it  must  be  distinguished  from  femoral 
hernia,  bursse,  or  cysts,  such  as  develop  occasionally  in  connection  with  the  hip 
joint,  and  soft,  rapidly  growing  tumors  springing  from  the  bone,  lymphatic  glands, 
or  cellular  tissues.  Its  chief  diagnostic  feature  is  the  ease  with  which  it  can  be 
made  to  disappear  by  gentle,  steady  pressure  when  the  patient  is  lying  down,  and 
the  gradual  way  in  which  it  fills  again.  Sometimes  the  neck  is  so  wide  that  there 
is  a  distinct  impulse  on  coughing,  and  not  unfrequently  fluctuation  can  be  made 
out  between  the  intra  and  extra-abdominal  parts. 

Spinal  paralysis,  like  suppuration,  may  begin  at  any  period,  although  natur- 
ally it  is  more  common  in  the  later  stages  of  the  disease.  Loss  of  motion  always 
precedes  that  of  sensation,  and  may  be  nearly  complete  without  the  latter  being 
seriously  impaired.  The  gait  becomes  shuffling  ;  the  movements  of  one  or  more 
of  the  limbs  are  awkward  ;  and  the  loss  of  power  becomes  more  and  more  evident, 
with  a  certain  degree  of  numbness,  until  at  length  complete  paraplegia  follows. 
So  long  as  the  cord  is  merely  compressed  the  patient  may  retain  power  over  the 
rectum  and  bladder,  but  this  too  is  not  unfrequently  lost  in  the  later  stages.  When 
myelitis  sets  in  there  is  often  severe  pain  along  the  course  of  the  spinal  nerves,  with 
spasmodic  muscular  contraction  ;  the  skin  becomes  dry  and  branny  ;  all  power  of 
the  sphincters  is  lost;  the  limbs  are  wasted,  the  joints  generally  speaking  flexed, 
and  the  muscles  rigid  and  not  unfrequently  thrown  from  time  to  time  into  violent 
spasmodic  contractions  from  the  uncontrolled  reflex  irritability  of  the  spinal  cord. 
Occasionally  the  inflammation  suddenly  becomes  acute  and  extends  upward,  with 
symptoms  of  high  fever,  to  the  meninges  of  the  brain. 

In  disease  of  the  cervical  spine  respiration  may  be  seriously  endangered  either 
from  displacement  forward  of  the  atlas  and  cranium  upon  the  axis  (Fig.  306),  or 
when  the  disease  is  lower  down  from  gradual  flattening  of  the  cervical  curve,  owing 
to  the  softening  of  the  ligaments.  Under  these  circumstances  any  sudden  move- 
ment of  the  head,  either  forward  or  backward,  or  even  lying  in  the  supine  position 
without  a  support  beneath  the  arch  of  the  cervical  spine,  may  cause  immediate 
asphyxia. 

The  peculiar  carriage  of  the  head,  which  is  held  perfectly  rigid  in  one 
position  (generally  poking  forward  or  to  one  side,  but  occasionally  dragged 
back)  ;  the  pain  along  the  course  of  the  spinal  nerves,  especially  the  great 
occipital ;  the  spasmodic  contraction  of  the  muscles  of  the  neck ;  and  the  pain 
when  any  pressure  is  made  on  top  of  the  head,  are  the  most  important  of  the 


7o6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

early  signs  of  disease  of  the  upper  cervical  vertebrae.  Many  of  these  may  occur 
together  under  other  circumstances,  when,  for  examjjle,  the  muscles  of  the  neck 
have  been  strained,  or  when   the  cellular  tissue  or   the  lymphatic  glands  lying 

between    them  are  inflamed  ;   and  it  may 

-  '"^  be  almost    impossible  at   first  to    make   a 

^.^,-  certain  diagnosis. 

jil^^''  S— ,-—  Treatment. — The  general  principles 

{  ■  -^  ,    ^     have  been  described  already  under  the  head 

*"'N.,  "^.  \-<^*>^     ^^  tubercular  osteitis.      With  very  few  ex- 

^Vk,  '-'F^'^         ceptions    local    removal   of    the    diseased 

*■}  l)ortion  is  out  of  the  question  ;  all  that  can 

/  be  done  is  to  improve  the  general  health 

/^  and  subdue  the  local  inflammation,  in  the 

hope  that  the  tissues  may  be  able  to  cope 

successfully  with  the  disorder. 

Rest    is    the   first  consideration.       In 
most    cases  it  is  advisable  to  confine  the 

Fig.  306. — Separation  of    the  Odontoid    Process    by  ^-        ,     r  ..•  ^  1         ^    ^      ^1  \         ^ 

Caries,  Ankylosis  of  the  Detached  Part  to  the    patient,  for  a  time,  at  least,  to  the  recumbcnt 
Atlas,  and  Reduction  of  the  Spinal  Canal  to  a   position,  on  a  well-iTiade  hair  iiiattress  with 

Narrow  Chink.  ^  ' 

sand-bags  as  splints.  In  disease  of  the 
upper  cervical  vertebrae  it  is  absolutely  essential,  a  bag  being  placed  on  either 
side,  coming  well  down  against  the  shoulder,  and  a  third  smaller  one  under  the 
arch  of  the  spine.  If  the  patient's  circumstances  are  favorable,  this  maybe  kept 
up  for  many  months  without  the  least  deterioration  of  health  ;  indeed,  distinct 
improvement  is  not  uncommon,  especially  when  the  pain  has  previously  been 
severe.  Later,  when  the  acute  symptoms  have  subsided  and  the  tenderness  on 
pressure  has  disappeared,  the  back  may  be  encased  in  some  kind  of  splint,  and 
the  patient  allowed  very  gradually  to  begin  to  move  about. 

Unfortunately,  this  is  not  practicable  in  the  majority  of  cases,  although  an 
attempt  should  always  be  made  to  secure  a  prolonged  rest  at  the  commencement. 
Even  with  a  splint,  however,  very  great  success  may  be  obtained,  if  only  the 
patient  can  be  kept  quiet,  supplied  with  good  food  and  fresh  air,  and  made  to  lie 
upon  a  reclining  chair  the  greater  part  of  the  day ;  but  with  children,  particularly 
in  the  poorer  classes,  in  whom  this  disease  is  so  common,  the  difficulty  is  almost 
insuperable. 

The  splints  in  common  use  are  made  of  plaster-of- Paris  (Sayre's  jacket),  poro- 
plastic  felt,  or  metal.  Of  these  the  first  is  by  far  the  cheapest,  and  is  especially 
useful  for  children,  in  whom  the  weight  of  the  body  is  light  and  the  bony  promi- 
nences well  defined.  For  older  patients,  and  particularly  women,  it  is  not  nearly 
so  suitable ;  the  weight  of  plaster  is  too  great,  and  the  fit  is  not  so  accurate  or 
close.  The  disadvantages  are  that  it  cannot  be  used  where  there  are  suppurating 
sinuses,  and  that  it  cannot  be  taken  off.  A  well-made  jacket  will  always  last  three 
months  and  sometimes  six,  although  for  the  sake  of  the  development  of  the  thorax 
it  is  never  advisable  to  leave  it  on  so  long  ;  but  the  objection,  to  many  people,  is 
quite  insuperable. 

Poroplastic  felt  is  more  expensive  and  does  not  fit  so  well  ;  but  it  is  much 
lighter  ;  it  can  be  taken  on  or  off  with  ease  ;  and  if  very  great  strength  is  required 
at  any  spot,  strips  of  metal  can  be  fastened  to  it.  Its  chief  use  is  in  the  later 
stages,  when  only  general  support  is  required  ;  and  it  is  best  to  obtain  it  roughly 
fitted  to  the  shape  of  the  trunk  already,  so  that  there  is  no  difficulty  in  moulding 
it.  Moist  or  dry  heat  may  be  used  to  render  it  flexible  for  the  time ;  but  if  any 
parts  are  required  permanently  soft,  as,  for  example,  over  the  breasts,  they  must 
either  be  left  so  in  the  manufacture  or  the  resin  dissolved  out  afterward.  It  is 
fastened  in  front  with  straps  and  buckles,  one  side  overlapping  the  other  consider- 
ably ;  and  in  taking  it  off  it  must  be  rotated  through  a  quarter  circle  first,  so  that 
the  thorax  may  slip  out  sideways. 

Metal  supports  are  very  much   more  expensive,  requiring  skilled  labor  and 


DISEASES  OF  THE  SPINAL  COLUMN. 


707 


constant  attention  afterward  ;  but  particularly  in  the  case  of  adults,  and  of  short 
but  stout  and  heavy  i)eople,  they  are  the  only  ones  of  real  service.  They  consist 
of  a  metal  girdle  which  can  be  buckled  round  the  pelvis ;  two  uprights,  one  on 
each  side,  carrying  crutches,  })artly  for  the  support  of  the  shoulders,  partly  to  pre- 
vent the  drooping  forward  of  the  up|)er  part  of  the  trunk,  and  to  give  a  point  of 
fixed  resistance  for  straps;  and  of  a   single  or  double  support  in   the  middle  line 


Fig.  307. — Apparatus  for  Applying  Sayre's  Jacket ;  Consisting  of  Tripod,  Pulleys,  and 
Suspension  Supports  for  Arms  end  Chin. 

behind,  fitted  to  the  spine,  and  capable  of  being  made  to  press  either  forward  or 
to  one  side,  by  means  of  a  ratchet  arrangement.  In  many  cases  it  carries  lateral 
plates  as  well,  so  that  when  the  patient  stands  upright  and  the  body  sinks  down 
against  them,  a  large  part  of  the  weight  is  transmitted  directly  to  the  pelvis.  These 
do  not,  of  course,  secure  the  same  amount  of  rest  as  a  well-made  plaster  splint,  but 
special  modifications  suited  to  individual  cases  may  be  devised  much  more  easily. 


Fig.  308. — Double  Thomas's  Splint  for  Caries  of  the  Neck. 

Sayre's  jacket  is  applied  to  the  patient  while  in  the  vertical  position,  slung 
from  the  head  and  shoulders  (Fig.  307).  A  specially  made  collar  is  fitted  under 
the  chin  and  the  occiput,  and  two  well-padded  straps  under  the  arms.  These  are 
fastened  at  a  proper  height  and  at  a  proper  distance  from  each  other  to  a  horizontal 
cross-bar,  which  in  its  turn  is  suspended  in  the  centre  of  a  tripod  stand,  and  is  so 
arranged  that  it  can  be  raised  or  lowered  at  once  without  any  jerk.     The  patient  is 


7oS     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 


first  fitted  with  a  sleeveless  merino  vest,  fastened  on  top  of  the  shoulders  and  com- 
ing down  well  over  the  crests  of  the  ilia.  Except  in  children  with  very  flaccid 
and  jirominent  abdomens,  a  pad  of  suitable  size  should  be  slipi>ed  in  from  below, 
between  the  vest  and  the  stomach,  and  withdrawn  when  the  jacket  is  dry  ;  and  in 
females  similar  smaller  ones  may  be  used  for  the  breasts.  Any  special  bony 
prominence  should  be  protected  by  surrounding  it  with  a  ring-pad  outside  the  vest, 
to  be  left  permanently.  The  bandages  are  made  of  very  coarse  crinoline  muslin 
torn  into  strips  about  four  inches  wide  ;  and  the  ])laster  is  well  rubbed  into  the 
meshes  as  they  are  rolled.  If  it  is  not  perfectly  fresh  it  should  be  re-baked,  or  a 
little  alum  may  be  added  to  the  water.  The  bandages  are  placed  under  water, 
standing  on  one  end,  one  at  a  time,  a  second  being  put  in  as  the  first  is  taken 
out. 

As  soon  as  everything  is  ready  the  patient  is  gently  raised  until  only  the  toes 
rest  upon  the  ground  ;  there  is  no  object  in  swinging  clear,  and  sometimes  it  causes 
considerable  alarm.  As  a  rule,  if  there  was  any  pain  before,  it  disajjpears  at  once, 
and  if  the  straps  are  properly  arranged  most  patients  describe  themselves  as  per- 
fectly comfortable.  The  effect  is  not  to  straighten  out  the  curve,  that  would  be 
most  undesirable,  but  to  fit  the  jacket  to  the  trunk  while  in  its  best  position,  with 
the  thorax  expanded.  When  the  patient  is  lowered  the  ribs  and  the  scapulae  sink 
down  and  are  fixed  by  the  weight  of  the  body  against  the  inner  wall.  The  first 
bandage  is  applied  round  the  hips  ;  and  then  successive  turns  are  carried  round  the 
abdomen  and  thorax,  without  making  any  reverses,  until  the  body  is  encased  suffi- 
ciently strongly,  from  the  armpits  to  three-quarters  of  an  inch  below  the  iliac 
crests.  x\n  assistant  in  the  meanwhile  smooths  the  surface  down,  and  if  there  are 
any  inequalities  rubs  a  small  quantity  of  plaster  in.  In  adults,  where  great 
strength  is  required,  strips  of  tin  may  be  inserted  here  and  there.  When  the 
casing  is  finished  the  patient  is  gently  lowered  to  a  horizontal  position  by  bringing 
up  behind  him  a  vertical  table  swinging  on  a  central  transverse  axis  and  provided 
with  cushions,  so  that  there  may  be  no  strain  until  the  plaster  is  thoroughly  set. 
Afterward  it  may  be  trimmed  down  under  the  arms  and  over  the  iliac  crests  if  it 
descends  too  low.  The  movable  pads  are  pulled  out  as  soon  as  the  casing  is  firm. 
In  disease  of  the  cervical  or  cervico-dorsal  vertebrae  absolute  rest  is  essential, 
until  it  is  certain  that  the  acute  symptoms  have  subsided  and  the  period  of  con- 
solidation is  well  established.  The  patient  lies  perfectly  flat  with  the  head  and 
shoulders  fixed  by  means  of  sand-bags ;  and,  as  already  mentioned,  care  must  be 

taken  to  preserve  the  contour  of  the  spine. 
Afterward  some  kind  of  appliance  must 
be  fitted  to  keep  the  head  and  neck  at 
perfect  rest. 

The  most  useful   is  the  modification 

of  a  double  Thomas's  splint  devised  by 

Krohne  (Fig.  308).     In  this  there  is  an 

upright  on  either  side,  coming  from  the 

thoracic  crescent  and  supporting  a  pad 

When  the  head  is  fastened  to  this  and  the 

trunk  is  well  secured,  the  immobility  is  comj)lete.     The 

patient,   of  course,  must  have  either  an  exceedingly  soft 

feather-bed  or  a  water  one  for  lying  down.     This  form  of 

ajjparatus  may  be  used  with  great  advantage  in  disease  of 

other  parts  of  the  spine  as  well. 

Furneaux  Jordan  recommends  plaster  bandages  ar- 
ranged in  a  figure-of-eight  for  cervical  caries.  The  centre 
of  the  upper  loop  is  on  the  forehead  ;  from  this  the  band- 
age passes  on  either  side  above  the  ears,  downward  on  to 
the  opposite  scapula,  and  beneath  the  axilla,  round  the 
thorax.  The  jury-mast  arrangement  of  Sayre  (Fig.  309), 
however,  is  better  than  this,  especially  when  the   disease  is  below  the  axis,  as  it 


for  the  occiput. 


Fig.  3C9. — Sayre's  Jury-mast. 


DISEASES  OF  THE  SPINAL  COLUMN.  yog 

permits  a  sli-lit  degree  of  rotation,  and  exerts  a  little  steady  extension.  It  con- 
sists of  a  metal  rod,  fastened  below  in  the  meshes  of  a  plaster  jacket,  exactly  op- 
posite the  spine,  and  curved  so  as  to  follow  the  outline  of  the  neck,  pass  round 
the  occiput,  and  end  on  the  top  of  the  head.  To  this  is  attached  a  collar  which 
supports  the  chin  and  the  occiput,  the  degree  of  tension  exerted  by  the  metal  being 
controlled  by  straps  and  buckles  ;  a  similar  apparatus  may  be  secured  to  a  poro- 
])lastic  jacket. 

Suppuration  in    Connection  loit/i  Spinal  Caries. 

As  a  rule,  abscesses  should  be  opened  early  and  freely ;  leaving  them,  in  the 
majority  of  cases,  only  enables  them  to  become  larger  and  more  complex  in  shape, 
and  an  imperfect  incision  is  a  premium  on  putrefaction.  Aspiration  is  of  little 
service,  although  occasionally  in  young  children,  when  the  condition  is  in  other 
respects  improving  and  the  abscess  is  not  increasing,  it  may  be  tried  once,  or  even 
twice,  in  the  hope  that  by  reducing  the  tension,  absorption  may  be  set  up.  No 
attempt  should  be  made  to  empty  the  abscess,  and  very  slight  suction  should  be 
employed,  for  fear  of  causing  hemorrhage  from  the  granulations.  As  a  rule,  if  it 
is  used  more  than  once  or  twice  the  opening  fails  to  close,  a  little  serum  drains 
away,  the  skin  becomes  ulcerated,  and  the  contents  discharge  themselves  slowly  and 
intermittently. 

[In  these  abscesses,  lavage  of  the  sac  with  iodine  water,  followed  by  injection 
of  iodoform  emulsion,  is  of  great  benefit.  The  trocar  and  cannula  used  for 
evacuation  should  be  large  enough  to  prevent  clogging  during  the  outflow.] 

Where  it  is  practicable,  a  spinal  abscess  of  any  size  should  be  opened  in  two 
places,  one  of  which  should  be  at  the  lowest  point.  If  the  interior  is  very  irregular 
in  shape,  divided  into  numerous  pouches  by  stout  bands  of  fascia  passing  across  it 
(such,  for  example,  as  Poupart's  ligament),  it  is  of  great  advantage,  wherever  it  is 
possible,  to  make  an  opening  into  each.  The  object  is  not  only  to  empty  it  of  its 
contents,  but  to  keep  it  empty,  and  this  is  impossible  with  a  complicated  cavity, 
altering  in  shape  with  every  movement  of  the  body,  if  only  one  opening  is  made. 
If  such  an  abscess  is  thoroughly  drained,  so  that  there  is  no  accumulation  of  putres- 
cible  fluid  possible,  the  caseous  material  that  clings  to  the  wall  is  thrown  off  by  the 
granulations,  the  amount  of  discharge  is  reduced  to  a  few  drachms  of  serum,  and 
all  the  outlying  parts  close  up,  leaving  only  one  sinus  leading  down  to  the  diseased 
bone.  The  drainage-tubes  must  be  of  the  largest  size,  with  walls  sufficiently  rigid 
not  to  collapse  under  pressure  ;  and  they  must  reach  at  first  at  least  to  the  bottom 
of  each  pouch. 

If  this  is  not  feasible,  either  antiseptic  dressing  must  be  applied  after  Lister's 
plan,  in  the  hope  that  putrefaction  may  be  prevented  for  an  indefinite  length  of 
time,  and  that  the  abscess  will  empty  itself  of  its  contents  by  slow  degrees  and  con- 
tract into  a  sinus,  or  the  interior  must  be  washed  out  either  continuously  or  at 
frequent  intervals,  with  some  antiseptic,  which,  if  it  is  retained  by  any  accident, 
in  an  outlying  pouch,  will  not  cause  poisonous  symptoms.  Treves  has  employed 
continuous  irrigation  with  water  in  one  or  two  cases  of  psoas  abscess  with  good 
results. 

A  retro-pharyngeal  abscess  may  break  of  itself  before  attention  is  drawn  to  it. 
If  it  is  diagnosed,  it  may  be  opened  either  through  the  mouth  (with  a  guarded  bis- 
toury, and  taking  care  that  pus  does  not  enter  the  larynx),  or  externally  by  incision 
through  the  skin  of  the  neck.  The  choice  of  locality  is  determined  by  the  direc- 
tion the  abscess  takes.     Sometimes  a  sequestrum  is  found. 

Abscesses  in  the  dorsal  and  lumbar  region  should  be  opened  freely  and 
explored  with  the  finger  to  ascertain  if  there  are  any  outlying  pockets  to  be 
drained  or  fragments  of  carious  bone  to  be  removed.  Sometimes  the  focus  of 
disease  can  be  reached  directly,  the  softened  bone  scraped  away,  and  iodoform 
applied. 

Psoas  abscesses  should  always  be  opened  in  the  lumbar  region.  Poupart's 
ligament  divides  the  cavity  into  two,  the  upper  half  being  usually  much  the  larger ; 


7IO     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

it  is  imi)ossil)le  to  drain  this  \)n)\)cv\y  from  ;i  single  opening  in  Scarpa's  triangle. 
The  incision  is  longitudinal,  by  the  side  of  the  erector  spinee  ;  all  the  structures 
are  divided  until  the  quadratus  lumborum  is  reached  ;  the  fibres  of  this  are  incised 
oi)posite  the  tip  of  the  third  lumbar  transverse  jjrocess,  and  with  them  the  anterior 
layer  of  the  transversalis  fascia  ;  and  then  the  finger  is  passed  along  the  anterior 
surface  of  the  muscle  until  the  psoas  is  reached.  The  line  of  safety  is  the  trans- 
verse process  :  a  lumbar  artery  lies  above  and  below.  In  someca.ses  an  incision  of 
this  kind  can  be  utilized  to  get  directly  at  the  seat  of  the  disease. 

In  most  instances  a  second  (and  sometimes  even  a  third)  oi^ening  is  required. 
Tills  must  be  made  in  the  situation  in  which  the  abscess  points,  either  above 
Poupart's  ligament  (with  an  incision  similar  to  that  for  tying  the  e.xternal  iliac 
artery),  or  below  it  in  Scarpa's  triangle,  or  on  the  outer  side  or  behind.  I  have, 
on  several  occasions,  passed  a  large  drainage-tube  (half-inch  internal  diameter) 
through  the  whole  length  of  the  psoas,  from  the  lumbar  region  to  the  thigh,  with 
very  great  success,  the  temperature  remaining  practically  unchanged  ;  and  after  a 
time  have  divided  this  in  the  middle,  so  that  the  central  portion  of  the  absce.ss 
should  collap.se  first.  Usually  it  results  in  the  inferior  opening  closing  completely, 
and  the  upiJcr  one  contracting  into  a  small  sinus,  which,  owing  to  its  being  {practi- 
cally straight,  scarcely  retains  any  discharge. 

Paraplegia. — As  the  inflammation  subsides  and  the  caseous  deposit  shrinks, 
the  paraplegia  not  unfrequently  undergoes  material  improvement  without  direct 
treatment  of  any  kind  ;  and  occasionally  rapid  recovery  of  power  follows  the  ap- 
plication of  a  Sayre's  jacket.  This  is  due,  in  some  instances,  to  the  weight  of  the 
upper  part  of  the  body  being  removed  and  the  pressure  on  the  soft  tissues  relieved  ; 
but  more  frequently  it  only  means  that  the  trunk  is  better  .supported  and  the  centre 
of  gravity  brought  over  the  feet  again.  Counter-irritation  is  sometimes  of  service. 
The  actual  cautery,  for  example,,  may  be  applied  either  in  lines  radiating  from  the 
central  projection,  or  a  row  of  points  may  be  placed  in  a  circle  around.  The  iron 
should  be  of  a  dull  red  heat,  and  the  whole  thickness  of  the  skin  should  not  be 
destroyed.  An  anaesthetic  is  advisable,  and  if  the  burns  are  covered  over  at  once, 
so  that  the  access  of  air  is  prevented,  the  subsequent  pain  is  very  slight. 

McEwen,  of  Glasgow,  has,  on  several  occasions,  resected  the  spines  and 
laminae  of  the  vertebrae,  exposed  the  sheath  of  the  cord,  and  excised  the  dense, 
thickened,  peri-meningeal  connective  tissue  pressing  upon  it,  with  very  great  suc- 
cess ;  and  this  example  has  been  followed  by  others.  There  is  no  doubt  that  where 
there  is  no  pyrexia,  where  the  symptoms  ])oint  to  pressure  upon  the  cord  without 
myelitis,  and  where,  although  the  inflammatory  process  has  ceased,  the  paraplegia 
does  not  improve,  and  is  not  influenced  by  treatment,  an  operation  of  this  kind  is 
not  only  justifiable,  but  strongly  to  be  recommended.  The  incision  should  lie 
in  the  median  line,  and  the  periosteum  with  the  muscles  on  either  side  should 
be  stripped  back,  so  that  when  the  flaps  are  replaced  a  tolerably  firm  casing  may 
be  formed  over  the  canal. 

Curvature  of  the  Spine. 

The  spine  may  become  bent,  either  from  primary  disease  of  the  bones  and 
joints  (caries,  osteo-arthritis,  new  growths,  etc.)  or  from  weakness  of  the  muscles 
whose  function  it  is  to  maintain  the  erect  j)osition,  the  vertebra;  only  becoming 
affected  secondarily  after  the  deformity  has  already  lasted  some  time,  owing  to  the 
unequal  distribution  of  the  weight  they  bear.  The  direction  may  be  either  antero- 
posterior or  lateral,  although  the  latter  rarely  occurs  by  itself.  The  former  is  known 
as  excurvation  or  kyphosis  when  the  projection  is  convex  backward,  incurvation  or 
lot'dosis  when  it  is  convex  forward  ;   the  latter  as  scoliosis. 

I.   A ntcro- Posterior   Curvature. 

Of  these  there  are  two-well-marked  varieties,  distinguished  from  each  other  by 
the  shape  of  the  curve  :   the  one  is  sharp  and  angular,  due  to  some  local  disease  of 


SPINAL  CURVATURE.  711 

the  bone;   the  other  is  uniform  and  gradual,  caused,  as  a  rule,  Ijy  a  general  affec- 
tion of  the  whole  or  part  of  the  spine. 

((/)  Aiii^n/ar. — in  by  far  the  majority  of  cases  this  is  the  result  of  caries  ;  but 
it  may  arise  from  myeloid  sarcoma  affecting  the  body  of  one  of  the  vertebra;,  from 
aneurysm,  carcinoma  (secondary),  and  in  infants  from  rickets.  The  prujection,  as 
its  name  implies,  is  sharj)  and  angular,  and  it  is  exaggerated  by  the  presence  of 
compensatory  curves  in  the  opposite  direction  above  and  below.  The-se  are  the 
natural  result  of  the  attempt  to  retain  the  erect  position  ;  if  the  sjjine  is  bent  for- 
ward at  any  one  spot,  owing  to  a  defect  in  the  bone,  the  head  and  the  upper  part 
of  the  trunk  must  be  thrown  back  in  order  that  the  centre  of  gravity  may  lie  over 
the  base  line  of  the  feet ;  in  other  words,  one  or  more  compensatory  curves  must 
be  developed  in  the  opposite  direction.  When  this  cannot  take  place,  oris  imper- 
fect, as  when  the  disease  involves  the  last  lumbar  vertebra,  the  patient  is  compelled 
to  stoop  forward. 

The  diagnosis  rarely  presents  any  difficulty.  In  progressive  caries  the  rigidity 
of  the  muscles,  the  tenderness  over  the  spinous  processes,  and  the  care  with 
which  the  patient  avoids  moving,  especially  in  any  way  that  might  jar  the  back, 
are  nearly  always  conclusive.  These  signs  are  lost  to  a  certain  extent,  it  is  true, 
after  the  inflammatory  stage  is  past  and  repair  is  complete;  but  the  diagnosis  is 
assured  then  by  the  fact  that,  with  the  exception  of  rickets,  the  other  diseases  that 
lead  to  the  formation  of  angular  curvature  have  little  or  no  tendency  to  get  well. 
Myeloid  sai-coma,  except  for  the  rapidity  with  which  the  curvature  is  formed, 
cannot  be  diagnosed  from  caries.  The  age  is  the  same,  and  the  symptoms  are  the 
same,  especially  as  it  is  always  attended  by  a  certain  amount  of  inflammation. 
Fortunately  it  is  much  more  rare. 

Rickets  in  infancy  may  be  a  source  of  considerable  difficulty  for  a  time,  as  the 
presence  of  this  disease  does  not  exclude  caries  as  well.  The  spine  of  a  rickety 
child  retains  for  a  long  time  the  normal  infantile  curve,  and  if  it  is  allowed  to  sit 
up  the  weight  of  the  upper  part  of  the  body,  acting  on  the  softened  bone,  may 
cause  a  very  sharp  bend  to  take  place  at  the  junction  of  the  dorsal  and  lumbar  region, 
where  caries  is  most  common.  In  most  cases  the  diagnosis  may  be  made  by  laying 
the  child  upon  its  stomach  across  the  nurse's  knee  ;  a  rickety  curve  can  usually  be 
straightened  out  by  a  little  manipulation  as  soon  as  the  weight  is  taken  off,  while  in 
caries  this  is,  of  course,  impossible,  as  the  muscles  retain  their  rigidity  ;  but  very 
often  in  the  really  severe  cases  of  rickets  this  fails  completely,  as  the  bones  are  as 
tender  and  the  muscles  as  rigid  as  in  actual  inflammation.  Fortunately,  in  such 
cases,  rest,  cod-liver  oil,  and  good  food  effect  a  complete  transformation  within  a 
week. 

{F)  Gradual. — This  may  be  caused  either  as  a  compensation  for  other  defects, 
or  by  some  affection  of  the  back  itself. 

Compensatory  curves  have  been  already  mentioned  in  connection  with  caries, 
but  they  are  the  natural  result  of  many  other  deformities.  Congenital  dislocation 
of  the  hip,  for  example,  and  ankylosis  of  the  hip  joint  in  a  flexed  position,  are  of 
necessity  attended  by  lordosis  ;  and  where  this  is  at  all  extensive  there  must  be  a 
compensating  degree  of  kyphosis  above.  The  same  thing  occurs  in  abdominal 
tumors  and  even  to  a  slight  degree  in  pregnancy. 

Weakness  of  the  muscles  of  the  back,  such  as  commonly  occurs  in  rickety 
children,  or  in  those  who  have  outgrown  their  strength,  is  a  very  frequent  cause  of 
kyphosis.  Sometimes  the  body  retains  its  symmetry  and  the  spine  remains  in  the 
middle  line  ;  more  frequently  it  yields  to  one  side  or  the  other,  and  lateral  curva- 
ture results  as  well.  Infantile  paralysis  and  progressive  muscular  atrophy  occa- 
sionally lead  to  the  same  result.  At  first  the  bodies  of  the  vertebros  are  unaffected, 
but  after  a  time  they  become  wasted  and  thinned  in  front ;  the  thorax  is  crushed 
together  and  the  deformity  is  permanent.  If  rickets  is  present  the  change  is  much 
more  rapid,  owing  to  the  softness  of  the  bones. 

In  old  age  the  normal  curves  of  the  spines  are  often  lost  and  replaced  by  a 
single  general  one,  especially  marked  at  the  junction  of  the  neck  and  thorax ;  and 


712    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

a  similar  deformity  is  produced  when  the  spinal  column  is  affected  by  osteo-arthritis 
or  osteitis  deformans. 

2.   Lateral  CuT^oature — Scoliosis. 

Lateral  curvature  may  result  either  from  want  of  symmetry  in  other  parts  of 
the  body,  the  spine  bending  to  one  side  to  compensate  for  some  other  defect,  and 
enable  the  head  and  centre  of  gravity  of  the  trunk  to  be  kept  vertically  over  the 
base  line  of  the  feet,  or  simply  from  weakness,  the  muscles  which  ought  to  keep  it 
straight  not  being  equal  to  the  work  ;  in  this  case  it  is  nearly  always  associated 
with  antero-posterior  curvature  as  well. 

{a)  Asymmetry. — Owing  to  its  position  in  the  central  axis  of  the  body,  the 
spine  is  necessarily  influenced  by  the  least  alteration  in  symmetry.     Whether  it  is 


•O^ 


'?s 


Fig.  310. — The  Ordinary  Form  of  Lateral  Curvature,  Lumbar  to  the  Left,  Dorsal  to  the  Right,  with 
growing  out  of  the  right  shoulder  and  a  depression  beneath  the  ribs. 

the  legs,  or  the  arms,  the  thorax,  or  even  the  head,  if  one  side  predominates 
unduly  over  the  other  the  effect  is  visible  on  the  spine. 

Inequality  in  the  length  of  the  lower  limbs,  for  example,  whether  it  arises 
from  congenital  defect  (and  the  legs  are  unequal  in  length  in  many  people,  without 
its  being  suspected),  fracture,  disease  of  the  hip,  or  any  other  reason,  must  cause 
curvature  of  the  spine.  The  base  line  of  the  pelvis  is  oblique  ;  the  last  lumbar 
vertebra  must  be  perpendicular  to  it  ;  and,  consequently,  if  the  person  is  to  stand 
erect,  the  spine  above  must  be  bent  back  to  the  opposite  side. 

Inequality  in  the  strength  or  the  development  of  the  upper  limbs  produces  a 
similar  though  less  marked  result.  The  most  striking  examples  are  seen  in  con- 
genital absence  of  one  of  the  arms  ;   but  in  people  who  are  very  distinctly  right- 


SPINAL  CURVATURE.  7,3 

haiuleil,  the  tlorsal   spine  is  always  slightly  convex   to  the   right,  and  sometimes 
very  decidedly  so. 

Asymmetry  of  tlie  thorax  is  e<iually  jjotent.  In  emi)yema,  when  the  walls  of 
one  side  have  collapsed  to  the  utmost,  this  is  visit)le  at  once,  the  sjjine  being  con- 
cave to  the  diseased  side  ;  but  even  after  an  attack  of  pleurisy  the  same  effect  may 
be  noted  for  some  considerable  time  after  recovery. 

Even  wry-neck  produces  the  same  result,  although,  of  course,  to  a  very  much 
less  extent.  In  neglected  cases,  in  which  the  head  is  bent  down  for  years,  the 
side  of  the  face,  the  chest,  and  in  women  even  the  mammary  gland,  fail  to  grow 
in  proportion,  and  the  spine  becomes  asymmetrical. 

Finally,  though  much  more  rarely,  lateral  curvature  may  arise  from  some 
defect  in  the  spine  itself,  caries,  for  example,  affecting  the  body  of  a  vertebra  on 
one  side ;  or  one-half  only  of  a  vertebra  being  developed  without  the  other. 
Paralysis  of  the  intercostal  or  other  muscles  acting  from  the  spine  upon  the  trunk 
might  cause  the  same  result. 

Occasionally,  the  deformity  produced  in  this  way  is  very  considerable  ;  but, 
as  it  is  always  secondary,  developed  to  compensate  for  another,  it  naturally  does 
not  admit  of  rectification. 

(/')  Muscular  Weakness. — This  is  the  most  common  cause  of  the  "growing 
out  of  the  shoulder  "  (generally  the  right  one),  which  is  the  symptom  first  noticed 
and  first  complained  oif  in  the  majority  of  cases  of  lateral  curvature.  The  muscles, 
which  ought  to  keep  the  spine  erect,  are  unable  to  do  so,  and  it  bends  over  to 
one  side,  and,  generally  speaking,  forward  as  well.  It  may  be  a  young,  rapidly 
growing  girl,  whose  strength,  especially  at  puberty,  is  unable  to  support  the 
weight  of  the  upper  part  of  the  trunk ;  or  a  person  of  better  physique  who  has  to 
carry  constantly  upon  one  arm  or  shoulder  a  load  that  is  too  heavy  ;  it  may 
be  the  outcome  of  some  exhausting  illness,  or  even  of  a  strain  injuring  some  of 
the  muscles :  the  cause  is  the  same  in  all,  the  weight  is  out  of  proportion  to  the 
strength. 

The  direction  of  the  curve  is  determined  by  some  slight  degree  of  asymme- 
try, natural  or  acquired.  In  right-handed  people  in  whom  there  is  a  dorsal  con- 
vexity this  is  the  guiding  cause.  The  posture  known  as  standing  at  ease  is 
another ;  the  weight  of  the  body  is  allowed  to  rest  on  one  leg,  the  other  side  of 
the  pelvis  droops,  the  base  line  becomes  oblique,  and  with  it  the  axis  of  the  lumbar 
spine.  To  compensate  for  this  the  thorax  is  thrown  over  to  the  opposite  side. 
In  other  cases  the  primary  curve  can  be  traced  to  a  cramped  position  in  writing, 
or  to  other  causes. 

This  variety  of  lateral  curvature  is  entirely  different  from  the  former ;  it  is  a 
primary  affection,  not  developed  to  compensate  for  anything  else ;  and,  unless 
steps  are  taken  to  prevent  it,  it  has  a  very  great  tendency  to  become  worse.  In 
many  cases,  it  is  true,  it  is  arrested  spontaneously  ;  the  period  of  growth  and  of 
physical  weakness  comes  to  an  end,  and  the  muscles  develop  sufficiently  to  pre- 
vent the  curve  becoming  more  distinct ;  but  it  rarely  happens  unless  the  treatment 
is  thoroughly  carried  out,  that  this  state  is  reached  without  leaving  some  degree  of 
deformity.  As  patients  become  stronger,  the  curve  ceases  to  increase,  but  they 
do  not  grow  out  of  it,  in  spite  of  the  popular  opinion  to  that  effect. 

Curves  in  the  spine  are  naturally  unable,  in  the  majority  of  cases,  to  remain 
single.  Where  the  lumbar  region  is  convex  to  the  left,  the  thoracic  must  be 
equally  convex  to  the  right,  and  sometimes  the  cervical  must  be  bent  back  again 
in  order  to  keep  the  head  and  the  centre  of  gravity  over  the  base  line  of  the  feet. 
One  of  these  curves  is  usually  considered  the  primary,  the  others  compensatory  ; 
but  they  must,  with  few  exceptions,  develop  together. 

Rotation. — Except  in  some  cases  of  thoracic  asymmetry,  lateral  curvature 
of  the  spine  never  occurs  alone.  It  is  always  and  necessarily  associated  with 
another  deformity  (rotation  of  the  vertebrae  on  a  vertical  axis),  which  is  even  more 
hard  to  correct,  and  which  causes  much  greater  distortion  of  the  trunk.  The 
direction  of  this  rotation  is  absolutely  constant ;  the  bodies  of  the  vertebrae  are 
46 


714     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

always  twisted  further  away  from  the  middle  line,  and  the  sijincs  brought  nearer 
to  it.     The  effect,  if  the  deformity  is  estimated  by  the  spinous  processes  alone,  is 
very  deceptive  ;  sometimes  they  are  rotated  so  far  back  that  they  are  almost  brought 
to  the  median  groove  again,  vertically  under  each  other,  as  if  the  spine  was  prac- 
tically straight,  while  in  reality  the  bodies  are  carried  further  and  further  away 
until  they  may  face   to   left  and   right,   instead  of  forward. 
The  rotation  ai)parently  corrects  the  deformity  ;    in  reality  it 
6^,^^  makes  it  infinitely  worse. 

^K*^^  The  cause  of  this  rotation  has  been  the  subject  of  much 

^l^  discussion.      Where  there  is  general  muscular  debility,  it  can 

«n*p^  hardly  be  due   to  muscular  spasm.      As  a  matter  of  fact  it  is 

pfi-'s^  purely  mechanical,   the   result    of  the  fashion  in  which   the 

vertebrse  are  articulated  together.  As  soon  as  the  least  lateral 
curve  makes  its  appearance,  the  weight  of  the  upper  half  of 
the  trunk  presses  obliquely  on  the  lower  iwrt  of  the  spine  ; 
and,  like  all  oblique  forces,  it  may  be  resolved  into  two,  one 
acting  vertically,  the  other  horizontally.  Of  these  the  latter 
only  is  concerned  with  the  rotation.  It  acts  almost  wholly 
upon    the    bodies    which    are    not   supported    by    anything 


Fig.  311. — Lateral  Curva- 
ture with  Slight  Rota- 
tion, bringing  the  spines 
back  to  the  middle  line, 
and  making  the  real  de- 
formity worse. 


Fig.  312. —  Extreme  Distortion  of  Thorax  consequent  upon 
Lateral  Curvature  of  the  Spine.  The  section  passed 
through  the  articulation  of  the  second  costal  cartilage 
with  the  sternum  on  the  left  and  the  seventh  dorsal  ver- 
tebra on  the  right.  The  vertebra,  being  just  at  the  junc- 
tion of  the  two  curvatures,  shows  very  little  rotation. 


laterally  ;  upon  the  spines  wliich  have  little  or  nothing  to  do  with  bearing  the 
weight  of  the  trunk,  and  which  are  ])rotected  on  either  side  by  the  articular 
processes,  it  has  little  or  no  effect;  and,  consequently,  the  former  are  deflected 
so  much  more  forcibly  than  the  latter  that  the  vertebrae  swing  round  upon  an  axis 
running  down  the  central  canal,  the  bodies  going  one  way,  more  out  of  the  per- 
pendicular, the  spines  the  other. 

Effect. — In  the  slighter  cases,  in  which  the  muscular  system  soon  regains  its 
strength,  no  gross  changes  are  produced.  In  the  more  severe  ones,  and  in  those 
dependent  upon  asymmetry,  the  whole  of  the  trunk  is  affected  more  or  less.  The 
vertebrae  on  the  concave  side  are  wasted  from  the  pressure,  so  that  the  bodies  be- 
come wedge-shaped  ;  the  ligaments  and  muscles  are  shortened  ;  and  the  fibro- 
cartilage  is  shallower  on  one  side  than  the  other.  Sometimes  in  very  severe  cases 
buttresses  of  bone  are  thrown  out  from  one  vertebra  to  another,  as  in  rickets,  for 
the  purpose  of  supj^ort.  On  the  convex  side  the  ribs  diverge,  so  that  the  shoulder 
is  raised,  on  the  opposite  one  they  converge;  so  that  it  is  equally  depressed  ;  and 


SPINAL   CURVATURE. 


7'5 


the  structures  that  follow  the  course  of  the  spine,  such,  for  example,  as  the  aorta, 
become  strangely  twisted  into  an  S  sha|)e. 

The  rotation  complicates  this  still  more  ;  the  vertebrit;  are  twisted  as  well. 
In  bad  cases  the  bodies  may  look  half  to  the  left  antl  half  to  the  right,  instead  of 
all  straight  forward  ;  and  in  the  lumbar  region  the  transverse  processes  on  the  con- 
vex side  may  project  so  directly  backward  as  to  be  mistaken  for  the  spines.  This 
is  not  without  its  effect  upon  the  vertebras;  their  symmetry  is  entirely  lost;  the 
spine  and  the  transverse  process  on  the  convex  side  are  twisted  toward  each  other  ; 
those  on  the  concave  side  apart.  The  thorax  shows  the  deformity  even  more  con- 
spicuously. The  ribs  on  the  convex  side  diverge  and  project  backward,  carrying 
the  scapula  with  them  ;  then  they  bend  back  upon  themselves  so  sharply  that  the 
true  antero-posterior  diameter  opposite  the  nipple  is  only  a  few  inches.  On  the 
concave  side  they  run  forward  in  the  opposite  direction,  with  scarcely  any  angle 
at  all,  so  that  the  sternum  is  carried  far  away  from  the  middle  line  toward  the 
concavity,  and  the  breast  on  that  side  is  thrust  as  prominently  forward  as  the  other 
one  is  depressed.  In  extreme  cases  the  ribs  on  the  concave  side  are  crushed  to- 
gether, while  those  on  the  other  grow  outward  and  backward  further  and  further 
until  their  angles  produce  a  lateral  hump  which  at  first  sight  is  not  unlike  that  due 
to  caries  (Fig.  313). 

The  effect  of  this  ui)on  the  thoracic  and  abdominal  viscera  is  most  serious. 
The  chest  is  crushed  down  from  above,  twisted  round,  and  fixed  in  such  a  way  that 
even  when  synostosis  does  not  occur  between  the  ribs, 
expansion  is  out  of  the  question,  and  respiration  must  be 
purely  diaphragmatic.  The  lungs  are  displaced,  altered 
in  shape,  and  unable  to  move  in  the  pleural  cavity  ;  the 
heart  is  thrust  to  one  side  ;  the  aorta  is  doubled  almost 
upon  itself;  and  the  liver  and  kidneys  are  forced  alto- 
gether out  of  position  ;  in  short,  there  is  not  one  of  the 
vi.scera  that  does  not  suffer  more  or  less  severely. 

In  children,  especially  when  there  is  a  tendency  to 
rickets,  the  vertebrte  very  soon  become  altered  in  shape  ; 
and  then  the  deformity  is  practically  permanent,  although 
some  improvement  may  be  effected  if  the  treatment  is 
commenced  before  the  period  of  sclerosis  and  condensa- 
tion sets  in.  When  the  disease  does  not  commence  until 
puberty,  the  bones  do  not  suffer  so  soon,  and  if  only- 
reasonable  care  is  taken  and  proper  treatment  carried  out 
until  full  growth  is  reached,  deformity  can  be  altogether 
prevented.  It  is  very  rare  for  lateral  curvature  to  com- 
mence after  one  and  twenty,  although  if  there  is  any 
already  existing  deformity,  it  is  not  uncommon  for  it  to  become  worse. 

Knock-knee  and  flat-foot  occur  under  the  same  conditions  as  lateral  curvature 
of  the  spine,  and  are  very  commonly  associated  with  it. 

Symptoms  and  Diagnosis. — The  lateral  curvature  in  asymmetry  gives 
rise  to  no  inconvenience  (unless,  as  sometimes  happens  in  fractures,  the  inequality 
is  produced  suddenly  and  late  in  life)  ;  and  if  the  muscles  are  well  developed  it  has 
no  tendency  to  become  worse.  It  is  the  result  of  compensation  and  does  not 
admit  of  correction. 

When  due  to  physical  weakness  its  first  commencement  very  rarely  receives 
any  attention  ;  the  nature  of  the  complaint  is  not  suspected  until  the  alteration  in 
the  figure  (generally  the  growing  out  of  the  right  shoulder)  is  distinct.  The  patient 
may  have  been  in  the  habit  of  standing  on  one  leg  for  some  time  past ;  or  of 
stooping  with  the  head  poking  forward,  the  shoulders  rounded,  and  the  abdomen 
projecting ;  but  as  a  rule  this  is  the  first  thing  to  cause  a  suspicion  that  there  is 
anything  more  serious  than  simple  laziness. 

It  is  practically  confined  to  childhood  and  youth,  and  is  much  more  common 
in  girls  than  boys.     To  some  extent  this  is  due  to  the  very  great  strain  upon  the 


Fig. 


.^Extreme  Scoliosis. 


7i6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

strength  at  puberty,  especially  as  this  is  often  accompanied  by  a  period  of  rapid 
growth  ;  but  there  is  no  question  that  it  is  largely  the  result  of  different  habits  and 
modes  of  life,  and  especially  of  insufficient  and  improper  exercise,  not  enough 
attention  being  paid  to  the  development  of  the  muscular  system. 

Pain  is  unusual,  although  when  the  disease  is  advanced  it  may  be  very  severe, 
possibly  from  jiressure  upon  the  intercostal  nerves.  Very  often  there  is  a  weary 
sense  of  aching  in  the  lumbar  region,  especially  of  an  evening  and  after  exertion  ; 
and  with  this  there  may  be  some  cutaneous  tenderness  over  the  bony  prominences, 
such  as  is  not  unfrequent  in  convalescents.  In  most  cases,  however,  this  is  either 
neglected  as  natural  in  connection  with  the  time  of  life,  or  is  stigmatized  as  grow- 
ing pain  ;  and  as  practically  there  are  no  other  symptoms,  the  patient  is  regarded 
as  simply  having  outgrown  her  strength,  until,  suddenly,  the  want  of  symmetry  is 
observed. 

Method  of  Examination, — The  clothing  is  arranged  so  that  the  body 
above  the  iliac  crests  and  the  gluteal  cleft  can  be  inspected  from  all  sides.  If, 
from  the  height  of  the  crests,  there  is  any  reason  to  suspect  inequality  of  the  lower 
limbs,  this  must  be  investigated  first,  and  compensation  made  by  placing  a  book 
under  the  shorter  leg. 

At  first  the  patient  stands  upright  with  the  feet  together,  in  a  natural,  uncon- 
strained position.  If  the  muscles  are  rigid  and  contracted,  so  that  the  attitude  is 
stiff,  they  nearly  always  give  way  in  a  minute  or  two.  In  the  meantime  the  tip  of 
each  spinous  process  is  marked  with  an  aniline  pencil.  In  an  ordinary  case,  with 
the  dorsal  convexity  on  the  right,  the  scapula  on  that  side  is  higher  and  more 
prominent,  the  chest  fuller,  and  the  iliac  crest  better  marked,  with  a  deep  depres- 
sion between  it  and  the  ribs  (Fig.  310).  On  the  left  the  outline  of  the  body  is 
nearly  straight.  Seen  from  the  side,  the  head  projects  forward,  the  thorax  is  flat, 
half-concealed  by  the  shoulders,  and  the  lower  part  of  the  abdomen  projects,  owing 
to  the  antero-posterior  bend  which,  when  the  muscles  are  weak,  nearly  always 
complicates  the  lateral  one.  In  front,  the  left  breast  stands  out  more  than  the 
other,  and  the  asymmetry  of  the  thorax  is  even  more  distinct. 

Next  the  patient  is  directed  to  stoop  forward,  the  knees  being  kept  straight, 
the  head  bent  down,  and  the  arms  hanging  loosely  in  front.  This  gives  an  idea  of 
the  amount  of  rotation.  The  ribs  posteriorly  are  uncovered  ;  and  the  projection 
backward  of  the  lower  part  of  the  chest  on  one  side,  and  of  the  erector  spinae  in 
the  lumbar  region  on  the  other,  is  brought  prominently  into  view.  It  is  often  of 
service  to  keep  a  record  of  this  position  by  moulding  a  malleable  piece  of  lead 
(as  suggested  by  Roth)  transversely  to  the  ribs,  between  the  angles  of  the  scapulae, 
and  taking  a  tracing  from  this  on  to  paper.  If  the  deformity  is  conspicuous  a 
second  may  be  taken  opposite  the  third  lumbar  spine. 

Afterward  the  patient  is  directed  to  straighten  her  back  by  her  own  unaided 
efforts  ;  and  if,  as  is  probable,  this  merely  results  in  increasing  the  deformity,  an 
attempt  must  be  made  by  manipulating  the  trunk  and  the  limbs  to  see  how  far  it  is 
possible  for  the  muscles  to  restore  the  symmetry.  In  cases  in  which  there  is  no 
osseous  deformity  this  can  usually  be  done  by  placing  the  patient  in  what  Roth  has 
called  the  key-note  position,  with  the  right  arm  directed  upward,  and  the  left  one 
at  right  angles  to  the  trunk. 

The  prognosis  depends  chiefly  upon  the  state  of  the  vertebrae.  If  they  are 
not  yet  affected,  the  patient  can  generally  be  cured,  if  she  will  take  sufficient 
trouble,  although  relapses  are  almost  sure  to  occur  from  time  to  time  until  the 
development  of  the  trunk  is  complete.  If,  on  the  other  hand,  osseous  deformity 
is  already  present,  neither  rotation  nor  curvature  can  be  corrected,  except  in  very 
early  cases,  and  where  there  is  evidence  of  recent  rickets,  all  that  can  be  done  is 
to  prevent  them  becoming  worse. 

Treatment. — The  essential  point  is  to  strengthen  the  muscles  by  regular  and 
systematic  exercises,  without  fatiguing  them. 

Good  food,  fresh  air,  iron,  cod-liver  oil,  and  tonics  are  essential,  as  patients 
who  suffer  from  lateral  curvature  are  nearlv  alwavs  anaemic  and  often  chlorotic. 


SPINAL   CURVATURE.  -jx-j 

The  clothing  should  be  arranged  so  as  to  avoid  compression  of  the  lower  part  of 
the  thorax ;  if  stays  are  worn  they  should  be  short,  and  there  should  be  a  vertical 
slip  of  elastic  on  each  side,  to  admit  of  easy  expansion,  and  great  care  must  be 
taken  to  avoid  injurious  habits,  which,  if  they  have  not  caused  the  deformity, 
have  at  least  made  it  worse,  such  as  long  standing,  especially  standing  at  ease  ; 
sitting  obliquely  in  a  cramped  position  when  writing  without  a  proper  back-rest, 
or  with  the  legs  crossed,  and  stooping.  The  back  should  be  well  sponged  and 
rubbed  every  morning,  and  massage,  stroking  and  kneading  the  muscles  on  either 
side  of  the  spine,  and  galvanism,  should  be  applied  to  relieve  the  aching  and  sense 
of  fatigue  which  are  nearly  always  present  at  first  after  any  little  exertion. 

Where  the  muscular  strength  is  good,  and  the  curvature  only  slight,  general 
exercises  may  be  prescribed,  especially  swimming,  balancing  a  light  weight  upon 
the  head,  swinging  by  the  hands,  and  the  use  of  a  light  pair  of  dumb-bells.  Many 
of  the  exercises  on  the  horizontal  bar  may  be  performed  as  the  general  nutrition 
improves ;  but,  whatever  is  done,  the  patient  should  always  stop  short  at  the  least 
sensation  of  fatigue,  and  should  rest  upon  a  properly-shaped  chair,  with  the  seat 
horizontal,  a  foot-rest,  a  cushion  arranged  to  fit  the  loins,  and  an  excavation  above 
for  the  shoulders.     A  similar  chair,  with  the  back  adjusted  so  that  the  angle  can 


Fig.  314. —  Barwell's  Sling  for  Correcting  the  Rotation  in  the  Recumbent  Position. 

be  altered,  should  be  used  for  all  purposes — meals,  playing  the  piano,  writing,  etc. 
At  night  Barwell's  sling  (Fig.  314)  is  sometimes  of  service. 

In  more  severe  cases,  in  which  the  strength  is  unequal  to  this,  much  milder 
exercises,  limited  to  special  groups  of  muscles,  must  be  prescribed  ;  the  intrinsic 
muscles  of  the  thorax  (deep  inspiration  and  expiration),  those  of  the  head  and 
neck,  those  of  the  upper  extremity  that  act  upon  the  trunk,  then  those  of  the 
lower  (circumduction  of  the  shoulder  and  hip),  the  erector  spinte,  the  abdominal 
group,  etc.,  being  worked  quietly  and  slowly,  one  after  the  other,  a  certain  number 
of  times  (depending  upon  the  strength  of  the  patient),  first,  so  far  as  possible,  in 
the  recumbent  position,  then  erect.  The  same  precaution  as  to  fatigue  must  be 
adopted  here  ;  and  after  each  practice  the  muscles  of  the  back  should  be  well  rubbed 
and  sponged. 

As  Roth  has  pointed  out,  it  is  essential,  first  of  all,  to  correct  the  antero- 
posterior curvature.  Afterward,  when  the  muscles  have  regained  their  power  over 
this,  exercises  may  be  practiced  in  the  key-note  position,  or  in  that  which  tends 
most  to  bring  the  spine  to  its  natural  shape.  Later  ones  may  be  more  severe,  as, 
for  example,  when  the  patient,  lying  prone  upon  a  table  with  the  pelvis  and  legs 
supported,  and  the  latter  fixed  (by  some  one  sitting  on  them),  raises  the  trunk 
from  below  to  the  horizontal  position  and  slowly  lowers  it  again. 


7i8    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

During  this  treatment  Roth  recommends  that  the  patient  should  stand  fre- 
quently in  front  of  a  looking-glass  with  the  eyes  closed,  and  straighten  herself  uj) 
until  she  believes  that  she  is  standing  erect;  generally  she  finds,  on  opening  her 
eyes,  that  the  head  is  on  one  side,  and  one  shoulder  unduly  raised.  By  degrees 
the  muscular  sense,  which  requires  re-educating,  becomes  so  much  improved  that 
she  is  enabled  to  j^lace  herself  in  a  better  position  voluntarily,  and  at  once. 

Mechanical  supports  should  never  be  used  for  lateral  curvature  of  the  s])ine 
when  it  is  possible  to  avoid  them,  and  then  only  in  the  daytime,  not  when  the 
patient  is  lying  down.  Where  there  is  paralysis  of  the  muscles  of  the  back,  or 
where,  as  I  have  seen  on  one  or  two  occasions,  lateral  curvature  has  developed 
rapidly  after  a  severe  strain  (some  of  the  muscles  probably  being  ruptured  or  so 
stretched  that,  for  the  time  at  least,  they  were  paralyzed),  they  are  undoubtedly 
beneficial  as  adjuncts,  only  they  must  be  gradually  left  off  as  the  muscles  regain 
their  power.  To  keep  them  on  only  causes  atrophy.  In  advanced  cases,  in  which 
the  deformity  is  so  great  as  to  resemble  angular  curvature  in  ajjpearance,  and  the 
muscles  are  hopelessly  wasted,  their  use  cannot  be  avoided  ;  the  deformity  is  per- 
manent, and  it  is  only  possible  to  prevent  its  becoming  worse  by  supporting  the 
trunk.  Many  of  these  cases  suffer  very  severe  pain,  probably  from  pressure  upon 
the  intercostal  nerves,  and  only  experience  relief  when  wearing  some  kind  of 
mechanical  support. 


IXFLAMMATIOX    OF    THE    SpINAL    CoRD    AND    MENINGES. 

Acute   Tfaumatic  Meningitis. 

This  is  not  uncommon  after  wounds  that  involve  the  membranes,  or  after  gun- 
shot injuries  of  the  vertebrae  ;  the  former  are  nearly  always  punctured,  the  latter 
are  invariably  bruised,  so  that  there  is  everything  to  favor  septic  inflammation  ; 
and  under  these  conditions  it  may  commence  in  the  membranes  themselves. 
Much  more  rarely  it  is  met  with  after  injuries  that  are  not  compound,  such  as 
sprains,  wrenches,  and  simple  fractures,  and  then  it  is  generally  due  to  the  e.vten- 
sion  from  surrounding  structures.  Periostitis  or  arthritis  breaks  out  and  runs  on 
to  suppuration  ;  or  an  absce.ss  forms  in  the  crushed  and  bruised  tissue  around  the 
theca  and  between  the  bones  ;  or  the  inflammation  starts  outside  the  spinal  column 
altogether,  and  spreads  into  it  along  the  nerves  or  lymphatics,  or  more  directly 
through  a  rupture  in  some  of  the  posterior  ligaments. 

The  pathological  appearances  naturally  differ  to  a  certain  extent  ;  sometimes 
the  effusion  seems  to  be  limited,  but  more  frecpiently  the  pus  spreads  down  the 
whole  length  of  the  theca  and  involves  the  subdural  as  well  as  the  subarachnoid 
space.  In  extreme  cases  the  cord  is  injected  and  softened  so  as  to  be  almost 
diffluent  ;  and  the  pia  mater  is  thickened  and  infiltrated  with  lymph  which  spreads 
along  the  veins  like  white  streaks  on  either  side. 

It  may  begin  within  a  day  or  two  after  the  accident,  or  when  it  is  due  to 
gradual  extension  it  may  not  make  its  appearance  for  a  long  time.  As  a  rule 
there  is  a  rigor  or  shivering  ;  the  temperature  rises  at  once,  and  may  become  ex- 
ceedingly high  in  the  first  few  hours  ;  the  pulse  becomes  full  and  rapid  ;  the 
respiration  is  shallow  and  hurried  ;  vomiting  is  not  infre(iuent  ;  and  delirium  and 
other  signs  of  the  most  intense  fever  follow  very  soon.  Reflex  action  is  at  first 
exaggerated  ;  very  soon  it  begins  to  fail  ;  voluntary  power  is  impaired  almost  from 
the  first.  There  is  the  most  intense  pain  down  the  back,  often  spreading  round 
the  trunk  as  the  roots  of  the  spinal  nerves  become  involved  ;  hyper?esthesia  is 
almost  always  present,  and  sometimes  it  is  general,  so  that  the  weight  of  the  bed- 
clothes on  any  part  of  the  body  causes  agony  ;  the  muscles  of  the  back  are  kept 
perfectly  rigid  ;  often  there  is  opisthotonos,  the  back  of  the  head  boring  into  the 
pillows  ;  and  sometimes  there  are  violent  spasmodic  contractions  of  the  muscles  of 
the  limbs  and  even  general  epileptiform  convulsions.     As  a  rule  respiration  soon 


MENING  OMYEL 1 TIS.  7 1 9 

begins  to  fail,  owing  to  the  cervical  portion  of  the  cord  becoming  involved,  and 
severe  cases  may  terminate  fatally  in  this  way  within  forty-eight  hours.  If  the 
patient  survives  longer,  very  rapid  muscular  wasting,  sloughing  bed-sores,  cystitis 
and  nephritis  are  not  uncommon. 

Myelitis. 

Red  softening  is  present  above  the  seat  of  injury  in  all  cases  of  severe  bruising 
of  the  cord,  whether  compound  or  not;  and  especially  in  the  cervical  and  upper 
dorsal  regions  frequently  proves  the  immediate  cause  of  death  by  extending  to  the 
respiratory  centres.  The  vessels  in  the  cord  and  in  the  pia  mater  dilate;  the 
hyperaemia  becomes  intense,  and  in  severe  cases  numerous  small  ecchymoses  make 
their  appearance  ;  the  nerve-cells  break  down  ;  the  medulla  pours  out  and  forms 
the  so-called  myelin  drops  ;  and  the  neuralgia  melts  away  as  the  exudation  pours 
out  through  the  walls  of  the  vessels.  In  some  cases  this  is  so  marked  that  actual 
suppuration  occurs,  small  collections  of  pus  being  found  here  and  there,  especially 
in  the  gray  substance,  and  the  cord  itself  above  the  seat  of  injury  is  almost  de- 
stroyed. 

The  symptoms  are  rarely  so  intense  as  in  acute  suppurative  meningitis  ;  there 
may  be  a  rigor  at  the  commencement,  but  the  fever  is  not  so  high,  nor  is  the  pain 
so  severe.  On  the  other  hand,  the  functions  of  the  cord  are  lost  much  sooner  ; 
there  may  be  transient  hypergesthesia,  or  the  sensation  of  a  band  round  the  body, 
but  it  lasts  a  very  short  time  ;  voluntary  power  fails  almost  from  the  first ;  muscular 
spasms  rarely  occur,  and  reflex  action,  though  it  may  be  slightly  exaggerated  just 
at  the  beginning,  is  soon  destroyed.  Rapidly  ascending  paraplegia  is  the  most 
marked  symptom. 

Acute  bed-sores,  sloughing  cystitis,  and  other  forms  of  intense  inflammation 
running  into  gangrene  are  especially  common  in  cases  of  myelitis,  and  probably 
are  in  a  certain  measure  caused  by  it. 

Chronic  Meningomyelitis. 

Injuries  to  the  spinal  column  are  occasionally  followed  by  a  peculiar  insidious 
form  of  inflammation  which  affects  both  cord  and  membranes.  It  may  occur 
after  any  accident,  no  matter  how  trivial,  but  it  seems  especially  prone  to  follow 
sprains  and  contusions  in  which  it  may  be  supposed  the  ligaments  have  been  torn 
or  blood  extravasated  into  the  canal.  There  is  no  doubt  it  does  occur  after  rail- 
way collisions,  perhaps  more  frequently  after  them  than  after  any  other  form  of 
accident,  though,  as  already  mentioned,  many,  if  not  most,  of  the  cases  of  so- 
called  railway  spine  are  better  explained,  in  part  by  the  injury  to  the  bones  and 
ligaments,  in  part  by  the  nervous  shock. 

The  symptoms,  especially  at  the  beginning,  are  very  ill-defined  :  generally  it 
is  impossible  to  fix  the  date  of  their  first  appearance  ;  it  may  be  a  few  days,  it  may 
be  a  few  months  after  the  accident,  and  they  are  hardly  ever  the  same ;  some 
depend  upon  the  degeneration  of  the  cord,  others  upon  the  thickening  of  the 
membranes.  In  most  cases  the  former  are  the  more  definite  ;  there  is  no  fever, 
the  movements  of  the  back  are  not  interfered  with,  and  there  is  no  pain  on 
pressure,  for  as  long  as  the  bones  and  ligaments  are  intact,  none  can  be  transmitted 
to  the  interior  of  the  canal.  But  there  is  very  soon  evidence  that  certain  portions 
of  the  nervous  system  are  beginning  to  lose  their  power  ;  rapid  wasting,  perhaps, 
and  loss  of  strength  are  noticed  in  a  particular  group  of  muscles,  and  it  is  found 
that  their  electric  reaction  is  no  longer  normal ;  sometimes  this  remains  stationary 
for  a  period,  sometimes  it  extends  until  a  whole  limb  is  paralyzed.  In  other  cases 
micturition  becomes  difficult,  or  defecation  involuntary  ;  sexual  power  may  dis- 
appear, or,  if  the  cervical  portion  of  the  cord  is  involved,  there  may  be  persistent 
vomiting  or  hiccough,  or  vision  may  be  impaired  from  interference  with  the 
accommodation.  Then  the  sensibility  of  the  skin  becomes  blunted,  a  slight 
degree  of  hypergesthesia  may  be  present  for  a  time,  but  this  soon  gives  way,  and 


720     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  cutaneous  reflexes  fail.  (Jne  portion  of  the  cord  after  another  becomes 
involved,  the  loss  of  power  becomes  more  and  more  general,  and  gradually,  as  the 
degeneration  extends,  the  muscles  of  resjjiration  become  affected,  and  death  ensues 
from  ascending  ])araplegia,  or  the  ])atient  becomes  so  weak  and  feeble  that  some 
slight  accidental  disorder  soon  proves  fatal. 

If,  in  addition  to  this,  the  membranes  are  thickened  or  adherent  to  the  cord, 
there  are  other  symptoms  as  well.  The  roots  and  the  spinal  nerves  are  affected  ; 
there  is  pain  on  moving  or  twisting  the  back  ;  the  spine  is  held  stiffly,  and  some- 
times there  is  a  certain  amount  of  muscular  spasm,  just  as  when  the  ligaments  are 
strained.  Frecjuently  there  is  a  sense  of  constriction,  as  if  a  girdle  were  tied 
round  the  body,  or  there  is  intense  pain  at  the  periphery  or  along  the  course  of 
certain  nerves  ;  formication,  tingling,  and  numbness  are  not  uncommon,  and  in  a 
few  instances  vasomotor  changes,  alterations  in  the  temperature  of  certain  parts, 
and  even  cutaneous  eruptions  have  been  noticed.  In  the  worst  cases  other  parts 
of  the  nervous  s)^stem  become  affected  as  well  ;  the  movements  of  the  tongue,  for 
examjile,  are  interfered  with  and  deglutition  and  articulation  impaired. 

Treatment. — The  treatment  of  these  inflammatory  complications  is  very 
unsatisfactory.  In  the  case  of  a  wound  means  must  be  taken  to  secure  primary 
union,  or,  if  this  is  out  of  the  question,  to  prevent  septic  absorption  by  efficient 
drainage.  Where  the  skin  is  uninjured,  all  that  can  be  done  is  to  rectify  any 
deformity  that  is  present,  and,  by  means  of  perfect  rest  maintained  for  a  sufficient 
length  of  time,  keep  the  consecutive  hyper^emia  within  due  bounds.  Leeches  and 
cupping  may  be  tried  where  the  hyperesthesia  is  very  marked,  or  if  there  is  much 
muscular  spasm,  but  care  must  be  taken  that  the  punctures  do  not  become  the 
starting  points  of  sores.  Ice  may  be  used  in  the  .same  way,  but  the  application 
must  be  continuous.  Ergot,  belladonna,  and  aconite  have  been  strongly  recom- 
mended, and  small,  frecpiently  repeated  doses  of  calomel  have  been  given  for  the 
same  reason  as  in  cerebral  inflammation,  but  it  very  rarely  happens  that  any 
distinct  benefit  can  be  traced  to  their  use. 

In  chronic  cases,  most  reliance  must  be  placed  upon  iodide  of  potash  and 
mercury  (especially  the  bichloride)  in  small  doses,  kept  up  for  a  long  period. 
Even  when  there  is  no  suspicion  of  sy})hilis,  their  use  has  been  followed  by  very 
considerable  benefit.  Counter-irritation,  flying  blisters,  dry  cupping,  stimulating 
liniments,  and  even  the  actual  cautery  are  sometimes  of  assistance  as  well.  So 
long  as  there  are  any  symptoms  of  progressive  inflammation,  galvanism,  strychnia, 
and  tonics  should  be  avoided  ;  afterward,  when  this  has  subsided,  they  may  prove 
of  service  in  restoring  the  nutrition. 


Tumors  of  the  Spinal  Cord. 

In  one  case  (Horsley  and  Cowers)  a  tumor  (myxoma)  was  successfidly  diag- 
nosed and  removed  from  the  spinal  cord.  It  had  caused  comj)lete  paralysis  of  the 
lower  limbs  and  bladder,  and  annssthesia  up  to  the  ensiform  cartilage,  with  severe 
girdle  i)ain  in  the  region  of  the  sixth  and  seventh  intercostal  nerves,  especially  on 
the  left  side.  At  the  time  of  the  operation  sensibility  was  absent  as  high  as  and 
including  the  fifth  dorsal  nerve  on  the  left  side  and  impaired  on  the  level  of  the 
fourth. 

A  longitudinal  incision  was  made  down  the  centre  of  the  back  ;  the  muscles 
separated  from  the  laminae  and  the  back  of  the  transverse  processes  by  the  free  use 
of  the  knife  ;  the  vertical  aponeurosis  divided  transversely  ;  the  spines  of  the  fourth, 
fifth,  and  sixth  vertebrae  removed  ;  and  then  the  laminae  and  ligamenta  subflava. 
The  dura  mater  was  then  split  up,  and  as  nothing  was  seen  the  spine  of  the  third 
was  taken  away  too.  A  small  almond-shaj^ed  growth  was  then  found  lying  upon 
the  posterior  root  zone  of  the  left  side,  involving  the  root  of  the  fourth  nerve  four 
inches  above  the  level  of  the  anaesthesia.  The  tumor,  with  the  nerve,  was  dis- 
sected off  the  cord  ;  the  margins  of  the  dura  mater  approximated  ;  the  skin  and 


TREPHINING  THE  SPINE.  721 

the   muscles    sutured  and  a  deep  drain    inserted.      The  patient  made  a   perfect 
recovery  in  every  way. 

The  dura  matral  sheath  of  the  cord  has  been  e.xposed  on  several  occasions  in 
removing  congenital  lipomata,  false  spina  bifida,  and  congenital  sacro-coccygeal 
tumors,  and  has  been  recognized  by  its  pulsation. 


Trephining  the  Spine. 

This  operation  has  been  performed  for  injury,  compression  of  the  cord  conse- 
quent upon  caries,  for  the  removal  of  tumors,  and  for  persistent  neuralgia.  With 
regard  to  the  first  of  these,  there  are,  according  to  Thorburn,  sixty-one  cases  on 
record,  of  which  one,  due  to  direct  violence,  was  a  complete  success.  Of  the 
remainder,  there  are  only  seven  in  which  the  locality  of  the  injury  is  known  and 
in  which  there  was  a  bona  fide  improvement,  and  all  these  were  in  the  lower  dorsal 
or  lumbar  region.  Further,  in  six  of  these  the  improvement  does  not  ai)pear  to 
have  been  traceable  to  the  cord,  but  to  the  cauda  equina ;  and  in  one  only  of  the 
whole  sixty  is  there  anything  like  satisfactory  evidence  of  recovery  of  any  part  of 
the  spinal  cord  itself. 

According  to  the  same  authority  trephining  the  spine  has  been  performed 
thirteen  times  (on  twelve  patients)  for  compression  of  the  cord  consequent  upon 
caries ;  and  in  seven  of  these  there  was  marked  relief,  directly  resulting  from  the 
operation.  In  one  case  the  phrenic  nerve  was  wounded,  causing  death  ;  and  in 
another  the  operation  is  stated  to  have  hastened  the  end  ;  the  rest  were  not  bene- 
fited or  injured  by  it.  Horsley's  is  the  only  case  in  which  the  vertebral  canal  has 
been  opened  and  the  dura  matral  sheath  slit  up  for  the  removal  of  a  tumor  that 
did  not  project  externally.  Abbe,  of  New  York,  has  divided  both  roots  of  the  sixth 
and  seventh  cervical  nerves  outside  the  dura,  and  the  posterior  roots  of  the  seventh 
and  eighth  inside,  for  intractable  brachial  neuralgia  ;  but  whether  with  permanent 
benefit  is  not  yet  known. 

No  special  directions  can  be  laid  down.  The  incision  should  be  in  the 
middle  line,  the  patient  being  supported  in  the  three-quarter  prone  position.  The 
periosteum,  with  the  muscles  covering  it,  should  be  detached  as  far  as  may  be 
required  from  the  spines  and  laminae  on  either  side,  partly  to  avoid  hemor- 
rhage, which  is  free  and  difficult  to  control,  partly  in  order  that  if  the  bone  is 
removed  a  firm  protection  may  be  left,  and  the  surface  of  the  laminae  deeply 
grooved  with  a  saw.  The  section  is  completed  with  bone  forceps.  The  subse- 
quent steps  depend  upon  the  nature  of  the  lesion  :  granulation  tissue  has  been 
scraped  away  until  the  surface  of  the  dura  mater,  apparently  unaffected,  was 
exposed  ;  dense  leathery  masses  of  thickened  inflammatory  deposit  have  been 
dissected  off  the  theca ;  and  considerable  portions  of  the  theca  itself  that  were 
hopelessly  involved  have  been  excised  as  well.  In  several  instances  in  which  this 
operation  has  been  performed  for  pachymeningitis,  the  pulsation  of  the  cord  has 
been  seen  to  commence  as  soon  as  the  thickened  tissue  was  removed ;  sensation 
and  warmth  have  reappeared  in  the  lower  limbs  within  twelve  hours,  and  voluntary 
movements  within  a  it\N  days. 


722     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTKR  IX. 

SURGICAL  INJURIES  AND  DISEASES   OF  THE  EVE. 

By  J.   Hutchinson,  Jun.,  f.k  c.s. 

I.   The  Methods  of  Examining  the  P>ye.     Errors  of  Refraction. 

For  oi)hthalmic  work,  the  student  should  be  provided  with  the  following  :  a 
refraction  ophthalmoscope  (of  which  there  are  many  varieties,  the  one  designed  by 
Mr.  Stanford  Morton  being  perhaps  the  best),  and  a  large  convex  glass  lens  having 
a  diameter  of  two  inches  and  a  focal  length  of  about  three  inches.  In  addition  to 
these,  for  estimating  refraction,  a  "  keratoscopy  mirror  "  is  useful,  and  a  pupillo- 
meter  should  be  added  to  the  ophthalmoscope  case. 

By  "  oblique  illumination  "  of  the  eye  is  meant  the  projection  of  light  from  a 
lamp  at  the  side  of  and  somewhat  in  front  of  the  patient's  head  through  the 
convex  lens  into  the  eye,  the  lens  being  held  at  about  its  focal  distance  from  the 
latter.  Oblique  illumination  is  especially  valuable  for  detecting  opacities  or 
"  nebulce  "  in  the  cornea,  foreign  bodies  on  the  latter,  or  commencing  cataract. 

By  "  indirect  oi)hthalmoscopic  examination"  is  understood  the  following: 
The  patient  is  seated  in  a  dark  room  with  a  light  behind  and  to  one  side  of  his 
head  ;  the  observer  uses  the  plane  mirror  of  the  ophthalmoscope  at  a  distance  of 
about  eighteen  inches,  and  reflects  the  light  into  the  pupil  of  the  patient's  eye  ;  then 
interposing  the  convex  lens,  held  in -the  left  hand  at  rather  less  than  its  focal 
distance  from  the  latter,  the  patient  is  directed  to  look  at  the  observer's  right 
ear  if  the  right  eye  is  being  examined,  at  the  left  ear  if  the  left  eye  is  under  ob- 
servation. By  this  means  an  inverted  image  is  obtained  of  the  optic  disc,  and 
the  whole  fundus  can  be  explored  by  making  the  patient  look  upward,  downward, 
and  to  either  side.  It  must  be  remembered  that  the  image  obtained  is  an  inverted 
one,  and  hence,  for  instance,  a  hemorrhage  seen  apparently  above  the  disc  is  really 
situated  below  it. 

In  the  "  direct  method  "  of  examination,  on  the  contrary,  the  image  obtained 
is  not  inverted.  The  oblique  mirror  of  the  ophthalmoscope  is  used,  the  light  being 
as  near  as  convenient  to  the  patient's  ear  ;  the  surgeon,  using  his  right  eye  when 
examining  the  patient's  right  one  and  vice  versa,  approaching  his  eye  and  instru- 
ment until  the  latter  is  just  in  front  of  the  cornea,  whilst  reflecting  the  light 
steadily  into  the  pupil.  If  the  patient  looks  straight  forward,  the  optic  disc  will 
be  seen  ;  if  straight  at  the  observer,  the  region  of  the  macula  or  yellow  spot  can  be 
explored,  etc.  Since  reflecting  the  rays  on  to  the  latter  region  j^roduces  reflex 
contraction  of  the  pupil,  it  is  a  great  convenience  if  the  contractor  pupilla;  be 
paralyzed  by  homatropine.  In  estimating  refraction,  too,  the  previous  use  of  this 
drug  is  often  necessary,  especially  in  young  subjects  and  in  those  with  hyperme- 
tropia  or  "long  sight."  An  aqueous  solution  of  homatropine  hydrobromate 
(four  grains  to  the  ounce)  is  employed,  two  or  three  drops  being  applied  within  the 
conjunctival  sac  every  ten  minutes.  After  this  has  been  repeated  three  or  four 
times,  practically  complete  paralysis  of  the  ciliary  muscle  and  contractor  pupill^e 
is  obtained,  both  muscles  recovering  within  twenty-four  hours.  For  ophthalmo- 
scopic use,  homatropine  has  largely  displaced  atropine,  since  the  paralytic  effects 
of  the  latter  often  persist  for  nearly  a  week.  Further,  if  atropine  be  used  in 
patients  of  advanced  age,  there  is  a  certain  risk  of  causing  glaucoma. 

The  student  should  practice  the  use  of  both  direct  and  indirect  ophthal- 
moscopic examination,  since  both  are  indispensable.  We  may  now  briefly  notice 
the  methods  of  detecting  and  estimating  errors  of  refraction  by  the  ophthal- 
moscope. 


EXAMINATION  OF  THE  EYE.  723 

In  hypcrmctropia,  otherwise  known  as  long  sight,  the  eye  is  shorter  than 
usual,  and  if  the  ciliary  muscle  be  at  rest,  parallel  rays  are  brought  to  a  focus 
behind  the  retina.  Rays  proceeding  from  an  object  at  a  distance  of  twenty  feet 
or  six  metres  may  be  regarded  as  parallel  ones.  Hence  a  hypermetropic  eye,  if 
the  ciliary  muscle  be  for  the  time  not  in  action,  has  a  certain  amount  of  defect  in 
distant  vision,  a  defect  which  the  patient  can  overcome  by  contracting  his  ciliary 
muscle,  rendering  the  lens  more  convex,  and  thus  bringing  the  rays  to  a  focus  on 
the  retina.  Rays  proceeding  from  a  near  object,  e.g.,  the  type  of  a  book,  can  also 
be  brought  to  a  focus  on  the  retina  with  extra  use  of  the  ciliary  muscle,  and  it  is 
in  near  vision  that  the  hypermetrope  nearly  always  notices  his  defect,  the  strain 
upon  the  accommodation  causing  aching  in  the  eyes  or  head. 

Hypermetropia  may  Ije  detected  by  the  surgeon  by  the  following  means  :  — 

1.  In  using  the  indirect  method,  if  the  image  of  the  disc  be  obtained  and- 
then  the  surgeon  gradually  withdraw  his  mirror  and  lens  whilst  keeping  the  disc  in 
view,  the  size  of  the  image  will  be  noticed  to  decrease. 

2.  If  the  direct  method  be  employed,  as  the  observer  approaches  the  patient 
whilst  reflecting  the  light  into  his  eye,  an  image  of  the  retinal  vessels  will  be 
obtained  at  a  distance  of  some  inches  from  the  eye.  This  image  will  appear  to 
move  (from  side  to  side  or  vertically)  in  the  same  direction  as  the  observer's  eye. 
The  distance  at  which  the  vessels  can  be  distinguished  varies  with  the  degree  of 
hypermetropia. 

3.  The  observer  uses  the  keratoscopy  mirror  (or  the  plane  one  in  his  ophthal- 
moscope) at  a  distance  of  at  least  one  metre,  and  reflects  the  light  from  the  lamp 
placed  above  and  behind  the  patient's  head  into  his  cornea,  making  a  shadow  pass 
across  the  latter  by  inclining  the  mirror.  If  the  shadow  passes  across  the  cornea 
in  the  direction  opposite  to  the  one  followed  by  the  mirror,  the  eye  examined  is 
either  hypermetropic  or  emmetropic  (of  normal  refraction).  The  test  being 
repeated  with  a  lens  *  of  -f-  i  D  (40")  focal  length  immediately  in  front  of  the 
patient's  eye,  if  the  latter  be  emmetropic  there  will  be  no  moving  shadow.  If 
hypermetropic,  lenses  of  increasing  strength  are  used  until  the  shadow  movement 
ceases,  when  the  deduction  of  about  i  D  from  the  lens  required  to  effect  this  will 
give  the  amount  of  hypermetropia. 

4.  By  using  the  direct  method  the  details  of  the  disc  can  be  clearly  seen  in  a 
hypermetropic  eye  when  -|-  glasses  are  used  in  the  ophthalmoscope.  The  highest 
lens  with  which  the  smaller  vessels  can  be  distinctly  seen  represents  the  total 
amount  of  hypermetropia.  The  observer's  eye  in  this  test  must  be  brought  close 
to  the  patient's. 

It  must  be  remembered  that  these  methods  of  estimating  the  amount  of 
hypermetropia  are  only  available  if  the  patient  be  relaxing  his  accommodation, 
and  most  easily  if  tht  ciliary  muscle  be  temporarily  paralyzed  by  homatropine  or 
atropine. 

In  myopia  or  short  sight  precisely  the  same  tests  are  employed  :  in  (i)  the 
size  of  the  image  increases  as  the  lens  and  ophthalmoscope  are  withdrawn  ;  in  (2) 
the  image  moves  in  the  opposite  direction  to  the  observer's  head  ;  in  (3)  the 
shadow  moves  across  in  the  cornea  in  the  same  direction  as  the  mirror  is  tilted  ; 
and  in  (4)  the  details  of  the  disc  cannot  be  clearly  defined  unless  a  —  lens  equal 
to  the  amount  of  the  patient's  myopia  is  used  in  the  ophthalmoscope. 

A  myopic  eye  is  one  in  which  the  length  of  the  globe  is  greater  than  normal, 
and  therefore  parallel  rays  passing  through  the  cornea  are  brought  to  a  focus  in 
front  of  the  retina.      Hypermetropia  is  a  congenital  condition,  does  not  tend  to 

*The  unit  of  the  Dioptric  System,  which  is  now  universally  employed,  is  a  lens  of  about  40 
English  inches  focal  length ;  -f-  2  D  signifies  a  convex  lens  of  V'  ^=  20^''  focal  length, —  5  D  a  con- 
cave lens  of  ■M'  =  %"  focal  distance,  etc.  To  convert  the  French  into  the  English  system,  divide 
the  number  of  dioptres  into  40.  The  standard  of  normal  acuteness  of  vision  is  represented  by  |, 
i.  e.,  letters  which  subtend  an  angle  of  5°  at  the  distance  of  6  metres  (about  20  feet)  are  used  and 
can  be  read  at  this  distance.  V  ^  ^'^^^  implies  that  the  patient  can  only  read  at  6  metres  type  which 
subtends  this  angle  and  should  be  read  at  12  metres  distance,  etc. 


724     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

increase  as  age  advances,  but,  on  the  other  hand,  occasionally  Ijeconies  less. 
Myopia  usually  comes  on  when  the  eyes  begin  to  be  used  much  for  near  vision — 
/.  e.,  at  school  or  during  early  adult  life — and  tends  to  increase  with  more  or  less 
rapidity.  Overwork  of  the  eyes  (especially  in  a  bad  light),  the  habit  of  stooping 
and  bringing  the  book,  etc.,  very  near  to  the  eyes,  and  reading  small  or  bad  print, 
favor  the  progress  of  myopia.  Twelve  inches  is  about  the  best  distance  for  near 
vision,  and  if  the  amount  of  myopia  be  so  great  as  to  compel  the  i)atient  to  hold 
his  books,  etc.,  nearer  than  this,  concave  glasses  should  be  given  of  a  sufficient 
strength  to  enable  him  to  read  comfortably  at  about  this  distance.  For  good 
distant  vision  a  myopic  patient  may  be  ordered  the  full  correcting  glasses,  and  if 
these  do  not  exceed  —  4  D  or  —  5  I),  they  may  be  used  for  both  near  and  dis- 
tant vision. 

A  hypermetropic  patient  has  no  difficulty  in  distant  vision,  as  a  rule,  but  the 
extra  strain  thrown  ui)on  his  ciliary  muscle  in  near  work  tends  to  produce  pain  in 
the  eyes  and  headache  (especially  frontal),  and  these  symptoms  may  be  entirely 
relieved  by  ordering  the  full  correction  to  be  worn  for  near  vision. 

Complications  of  Hypcrinctropia  and  Myopia. — The  chief  complication  of 
hypermetropia  is  convergent  strabismus,  the  form  of  squint  most  often  met  with 
in  practice.  In  this,  whilst  one  eye  is  directed  upon  a  near  object,  the  axis  of  the 
other  i)asses  to  its  inner  side  (/.  e.,  between  the  object  and  the  non-squinting  eye). 
Generally  the  squint  affects  the  same  eye  always  ;  it  is  then  said  to  be  constant, 
and  the  vision  of  the  affected  eye  is  often  defective  {e.  g.,  /^).  The  image  is  men- 
tally ignored,  and  hence  the  patient  does  not  complain  of  double  vision.  Con- 
vergent strabismus  comes  on  in  childhood,  and  if  the  case  is  seen  early  and  the 
squint  be  not  of  very  high  degree,  it  can  be  cured  by  the  continuous  use  of  fully 
correcting  glasses  (/.  <?. ,  those  equal  to  the  total  amount  of  hypermetropia  found). 
It  must  not,  however,  be  expected  that  vision  will  much  improve  in  the  defective 
eye,  though  it  is  well  to  advise  the  patient  to  practice  this  eye  by  covering  the 
other  from  time  to  time.  If  the  squint  be  alternating  (that  is,  if  first  one  eye 
squint  and  then  the  other)  vision  is  usually  good  in  both. 

If  the  strabismus  has  existed  for  some  years,  or  if  it  be  of  high  degree 
(20^-30°),  probably  a  tenotomy  of  one  internal  rectus  muscle  will  be  required. 
In  most  cases  it  is  advisable  to  give  the  correcting  glasses  a  trial  for  some  months, 
and  then  to  perform  the  tenotomy  if  the  squint  is  still  present,  ordering  the 
patient  to  continue  their  use  after  the  operation. 

There  are  several  complications  of  myopia,  especially  if  it  tends  steadily  to 
increase.  Perhaps  the  most  frequent  is  the  occurrence  of  floating  specks  (muscae 
volitantes)  seen  before  the  eye,  and  due  in  some  cases  to  actual  opacities  in  the 
vitreous,  though  often  none  can  be  detected. 

Hemorrhages  into  the  vitreous  or  retina,  detachment  of  the  latter  from  the 
choroid,  and  atrophic  patches  in  the  region  of  the  yellow  spot  (choroiditis  poste- 
rior) are  serious  and  not  uncommon  results  of  progressive  myoj)ia. 

Owing  to  the  strain  jnit  upon  the  internal  recti,  divergent  strabismus  may 
come  on,  and  give  rise  to  double  vision.  Besides  ordering  suital)le  glasses  for  a 
myopic  patient,  the  surgeon  should  caution  him  against  too  i)rolonged  work  with 
the  eyes,  and  should  insist  upon  the  light  used  in  the  evening  being  steady,  of 
good  quality,  and  so  placed  that  the  glare  may  not  come  upon  the  eyes  them- 
selves. Tonics  also  may  be  of  use,  and  means  should  be  taken  to  prevent  stoop- 
ing at  the  work,  and  books  with  very  small  or  bad  type  should  be  avoided.  If 
divergent  strabismus  is  present,  it  may  be  treated  by  division  of  one  or  both 
external  recti,  or  by  advancement  of  one  internal  rectus. 

A  very  constant  ophthalmoscopic  feature  of  high  myopia  is  the  formation  of 
a  whitish  crescent  at  the  outer  side  of  the  disc,  due  to  the  exposure  of  the  sclerotic 
by  the  shifting  of  the  choroidal  edge  (this  is  known  as  a  posterior  stap/i\/oma). 

In  both  simple  hypermetropia  and  myopia  parallel  rays  are  brought  to  a 
focus  either  behind  or  in  front  of  the  retina  when  the  accommodation  is  at  rest. 
But  sometimes  one  meridian  of  the  cornea  or  lens  is  more  curved  than  another, 


EXAMINATION  OF  THE   EYE. 


725 


and  in  such  a  case  the  rays  i)assing  through  the  two  meridia  are  brought  to  differ- 
ent foci.  Such  a  condition  is  termed  astii^miifisi/i.  If  the  two  meridia  are  at 
right  angles  to  each  other,  as  is  usual,  the  astigmatism  is  said  to  be  regular,  and 
can  be  corrected  by  suitable  cylindrical  lenses.  If,  on  the  other  hand,  one  small 
part  of  the  cornea  is  more  refractive  than  the  rest  (as  in  conical  cornea  or  after 
ulceration)  the  astigmatism  is  said  to  be  irregular,  and  cannot  be  benefited  by 
glasses. 

As  a  ride,  in  regular  astigmatism  the  vertical  meridian  of  the  cornea  is  more 
refractive  than  the  horizontal :  if  both  are  myopic,  the  case  is  said  to  be  one  of 
compound  myopic  astigmatism,  etc.;  if  one  meridian  is  myopic  and  the  other 
hypermetroi)ic,  the  term  mixed  astigmatism  is  used.  Often  the  meridia  are  not 
vertical  and  horizontal,  but  placed  oblicpiely,  whilst  still  at  right  angles  to  each 
other.  Then  the  exact  ol)li(piity  has  to  be  carefully  ascertained,  and  for  deter- 
mining this  keratoscopy  is  invaluable,  its  result  being  always  confirmed  by  trial 
with  cylindrical  glasses  in  distant  vision. 

Regular  astigmatism  is,  as  a  rule,  congenital.  Low  degrees  are  very  common 
and  may  give  little  or  no  trouble  ;  occasionally  it  is  left  after  extraction  of  cata- 
ract or  iridectomy,  owing  to  traction  on  the  cornea  by  the  scar  of  the  operation 
wound. 

Apart  from  the  errors  of  refraction  we  have  briefly  noticed,  we  have  to  con- 
sider weakness  of  sight  due -to  muscular  failure  and  to  senile  changes  in  the  eye. 
The  power  of  accommodation  for  near  objects  depends  on  two  factors — the  strength 
of  the  ciliary  muscle  and  the  elasticity  of  the  lens ;  and  it  steadily  decreases  from 
childhood  to  old  age.  It  may  be  repre.sented  by  the  highest  concave  lens  which 
can  be  overcome  by  contraction  of  the  ciliary  muscle — thus,  for  instance,  a 
patient  with  normal  vision,  at  the  age  of  15,  can  overcome  a  lens  of  —  12  D 
(/.  e.,  can  read  f  still  by  an  effort  when  this  lens  is  placed  before  his  eye).  The 
"  near  point  "  (the  shortest  distance  from  the  eye  at  which  it  is  possible  to  read 
I  J.)  will  be  represented  by  40  divided  by  12  or  T^yi  inches.  At  45  years  the 
accommodation  is  only  4.5  D  and  the  near  point  9".  It  is  about  at  this  age  that 
it  becomes  necessary  to  assist  the  accommodation  with  convex  lenses  for  near 
vision,  and  the  following  table  indicates  the  requisite  correction  (ox  presbyopia  or 
"  old  sight." 


Glass  required  for  Reading 
Age.  at  about  12",  etc. 

45, +  I  D 

50, +  2  D 

55, +  3  U 

60 .    .  +  4  D 


Age. 

65, 
70, 

75, 


Glass  required  for  Reading 
at  about  12",  etc. 


+  4.5D 

+  5-5D 
+  6D 


The  onset  of  presbyopia  is  delayed  by  myopia,  hastened  by  hypermetropia ; 
thus,  a  patient  with  myopia  of  —  4  D  may  not  require  glasses  for  reading  until  the 
age  of  60  ;  a  patient  with  -f-  2  D  of  hypermetropia  wall  need  about  -|-  3  D  for  read- 
ing at  45  years,  etc. 

In  early  life  the  ciliary  muscle  may  be  temporarily  weakened  from  various 
causes — diphtheria,  prolonged  suckling  in  women,  etc.  Difificulty  in  near  vision 
and  aching  of  the  eyes  may  also  depend  upon  strain  of  the  internal  recti  muscles 
from  overwork,  and  in  a  few  cases  prisms  are  of  service.  As  a  rule  these  cases  of 
"asthenopia"  are  best  treated  by  tonics,  rest  of  the  eyes,  out-door  exercise,  and 
other  measures  to  improve  the  general  health  of  the  patient. 


726    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


SECTION  I.— INJURIES. 

I.   Burns  and  Scalds. 

In  cases  of  simple  burns  of  the  face  the  eyelashes  are  often  temporarily  de- 
stroyed, and  muco-purulent  conjunctivitis  is  not  infrequently  observed.  The  ex- 
treme sensibility  of  the  cornea  and  conjunctiva  render  the  slightest  burn  or  scald  of 
these  parts  very  painful,  and  continuous  cold  apjilications  (iced  water  or  boracic 
solution)  and  i)ure  cocaine  used  with  vaseline  are  very  useful  in  relieving  the  pain. 
As  soon  after  the  accident  as  possible  it  should  be  ascertained  whether  the  cornea 
has  been  damaged,  for  the  prognosis  as  regards  vision  will  depend  chiefly  upon 
this  point.  If  a  whitish  opacity  is  seen  a  very  guarded  prognosis  should  be  given, 
since  it  rarely  clears  off  completely,  and  in  some  cases  the  whole  cornea  may 
slough.  If  the  ocular  or  palpebral  conjunctiva  be  much  burned,  adhesion  of  the 
two  (symblepharon)  is  very  likely  to  take  place — and  during  the  healing  process 
this  adhesion  should  be  limited  as  far  as  possible  by  the  frequent  insertion  of 
boracic  acid  ointment  or  vaseline.  Scalds  from  (luicklime,  sulphuric  acid,  caustic 
potash,  or  soda,  etc.,  are  not  infrequent,  and  in  their  treatment  a  weak  neutraliz- 
ing solution  (acid  or  alkaline)  should  be  freely  syringed  between  the  lids.  Any 
particles  of  lime  or  mortar,  etc.,  which  may  have  got  into  the  palpebral  sacs  should 
be  removed  by  syringing,  the  use  of  forceps,  etc.,  and  in  severe  cases  (especially 
in  children)  it  is  best  to  give  an  anaesthetic  in  order  to  effect  this  thoroughly. 

Lead  lotion  should  not  be  used  in  these  cases,  for  fear  of  lead  deposit 
on  the  cornea. 

2.   Foreign  Bodies. 

The  removal  of  foreign  bodies  from  the  corneal  surface  is  described  under 
Disea-ses  of  the  Cornea  ;  sometimes  a  piece  of  iron  is  driven  into  the  anterior 
chamber,  the  lens  or  the  vitreous.  In  such  cases  its  removal  has  been  frequently 
accomplished  by  the  use  of  the  fine-pointed  electro-magnet  introduced  through 
the  original  wound  or  a  fresh  one  made  with  a  narrow  keratome.  The  "  cannula- 
forceps  "  is  also  of  use  if  the  foreign  body  is  not  of  iron  and  can  be  readily  seen. 
Traumatic  cataract  is  certain  to  result  if  the  lens  capsule  is  wounded  by  a  foreign 
body ;  it  should  be  treated  by  continuous  cold  applications  and  the  frequent  use 
of  atropine  for  a  few  days.  The  lens  swells  up,  becomes  milky-white  and  gener- 
ally protrudes  into  the  anterior  chamber.  So  long  as  the  tension  of  the  globe 
remains  normal  no  other  treatment  is  needed  than  that  mentioned  ;  but  if  it  is 
distinctly  raised  and  there  is  marked  pain  and  congestion,  it  may  become  neces- 
sary to  incise  the  periphery  of  the  cornea  with  a  narrow  keratome  and  let  out  the 
soft  opaque  matter  with  a  curette  introduced  into  the  little  wound  thus  made. 
Atropine  and  ice  should  be  again  employed  after  the  operation. 

Although  a  foreign  body  may  remain  embedded  for  long  in  the  vitreous, 
sclerotic,  etc.,  without  giving  trouble,  as  a  general  rule  an  eye  with  such  an  injury 
retains  but  little  sight,  and  is  to  a  certain  e.xtent  liable  to  set  up  sympathetic  oph- 
thalmia in  the  other  one.  Severe  inflammation  or  suppuration  of  the  injured  eye 
may  result  from  the  introduction  of  septic  matter  with  the  foreign  body,  and  in 
this  case  excision  of  the  globe  should  be  performed.  The  same  rule  holds  good 
if  there  is  reason  for  believing  that  the  eye  (although  quiet)  contains  a  foreign 
body  and  has  permanently  lost  all  visual  power. 

3.  Wounds. 

Abrasions  of  the  corneal  surface  produce  much  pain  and  photophobia,  and  in 
elderly  people  may  be  the  starting  point  of  hypopyon,  iritis,  or  serpiginous  ulcer- 


INJURIES  OF  THE  EYE.  727 

ation.      Continuous  warm  boracic  fomentations,  the  use  of  cocaine  and   (if  there 
is  any  susi)icion  of  iritis)  of  atropine,  form  the  suitable  treatment. 

Perforating  wounds  of  the  cornea  are  very  bal)le  to  be  attended  by  prolapse 
of  the  iris,  which  follows  the  escape  of  the  aciueous  humor.  Cocaine  having  been 
used  (in  certain  ca.ses  general  anaesthesia  is  better),  an  attempt  should  be  made  to 
reduce  the  prolapsing  part  with  a  small  curette  or  caoutchouc  spatula  ;  but  if  this 
fails  the  protruding  part  of  the  iris  should  be  gently  drawn  forward  with  fine  for- 
ceps and  snipped  off  with  scissors.  Either  eserine  or  atropine  should  subsequently 
be  used  for  some  days,  so  as  to  draw  the  rest  of  the  iris  away  from  the  wound  ; 
eserine  if  the  latter  is  in  the  periphery  of  the  cornea,  atropine  if  it  is  central  or  if 
there  is  fear  of  iritis. 

Any  wound  of  the  sclero-corneal  junction  or  involving  the  structures  immedi- 
ately in  front  of  or  behind  this  spot,  is  dangerous,  owing  to  the  risk  oi  sympathetic 
ophthalmia.  This  disease  consists  essentially  in  an  iridocyclitis  of  the  non -injured 
eye,  coming  on  usually  within  a  few  weeks  (but  sometimes  many  months  or  even 
years)  after  the  date  of  injury.  Sometimes  it  takes  the  form  of  serous  iritis  with 
dotted  opacities  on  the  back  of  the  cornea,  sometimes  optic  neuritis  develops. 
But  the  usual  form  consists  in  iritis  leading  to  tough 
adhesions  and  secondary  cataract,  and  tending  slowly 
to  completely  destroy  the  sight.  What  is  the  explana- 
tion of  this  disease,  whether  some  infective  material  is 
conveyed  into  the  circulation  from  the  injured  and 
inflamed  eye  and  lodges  in  the  other  one,  or  whether 
the  inflammation  travels  along  the  optic  or  ciliary 
nerves,  remains  doubtful.  The  important  fact  to 
remember  is  that  (with  rare  exceptions)  sympathetic 
ophthahnia  is  due  to  a  wound  involving  the  ciliary 
region,  especially  if  it  inflames;  and  hence  immunity 
from  the  disease  is  worth  procuring  at  the  expense  of 
excision  of  the  injured  eye,  if  the  latter  retain  little 
or  no  vision  ;  for  removal  of  the  exciting  eye  after 
sympathetic  ophthalmia  has  come  on  is  useless. 

The  treatment  in  the  latter  case  consists  mainly  in 
using  atropine,    counter-irritation  to   the  temple  and     fk;.  315.— Prolapse  of  inflamed  iris 
protecting   the  eyes    from    light.      Mercury,   quinine  through  a  Wound  of  the  comea 

,    ,      ,,      ,  .  .         ^    ,,"     ,  J  <T,  cornea ;  /;,  prolapsing  part   of 

and  belladonna  given   in   full   doses   have   each  their         <r,  the  iris ;«',  ciliary  region, 
advocates. 

Occasionally  a  free  iridectomy,  performed  after  the  acute  stage  has  passed  off, 
is  useful. 

Sympathetic  i^-ritation  is  a  less  severe  complication  of  wounds  of  the  eye, 
though  sometimes  it  passes  on  to  true  ophthalmia.  Its  symptoms  are  attacks  of 
congestion  and  watering  of  the  non-injured  eye,  failure  of  accommodation,  irrita- 
bility on  exposure  to  light,  etc.  In  such  a  case  it  is  best  to  excise  the  injured 
eye. 

4.   Contusion  or  Concussion  Injuries. 

In  most  cases  of  "  black-eye  "  the  globe  itself  escapes  injury  ;  the  best  way  of 
obtaining  absorption  of  the  extravasation  consists  in  using  warm  fomentations  after 
the  first  twenty-four  hours  (during  which  cold  should  have  been  applied).  The 
following  may  result  from  blows  involving  the  eye  itself: — 

1.  Traumatic  mydriasis — /.  e.,  fixed  dilatation  of  the  pupil  with  more  or  less 
failure  of  accommodation.  It  is  a  singular  fact  that  this  mydriasis  may  persist  for 
many  years,  or  may  disappear  in  a  few  days. 

2.  Hemorrhage  into  the  anterior  chamber  is  of  slight  importance,  since  the 
blood  is  rapidly  absorbed  under  belladonna  fomentations.  Hemorrhage  into  the 
vitreous  is  much  more  serious,  and  generally  affects  the  vision  permanently.  It 
must  be  suspected  to  have  occurred  after  an   injury,  when  (the  lens  and  cornea 


728    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

being  clear)  no  reflex  can  be  obtained  from  the  back  of  the  eye  on  ophthalmo- 
scopic examination.  Sometimes  the  floating  clots  can  be  detected  by  oblique 
illumination. 

3.  Dislocation  of  the  lens  may  be  either  into  the  anterior  chamber  or  (more 
commonly)  into  the  vitreous  ;  a  very  slight  displacement  is  of  serious  import  as 
regards  vision.  It  may  be  suspected  from  tremor  of  the  iris  on  sudden  movement 
of  the  eye,  and  from  bulging  of  the  iris  at  one  part  and  recession  at  another.  If 
the  ])upil  be  dilated  the  edges  of  the  lens  can  usually  l)e  detected  as  a  dark  colored 
line  if  it  is  dislocated.  Cataract  and  glaucoma  are  both  liable  to  ensue,  and  in 
some  cases  the  disjjlaced  lens  causes  iritis,  or  shrinks  up  or  calcifies.  Any  treat- 
ment but  excision  of  the  eye  is  as  a  rule  useless. 

4.  Rupture  of  the  Globe. — This  usually  occurs  at  or  toward  the  ciliary  region 
where  the  sclerotic  is  thinnest,  and  calls  for  excision  in  most  cases.  Both  lens 
and  iris  have,  however,  been  completely  extruded  through  a  rupture  and  the  eye 
has  retained  some  vision. 

5.  Detachment  of  Part  of  the  Iris  from  its  Ciliary  Origin. — This  is  known  as 
"  coredialysis, "  and  may  not  be  limited  to  one  point. 

6.  Rupture  of  choroid  or  retina,  generally  recognizable  with  the  ophthalmo- 
scope as  linear  bands  of  white  with  pigmented  borders.  Its  effect  upon  vision  will 
depend  upon  whether  the  rupture  involves  the  yellow-spot  region  or  not.  Detach- 
ment of  the  retina  may  also  result  in  myopic  eyes  from  very  slight  contusions ;  it 
is  recognized  with  the  ophthalmoscope  as  a  white  mass  bulging  into  the  vitreous, 
often  furrowed  on  its  surface  and  with  the  retinal  vessels  running  over  it.  If  limited 
to  one  segment  of  the  retina,  vision  may  be  impaired  only  in  the  corresponding 
part  of  the  field,  but  not  infrequently  sight  is  completely  lost. 

7.  A  peculiar  form  of  retino-choroiditis,  in  which  there  is  both  atrophy  and 
pigmentation,  is  liable  to  come  on  within  a  few  weeks  of  concussion  of  the  globe. 
It  may  be  limited  to  the  yellow-spot  region  or  may  be  generally  diffused,  sight 
being  impaired  to  a  corresponding  extent.  The  possibility  of  this  should  be  borne 
in  mind  in  giving  a  prognosis  as  regards  vision  after  a  blow  on  the  eye. 

8.  Concussion  cataract  is  described  under  Diseases  of  the  Lens  (see  page 
730- 


SECTION  11 —DISEASES. 


DISEASES  OF  THE  CONJUNCTIVA. 

The  chief  of  these  are  :  (i)  catarrhal  or  muco-purulent  ophthalmia  ;  (2) 
purulent  ophthalmia ;  (3)  granular  conjunctivitis ;  and  (4)  chronic  conjuncti- 
vitis without  granulations.     ' 

I.  Catarrhal  Ophthalmia. 

An  acute  form  of  conjunctivitis,  attended  with  more  or  less  discharge  of 
mucus  or  muco-pus,  occurring  at  all  ages,  but  especially  in  children  and  young 
adults,  and  decidedly  contagious.  The  cause  is  often  doubtful  :  exposure  to 
draught  is  sometimes  assigned  ;  the  subjects  have  not  uncommonly  recently  re- 
covered from  measles  or  scarlet  fever  (especially  the  former)  ;  while  sometimes  it 
runs  through  all  the  members  of  a  family  or  dwellers  in  a  house.  It  appears  to 
be  most  prevalent  in  the  spring  and  autumn.  The  first  symptom  is  a  feeling  of 
grit  under  the  lids,  with  pain  and  perhaps  photophobia ;  the  lids  are  stuck  together 
on  waking  in  the  morning,  and  when  the  eyes  are  examined,  the  whole  conjunc- 
tiva is  seen   to  be  intensely  congested.      In  strumous  subjects  especially,  phlyc- 


DISEASES  OF  THE  CORNEA    AND   IRIS.  729 

tenules  or  i)hlyctenular  ulcers  are  met  with  at  the  same  time,  and  such  cases  are 
slower  in  their  course  than  the  uncomplicated  ones,  which,  as  a  rule,  completely 
recover  in  a  week  or  two.  Catarrhal  ophthalmia  can  be  readily  distinguished  from 
the  more  serious  purulent  form  due  to  gonorrhoeal  infection,  by  the  character  of 
the  discharge,  which  in  the  former  disease  is  rarely  profuse,  and  consists  of  whitish- 
yellow  sticky  mucus  ;  small,  conjunctival  ecchymoses  are  often  seen  at  the  onset 
of  the  attack. 

Treatment. — A  mild,  astringent  lotion  should  be  used  tVeely  to  bathe  the 
conjunctival  surface  three  or  four  times  a  day,  and  the  edges  of  the  lids  .should  be 
anointed  with  some  simple  ointment  (ung.  galeni,  ung.  cetacei,  or  a  very  weak 
ointment  of  the  yellow  oxide  of  mercury)  at  night-time.  Either  of  the  following 
lotions  are  useful : — 

Acidi  boracici, Sr-  x 

Zinci  sulphatis, gr.  ij 

Glycerini, rr^x 

Aq.  destill.,  or  aq.  losarum, ^j. 

Argenti  nitratis, gr.  j,  or  gr.  ij 

Aq.dest. |j. 

or  a  saturated  solution  of  boracic  acid  in  distilled  water. 

Photophobia  is  rarely  very  pronounced,  unless  a  corneal  ulcer  is  present,  but 
it  is  well  to  use  a  shade  for  a  Iqw  days ;  the  common  practice  among  patients  of 
tying  the  eyes  up,  or,  worse  still,  of  applying  poultices,  should  be  forbidden. 


DISEASES  OF  THE  CORNEA. 

Being  a  non-vascular  tissue,  exposed  to  various  irritants  from  without,  the 
corneal  surface  is  very  liable  to  inflame  and  ulcerate,  particularly  in  subjects  in 
weak  health,  and  the  several  forms  of  corneal  ulcer  constitute  a  large  proportion 
of  the  total  cases  observed  in  ophthalmic  practice.  Further,  the  whole  substance 
of  the  cornea  is  liable  to  inflammation,  due  to  inherited  syphilis  (interstitial 
keratitis)  ;  and  some  rarer  forms  of  corneal  disease  are  met  with  secondary  to 
iritis,  cyclitis,  or  complicating  granular  lids,  ophthalmia  neonatorum,  etc. 

We  may  here  mention  the  impaction  of  foreign  bodies  in  the  cornea,  such  as 
fragments  of  steel  or  dust.  The  reaction  in  these  cases  is  generally  severe,  pain 
and  congestion  coming  on  rapidly  ;  and  in  such  cases  a  careful  examination  should 
be  made  of  the  corneal  surface  by  oblique  illumination.  The  detection  and 
removal  of  the  foreign  body  is  much  aided  and  rendered  painless  by  instilla- 
tion of  cocaine  (2  per  cent,  solution  applied  a  few  times  at  intervals  of  a  minute 
or  two). 

The  patient's  eye  being  steadied  by  the  surgeon's  left  intiex  finger  pressing 
on  the  lower  lid,  the  foreign  body  may  be  removed  either  by  a  corneal  spud  or  a 
sharp  needle ;  and  it  is  often  advisable  to  tie  the  eye  up  for  a  few  hours  after  the 
little  operation.  If  not  found  on  the  cornea,  each  lid  should  in  turn  be  everted 
and  a  thorough  search  made  for  the  foreign  body. 


DISEASES  OF  THE  IRIS. 

Very  occasionally  melanotic  sarcomata  originate  in  the  iris,  cysts  may  develop 
in  it  (sometimes  in  connection  with  an  eyelash  driven  into  the  anterior  chamber), 
and  an  interesting  congenital  condition  is  met  with  under  the  name  of  coloboma 
of  the  iris.  This  consists  in  an  incomplete  closure  of  the  iritic  circle,  the  gap 
being  constantly  situated  in  the  lower  (or  lower  and  inner)  part  ;  it  may  co-exist  or 
not  with  coloboma  of  the  choroid.  Tubercle  also  occasionally  affects  the  iris, 
and  miliary  gummata  may  form  in  it,  both  from  acquired  and  inherited  syphilis. 
47 


730    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

These  conditions,  however,  are  all  of  comparative  rarity  and  slight  importance 
considered  with  regard  to  inflammation  of  the  iris — iritis  in  its  various  forms. 

Iritis  may  be  due  to  one  of  many  causes,  the  following  being  the  chief;  sec- 
ondary syphilis,  rheumatism,  injury,  inherited  gout,  and  gonorrhoea — the  first  two 
being  by  far  the  most  frequent.  In  addition  we  may  note  struma  as  a  cause, 
although  the  expression  is,  of  course,  rather  vague,  and  sympathetic  ophthalmia 
includes  iritis  as  one  of  its  manifestations. 

Iritis  may  be  acute,  sub-acute,  or  very  insidious  and  chronic  in  its  course, 
and  hence  the  symptoms  may  differ  in  individual  cases  ;  the  following  are  the  most 
important. 

1.  The  pupil  is  not  perfectly  round,  and  does  not  dilate  well  on  shading  the 
eye,  or  after  the  application  of  atropine  or  honiatroi)ine.  Small  adhesions  to  the 
front  of  the  lens  are  common,  giving  an  irregular  outline  to  the  pupil,  or  deposits 
of  uveal  pigment  may  be  noticed  within  its  margin. 

2.  The  iris  is  altered  in  color  and  its  reticulated  structure  somewhat  obscured  ; 
a  greenish  or  gray  hue  is  the  most  common,  but  an  originally  brown  iris  does  not 
change  much.  Often  minute  vessels  can  be  detected  on  the  inflamed  iris,  running 
in  toward  the  pupil,  and  sometimes  nodules  of  lymph  are  developed. 

3.  There  is  congestion  of  the  conjunctival  vessels,  a  congestion  which  is  not 
obliterated  by  gentle  pressure  ;  there  is  more  or  less  intense  photophobia,  pain  in 
the  eye  itself,  and  pain  referred  to  the  forehead  or  adjoining  parts.  This  referred 
pain,  often  localized  in  the  distribution  of  the  supra-orbital  nerve,  is  to  be  ac- 
counted for  by  the  fact  that  the  sensory  nerves  of  the  iris  are  derived  from  the 
ophthalmic  trunk. 

Of  these  symptoms  the  imperfect  action  of  the  pupil  to  light  and  homatropine 
is  the  most  important.  Sometimes  the  tension  of  the  globe  is  raised  in  iritis,  and 
secondary  glaucoma  may  be  ultimately  produced  by  complete  adhesion  of  the  iris 
to  the  lens  (total  posterior  synechia),  the  aqueous  being  unable  to  escape  from  the 
posterior  chamber  and  bulging  the  peripheral  part  of  the  iris  forward  {iris  bombe). 

Syphilitic  iritis  occurs,  with  the  exception  of  that  form  sometimes  accom- 
panying interstitial  keratitis,  during  the  secondary  stage,  and  very  rarely  relapses. 
From  three  to  six  months  after  the  chancre  (in  congenital  syphilis  at  the  same  date 
from  birth)  is  the  usual  time  of  its  onset.  It  often  affects  both  eyes,  though  com- 
monly after  a  short  interval,  and,  curiously,  it  may  come  on  in  the  second  eye 
whilst  the  patient  is  under  mercurial  treatment  for  the  attack  in  the  other  one.  It 
is  especially  in  syphilitic  iritis  that  small  nodules  of  lymph  (minute  gummata)  are 
met  with  in  the  iris,  and  delicate  shreds  of  lymph  may  sometimes  be  seen  in  the 
anterior  chamber.  If  treatment  be  neglected  the  pupil  may  become  occluded  by 
this  lymph  and  practical  blindness  result  in  the  affected  eye;  under  mercury,  how- 
ever, in  recent  cases  it  is  speedily  absorbed. 

Single  large  adhesions  are  very  characteristic  of  si)ecific  iritis  ;  in  infants  it  is 
much  more  common  amongst  females  than  males,  and  would  appear  occasionally 
to  develop  in  ntero. 

Rheumatic  iritis  comes  on,  as  a  rule,  during  adult  life,  sometimes  from  expo- 
sure to  wet  and  cold,  and  generally  a  history  of  lumbago  or  articular  rheumatism 
can  be  obtained.  It  is  very  prone  to  relapse,  and  the  pain,  congestion,  and 
photophobia  are  more  intense  than  is  commonly  the  case  with  iritis  due  to  other 
causes.  Tough  adhesions  to  the  lens  are  prone  to  occur,  but  nodules  of  lymph 
are  rarely  seen. 

Serous  iritis  (or  kerato-iritis)  is  a  very  chronic  form  of  the  disease,  charac- 
terized by  the  dej^osit  on  the  back  of  the  cornea  (Descemet's  membrane)  of  a 
number  of  minute  dots  of  lymph,  arranged  in  a  triangle  with  its  apex  toward  the 
centre  of  the  cornea  and  its  base  at  the  lower  border.  The  pain,  congestion,  etc., 
are  not  severe,  but  it  is  a  very  troublesome  form  of  iritis  to  treat.  The  patients  are 
commonly  women,  especially  those  of  strumous  tendency  ;  serous  iritis  may,  how- 
ever, be  a  symptom  of  sympathetic  ophthalmia.  Peripheral  choroiditis  (in  the 
form  of  rather  faint  patches)  is  present  in  many  if  not  all  cases  of  serous  iritis. 


CATARACT. 


731 


Iritis  from  inherited  gout  is  insidious  but  destructive  in  its  nature,  and  is  gen- 
erally accompanied  by  inflammation  of  the  ciliary  body  (cyclitis)  ;  the  same  may 
be  said  of  iritis  due  to  gonorrhoea  or  gonorrhceal  rheumatism. 

Treatment. — By  far  the  most  important  measure  in  treating  any  case  of  iritis 
(so  long  as  the  attack  is  in  the  active  stage)  is  to  use  atropine  vigorously.  An 
acjueous  solution  (four  grains  to  the  ounce),  or  a  mi-xture  with  ten  grains  of  cocaine 
in  pure  vaseline,  should  be  applied  within  the  lids  at  frecjuent  intervals  until  the 
pupil  is  dilated  so  far  as  the  case  will  allow.  Recent  adhesions  will  yield  to  the 
use  of  atropine  three  or  four  times  daily,  but  the  mydriatic  has  no  power  over  old 
synechiie,  and  its  only  result  is  then  to  cause  irritation. 

Whilst  the  use  of  atropine  is  most  important  in  all  cases  of  acute  iritis,  the 
other  measures  will  vary  according  to  the  cause  of  the  disease.  In  treating  trau- 
matic iritis,  apply  cold  to  the  eye  ;  other  forms  are  more  relieved  by  warm  bella- 
donna fomentations,  etc.  A  blister  on  the  temple  sometimes  relieves  the  pain,  or 
leeching  may  be  tried  in  the  same  situation.  Mercury  should  be  given  in  cases 
of  acute  syphilitic  iritis,  the  dose  being  increased  until  the  gums  are  touched.  The 
form  in  which  it  is  prescribed  varies  much ;  a  convenient  one  is  :  two  grains  of 
gray  powder  with  one  of  Dover's  powder  two  or  three  times  a  day.  Mercurial  in- 
unction ensures  a  rapid  effect  if  performed  thoroughly — but  is  not  a  cleanly  method. 
In  the  treatment  of  rheumatic  iritis  salicylate  of  soda  (in  fifteen-grain  doses)  is 
sometimes  useful ;  the  bicarbonate  and  iodide  of  potassium  also  appear  to  do  good. 
Of  course,  exposure  to  draught  or  cold  should  be  carefully  avoided,  and  the  affected 
eye  should  be  protected  by  cotton-wool  and  bandage,  etc.  Dry  heat  appears  to  be 
particularly  efficient  in  easing  the  pain  of  rheumatic  iritis.  Stimulants  should  be 
avoided  ;  a  brisk  purge  is  often  advisable  in  commencing  the  treatment,  and  per- 
fect rest  of  the  eyes  in  a  darkened  room  and  the  use  of  a  shade  are  essential  in 
treating  acute  iritis.  In  the  more  chronic  forms,  or  when  several  relapses  have 
occurred,  a  free  iridectomy  upward  is  sometimes  advisable,  one  object  of  the  ope- 
ration being  to  keep  open  the  communication  between  the  anterior  and  posterior 
chambers.  It  should  not,  as  a  rule,  be  performed  whilst  any  active  inflammation 
is  going  on,  or  the  aperture  made  would  then  be  closed  again  by  the  effusion  of 
lymph. 

In  treating  serious  iritis  tonics  and  iron  or  cod-liver  oil  are  the  most  useful 
medicines,  whilst,  of  course,  atropine  should  be  employed  locally. 


CATARACT. 

This  term  includes  many  varieties  of  opacity  of  the  lens,  the  prognosis  and 
treatment  of  which  differ  greatly  :  some  steadily  advancing  until  the  whole  lens 
becomes  opaque,  others  remaining  stationary  for  many  years  and  not  preventing  a 
fair  amount  of  vision. 


I.  Pyramidal  or  Anterior  Polar  Cataract 

consists  in  a  small  central  opacity  on  the  anterior  surface  of  the  lens  immediately 
beneath  the  capsule  ;  it  is  nearly  always  the  result  of  an  attack  of  ophthalmia  neo- 
natorum (or  small  perforating  ulcer  of  the  cornea),  has  very  little  tendency  to 
advance,  and  requires,  as  a  rule,  no  operative  treatment.  If,  however,  it  be  large 
enough  to  interfere  much  with  vision  an  iridectomy  performed  downward  and 
inward  would  be  indicated. 


2.  Posterior  Polar  Cataract 

is  often  of  a  stellate  form,  is  situated  at  the  posterior  pole  of  the  lens,  and  is  usually 
found  in  association  with  high  degrees  of  myopia,  or  as  a  result  of  a  blow  on  the  eye. 
In  the  latter  case  the  opacity  is  often  of  a  curious  punctate  or  wavy  outline,  and 


732    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

must  be  distinguished  from  the  cases  of  traumatic  cataract  due  to  direct  wound,  in 
which  the  whole  lens  swells  and  becomes  opafpie.  Posterior  polar  cataract  is 
usually  very  slow  in  progress. 

3.   Lamf.i.i.ak  Cataract 

is  met  with  in  early  life,  its  subjects  having  nearly  always  suffered  from  convulsions 
in  infancy,  and  fre<iuently  presenting  what  are  known  as  mercurial  teeth,  /.  e.,  the 
permanent  incisors  and  canines  are  worn  horizontally  in  grooves,  the  enamel  being 
most  deficient  toward  the  cutting  edges.  The  theory  assigned  for  this  dental  mal- 
formation is  that  the  mercury  given  for  the  convulsions  leads  to  slight  stomatitis, 
which  affects  the  development  of  the  permanent  teeth.  Besides  the  incisors  and 
canines,  the  first  molars  are  lial)le  to  show  changes,  the  crowns  being  deficient  in 
enamel,  often  presenting  fine  spicules,  and  wearing  down  early.  Lamellar  cataract 
consists  in  an  oi)a(iue  layer  between  the  cortex  and  centre,  both  of  which  remain 
clear  ;  the  lamella  affected  may  be  so  thin  as  to  be  only  visible  by  careful  focal 
illumination  when  the  pupil  is  dilated,  and  vision  may  be  but  little  imj)aired.  If 
this  be  the  case,  no  treatment  is  advisable,  but  in  the  majority  of  cases  a  needling 
operation  is  required.      Lamellar  cataract  is  always  symmetrical. 

4.   Senile  Cataract 

is  that  form  coming  on,  as  a  rule,  after  forty-five  or  fifty  years  of  age  ;  it  is  always 
of  the  hard  variety,  /.  c,  suitable  for  extraction  and  not  for  needling  operations. 
It  may  commence  by  a  number  of  peripheral  opaque  striae,  or  by  a  central  (nuclear) 
opacity  which  slowly  involves  the  rest  of  the  lens.  The  progress  of  senile  cataract 
is  very  variable,  though,  perhaps,  in  the  majority  of  cases,  it  becomes  complete 
within  two  or  three  years  of  its  commencement. 

Senile  cataract  is,  as  a  rule,  of  a  white  or  grayish-white  color,  but  is  occa- 
sionally amber  or  (very  rarely)  brownish-black. 

We  have  also  to  note  that  cataract  may  be  secondary  to  iritis,  glaucoma,  or 
other  degenerative  changes  in  the  eye,  that  it  may  occur  in  a  lens  dislocated  by 
injury,  or  in  connection  with  advanced  diabetes  mellitus.  None  of  these  forms 
are  at  all  favorable  for  operation. 

Symptoms  and  Treatment  of  Cataract. — The  first  sym])tom  of  com- 
mencing cataract  is  dimness  of  vision,  both  fur  near  and  distant  objects,  and  the 
opacity  is  best  recognized  by  oblique  illumination  in  a  dark  room.  Peripheral  strife 
may  only  be  detected  if  the  pujjil  be  first  dilated  with  homatropine,  etc.  As 
already  stated,  the  rate  of  progress  is  very  variable,  and  hence  it  is  well  not  to 
alarm  the  patient  by  using  the  word  "cataract"  in  the  early  stage.  So  long  as 
one  eye  retains  sufficient  vision  to  enable  the  patient  to  work,  any  operation 
should  be  deferred.  A  senile  cataract  is  considered  to  be  ripe  or  ready  for  ope- 
ration when  the  whole  lens  has  become  o])aque  ;  this  is  best  estimated  l)y  observ- 
ing whether  during  oblique  illumination  the  iris  shows  a  shadow  or  not  on  to  the 
opaque  part,  i.  e.,  if  there  is  still  a  clear  part  between  the  iris  and  the  opacity. 
But  there  are  other  points  to  be  ascertained  before  recommending  operation.  Any 
condition  of  bad  health,  or  the  existence  of  inflammation  of  the  lachrymal  sac, 
requires  to  be  treated  before  extraction  can  be  justifiably  undertaken.  In  the  case 
of  the  latter,  the  presence  of  muco-purulent  discharge  at  the  time  of  operation 
would  be  almost  certain  to  lead  to  suppuration  of  the  globe.  Then,  in  a  case 
suitable  for  operation,  the  i)upil  should  contract  to  light,  and  the  patient  should 
be  able  to  detect  the  position  of  a  lighted  candle  held  a  few  feet  away  at  various 
parts  of  the  field  of  vision.  Tliese  tests  show  roughly  that  the  retina  is  not  dis- 
eased. Cataract  in  highly  myopic  patients  is  not  very  favorable  for  operation, 
since  it  is  often  accompanied  by  abnormal  fluidity  of  the  vitreous,  which  will  tend 
to  escape  at  the  time  of  operation,  and  by  degenerative  changes  in  the  retina  and 
choroid.      (For  the  various  operations  on  cataract,  see  p.  740.) 


GLAUCOMA.  733 


GLAUCOMA. 


The  essential  feature  of  this  disease  is  increase  of  tension  in  the  globe,  and 
we  may  have  such  increase  of  tension  resulting  from  iritis,  swelling  of  the  lens  in 
traumatic  cataract,  etc.,  when  it  is  called  secondary  glaucoma,  or  occurring  with- 
out obvious  cause,  when  it  is  termed  [)rimary  glaucoma.  But  the  most  important 
division  is  into  the  chronic  and  acute  forms,  for  not  only  do  some  of  the  symp- 
toms differ,  but  the  treatment  also. 

There  is  in  the  normal  eye  a  constant  passage  of  fluid  from  the  angle  of  the 
anterior  chamber  into  the  adjoining  venous  channels  (canal  of  Schlemm,  etc.), 
and  there  is  no  doubt  that  one  frequent  cause  of  glaucoma  is  an  obstruction  to 
the  filtration  at  this  si)Ot.  A  good  instance  is  afforded  by  the  attack  of  glaucoma 
which  occasionally  is  brought  on  by  the  use  of  atropine  in  elderly  subjects — the 
mydriatic,  so  to  speak,  forcing  the  iris  into  the  angle  of  the  anterior  chamber: 
such  an  attack,  as  a  rule,  is  cured  by  the  use  of  eserine,  which,  by  contracting  the 
pupil,  draws  the  iris  away  from  the  angle.  Glaucoma  is  more  common  after  mid- 
dle life  than  before,  and  we  may  associate  with  this  the  fact  that  as  age  advances 
the  lens  becomes  relatively  larger  and  may  therefore  help  in  causing  obstruction 
to  the  outflo\t  (Priestley  Smith).  There  is,  however,  a  curious  form  of  glaucoma 
known  as  buphthalmos,  met  with  in  children,  in  which  the  whole  eye  is  enlarged, 
hard,  and  the  anterior  chamber  deeper  than  normal.  Chronic  inflammatory  pro- 
cesses at  the  ciliary  region  are  also  an  important  cause  of  glaucoma. 

I.  Acute  Glaucoma 

is  much  more  common  amongst  women  than  men,  and  is  especially  prone  to  occur 
after  the  age  of  forty-five.  Whilst  no  cause  can  be  assigned  in  many  cases,  in 
some  it  appears  to  be  due  to  excessive  use  of  the  eyes,  severe  mental  emotion  or 
shock.  The  subjects  are  nearly  always  hypermetropic,  acute  glaucoma  being 
decidedly  rare  in  myopic  eyes.  Certain  premonitory  signs  often  precede  the  acute 
attack  :  rapid  increase  of  presbyopia,  passing  congestion  of  the  eye,  colored  rings 
seen  by  the  patient  around  a  distant  light,  being  the  usual  ones.  The  sight  then 
becomes  rapidly  worse,  the  patient  complains  of  seeing  objects  obscured  as  though 
by  a  fog,  there  is  intense  pain  in  the  eye  and  forehead,  and  frequently  sickness 
accompanies  the  pain.  On  examining  the  eye,  marked  congestion,  with  often 
oedematous  swelling  of  the  conjunctiva  (chemosis)  is  found,  the  pupil  is  somewhat 
dilated  and  responds  badly  to  light,  the  anterior  chamber  is  shallow  (as  a  rule), 
the  media  hazy.  The  cornea  may  be  so  "steamy"  that  no  view  of  the  fundus 
can  be  obtained  ;  but,  if  the  disc  can  be  seen,  the  veins  are  found  to  be  engorged, 
and  there  is  arterial  pulsation.  The  visual  field  is  much  narrowed,  the  inner  side 
going  first. 

Mistakes  in  diagnosis  are  often  made,  the  sluggish  pupil  suggesting  iritis, 
or  the  congestion  and  chemosis  may  be  thought  to  be  simple  conjunctivitis,  or  the 
vomiting  and  headache  may  be  mistaken  for  a  "bilious  attack."  The  essential 
point  in  the  diagnosis  consists  in  estimating  the  tension  of  the  globe  :  this  is  done 
by  placing  the  two  index  fingers  on  the  upper  lid  as  the  patient  looks  down  ;  gen- 
tle downward  pressure  is  then  made  with  one  finger,  and  the  resistance  of  the  eye 
felt  by  the  other.  Some  surgeons  use  the  index  and  middle  finger  of  one  hand  in 
estimating  tension.  The  two  eyes  should  always  be  tried,  and  only  practice  will 
enable  the  student  to  estimate  slight  degrees  of  increase.  In  acute  glaucoma, 
however,  the  abnormal  hardness  of  the  globe  is  very  easily  recognized. 

Prognosis  and  Treatment. — If  acute  glaucoma  be  neglected,  the  eye 
becomes  rapidly  and  permanently  blind.  Irretrievable  damage  to  the  retina  may 
be  done  in  a  few  days  ;  on  the  other  hand,  if  the  disease  be  early  recognized  and 
treated,  a  most  satisfactory  result  is  usually  obtained.  As  soon  as  possible  a  free 
upward  iridectomy  should  be  performed  (see  p.  739),  though  as  a  temporary 
measure  eserine  drops  (two  grains  to  the  ounce)  maybe  used.    Eserine  (and  pilo- 


734    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

carpine  to  a  less  extent)  has  a  great  effect  in  reducing  tension  of  the  eye,  and  in  a 
few  cases  its  use  may  obviate  the  necessity  for  operation  ;  but  it  may  be  repeated 
that  the  treatment  for  acute  glaucoma  is  iridectomy,  which  is  often  followed  by 
complete  and  ])ermanent  restoration  of  sight.  In  many  cases,  however,  only 
partial  success  results  from  the  oi)eration,  because  it  has  been  too  long  deferred, 
and  in  a  few  severe  retinal  hemorrhage  follows  it,  or  the  glaucomatous  symptoms 
may  recur  after  a  time. 

2.  Chronic  Glaucoma 

comes  on  gradually  and  is  characterized  by  less  congestion  of  the  eye,  pain,  etc., 
than  the  acute  form.  The  pupil  may  be  but  little  dilated  and  the  media  may  be 
fairly  clear,  the  disc  in  an  advanced  case  is  seen  to  be  deeply  cupped  (the  vessels 
curving  sharply  round  its  margin)  and  atrophied.  Venous  (and  with  .slight  pres- 
sure on  the  globe,  arterial)  pulsation  is  present  in  the  vessels  of  the  disc.  The 
field  is  either  concentrically  contracted  or  irregularly  limited — especially  on  the 
nasal  or  inner  side.  Attacks  of  "  fog  or  mist  before  the  eyes  "  and  of  halos  round 
a  light  are  often  complained  of,  and  the  sight  steadily  deteriorates.  The  rate  of 
progress  is,  however,  very  uncertain  in  different  cases. 

The  treatment  consists  in  avoiding  over-use  or  strain  of  the  eyes ;  the  patient 
should  be  provided  with  proper  glasses ;  tonics  and  laxatives  may  be  useful,  and  a 
weak  solution  of  eserine  {}i  to  y^  grain  to  the  ounce)  should  be  dropped  into  the 
eye  once  or  twice  daily.  Pilocarpine  (one  to  two  grains  to  the  ounce)  may  be 
used  instead  of  eserine.  By  these  means  a  patient  with  chronic  glaucoma  may 
retain  moderate  vision  for  a  long  time,  but  in  some  cases  the  best  chance  is  offered 
by  a  free  iridectomy.  If  the  tension  should  continue  or  return,  a  second  iridec- 
tomy or  a  sclerotomy  may  be  useful.  It  is  necessary  that  the  patient's  age  and 
state  of  health  should  be  taken  into  account  before  recommending  operation, 
especially  as  chronic  glaucoma  is  prone  to  occur  in  those  who  are  of  feeble  or 
worn-out  constitution. 

One  danger  of  the  operation  may  here  be  mentioned — that  of  wounding  the 
lens — in  which  case  a  traumatic  cataract  will  inevitably  follow.  The  risk  of  it  is 
much  less  if  a  Graefe's  knife  be  used  instead  of  a  keratome. 


DISEASES  OF  THE  CHOROID. 
We  have  to  consider  briefly  :   (i)  tuberculosis  and  (2)  tumors  of  the  choroid. 

I.  Tubercle  of  the  Choroid 

is  distinguished  by  the  ophthalmoscope  as  ill-defined,  light,  raised  patches,  as 
large  as,  or  larger  than,  the  optic  disc.  It  is  nearly  always  a  sign  of  advanced 
general  tuberculosis,  especially  when  the  meninges  of  the  brain  are  affected,  and 
is  decidedly  a  rare  affection. 

2.  Tumors  of  the  Choroid. 

Melanotic  sarcoma  is  the  most  frequent  i)rimary  growth,  and  there  is  the 
same  tendency  to  rapid  general  infection  through  the  blood  as  in  melanotic  sar- 
coma starting  in  the  skin.  Nevertheless,  if  the  eye  containing  the  tumor  be  ex- 
cised early,  a  radical  cure  is  possible.  These  sarcomata  are  composed  of  spindle 
and  round  cells,  occasionally  non-pigmented  ;  in  all  cases  the  tumor  tends  to  pro- 
ject into  the  vitreous,  as  well  as  to  invade  the  sclerotic  and  orbital  tissues.  Glioma, 
starting  in  the  eye,  grows  backward  along  the  optic  nerve  to  the  brain,  and  is 
more  common  in  childhood  than  is  sarcoma  of  the  choroid.  The  latter  may  be 
recognized  ophthalmoscopically,  before  it  has  protruded  through  the  sclerotic  ;  it 


DISEASES  OF  THE   EYELIDS,   ORBIT,   ETC.  735 

often  commences  at  or  near  the  ciliary  region,  and  pushes  the  iris  somewhat  for- 
ward, while  increasing  the  tension  of  the  globe. 

Excision  of  the  eye  is  the  only  treatment,  and  the  earlier  it  is  done  the  greater 
the  chances  of  non-recurrence. 


DISEASES  OF  THE  EYELIDS,  ORBIT,  Etc. 

The  lax  tissue  of  the  eyelids  is  especially  prone  to  oedematous  swelling,  some- 
times the  remains  of  an  attack  of  facial  erysipelas,  more  often  a  sign  of  general 
want  of  tone,  of  senility,  or  of  more  serious  visceral  disease.  Occasionally  we 
meet  with  persistent  oedema  of  the  lids  for  which  no  cause  can  be  assigned,  or 
which  has  started  in  some  long  past  erysipelatous  affection.  Abscess  of  the  lid  is  a 
not  uncommon  complication  of  facial  erysipelas,  and  should  be  incised  as  early  as 
possible  ;  occasionally  it  is  due  to  an  embedded  foreign  body.  There  is  consider- 
able risk  of  an  orbital  abscess  finding  its  way  backward  into  the  skull,  and  sudden 
death  may  result  from  this,  hence  the  importance  of  opening  and  draining  any 
collection  of  pus  in  this  situation.  An  exploration  can  readily  be  made  with  a 
sharp  tenotome  introduced  parallel  to  the  orbital  roof  or  floor. 

Blepharitis    (or  Sycosis)  Tarsi 

is  the  name  given  to  inflammation  of  the  lid  margins  of  an  eczematous  nature. 
There  may  be  small  ulcers  along  the  lid  borders,  or  simply  pustules  and  crusts, 
the  hairs  tending  in  old  cases  to  atrophy  and  fall  out.  In  some  cases  the  hair- 
bulbs  form  the  centres  of  small  pustules,  and  it  is  for  these  that  regular  epilation 
with  forceps  is  advisable  ;  when  the  blepharitis  is  more  of  an  eczema  than  a  sycosis 
it  may  usually  be  cured  without  resorting  to  this  painful  measure. 

The  disease  is  most  common  in  children,  often  follows  an  attack  of  measles 
or  scarlet  fever,  and  is  very  chronic  in  its  course.  It  may  also  be  set  up  in  adults 
by  prolonged  overwork  of  the  eyes  in  ill-ventilated  rooms,  and  sometimes  is  asso- 
ciated with  uncorrected  errors  of  refraction. 

There  is  more  or  less  gummy  discharge  and  lachrymation,  the  lids  adhere 
together  on  waking  up,  and  the  condition  is  aggravated  by  exposure  to  cold  winds, 
etc.  A  large  proportion  of  its  subjects  are  anaemic  or  show  signs  of  scrofulous 
tendencies.  The  treatment  is  satisfactory  if  the  case  be  seen  early,  but  when 
blepharitis  has  existed  for  long  it  becomes  well-nigh  incurable.  All  scabs  should 
be  removed  twice  a  day  by  free  bathing  with  warm  water  (or  a  lotion  containing 
five  or  ten  grains  of  bicarbonate  of  soda  to  the  ounce),  and  a  stimulating  ointment 
(the  ung.  hydrarg.  nit.  dil.,  or  the  ung.  hydrarg.  oxidi  flavi)  applied  to  the  edges 
of  the  lids.  Sometimes  an  astringent  lotion  (see  treatment  of  conjunctivitis)  suits 
well,  and  the  application  of  a  twenty-grain  solution  of  nitrate  of  silver  from  time 
to  time  may  be  useful.  Any  decided  error  of  refraction  should  be  corrected  ;  if 
there  is  photophobia,  the  use  of  cobalt-tinted  protective  glasses,  or  of  "goggles," 
is  advisable.  Cod-liver  oil  should  be  given  in  the  strumous  cases  and  preparations 
of  iron  in  the  anaemic  ones.  Sometimes,  as  already  mentioned,  it  is  necessary 
to  epilate  or  to  apply  the  mitigated  nitrate  of  silver  stick  from  time  to  time  to  the 
little  sores. 

Lachrymal  Obstruction. 

The  chief  symptom  of  impeded  passage  of  tears  into  the  nose  is  epiphora,  or 
their  flowing  over  the  cheek.  The  obstruction  may  be  situated  at  the  puncta  (or 
the  latter  may  be  displaced,  owing  to  entropion  or  ectropion),  in  the  canaliculi, 
lachrymal  sac,  or  nasal  duct:  If  it  is  in  the  latter,  pressure  over  the  sac  with 
the  finger  will  cause  a  sudden  regurgitation  of  fluid  (more  or  less  mucoid  of  even 
purulent)  through  the  puncta.  This  distention  of  the  sac  (jmicocele)  by  retained 
mucus  and  tears  can  often  be  seen  as  a  rounded  swelling  at  the  inner  canthus ;  it 


736    BISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

is  always  liable  to  set  up  inflammation  and  suppuration,  and  if  the  abscess  is 
allowed  to  burst  it  commonly  does  so  below  the  tendo  oculi.  A  fibrous  stricture 
of  the  nasal  duct  is  not  infre(iuently  the  cause  of  lachrymal  obstruction,  being 
itself  probably  due  to  some  chronic  inflammation  of  its  lining  mucous  membrane. 
Disease  of  its  bony  wall  {e.g.,  from  inherited  syphilis)  may  also  give  rise  to  most 
intractable  lachrymal  obstruction. 

In- cases  of  chronic  conjunctivitis  with  epiphora,  but  without  mucocele  or 
other  evidence  of  organic  obstruction,  astringent  drops  or  lotion  (two  grains  of 
nitrate  of  silver  or  sulphate  of  zinc,  or  one  grain  of  chloride  of  zinc  to  the  ounce) 
are  of  use.  If  there  is  displacement  of  one  or  both  puncta  or  narrowing  of  the 
duct,  considerable  advantage  is  gained  by  slitting  up  the  canaliculus  with  a  Weber's 
probe-i)ointed  knife.  The  lachrymal  duct  can  then  be  exjilored  by  probes,  any 
stricture  dilated,  and  frequent  irrigation  employed.  It  must,  however,  be  admitted 
that  the  gradual  dilatation  of  these  strictures  is  commonly  very  unsatisfactory,  even 
when  aided  by  the  frequent  use  of  astringent  and  antiseptic  lotions,  and  somewhat 
better  results  are  obtained  from  introducing  a  leaden  style  (the  upper  end  of  which 
is  bent  down  .so  as  to  prevent  it  slipping  right  in),  which  is  worn  for  many  months 
at  a  time.      Boracic  or  weak  sulphate  of  zinc  lotion  should  also  be  used. 

Syphilitic  Affections  of  the  Lids. 

Primary  chancres  are  occasionally  met  with  both  on  the  conjunctival  and  cuta- 
neous surfaces  ;  they  are  always  accompanied  by  pre-auricular  or  submaxillary 
buboes,  the  presence  of  this  gland-enlargement  assisting  greatly  in  the  diagnosis. 
During  the  secondary  stage,  especially  if  there  is  a  well-marked  eruption  on  the 
face,  a  syphilitic  form  of  blepharitis  with  multiple  small  ulcers  along  the  lid-bor- 
ders is  sometimes  observed.  Tertiary  ulceration  of  the  eyelids  is  noteworthy  from 
the  fact  that  it  is  difficult  to  cure  by  the  ordinary  treatment  (iodoform  locally  and 
iodides  internally),  and  is  very  prone  to  relapse.  It  is  a  rare  disease,  the  subjects 
being  usually  women  who  have  suffered  severely  from  other  syphilitic  symptoms. 

Tumors  of  the  Eyelids  and  Orbit. 

By  far  the  most  common  is  what  is  known  as  a  meibomian  cyst  or  chalazion. 
It  occurs  (usually  in  young  or  middle-aged  adults)  as  a  small,  rounded,  well-defined 
lump  in  the  eyelid,  which  really  starts  in  the  meibomian  gland  layer,  but  tends  to 


Fig.  316. —  Beer's  Cataract  Knife. 

project  most  toward  the  skin.  Sometimes  more  than  one  is  present  at  the  same 
time,  and  there  is  a  tendency  for  them  to  recur  in  certain  individuals.  They  con- 
sist of  a  gelatinous  mass  of  small  cells  situated  around  one  of  the  meibomian 
glands,  and,  though  they  may  sometimes  long  remain  quiet,  tend,  as  a  rule,  to 
inflame  and  suppurate.  Hence  it  is  advisable  to  operate  on  them  as  soon  as 
they  attain  a  sufficient  size  to  be  easily  recognized  by  the  finger  passed  over  the 
affected  lid.  The  latter  should  be  everted,  the  conjunctival  surface  over  the 
tumor  treated  with  pure  cocaine  to  procure  anaesthesia,  then  a  small,  crucial  in- 
cision made  with  a  Beer's  knife,  and  the  little  tumor  evacuated  by  means  of  a 
small  curette  and  finger  pressure.  If  the  cyst  has  already  suppurated,  an  incision 
alone  will  suffice. 

A  stye  consists  in  inflammation  and  suppuration  about  one  of  the  sebaceous 
glands  at  the  edge  of  the  lids.  As  is  the  case  with  meibomian  tumors,  there  is 
usually  a  strong  tendency  to  recur.      Hot  fomentations  and  a  small  ir.cision,  to  let 


DISEASES  OF  THE  EYELIDS,   OR^IT,  ETC.  737 

out  the  pus,  constitute  the  local  treatment ;  any  accompanying  conjunctivitis  or 
error  of  refraction  should  be  attended  to,  and  a  tonic  is  often  useful. 

Horns  are  occasionally  seen  growing  from  one  or  other  eyelid  ;  they  inva- 
riably originate  in  a  sebaceous  gland,  and,  however  hard  toward  the  apex,  are 
fairly  soft  at  their  base.      Excision  with  scissors  is  required. 

Ncevi  are  common  about  the  eyelids  as  elsewhere  on  the  face  ;  the  cutaneous 
purple  ones  should  be  treated  Avith  a  very  fine  cautery  point  (the  galvano-cautery 
wire-loop  is  suitable),  or  by  electrolysis.    The  advan- 
tage of  the  latter  is  the  subsequent  absence  of  scar-  _^ 
ring,  but  it  is  a  slow  and  rather  uncertain  method. 
The  most  difficult  form  to  treat  is  the  large  subcuta- 
neous venous  nsevus,  which  may  cause  the  affected         ■        '  -•»^-f7 
eyelid  to  constantly  project  over  the  eye.      Repeated 

punctures    with   the    fine    point   of  the    Pacquelin's  ^r%^ 

cautery  form  the  most  satisfactory  treatment,  an  in-  ''i^-'^ 

terval  of  a   few  weeks  being  allowed  between  each 
application. 

A   form    of   congenital    growth   occasionally    met    Fig.  317— a   Small,  Melanotic  Growth 
•  .■>         .     .-x  J  r   ii  T  J        •       ^1-  •  4.    J        on  the  Lower  Eyelid,  commencing  in 

With  at  the  edge  of  the  eyelids  is  the  pigmented     amoie. 

mole,  forming  a  small,  lobulated  excrescence.     It  is 

of  importance  from  the  risk  of  melanosis  starting  from  it  in  later  life,  and  hence 

should  be  excised. 

Alolluscum  contagiosum  is  treated  in  the  section  on  Diseases  of  the  Skin.  A 
favorite  starting-place  for  rodent  ulcer  is  the  inner  part  of  the  upper  or  lower  eye- 
lid. It  commences  as  a  small,  smooth  infiltration  of  the  skin,  and  tends  to  have 
a  crescentic  outline  and  to  ulcerate  sooner  or  later,  then  steadily  advancing  both 
in  depth  and  on  the  surface.  It  may  occur  as  early  as  thirty  years  of  age,  but  is 
most  common  in  more  elderly  patients,  and,  as  is  well  known,  causes  no  glandular 
enlargement,  however  long  it  exists. 

The  best  treatment  is  excision,  scraping  or  cauterization  being  more  likely  to 
be  followed  by  recurrence,  unless  very  thoroughly  done. 

Dermoid  cysts  occur  as  rounded,  subcutaneous  tumors,  especially  over  the 
external  angular  process  of  the  frontal  bone,  which  is  often  slightly  indented 
beneath  them.  They  are  always  congenital,  and  due  to  peculiarity  in  develop- 
ment, and  do  not,  as  a  rule,  increase  much  after  the  first  year  or  two.  They  have 
a  fibrous  wall  lined  with  epithelium,  their  contents  being  chiefly  sebaceous  matter, 
cholesterin,  and  abortive  hairs.  If  prominent  enough  to  be  unsightly,  the  cyst 
should  be  excised  (without  opening  the  cyst-wall  during  the  operation,  if  it  can 
be  avoided),  the  wound  being  made  parallel  to  the  eyebrow,  and  carefully  sutured 
with  fine  silk.     A  spirit  lotion  or  iodoform  should  be  used  in  the  dressing. 

Pulsating  Orbital  Tumor. 

This  term  includes  several  conditions,  producing  the  following  symptoms  : 
(i)  protrusion  of  one  eye  (occasionally  of  both),  with  dilatation  of  its  superficial 
vein ;  (2)  pulsation  to  be  felt  in  the  orbit,  generally  best  through  the  upper  lid  ; 
(3)  a  continuous  bruit,  which  is  not  only  readily  heard  by  the  surgeon,  but  gives 
great  annoyance  to  the  patient ;  (4)  frequently  paralysis  of  one  or  other  oculo- 
motor muscle.  Although  the  pathology  of  this  affection  is  still  not  completely 
ascertained,  it  is  certain  that  the  most  usual  condition  is  a  great  dilatation  of  the 
ophthalmic  vein  (due  in  most  cases  to  a  communication  with  the  internal  carotid 
artery  in  the  cavernous  sinus). 

More  rarely  a  true  aneurysm  of  the  carotid  or  ophthalmic  arteries  is  present. 

Pulsating  orbital  tumor,  like  arterio-venous  aneurysm  elsewhere,  is  generally 
the  result  of  injury — a  fall  or  blow  on  the  head  involving  fracture  of  the  base,  a 
punctured  wound  of  the  orbit  with  a  sword  or  stick,  etc. — and  is,  therefore,  most 
common  in  males.     It  develops  gradually  within  a  iQ.\\  weeks  of  the  injury,  the 


738     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

symptoms  increasing  in  severity  until  sometimes  vision  is  lost,  owing  to  the  ex- 
treme protrusion  of  the  globe  and  stretching  of  the  optic  nerve.  In  some  cases, 
it  arises  independently  of  any  injury,  and  this  spontaneous  form  is  usually  of 
sudden  onset,  and  is  most  common  in  females. 

It  is  an  interesting  fact  that,  however  great  be  the  protrusion  {proptosis)  the 
vessels  of  the  optic  disc  present  but  little  that  is  abnormal,  beyond  pulsation  of 
the  veins.  As  already  mentioned,  however,  the  veins  of  the  conjunctiva  and  lids 
are  usually  much  dilated. 

The  progress  of  the  disease  is  variable  ;  a  gradual  diminution  of  the  protru- 
sion and  spontaneous  cure  is  possible,  though  most  of  the  cases  are  submitted  to 
treatment.  This  consists  in  :  (i)  digital  compression  of  the  common  carotid, 
which  unfortunately  can  only  be  carried  out  for  short  periods,  owing  to  the  pain 
it  causes;  (2)  the  use  of  ice  or  graduated  compression  over  the  globe  and  eye- 
lid ;  (3)  ligature  of  the  carotid  artery.  Attempts  have  been  made  more  than 
once  to  ligature  the  dilated  vessel  in  the  orbit,  but  have  almost  always  failed. 

Tying  the  common  carotid  has  been  followed  by  cure  in  a  fair  proportion  of 
cases,  but  it  is  a  proceeding  attended  with  serious  risk,  and  should  not  be  resorted 
to,  unless  milder  measures  have  failed,  and  the  symptoms  are  steadily  increasing 
in  severity. 

OPERATIONS. 

The  introduction  of  cocaine  has  greatly  limited  the  use  of  ether  and  chloro- 
form in  ophthalmic  surgery ;  general  anaesthesia  is  now  only  required,  as  a  rule, 
for  excision  of  the  globe,  tenotomy  in  young  children,  advancement  of  a  rectus, 
and  iridectomy  for  glaucoma.  Extraction  of  cataract  can  nearly  always  be  effected 
under  local  anaesthesia,  and  thus  the  risk  of  after-vomiting  avoided,  but  occasion- 
ally it  is  necessary  to  give  ether  or  chloroform  if  the  patient  be  very  restless  or 
l)ossess  no  self-control.  To  obtain  local  anaesthesia  of  the  cornea  and  ocular  con- 
junctiva, the  best  way  is  to  drop  on  to  them  a  2  per  cent,  solution  of  freshly  pre- 
pared cocaine  (made  with  some  boracic  acid  in  it  for  the  purpose  of  antisepsis) 
several  times  during  the  ten  minutes  which  precede  the  operation.  It  must  be 
remembered,  however,  that  the  cocaine  does  not  anaesthetize  the  lid-borders  nor 
the  iris,  hence  the  introduction  of  a  speculum  and  iridectomy  cause  slight  pain. 
In  doing  extraction  of  cataract  with  iridectomy,  it  is  well  to  warn  the  patient  ot 
this  before  introducing  the  iris  forceps,  for  fear  that  a  sudden  movement  should 
endanger  the  success  of  the  operation. 

Hypodermic  injection  of  a  few  drops  of  cocaine  solution  may  be  used  in  per- 
forming tenotomy  or  excising  part  of  the  eyelid,  etc.;  and,  for  the  removal  of  a 
meibomain  tumor  or  applying  astringents  to  the  conjunctiva,  anaesthesia  is  best 
procured  by  applying  powdered  cocaine  and  allowing  it  to  dissolve  locally. 

I.  Excision  of  the  Globe. 

Instruments  required  :  spring  speculum,  fixation  forceps,  scissors  curved  on 
the  flat,  strabismus  hook.  Standing  behind  the  patient,  introduce  and  fix  the 
speculum,  pick  up  the  conjunctiva  just  al)Ove  the  cornea,  and  divide  it  all  round 
close  to  the  sclero-corneal  junction.  Having  opened  Tenon's  cai)sule,  introduce 
the  hook  under  each  of  the  recti  muscles  in  turn  and  divide  them.  Then  open 
the  speculum  as  widely  as  possible,  press  it  backward  and  make  the  globe  pro- 
trude. Steadying  it  with  the  fingers  of  the  left  hand,  introduce  the  scissors 
behind  the  globe  from  the  right-hand  side,  open  them  to  receive  the  optic  nerve 
within  the  blades,  and  divide  it  with  a  single  cut.  One  or  both  oblique  muscles 
and  some  connective  tissue  may  still  require  to  be  divided.  A  small  sjjonge  should 
be  at  once  applied  and  kept  in  place  by  a  pad  and  firm  bandage.  The  wound 
heals  usually  within  a  week,  and  about  a  month  after  the  operation  a  glass  eye 
may  be  worn.  It  is  well  to  use  some  boracic  lotion  and  ointment  daily  for  a  week 
or  two  after  the  operation. 


OPERATIONS  ON  THE  EYE. 


739 


Lately  the  introduction  of  small  celluloid,  glass  or  silver  globes  within  Tenon's 
capsule,  to  take  the  place  of  the  excised  eye,  has  been  extensively  tried.  The 
capsule  and  conjunctiva  should  be  sewn  up  separately  with  fine  silk,  and  it  is  well 
to  use  a  drain  of  horsehair  for  a  day  or  two.  If  the  operation  succeeds,  the  move- 
ments of  the  glass  eye  are  generally  imi)roved  by  the  presence  of  the  globe 
behind  it,  but,  unfortunately,  there  is  a  strong  tendency  on  the  part  of  the  latter 
to  work  out. 

A  glass  eye  should  be  removed  every  night  and  cleansed,  and  it  needs  to  be 
renewed,  as  a  rule,  once  a  year. 

2.  Tenotomy. 

(The  common  operation — division  of  the  internal  rectus — will  be  described.) 
The  operator  stands  at  the  right  side  of  the  i)atient,  introducing  the  speculum,  and 
seizes  a  little  fold  of  conjunctiva  with  the  fixation  forceps — the  point  aimed  at 
being  the  junction  of  the  inner  and  lower  corneal  tangents.  With  a  small  pair  of 
straight  scissors  he  makes  an  opening  in  the  conjunctiva  and  Tenon's  capsule  at 
the  same  time.  If  this  is  not  done,  the  capsule  should  be  picked  up  separately  and 
incised.  The  strabismus  hook  (which  should  always  be  blunt-ended)  is  now  passed 
with  its  head  directed  backward  toward  the  apex  of  the  orbit,  then  brought 
under  the  rectus  tendon,  and  the  latter  slightly  raised  on  the  hook,  whilst  one 
blade  of  the  scissors  is  introduced  under  it,  the  other  passing  between  the  con- 
junctiva and  tendon.  The  latter  is  now  cut  through,  and  the  hook  may  be  reintro- 
duced if  it  is  thought  some  part  of  the  muscle  has  remained  undivided.  A  pad 
and  bandage  are  usually  applied  for  a  few  days — the  conjunctival  wound  is  so  small 
that  no  suture  is  required. 

It  is  never  advisable  to  perform  tenotomy  on  both  eyes  at  a  time,  for  fear  diverg- 
ence should  result.  Squints  of  25°  or  more  will  not  be  cured  by  a  single  tenoto- 
my ;  but  it  is  best  to  perform  the  second  operation  after  a  considerable  interval ; 
of  course,  all  errors  of  refraction  should  be  corrected. 

Sometimes  tenotomy  of  one  muscle  is  combined  with  advancement  of  its 
opponent,  e.g.,  for  divergent  strabismus  the  external  rectus  is  divided  and  the 
internal  one  advanced.  The  operation  of  advancement  is  too  complex  to  be 
described  here. 

3.  Iridectomy. 

As  already  described  (p.  728),  in  cases  of  wound  of  the  globe  with  prolapse 
of  the  iris,  an  iridectomy  may  be  required.     Apart  from   this  it  is  performed 


Fig.  318. — Iridectomy  Downward  Fig.    319. — Iridectomy   for 

and  Inward  for  Artificial  Pupil.  Glaucoma.  {^De  Wecker.) 

either  for  optical  purposes  (/.  <?. ,  to  provide  an  artificial  pupil  in  cases  in  which 
the  natural  one  is  hidden  by  a  corneal  nebula  or  obstructed  by  lymph)  or  to 
facilitate  the  extraction  of  cataract.  In  either  case  only  a  small  iridectomy  is 
generally  made.  But  in  the  case  of  iridectomy  for  glaucoma  it  is  necessary  to 
remove  a  large  portion  of  the  iris  and  take  it  right  up  to  the  ciliary  attachment 
(see  Fig.  319).  . 

Iridectomy  for  optical  purposes  is  made  by  choice  downward,  or  downward 
and  inward  ;  but  its  position  must,  of  course,  depend  on  that  of  the  clear  part  of 
the  cornea.  Iridectomy  for  glaucoma  is  nearly  always  performed  upward,  so  that 
the  coloboma  may  be  concealed,  to  some  extent,  by  the  upper  lid.  In  doing  the 
former,  a  keratome  is  usually  employed,  whilst  many  prefer  Graefe's  knife  for  the 


740    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

latter  operation.  There  is  a  certain  amount  of  risk  in  using  the  keratome  that  the 
lens  capsule  may  be  wounded,  though  this  does  not  often  happen. 

The  operation  for  glaucoma  may  be  briefly  described.  An  anaesthetic  is  ad- 
visable. The  speculum  having  been  introduced,  the  conjunctival  surface  is  cleansed 
with  boracic  lotion.  The  operator,  standing  behind  the  patient,  fixes  the  globe  by 
grasping  the  conjunctiva  with  the  forceps  below  the  cornea,  and  then  with  a  broad 
keratome  or  a  draefe's  knife  makes  an  incision  about  i  mm.  behind  the  sclero-cor- 
neal  junction,  ecpial  to  nearly  one-third  of  the  corneal  circumference,  and  just  in 
front  of  the  attachment  of  the  iris.  The  instrument  is  slowly  withdrawn,  the 
escape  of  the  aqueous  causing  the  iris  to  bulge  toward  the  wound.  A  pair  of  iris- 
forceps  is  now  introduced,  opened,  and  made  to  seize  the  iris  toward  its  pupillary 
border,  the  assistant  having  taken  charge  of  the  fixation-forceps.  The  iris  is  now 
drawn  out  and  cut  through  at  the  right-hand  margin  of  the  wound  ;  by  gentle  trac- 
tion it  is  torn  away  from  its  ciliary  attachment  as  far  as  the  left-hand  border  of  the 
wound  and  again  divided.  A  fine  caoutchouc  spatula  or  curette  is  now  used  to  de- 
press either  border  of  the  iris  from  the  wound,  any  blood  is  gently  wiped  away  with 
cotton-wool  pledgets,  a  drop  of  eserine  solution  applied,  and  the  speculum  removed 
cautiously.  The  eye  is  kept  bandaged  up  for  several  days,  sal-alembroth  wool  and 
gauze  being  used  for  the  dressing.  It  should  be  removed  daily,  the  lids  bathed, 
and  the  dressing  reapplied. 

Complication  of  the  Operation,  etc. — Owing  to  the  anterior  chamber  being 
generally  very  shallow  in  acute  glaucoma,  it  requires  considerable  skill  to  make  the 
section  behind  the  sclero-corneal  junction  and  yet  in  front  of  the  iris.  On  account 
of  the  tension  a  sudden  spurt  of  aqueous,  as  soon  as  the  section  is  made,  is  very 
liable  to  occur  and  to  increase  the  risk  of  wound  of  the  lens. 

The  dilated  blood-vessels  of  the  conjunctiva  bleed  readily  during  the  section, 
and  it  occasionally  happens  that  the  sudden  relief  of  tension  is  followed  by  profuse 
intra-ocular  hemorrhage,  destroying  vision  and  rendering  subsequent  enucleation 
necessary. 

4.   Needling  Operations  for  Soft  Cataract. 

These  are  only  suitable  in  early  life,  and  are  used  chiefly  for  lamellar  or  con- 
genital cataract.  It  may  be  necessary  to  give  an  anaesthetic,  though  cocaine  will 
often  suffice.  The  pupil  should  be  fully  dilated  with  atropine  before  the  operation, 
and  its  use  continued  during  the  whole  process  of  swelling  up  and  absorption  of 
the  lens  matter,  this  often  taking  many  weeks.  The  lids  being  either  held  open 
or  kept  so  by  a  speculum,  a  cataract  needle  is  introduced  through  the  cornea  near 
its  margin  and  directed  toward  the  centre  of  the  pupil ;  its  point  is  then  turned 
backward  and  made  to  tear  the  capsule  and  front  of  the  lens.  The  needle  is  with- 
drawn, taking  care  not  to  touch  the  iris.  It  is  well  to  use  ice-water  dressing  for 
forty-eight  hours,  and  to  keep  the  patient  in  a  darkened  room  (Nettleship).  The 
lens  matter,  if  exposed  to  the  action  of  the  aqueous  humor,  swells  and  projects 
into  the  anterior  chamber,  and  is  slowly  absorbed.  After  a  month  or  two,  if  no 
irritation  or  congestion  is  present,  the  needling  may  be  repeated,  and  sometimes 
three  or  four  operations  are  required. 

Some  operators  prefer  to  hasten  the  process  by  needling  freely  at  first,  and 
when  the  lens  has  become  swollen  and  softened,  letting  it  out  through  a  small 
incision  made  with  a  narrow  keratome,  either  by  the  curette  and  slight  finger- 
pressure,  if  required,  or  by  the  use  of  a  special  suction  instrument.  Of  course, 
after  the  cataract  has  been  removed,  the  patient  will  require  convex  lenses  to  read 
with — about  10  D  to  12  D  for  distant  vision,  about  16  I)  to  18  D  for  near  vision. 

5.   Extraction  of  Hard  Cataract. 

The  oi)eration  generally  performed  is  what  is  known  as  a  modified  Graefe's 
extraction,  the  narrow  knife  named  after  that  surgeon  being  used,  and  the  section 
lying  chiefly  at  the  sclero-corneal  junction. 


OPERATIONS  ON  THE  EYE.  741 

Fretiuently  a  small  upward  iridectomy  is  performed  some  weeks  or  months 
before  the  removal  of  the  cataract,  and  this  proceeding,  though  it  involves  two 
operations,  appears  to  increase  the  chance  of  the  result  proving  satisfactory.  If 
preliminary  iridectomy  is  not  done  the  proceeding  is  as  follows  :  the  eye  being 
under  the  full  influence  of  cocaine,  and  a  boracic  solution  having  been  used  to 
render  the  conjunctiva  aseptic,  the  speculum  also  being  in  place,  the  operator 
fixes  the  eye  as  already  described  (see  Iridectomy)  and  introduces  the  knife  with 
its  point  directed  toward  the  centre  of  the  pupil,  at  or  just  behind  the  sclero- 
corneal  junction.  As  soon  as  the  blade  is  well  in  front  of  the  iris  the  handle  is 
depressed  and  the  point  carried  across  to  emerge  at  a  point  corresponding  to  the 
one  of  entrance.  The  puncture  and  counter-puncture  are  so  placed  as  to  include 
between  them  about  two-fifths  of  the  corneal  circumference.  The  incision  is  then 
completed  by  to-and-fro  action  of  the  knife,  the  edge  of  which  is  turned  some- 
what forward  as  it  cuts  through.  Care  should  be  taken  not  to  press  upon  the 
globe  with  the  fixation  forceps,  which  simply  effect  gentle  downward  traction. 
The  iris  forceps  is  now  introduced,  the  upper  part  of  the  iris  drawn  out  and 
removed  by  a  single  cut  of  the  scissors  (the  amount  removed  being  much  smaller 
than  is  necessary  for  glaucoma).  The  cystotome  is  then  passed  into  the  anterior 
chamber,  its  point  turned  toward  the  lens  and  made  to  tear  through  the  capsule 
transversely  (some  operators  add  a  vertical  division  of  the  capsule).  By  steady 
pressure  with  a  curette,  placed  at  the  lower  border  of  the  cornea,  the  lens  is  now 
made  to  tilt  forward  and  to  present  in  the  wound.  The  pressure  is  relaxed  as 
soon  as  the  greatest  diameter  of  the  lens  has  emerged,  for  fear  of  escape  of  vitre- 
ous. Frequently  some  manipulation  with  the  finger  through  the  lower  lid  is 
finally  needed  to  coax  out  bits  of  lens  cortex  which  have  remained. 

The  margins  of  the  iris  should  now  be  depressed  away  from  the  wound  if  they 
tend  to  protrude,  and  after  it  has  been  ascertained  that  the  edges  of  the  wound  lie 
in  good  apposition,  the  upper  lid  should  be  cautiously  lifted  over  it  and  the  closed 
eyes  bandaged  up  with  a  four-tailed  bandage. 

It  should  be  noted  that  before  bringing  pressure  on  the  globe  to  extract  the 
lens  the  speculum  should  be  relaxed  or  held  forward  by  the  assistant. 

After-treatment. — The  patient  is  usually  kept  in  a  darkened  room  for  about  a 
week,  the  bandage  changed  and  the  lids  bathed  once  or  twice  daily,  and  atropine 
used  if  frontal  pain,  etc.,  suggests  the  onset  of  iritis.  Leeches  to  the  temple  are 
also  advised  by  some  surgeons  in  the  latter  case.  At  the  end  of  a  fortnight,  if  all 
goes  well,  the  patient  may  go  about  with  protective  goggles,  and  a  few  weeks  later 
be  tested  for  glasses. 

Complications,  etc. — Escape  of  vitreous  is  much  to  be  dreaded  if  the  incision 
be  made  too  far  back,  in  myopic  eyes,  etc.  Should  it  occur  before  the  lens  pro- 
jects the  scoop  should  at  once  be  introduced  and  the  lens  drawn  out  with  it. 
The  operation  should  in  any  case  be  brought  to  a  speedy  close  and  the  eye  band- 
aged up. 

In  a  certain  small  proportion  of  cataract  cases  the  eye  suppurates,  or  becomes 
the  seat  of  severe  iritis.  In  a  great  many  it  is  necessary  to  perform  subsequent 
needling  operations  for  the  removal  of  opaque  capsule. 


742    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  X. 

INJURIES  AND  DISEASES  OF  THE  FACE  AND  NOSE. 
MALFORMATIONS. 

Malformations  of  the  face  result  from  imperfect  development  or  incomjjlete 
fusion  of  the  median  (fronto-nasal)  maxillary  or  mandibular  jjrocesses.  They  may 
affect  the  soft  parts  only,  the  bones  being  properly  formed  beneath,  or  the  soft 
parts  and  the  bones  as  well. 

Hare-lip,  which  is  by  far  the  most  common,  is  due  to  the  failure  of  union 
between  the  margins  of  the  maxillary  and  fronto-nasal  lobes.  It  may  occur  on 
one  side  only  (and  then  nearly  always  upon  the  left)  or  on  both,  and  there  may 
be  merely  a  notch  on  the  red  margin  of  the  lip,  or  a  deep  wedge-shaped  defect, 


Fig.  320. — Double  Hare-lip. 

or  a  complete  division  extending  into  the  nose.  In  this  last  case  there  is  always 
at  the  same  time  a  defect  in  the  alveolar  border,  usually  between  the  middle  and 
lateral  incisor  teeth  ;  and  in  many  instances  the  palate  is  imperfectly  developed 
as  well. 

When  the  hare-lip  is  double  and  extends  into  the  bone  on  both  sides  (a 
condition  always  associated  with  cleft  palate)  the  extremity  of  the  fronto-nasal 
process,  carrying  the  two  premaxillary  bones,  with  the  germs  of  most  of  the 
incisor  teeth,  is  completely  detached  from  the  maxillse  and  often  from  the  vomer, 
so  that  it  remains  suspended  from  the  column,  and  sometimes  from  the  tip  of  the 
nose  (Fig.  320). 

In  comparison  with  this,  other  malformations  on  the  exterior  of  the  face  are 
very  rare.  The  maxillary  sometimes  fails  to  unite  with  the  mandibular  process, 
so  that  the  mouth  is  prolonged  upward  toward  the  ear  (macrostoma)  ;  the  lach- 
rymal cleft  may  remain  open,  and  a  median  fissure  may  make  its  appearance  in 
the  fronto-nasal  process,  between  the  two  premaxillary  bones.  Supernumerary 
auricles  are  not  uncommon,  and  are  often  associated  with  macrostoma.  Similar 
growths  of  smaller  size  may  be  met  with  in  the  neck  at  the  sites  of  the  second  and 
third  branchial  clefts. 

Treatment. — The  operation  for  hare-lip  has  been  performed  within  a  few 
hours  of  birth.  As  a  rule  it  is  advisable  to  wait  until  the  child  is  a  month  or  six 
weeks  old,  and  in  complicated  cases  later  still.  Chloroform  should  be  used  as  the 
anaesthetic,  and  the  assistant  who  fi.xes  the  head  should  at  the  same  time  compress 
the  facial  arteries  where  they  pass  over  the  lower  jaw.  Sometimes  it  is  advisable 
to  secure  the  coronaries  as  well,  either  with  the  finger  and  thumb,  after  the  lip  has 
been  detached,  or  with  a  pair  of  forceps,  the   blades   of  which  are  guarded  with 


HARE  LIP. 


743 


rubber.  It  is  convenient  to  wrap  the  child  round  in  a  towel  so  as  to  prevent  any 
movement  if  the  an;x'sthesia  is  not  sufficiently  long. 

The  lips  are  first  thoroughly  freed  by  dividing  the  folds  of  mucous  membrane 
keeping  the  knife  close  to  the  bone.  Then  the  edges  are  pared,  the  opposing  red 
margins  removed,  and  the  raw  surfaces  brought  together  in  such  a  way  as  to  main- 
tain the  border  line  of  the  lip  as  accurately  as  possible. 

Where  the  cleft  is  incomplete,  Nelaton's  incision  is  the  best.     The  angle  of 


^-^"is^.^y'SJ 


Fig.  yi\, — Operation  for  single  Hare-lip  when  the  Fissure  does 
not  extend  into  the  Mostril. 

each  flap  is  grasjjcd  in  turn  with  a  pair  of  forceps  and  a  /y-shaped  incision  made 
above  the  cleft,  the  length  of  the  two  sides  depending  upon  the  degree  of  deform- 
ity. A  silk  ligature  is  then  passed  through  the  incision  and  drawn  down- 
ward ;  this  inverts  the  flap  and  brings  together  the  opposing  surfaces,  which 
may  be  at  once  secured  with  sutures.  A  slight  projection  is  left  on  the  border  of 
the  lip,  but  it  soon  disappears.  The  vertical  cicatrix  after  the  operation  for 
hare-lip  has  a  strong  tendency  to  contract,   and  if  the  red   line  is  accurately 


Fu;.  322.— Operation  for  Single  Hare-lip  when  the  Sides  of  the  Fissure  are  Unequal. 

adjusted  in  the  infant  there  is  almost  sure  to  be  a  notch  in  the  adult.  This 
operation  is  sometimes  performed-  at  puberty  to  rectify  the  defect  left  by  a  pre- 
vious one. 

The  same  incisions  are  made  when  the  cleft  is  complete,  if  the  two  sides  are 
fairly  equal.  The  apex,  of  course,  is  wanting,  and  the  two  are  separate  above  as 
well  as  below.    The  flaps  reflected  from  the  margins  are  turned  down  in  the  same 


Fig.  323. — Operation  for  Double  Hare-lip. 


way,  but  the  whole  length  is  not  required  and  should  not  be  preserved.     This  is 
sometimes  known  as  Malgaigne's  operation. 

If  the  two  borders  are  very  unequal — one,  for  example,  short  and  vertical,  the 
other  long  and  sloping — a  further  modification  is  advisable.  The  flap  on  the 
sloping  side  is  completely  cut  away;  that  on  the  vertical,  on  the  other  hand, 
remains  attached  at  its  lower  extremity,  and  is  turned  down  so  that  it  lies  under 


744    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  cut  surface  of  the  other.  For  this  to  succeed,  the  lips  must  be  thoroughly 
freed  and  the  flaps  thick  and  substantial. 

Double  hare-lip  is  more  serious.  If  the  intermaxillary  bones  are  in  their 
l^roper  situation  and  the  median  portion  is  well  develo[jed,  the  difficulty  is  not 
very  great.  The  sides  and  lower  border  of  the  central  jjrojection  must  be  freely 
pared,  the  whole  of  the  red  border  being  removed,  and  two  flaps  must  be  fashioned, 
one  on  each  side,  from  the  lateral  portions,  so  that  they  may  meet  each  other  in 
the  middle  line,  below  the  median.  To  secure  a  good  result,  both  sides  must  be 
done  at  the  same  time. 

The  intermaxillary  bones,  even  when  they  project  as  far  forward  as  the  tip 
of  the  nose,  should  always  be  preserved  if  they  possibly  can.  It  is  true,  the  in- 
cisor teeth  rarely  or  never  develop  properly,  and  that  it  adds  greatly  to  the  diffi- 
culty of  securing  primary  union,  but,  if  the  part  is  removed,  the  upper  lip  sinks 
inward  so  as  to  produce  a  most  unpleasing  eff'ect.  In  many  cases  it  can  be  pressed 
back.  If  this  cannot  be  done,  or  if  it  tends  to  come  forward  again,  the  septum 
may  be  broken  by  grasping  it  with  the  blades  of  a  pair  of  forceps  (guarded  with 
rubber)  and  twisting  it.  If  this  does  not  succeed,  a  triangular  portion  of  the  car- 
tilage behind  it  may  be  excised,  a  longitudinal  incision  being  made  along  its 
lower  border,  and  the  soft  parts  carefully  separated  on  either  side,  so  as  to  pre- 
serve the  blood-supply  intact.  In  any  case,  it  is  advisable  to  secure  it  in  its 
proper  position  by  means  of  a  chromic  gut  suture  passed  through  the  maxilla,  as 
the  least  pressure  forward  prevents  the  soft  parts  uniting  ;  and  sometimes  this  may 
be  done  with  advantage  a  week  or  two  before  the  lip  is  touched.  There  are,  how- 
ever, a  few  cases  in  which  the  defect  is  so  great,  involving  the  nose  as  well,  that 
the  bones  must  be  sacrificed  (not  the  periosteum,  which  can  be  left  intact),  and 
the  soft  parts  used  as  a  support  for  the  hip.  The  cleft  in  this  case  is  closed  by  the 
lateral  flaps  alone. 

Silk-worm  gut  should  be  used  for  the  sutures,  one  of  which  should  l:)e  passed 
through  the  margin;  another,  if  possible,  from  the  mucous  surface;  the  rest,  as 
many  as  may  be  required,  must  be  inserted  through  the  skin.  Hare-lip  pins  are 
to  be  avoided;  the  coronary  artery  can  be  .secured,  and  accurate  adjustment 
maintained  as  well  with  ordinary  sutures,  without  the  ri.sk  of  leaving  such  scars. 
The  wound  may  either  be  left  exposed  to  the  air  for  a  minute  or  two,  that  the  dis- 
charge may  dry  upon  it,  or  dusted  lightly  with  iodoform.  Collodion  is  liable  to 
cause  great  smarting.  If  the  lip  is  properly  separated  from  the  bone  beneath, 
there  is  very  little  tension  on  the  parts.  To  prevent  the  muscles  interfering  with 
union,  two  pieces  of  strapping,  cut  in  the  shape  of  a  banjo,  should  be  applied, 
one  to  each  cheek,  and  then,  while  the  tissues  are  rolled  up  together  under  the 
nose  by  the  pressure  of  the  finger  and  thumb,  the  tails  should  be  secured  across 
the  front,  slipping  one  through  a  slit  in  the  other.  The  same  precaution  should 
be  adopted  when  the  wound  is  dressed,  the  head  of  the  infant  being  held  between 
the  knees,  while  the  nurse,  seated  in  front,  supports  the  body  and  holds  the  limbs. 
Many  kinds  of  trusses  and  supports  have  been  devised  to  hold  the  cheeks  together, 
but  none  of  them  are  thoroughly  satisfactory,  and  I  have  .seen  children  with  great 
scars  upon  their  cheeks  caused  by  sloughing. 

The  sutures  are  removed  upon  the  second  day ;  deep  ones  passed  through  the 
bone  may  be  left  longer,  and  if  of  catgut  need  not  be  interfered  with.  Even  if 
primary  union  fails,  the  gap  may  be  bridged  across  by  granulations,  but  the  cicatrix 
is  very  conspicuous.  The  child  must,  of  course,  be  kept  quiet ;  it  may  be  allowed 
to  take  the  breast  as  usual,  but  should  not  retain  a  rubber  teat  constantly  in  its 
mouth,  and  care  must  be  taken  to  keep  the  nostrils  clear  with  a  camel's-hair  brush 
and  vaseline. 


INJURIES  AND  DISEASES  OF  THE   FACE.  745 

INJURIES  AND  DISEASES  OF  THE  FACE. 

Wounds. 

Owing  to  the  abundant  supply  of  l)lood,  wounds  of  the  face  heal  very  rapidly. 
In  burns,  however,  and  in  gunshot  injuries  in  which  there  is  much  loss  of  ti.ssue, 
great  care  is  required  to  prevent  deformity  ;  the  lower  lip,  for  example,  may  be 
drawn  down  to  the  neck,  or  the  lower  eyelid  permanently  fixed  in  a  position  of 
ectropion.  Even  when  they  are  badly  bruised,  the  edges  should  always  be  brought 
accurately  together  and  fastened  by  sutures  :  fine  silver  wire  or  silk-worm  gut  if 
the  depth  is  not  great;  hare-lip  pins,  if,  for  instance,  the  lip  is  divided  through 
into  the  mouth.  It  is  essential  to  bring  the  scar  into  such  a  position  that  it  will 
have  the  least  effect  upon  the  eyelids  and  the  mouth.  A  double  set  of  sutures  is 
sometimes  advantageous,  one  through  the  mucous  and  the  other  through  the  cuta- 
neous surface  ;  and  the  latter  may  be  subcuticular,  /.  e.,  carried  through  the  corium 
from  side  to  side,  without  appearing  upon  the  surface.  In  this  case  fine  catgut 
must,  of  course,  be  used.  Bleeding  generally  stops  of  itself,  or  as  soon  as  the 
surfaces  are  brought  into  apposition  ;  but  the  facial  artery  may  require  twisting  or 
tying.  Sutures  should  be  removed  as  early  as  possible,  and  the  edges  of  the  wound 
supported  by  pressure,  so  as  to  avoid  scarring.  Many  instances  are  on  record  of 
large  portions  of  the  nose  having  united  again  after  being  completely  detached. 


Fractures 

of  the  bones  of  the  face  are  dealt  with  elsewhere.  They  are  very  frequently  com- 
pound and  comminuted  ;  but  extensive  necrosis  is  unusual,  and  the  prognosis,  so 
far  as  life  is  concerned,  is  very  good,  unless  the  base  of  the  skull  (the  roof  of  the 
nose,  for  example)  is  involved.  Accurate  apposition,  however,  so  as  to  avoid 
deformity,  is  often  a  matter  of  great  difficulty. 

Foreign  Bodies  in  the  Nose. 

Pebbles,  dried  peas,  pieces  of  slate-pencil,  and  the  like,  are  often  pushed  up 
the  nose  by  children,  and  frequently,  before  the  case  is  seen,  are  driven  out  of 
sight  by  ill-advised  attempts  at  removal.  With  a  proper  light  there  is  generally 
but  little  difficulty  in  laying  hold  of  them  from  the  front  with  polypus-forceps  ; 
but  in  many  cases  an  anaesthetic  is  advisable,  as  it  may  be  necessary  either  to  push 
them  back  into  the  pharynx,  or  to  pass  the  fingers  round  the  soft  palate  into  the 
posterior  nares.  In  the  case  of  adults,  a  recurrent  stream  of  warm  water  may  be 
used,  and  a  sufficient  degree  of  anaesthesia  obtained  by  brushing  the  surface  over 
with  a  5  per  cent,  solution  of  cocaine.  It  must  always  be  remembered  that 
a  pointed  foreign  body,  such  as  a  sharp  piece  of  stick,  is  very  easily  driven 
through  the  cribriform  plate. 

Division  of  the  Parotid  Duct 

is  liable  to  be  followed  by  salivary  fistula,  the  opening  of  the  cutaneous  surface 
persisting,  and  the  whole  or  greater  part  of  the  secretion  pouring  on  to  the  skin, 
and  giving  rise  to  great  discomfort  and  annoyance.  To  avoid  this,  the  wound,  if 
it  does  not  already  extend  into  the  mouth,  should  be  completed,  and  a  catgut 
suture  passed  through  the  mucous  membrane  of  the  cheek  and  the  adjacent  wall  of 
the  duct  on  either  side,  and  knotted  on  the  oral  surface.  The  edges  of  the  wound 
in  the  skin  must  then  be  brought  together  accurately,  and  rendered  as  secure  as 
possible  with  collodion.  Even  if  union  does  not  take  place  at  the  first,  the  open- 
ing has  a  strong  tendency  to  close,  if  only  the  saliva  can  find  its  way  into  the 
mouth. 

48 


746    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

AFrF.CTIONS    OF    THE    FaCE. 

Facia/  Carbunclr. — A  peculiar  form  of  carbuncle,  caused,  probably,  by  direct 
inoculation  from  some  foul  and  jnitrid  source,  is  occasionally  met  with  u])on  the  lip. 
It  differs  from  the  ordinary  variety  in  the  age  of  the  patient  (most  of  those  I  have 
seen  have  been  in  young  men  who  were  apj)arently  in  good  health)  and  in  the  fact 
that  numerous  small  abscesses  are  usually  jiresent  rather  than  one  single  extensive 
slough.  Probably  this  may  be  accounted  for  by  the  radial  direction  of  the  con- 
nective-tissue fibres  in  this  part.  The  ordinary  form  may  occur  upon  other  parts  of 
the  face,  as  on  the  neck  and  back,  in  older  people  whose  health  is  broken  down. 
The  subcutaneous  induration  is  often  of  immense  size,  forming  a  hard,  brawny 
swelling  which  extends  all  over  the  cheek  and  even  down  on  to  the  neck.  Sometimes 
this  is  preceded  by  a  pustule  (especially  in  inoculation  cases)  and  frequently  is  ac- 
companied by  the  formation  of  vesicles,  so  that  in  si)ite  of  the  intense  pain  there 
is  a  superficial  resemblance  to  true  anthrax;  the  bacilli  of  this  disease,  however, 
are  never  jjresent.  In  a  severe  case  the  constitutional  symptoms  are  typhoid  from 
the  commencement,  but  in  many  of  the  milder  inoculation  ones  the  patient  is  but 
little  inconvenienced. 

Facial  carbuncle  is  always  serious,  owing  to  the  risk  of  meningitis  and  pyaemia. 
This  arises  entirely  from  the  anatomical  relations  of  the  part,  the  free  communica- 
tion between  the  infraorbital  and  ophthalmic  veins  and  the  venous  sinuses  of  the 
cranium  on  the  one  hand,  and  between  the  facial  and  jugular  on  the  other;  it  is 
not  the  result  of  any  specific  quality.  Septic  embolism  of  the  lungs  is  found  in  a 
very  large  proportion  of  fatal  cases. 

The  treatment  consists  in  free  incision.  In  the  labial  form,  for  example,  the 
patient  should  be  anaesthetized,  and  the  whole  swelling  cut  across  with  a  sharp- 
pointed  bistoury,  introduced  into  the  red  margin,  with  the  surface  of  the  blade 
parallel  to  the  skin.  Afterward  the  sloughs  must  be  scraped  out,  and  the  resulting 
cavities  and  the  abscesses  that  are  opened  thoroughly  sponged  with  a  20  per  cent, 
solution  of  carbolic  acid.  Usually  this  stays  the  progress  of  the  inflammation  at 
once,  but  the  patient  often  must  pass  through  a  long  and  trying  illness  before  con- 
valescence is  complete. 

Anthrax. — True  malignant  pustule,  due  to  the  inoculation  of  the  bacillus 
anthracis,  is  occasionally  met  with  upon  the  face  ;  but,  excei)t  that  its  course  is  often 
exceedingly  rapid,  it  does  not  differ,  in  any  material  respect,  from  the  same  disease 
in  other  parts  of  the  body. 

Cancrum  Oris,  Noma,  or  Gangrenous  Stomatitis. — A  peculiar  form  of  inflam- 
mation, affecting  the  tissues  of  the  cheek  and  rapidly  running  on  to  gangrene, 
sometimes  occurs  in  poor,  half-starved  children,  during  convalescence  from  specific 
fevers,  especially  measles  and  scarlatina.  Its  course  and  general  characteristics  are 
so  uniform,  that  it  has  been  sujtposed  by  many  to  result  from  the  action  of  a 
specific  germ  ;  but,  in  spite  of  the  fact  that  cases  of  this  kind  frequently  occur 
together  (I  have  seen  three  from  the  same  house,  inhabited,  it  is  true,  by  many 
families),  it  is  very  doubtful  if  there  is  anything  of  the  kind.  It  seems  much  more 
probable  that  it  is  akin  to  phagedaena,  caused  by  the  ordinary  organisms  of  sup- 
puration acting  under  specially  favorable  conditions,  and  that  when  several  cases 
of  it  are  met  with  at  the  same  time,  their  occurrence  is  the  result  of  the  close 
similarity  in  the  circumstances  of  life. 

Sometimes  it  begins  on  the  mucous  surface,  a  sloughing  ulcer  forming  near 
the  orifice  of  Steno's  duct  (it  has  been  suggested  that  the  administration  of  mer- 
cury favors  its  occurrence),  more  often  in  the  substance  of  the  cheek  itself.  In 
either  case  the  first  external  sign  is  an  ill-defined  but  exceedingly  hard  patch,  usu- 
ally in  the  centre  ;  the  skin  over  it  is  dusky,  glazed,  and  (.edematous  ;  the  mucous 
membrane  may  be  raised  and  livid,  or  already  covered  with  an  ashy-gray  slough  ; 
there  is  little  or  no  pain,  unless  it  is  handled  roughly,  and  the  child  scarcely  pays 
any  attention  to  it.  Then  a  bulla  arises  in  the  middle,  bursts,  and  leaves  a  patch 
of  black  gangrene,  which  steadily  increases  in  size,  preceded  by  a  narrow,  dusky 


AFFECTIONS  OF  THE   FACE.  747 

rial,  until  the  whole  of  the  cheek  is  a  coal-black  slough,  the  lips  destroyed,  the 
side  of  the  nose  eaten  away,  and  the  jaws  beneath  exposed  without  even  a  cover- 
ing of  periosteum.  The  destruction  on  the  inner  surface  of  the  cheek  is  even 
wider  than  that  on  the  outer.  I  have  .seen  it  develop  on  the  second  side  while  the 
first  wivs  still  in  progre.ss,  until  the  whole  of  the  face  was  destroyed,  with  the  ex- 
ception of  the  no.se  and  a  small  median  portion  of  the  two  lips. 

A  similar  affection  has  been  described,  affecting  the  external  organs  of  gene- 
ration in  female  children  living  under  the  .same  conditions,  but  it  is  much  more 
rare. 

The  constitutional  disturbance  throughout  is  strangely  slight.  The  child 
often  does  not  notice  it  but  plays  with  its  toys,  eats  and  sleeps  as  if  it  were  abso- 
lutely unconcerned  ;  then  it  either  suddenly  collapses  or  is  attacked  by  septic 
pneumonia. 

The  only  treatment  of  any  avail  is  the  actual  cautery  :  the  whole  of  the  affected 
part  must  be  deliberately  exci.sed.  If  the  skin  is  not  yet  involved  (such  ca.ses  are 
rarely  seen  in  time)  it  must  be  done  from  the  interior,  but  nearly  always  there  is 
already  a  blackened  slough.  The  prognosis,  so  far  as  life  is  concerned,  is  very 
bad  :  recovery  may,  however,  take  place  even  when  the  jaws  have  been  involved, 
leaving  the  most  frightful  deformity. 

Erysipelas  of  the  face  is  dangerous,  from  the  risk  of  its  spreading  to  the  me- 
ninges (though  this  is  not  so.  common  as  when  the  scalp  is  involved)  and  to  the 
throat,  causing  erysipelatous  laryngitis.  The  swelling,  when  it  spreads  into  the 
eyelids,  is  often  enormous,  and  may  require  relief  by  puncture ;  on  the  nose  and 
ears,  on  the  other  hand,  it  is  very  slight,  but  intensely  painful.  Repeated  attacks 
lead,  at  length,  to  a  very  disfiguring  degree  of  solid  oedema. 

Lupus. — The  face  is  the  favorite  locality  for  all  forms  of  lupus.  The  common 
variety,  that  which  develops  in  young,  fair-complexioned,  and  perhaps  scrofulous 
subjects,  and  is  characterized  by  the  presence  of  little  semi-translucent  tubercles, 
which  break  and  leave  superficial  sores,  is  especially  frequent  round  the  alae  of  the 
nose  and  on  the  lips  and  cheeks.  Sometimes  it  causes  very  serious  deformity, 
destroying  the  cartilages,  leaving  the  apertures  of  the  nostrils  widely  open  upon 
the  face,  and  spreading  into  the  gums  and  palate.  It  may  be  known  by  the  age 
at  which  it  occurs ;  its  chronic,  persistent  course,  the  characteristic  tubercles,  and 
the  thin  red  cicatrices,  always  on  the  point  of  breaking  down.  Erythematous 
or  butterfly  lupus,  in  which  the  amount  of  new  growth  is  very  much  less,  is  more 
rare  ;  and  rarer  still  is  an  eczematous  variety,  often  taken  for  eczema,  but  differ- 
ing from  it  in  the  presence  of  a  certain  though  small  amount  of  lupus  tissue,  and 
in  the  fact  that  it  leaves  a  scar. 

Syphilis. — All  forms  of  syphilitic  eruption  are  common  upon  the  face.  Pri- 
mary chancres  are  often  met  with  on  the  lips,  and  may  occur  upon  the  eyelids  and 
other  parts.  They  are  easily  recognized  by  the  peculiar  character  of  the  indura- 
tion, and  are  distinguished  from  epithelioma  by  the  aspect  of  their  base  (which 
is  not  covered  with  epithelial  debris),  by  the  rapidity  with  which  the  sore  develops, 
and  the  quickness  with  which  the  glands  become  involved.  It  rarely  happens 
that  a  hard  chancre  has  lasted  a  fortnight  before  some  evidence  of  these  can  be 
found,  while  an  epithelioma,  unless  it  has  been  irritated,  rarely  produces  any 
effect  under  three  or  four  months.  Age  is  not  so  sure  a  test.  Hunterian  chan- 
cres may  occur  at  any  time  of  life,  and  I  have  seen  a  typical  epithelioma  of  the 
lip  in  a  man  only  thirty  years  of  age.  Sex,  however,  is  sometimes  of  help,  as 
epithelioma  is  very  rare  in  women. 

Secondary  eruptions  rarely  fail.  Roseola  is  the  most  common,  especially  on 
the  forehead,  under  the  roots  of  the  hair,  and  in  parts  that  are  irritated  by  shaving. 
Alopecia  may  occur,  although  it  is  not  so  frequent  as  upon  the  scalp.  The  most 
serious  is  a  form  of  phagedaena,  which,  from  a  superficial  resemblance  it  possesses, 
has  been  called  syphilitic  lupus.  It  attacks  the  alae  of  the  nose,  and  causes  greater 
destruction  in  three  days  than  lupus  in  as  many  months.  Very  often  it  is  associated 
with  rupia,  and  occasionally,  especially  when  it  occurs  in  the  later  periods  of  the 


74S    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

disease,  with  what  used  to  be  called  hypertrophic  lupus,  an  enormous  purplish-red 
enlargement  of  the  lower  half  of  the  nose.  The  only  treatment  is  the  acid  nitrate 
of  mercury  as  soon  as  there  is  the  least  indication  of  its  appearance.  The  cicatrix 
is  firm  and  dead  white,  without  the  least  tendency  to  break  down,  and  utterly 
unlike,  therefore,  that  which  follows  tubercular  lupus. 

Tertiary  symptoms  are  almost  as  frequent.  Papular  serpiginous  eruptions  are 
common  upon  the  skin  around  the  mouth  and  nose,  and  rhagades  and  painful  fis- 
sures frequently  occur  at  the  angles.  The  former  subside  under  treatment  without 
a  permanent  mark  ;  the  latter  leave  dead-white  linear  radiating  cicatrices.  In  the 
later  stages,  when  the  amount  of  exudation  is  greater,  these  papules  are  succeeded 
by  scaly  dusky-red  tubercles,  still  arranged  in  the  same  way.  At  first  these  may 
also  be  absorbed,  although  they  are  liable  to  leave  behind  atrophied  ]iatches  of  skin 
where  the  papillae  have  been  destroyed  ;  after  a  time,  however,  especially  if  the 
health  begins  to  fail,  they  increase  in  size,  and  then  they  usually  break  down  and 
suppurate.  I^ter  still,  and  in  intractable  cases,  the  amount  of  exudation  may  be 
so  great  that  the  tissues  perish  and  sloughing  gummata  form.  Sometimes  it  is  only 
the  skin  that  is  affected  ;  more  often  there  is  a  sodden  mass  in  the  subcutaneous 
tissue  ;  and  occasionally  the  bones  are  exposed  and  huge  sequestra  similar  to  those 
met  with  upon  the  forehead  slowly  exfoliate.  Finally,  in  a  few  very  rare 
instances,  phagedaenic  gangrene  sets  in  and  rapidly  proves  fatal,  from  septicaemia 
or  septic  ])neumonia. 

Similar  affections  occur  in  the  hereditary  form,  and  when  no  evidence  can  be 
obtained  from  the  condition  of  the  teeth  or  the  cornea  or  the  sunken  bridge  of  the 
nose,  it  is  often  enough  to  mark  the  dead-white  pits  that  surround  the  mouth  and 
the  linear  radiating  cicatrices  that  spread  from  the  angles  and  the  nose.  A 
median  cicatrix  in  the  lower  lip  is  of  no  significance  in  this  respect. 

Leprosy. — The  earlier  manifestations  of  this  disease  are  occasionally  met  with 
upon  the  face  in  the  shape  of  du.sky  erythematous  patches,  slightly  scaly,  and 
sometimes  symmetrical.  As  they  increase  in  size  the  centre  becomes  anaesthetic 
and  grows  paler  and  paler  until  it  is  dead-white.  Tubercular  masses,  leading  to 
great  disfigurement,  are  common  in  the  later  period. 

Rhinoscleroma  is  a  very  rare  disea.se,  which  is  only  known  to  occur  upon  the 
nose  and  upper  lip.  It  first  appears  as  a  hard  nodule,  covered  over  with  reddish 
skin,  growing  usually  from  the  columna.  As  time  passes  it  slowly  increases  in 
size  until  it  forms  a  dense,  bossy  mass,  as  hard  as  a  fibroma,  which  blocks  up  the 
nostrils,  extends  along  the  inferior  meatus,  involves  the  palate,  and  causes  an 
immense  projection  of  the  upper  lip.  By-and-by  it  begins  to  ulcerate,  but  the 
process  is  always  slow.  It  may  be  excised,  but,  unless  it  is  removed  very 
thoroughly,  the  wound  heals  up  and  the  growth  begins  again.  The  lymphatic 
glands  never  appear  to  be  involved.  Histologically  it  resembles  other  granula- 
tion-tissue growths,  composed  of  ordinary  round  cells  with  a  few  of  larger  size. 
Sometimes  it  appears  as  if  the  epidermis  were  inclined  to  grow  downward,  as  in 
epithelioma.  Payne  and  others  have  described  short  ovoid  bacilli  in  connection 
with  it,  but  its  proper  relationship  is  still  uncertain. 

Tumors  of  the  Face. 

Dermoid dS\A  sebaceous  cysts  are  of  common  occurrence;  meibomian  cysts. 
which  are  developed  in  the  eyelids,  and  lipoma  nasi  (Fig.  324)  have  been 
described  elsewhere.  The  various  forms  of  hairy  moles  and  of  mpvi  which  are 
frequently  met  with  require  very  careful  treatment,  for  fear  of  leaving  a  worse 
deformity.  The  former,  if  small,  may  be  excised  ;  the  hair-sheaths  in  the  larger 
ones  are  best  destroyed  by  electrolysis,  but  the  method  is  very  tedious.  The  same 
may  be  said  of  naevi ;  subcutaneous  ones  can  be  dissected  out,  leaving  a  fine  linear 
cicatrix,  which,  if  carefully  planned,  is  almost  invisible  in  a  few  years'  time  ; 
cutaneous  ones,  on  the  other  hand,  especially  those  of  any  extent  and  in  the 
region  of  the  eyelids,  should  be  very  carefiilly  dealt  with.     The  most  satisfactory 


TUMORS  OF  THE   FACE.  749 

method  is  the  application  of  the  constant  current,  using  only  the  positive  pole 
(the  negative  api^lied  to  the  skin  elsewhere),  but  it  requires  a  great  deal  of 
patience. 

Molluscuni  LOniai:;iosum  is  very  common  in  children  and  can  l)e  recognized  by 
the  clear  semi-translucent  appearance  of  the  little  masses,  even  when  there  is  no 
depression  upon  them.  The  other  variety  (^Jibrosinn)  is  rarer,  the  face  often  re- 
maining free  when  the  body  is  almost  covered. 

Epithelioma. — Squamous-celled  carcinoma  may  occur  in  the  same  region  of 
the  face  as  rodent,  or  upon  the  nose,  but  the  favorite  locality  is  the  lower  lip,  on 
the  red  portion,  or  at  the  junction  of  this  with  the  skin.  On  the  upper  it  is 
exceedingly  rare.  There  is  no  doubt  that  it  is  often  caused  by  the  persistent 
irritation  of  a  clay  pipe,  the  soft  epidermis  of  the  lip  adhering  to  the  porous  sur- 
face of  the  clay,  so  that  when  this  is  removed,  it  brings  away  with  it  the  protect- 
ing layer  ;  and  it  is  said  to  be  nearly  as  common  among  the  women  of  the  lower 
classes  in  Ireland  as  among  men  ;  but  there  is  no  doubt  that  it  does  occur  also  in 
those  who  have  never  smoked. 


Fig.  324. — Lipoma  Nasi. 

It  may  commence  in  various  ways  ;  either  as  a  crack  or  fissure  which  refuses 
to  heal  and  grows  harder  and  harder,  or  as  a  raised  papillomatous  surface  covered 
with  unaltered  epithelium.  At  first  its  progress  is  slow  ;  and  particularly  in  old 
people,  it  may  remain  concealed  beneath  a  scab  for  months  without  apparently 
undergoing  any  change.  By  degrees,  however,  it  a.sssumes  the  type  of  an  epithe- 
liomatous  ulcer,  with  a  ragged,  irregular,  sloughing  base,  and  raised,  everted,  and 
hardened  edges.  Sometimes,  when  it  is  irritated  (especially  by  caustics)  it  fun- 
gates  and  grows  with  great  rapidity.  If  it  is  left,  the  glands  beneath  the  jaw  be- 
come affected,  the  disease  spreads  into  the  surrounding  tissues,  the  ulceration 
extends  wider  and  wider  and  becomes  intensely  painful,  and  the  patient,  after  a 
time,  begins  to  sink  very  rapidly,  worn  out  by  the  pain,  inability  to  take  food, 
and  repeated  hemorrhages,  and  half  poisoned  by  the  passage  of  septic  debris  into 
the  lungs  and  the  alimentary  canal.  The  glands  often  attain  a  very  large  size 
and  fungate  through  the  skin  as  well  as  into  the  mouth,  bleeding  profusely  at  the 
slightest  touch  ;  but  wider  secondary  deposits  are  rather  the  exception. 

Exclusion  should  be  performed  as  soon  as  possible,  the  whole  affected  portion 


750     DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

being  removed  by  a  V-shaped  incision.  As  patients  usually  apply  for  treatment 
earlier  than  in  other  forms  of  carcinoma,  the  results  are  fairly  good  ;  but  care 
must  be  taken  to  keep  clear  of  the  growth  on  either  side,  as  there  is  a  distinct 
tendency  for  it  to  spread  laterally  under  the  epithelium.  The  assistant  should 
grasp  the  lip  with  his  finger  and  thumb  so  as  to  compress  the  coronary  arteries. 
Hare-lii)  pins,  passed  from  the  cutaneous  almost  to  the  mucous  surface,  are  used 
to  bring  the  wound  together,  silk  being  twisted  over  them  in  a  figure-of-eight,  but 
they  must  not  be  left  more  than  forty-eight  hours.  One  or  two  other  sutures  may 
be  inserted  with  advantage  and  left  a  day  or  two  longer. 

When  the  glands  are  involved,  the  same  operation  should  be  performed,  and 
the  secondary  deposits  excised,  if  there  is  a  chance  of  removing  the  whole  of  the 
disease.  It  is  true  there  is  scarcely  a  hope  of  curing  the  patient ;  but,  at  the  risk 
of  what  is  not  a  very  severe  operation,  there  is  a  possibility  of  giving  him  material 
relief,  and  of  freeing  him  from  a  foul  and  offensive  ulcer,  involving  more  or  less 
the  whole  of  his  mouth,  poisoning  him,  and  rendering  existence  almost  intolerable. 
Rodent  Ulcer. — This  is  a  variety  of  epithelioma  (beginning  in  connection 
with  the  hair-sheaths)  which  is  rarely  met  with  under  fifty  years  of  age  and  in 
other  parts  of  the  body  than  the  forehead,  face,  and  scalp.  It  is  exceedingly  slow 
in  its  progress,  and  does  not  involve  the  lymphatic  glands ;  but  if  left  to  itself  or 
incompletelv  removed,  it  tends  slowly  to  infiltrate  and  eat  into  all  the  structures 
near,  until,  if  it  is  growing  at  the  corner  of  the  eye  (its  favorite  seat),  it  may  de- 
stroy the  eyeball  and  expose  the  brain.  It  usually  begins  as  a  reddish-brown 
elevation  of  the  skin,  like  a  wart.  By  degrees  this  becomes  scaly,  and  then,  after 
the  surface  has  come  away  a  few  times,  a  small  ulcer  forms  ;  the  edges  irregular, 
sinuous,  a  little  raised  and  already  hardened  ;  the  base  depressed,  pale,  devoid  of 
granulations,  and  secreting  a  thin  serous  fluid.  The  longer  it  lasts  the  wider  and 
deeper  it  spreads ;  but,  usually,  it  is  several  years  before  it  attains  any  size. 
Throughout,  unless  it  is  irritated  and  inflamed,  it  retains  the  same  indolent  char- 
acter, but  I  have  known  it  spread  much  more  rapidly  after  ineffectual  attempts  at 
removal  by  means  of  caustics  and  i)oultices. 

The  only  treatment  is  complete  removal,  the  earlier  the  better. 

Other  forms  of  malignant  growth  (independently  of  those  spreading  from  the 
bones  and  subjacent  structures)  are  rare.  I  have  met  with  a  pigmented  form  of 
epithelioma  upon  the  cheek,  and  with  one  or  two  instances  in  which  sarcomatous 
growths  apparently  originated  in  the  subcutaneous  tissue ;  but  the  diagnosis  and 
treatment  ])resent  no  special  feature  of  interest. 

The  diagnosis  between  lupoid,  syphilitic,  rodent,  and  epitheliomatous 
ulcers  upon  the  face,  occasionally  presents  a  little  difficulty. 

Age. — Lupus  occurs  chiefly  in  young  adults  ;  syphilis  in  adult  life ;  epitheli- 
oma and  rodent  not  until  much  later. 

Course. — Lupus  is  very  chronic  ;  probably  it  has  already  lasted  months  or 
even  years.  Syphilis  is  more  acute,  often  it  is  only  a  question  of  days  ;  although 
I  have  known  patches  of  a  syphilitic  tubercular  eruption  persist  for  months  with- 
out much  change.  Epithelioma  is  fairly  rapid,  especially  if  it  is  irritated,  making 
more  progress  in  a  month  than  rodent  in  a  year. 

Tendency  to  Heal. — This  is  nearly  always  present  in  lupus,  and  the  cicatrix 
is  red,  and  so  thin  that  it  is  always  breaking  down  again.  If  it  occurs  in  syphilis, 
the  scar-tissue  is  dense  and  white.  It  is  not  present  in  rodent  or  epithelioma, 
except  as  a  result  of  operation. 

Origin. — Groups  of  semi-translucent  lupus  tubercles  round  the  margin  are  dis- 
tinctive; those  of  syphilis  are  never  really  like  them,  except  in  shape.  A  single 
hard  nodule  may  precede  the  others. 

Edges. — The  outline  of  lupus  is  usually  irregular  and  the  margins  soft.  Syph- 
ilitic eruptions  have  a  tendency  to  assume  a  crescentic  form.  Rodent  is  gener- 
ally circular,  with  hard,  rounded,  rolled-over  margins  ;  while  in  epithelioma  the 
induration  always  extends  a  considerable  distance. 

Base. — In  lupus  the  surface  is  concealed  beneath  scabs  or  covered  with  pale, 


DISEASES  OF  THE  NOSE—EPISTAXIS.  751 

flabby  granulations.  A  syphilitic  sore,  so  long  as  it  is  spreading,  is  f(jul  and 
sloughing  ;  rodent  is  smooth  and  glossy  on  the  surface  ;  while  the  floor  of  an  epi- 
thelioniatous  sore  is  hard,  nodular,  covered  with  epithelial  debris,  and  secretes  a 
foul,  purulent  tlischarge. 

DISEASES  OF  THE  NOSE. 
Malformations  and  Deformities. 

Congenital  malformations  are  rare  ;  deformities  on  the  other  hand,  resulting 
from  injury,  lupus,  or  syphilis,  are  very  common. 

Deviations  of  the  septum  should  be  straightened  at  once  by  means  of  forceps  ; 
but  the  tendency  to  return,  even  in  the  case  of  accidents,  is  so  great  that  either 
the  process  has  to  be  rejieated  again  and  again,  or  a  truss  or  mask,  devised  for 
each  special  case,  must  be  worn  at  night. 

Extensive  destruction  of  the  soft  parts  can  sometimes  be  remedied  by  means 
of  a  plastic  operation;  but,  in  cases  in  which  it  is  due  to  disease,  this  should 
never  be  attempted  until  the  stump  is  perfectly  sound.  The  two  best  known 
methods  are  the  Indian,  and  that  first  carried  out  by  Tagliacozza  (the  Italian). 

In  the  former  a  flaj)  of  suitable  shape  is  marked  out  upon  the  forehead,  hav- 
ing its  i)edicle  immediately  over  the  root  of  the  nose,  or  slightly  to  one  side,  so 
that  it  can  be  twisted  down  more  easily.  This  is  carefully  dissected  up  (Langen- 
beck  recommends  that  the  periosteum  should  be  brought  away  with  it),  adjusted  in 
a  bed  prepared  for  it  by  cutting  away  the  old  scar  tissue  around  the  margins  of 
the  orifice,  and  secured  with  sutures,  hollow  plugs  being  inserted  into  the  nostril, 
so  that  it  may  retain  its  shape.  To  avoid  the  sinking  inward  of  the  tip,  Langen- 
beck  reflected  some  of  the  bony  margin  of  the  nostril,  fashioning  a  flap  from  each 
side,  so  that  they  should  meet  like  the  rafters  of  a  roof  in  the  middle ;  but  when 
the  nose  has  been  destroyed  by  inflammation  this  proceeding  is  rarely  practicable. 

In  the  Indian  method  the  skin  is  taken  from  the  arm  over  the  biceps.  In  the 
original  plan  the  flap  was  raised  by  an  incision  down  each  side  and  left  to  granu- 
late ;  then  the  upper  end  was  separated  ;  and  after  the  skin,  detached  now  on  three 
sides,  had  begun  to  shrink,  it  was  carefully  fi.Kcd  by  sutures  in  the  freshly  cut  mar- 
gins of  the  defect.  The  arm  is  fixed  with  plaster  bandages  in  a  suitable  position, 
and  it  must  be  retained  like  this  without  the  slightest  traction  for  at  least  eight 
days.  The  treatment  has  since  been  shortened  by  detaching  the  flap  at  an  earlier 
date,  but  naturally  with  some  risk. 

Of  these  two  methods  there  is  no  doubt  the  former  is  the  better  where  it  is 
practicable,  in  spite  of  the  scar  it  leaves.  In  the  latter  the  transplanted  flap  sinks 
into  a  shapeless  mass.  Neither,  however,  is  really  satisfactory,  and  it  is  probable 
that  in  most  cases  the  deformity  would  be  better  concealed  by  an  artificial  nose, 
made  from  vulcanite  or  enameled  silver,  and  fastened  on  to  a  spectacle  frame. 

In  cases  in  which  one  ala  only  is  defective,  Langenbeck's  plan  of  reflecting  a 
flap  from  the  other  on  the  opposite  side  (leaving  it  attached  by  a  bridge  upon  the 
dorsum)  tends  to  diminish,  or  at  least  equalize  the  deformity.  There  is,  however, 
some  difficulty  in  separating  the  skin  from  the  cartilage  without  cutting  or  bruising 
it,  owing  to  the  very  close  connection  that  exists  between  the  two. 

Epistaxis. 

Hemorrhage  from  the  nose  may  be  very  serious,  the  blood  jiouring  down  the 
posterior  nares  as  well  as  the  anterior,  and  being  swallowed,  so  that  the  patient  is 
not  aware  of  the  amount  that  is  lost.  In  most  instances  it  is  merely  a  symptom 
of  some  other  trouble,  sometimes  a  very  grave  one  ;  but,  for  convenience  of  classi- 
fication, the  causes  may  be  divided  into  general  and  local. 

{a)  General. — Some  of  them  are  congenital — haemophilia,  for  example — and 
a  curious  tendency  toward  nose-bleeding,  which  is  not  uncommon  in  certain 
families,  sometimes  in  both  sexes,  more  often  in  the  males  alone,  and  only  persists 


752    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


during  certain  years  of  life.  Morbid  conditions  of  the  blood,  as  in  scurvy,  leu- 
kjemia,  purpura,  acute  specific  fevers,  etc.  ;  and  general  affections  of  the  circula- 
tion, such  as  are  met  with  in  connection  with  Bright's  disease,  cirrhosis  of  the 
liver,  plethora  and  gout  are  more  common.  In  some  instances  epistaxis  is  said  to 
be  vicarious. 

{/>)  Local. — All  forms  of  injury,  inflammation  (whether  specific  or  not),  and 
new  growths,  may  be  attended  by  epistaxis.  It  rarely  haj)i)ens,  however  (except 
in  the  case  of  naso-pharyngeal  polypi,  and  occasionally  as  a  result  of  injury),  that 
the  loss  from  these  causes  is  of  the  same  serious  and  persistent  character  as  from 
the  former.  It  may  be  smart  for  the  time,  but  as  there  is  no  constitutional  dis- 
order, no  serious  affection  of  the  blood  or  blood-vessels,  it  can  usually  be  checked 
without  difficulty. 

Treatment. — Raising  the  corresponding  arm  above  the  head ;  compressing 
that  side  of  the  nose  with  the  finger  ;  cold-sponging  of  the  face  ;  applying  cold  to 
the  nape  of  the  neck,  and  other  simple  remedies  should  be  tried  first.  If  they  do 
not  succeed,  the  patient  should  lie  down  and  an  ice-bag  be  applied  over  the  nose, 
but  watch  must  be  kej^t  that  the  blood  does  not  trickle  down  into  the  ]jharynx. 
All  muscular  eftbrt,  and  especially  blowing  the  nose,  must  be  forbidden.  Washing 
out  the  nose  with  ice-cold  water,  or  with  water  tinged  with  perchloride  of  iron,  is 
more  effectual.  The  internal  administration  of  such  drugs  as  acetate  of  lead,  gallic 
acid,  and  ergot,  is  of  little  use,  though  more  may  be  said  in  favor  of  opium.  Finally 
if  the  hemorrhage  persists  or  returns  again  and  again,  the  nostrils  must  be  plugged. 
There  are  two  ways  in  which  this  may  be  accomplished.  The  best  is  with  a 
thin  dilatable  rubber  tube,  which  may  with  advantage  have  two  bulbs  upon  it 
about  an  inch  apart,  for  the  better  closing  of  the  apertures.  This  must  be  passed 
by  means  of  a  long  probe  along  the  floor  of  the  inferior  meatus,  until  the  further  of 
the  two  bulbs  lies  in  the  posterior  nares ;  then  distended  to  its  utmost  with  air  or 
water,  and  the  contents  prevented  from  escaping  by  clamping  or  tying  the  project- 
ing end.  It  fits  accurately  into  all  the  recesses,  exerting  an  equable  degree  of 
pressure,  and  fills  the  cavity  so  closely  that  very  little  blood  collects.  At  the  end 
of  twenty-four  hours  the  contents  may  be  allowed  to  escape,  and  the  bag  quietly 
withdrawn. 

Where  this  is  not  at  hand  and  cannot  be  improvised,  Bellocq's  sound,  or, 
failing  this,  a  gum-elastic  catheter,  must  be  used.  The  sound  is  i)assed  down  the 
nostril ;  the  end  protruded,  and  caught  in  the  mouth  ;  it  is  then  threaded  with 
stout  silk  and  withdrawn,  leaving  a  double   ligature  passing  along  the  inferior 

meatus,  behind  the  soft 
palate  and  out  through  the 
mouth.  Two  plugs  are  then 
prepared,  of  compressed 
sponge  or  cotton-wool,  about 
the  size  of  the  last  jjhalanx 
of  the  thumb.  One  of  these 
is  tied  tightly  round  the 
middle  and  fastened  to  the 
threads  hanging  from  the 
mouth.  The  ends  should 
not  be  cut  off,  but  left,  so 
that  when  the  plug  is  car- 
ried on  the  tip  of  the  finger 
to  its  jjroper  site,  the  pos- 
terior nares,  they  may  hang 
down  in  the  pharynx.  As 
soon  as  this  is  adjusted  the 
other  ends,  projecting  from 

Fig.  325 — Bellocq's  Sound.  ^1  ^    -i       •  <-       "". 

the    nostril    in    front,    are 
drawn  tight  and  knotted  securely  together  over  the  other  plug,  which  is   placed 


INFLAMMATION  OF  NASAL   MUCOUS  LINING.  753 

between  them  in  the  anterior  opening.  At  the  end  of  twenty-four  hours  the 
string  that  hangs  down  the  pharynx  shouUl  be  fished  up,  the  knot  that  secures  the 
anterior  phig  divided,  and  the  two  gently  drawn  away.  If  they  are  left  longer 
they  are  very  likely  to  cause  ulceration  ;  and,  as  the  whole  cavity  of  the  nose  is 
filled  with  blood,  which  soon  decomposes,  this  may  lead  to  very  severe  inflam- 
mation and  necrosis,  or  even  worse. 

Inflammation  of  the  Mucous  Lining. 

Acute  catarrhal  iiiflammation  is  easily  caused  by  exposure  to  cold  or  by 
irritating  dust  or  vapors.  The  mucous  membrane  becomes  swollen,  there  is  a 
profuse  watery  discharge  with  sneezing  (coryza),  the  respiration  through  the  nose 
is  obstructed,  smell  and  taste  are  lost,  and,  if  the  lining  of  the  frontal  sinuses  is 
affected,  there  is  usually  frontal  headache  with  a  certain  amount  of  fever.  In 
most  i)eople  this  subsides  as  soon  as  the  irritant  is  removed,  or  yields  at  once  to 
ordinary  remedies,  such  as  Dover's  powder  or  a  Turkish  bath  ;  but,  occasionally, 
either  because  the  tissues  are  peculiarly  delicate  and  unable  to  regain  their  strength 
at  once,  or  because  of  the  persistence  of  some  irritant,  the  inflammation  continues, 
spreads  over  the  adjacent  mucous  surface,  and  becomes  chronic. 

Chronic  inflammation  is  either  the  result  of  frequent  repetition,  the  congestion 
and  exudation  of  one  attack  not  having  time  to  subside  before  they  are  niade 
worse  by  another ;  or  of  some  constitutional  disorder  such  as  tubercle,  syphilis, 
or  gout.  In  many  cases  it  is  associated  with  outgrowths  from  the  mucous  mem- 
brane (polypi  and  adenoid  growths)  caused  by  the  persistent  irritation. 

Numerous  varieties  have  been  described,  some  well  characterized.  One,  for 
example,  is  frequent  in  syphilis,  especially  the  hereditary  form,  causing  what  is 
known  as  snuffles.  Another,  the  hypertrophic  variety,  is  almost  as  common  in 
scrofulous  subjects  about  puberty.  The  mucous  membrane  (chiefly  that  covering 
the  inferior  turbinate  bone)  is  enormously  thickened  ;  the  surface  is  red  and  gran- 
ular, secreting  a  thick  muco-purulent  discharge ;  the  nasal  passages  are  blocked, 
the  hypertrophied  mucous  membrane  fills  the  posterior  nares,  and  projects  so  far 
into  the  anterior  that,  in  spite  of  the  color  and  rough  appearance  of  the  surface, 
it  is  often  mistaken  for  a  polypus ;  the  wall  of  the  pharynx  becomes  affected,  the 
Eustachian  tubes  are  closed,  and  the  tone  of  the  voice  completely  altered.  In  a 
third  {atrophic  catar7li),  which  may  possibly  be  a  further  development  of  this,  the 
change  is  exactly  the  opposite ;  the  mucous  membrane  becomes  atrophied,  the 
glands  disappear,  and  the  nasal  cavities  are  enlarged.  With  this  is  often  asso- 
ciated a  form  of  ozaena,  due  apparently  to  the  decomposition  of  discharge  retained 
in  outlying  dilatations  or  prevented  from  esca])ing  by  the  crusts  and  scabs  that 
form.  In  many  instances,  however,  particularly  when  there  is  no  specific  irri- 
tant, no  definite  classification  is  possible  ;  the  mucous  membrane  simply  becomes 
rough  and  granular,  the  layers  beneath  hard  and  fibrous,  the  glands  enlarge,  their 
secretion  alters,  the  veins,  and  probably  the  lymphatics,  become  varicose,  and  the 
smooth,  soft,  natural  surface  is  completely  lost. 

Treatment. — Syphilitic  coryza  quickly  disappears  under  mercury  ;  and, 
though  the  prospect  is  less  hopeful,  a  very  great  deal  of  improvement  can  be 
effected  in  scrofulous  cases  by  iron,  cod-liver  oil,  and  especially  residence  at  the 
seaside.  Local  treatment,  however,  is  usually  required  as  well.  Temporary  relief, 
especially  from  the  attacks  of  sneezing,  which  are  often  very  painful,  can  be  ob- 
tained by  brushing  the  mucous  membrane  over  with  a  5  per  cent,  solution  of 
cocaine.  The  spray  or  the  nasal  douche  is  more  effectual  for  checking  secretion 
and  diminishing  congestion.  Tannic  acid,  sulphate  or  chloride  of  zinc,  carbolic 
acid,  tincture  of  eucalyptus,  and  many  other  astringents  and  antiseptics  are  recom- 
mended ;  the  chief  thing  is  the  thoroughness  of  their  application.  If  the  spray 
is  used,  it  must  be  directed  up  the  posterior  nares  by  means  of  a  properly  curved 
nozzle,  as  well  as  up  the  anterior ;  if  the  douche,  the  stream  must  be  of  full 
volume  and  allowed  to  flow  back  through  both  nostrils.     Afterward  an  astringent 


754    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

powder  (tannic  acid,  for  example,  with  subnitrate  of  bismuth,  or  ahim  and  oxide 
of  zinc)  should  be  applied,  but  care  must  be  taken  not  to  make  the  inflammation 
worse  by  constant  irritation. 

In  cases  in  which  the  hyjjertrophy  is  extreme,  it  may  be  necessary  to  reduce 
the  swelling  by  caustics  or  by  removing  some  of  the  redundant  tissue.  Nitric 
acid  has  ])een  applied  with  benefit,  and  so  has  the  actual  cautery  ;  and  portions  of 
the  turbinate  bones  may  easily  be  removed  with  forceps  (this  is  often  done  in  the 
case  of  polypi),  but  the  most  effectual  method  is  the  galvano-cautery,  the  loop  of 
wire  being  adjusted  over  the  projecting  part  and  gradually  tightened  up ;  the 
margin  of  the  septum  and  of  the  ala  must  be  protected  with  an  ivory  speculum. 

Inflammation  ok  thk  Bones  of  the  Nose, 

leading  to  caries  and  necrosis,  is  usually  the  result  of  syphilis,  hereditary  or  ac- 
quired ;  but  it  may  be  due  to  tul)ercle  or  glanders,  to  injury,  the  presence  of 
foreign  bodies,  septic  decomposition,  mercury,  and  occasionally  the  fumes  of 
bichromate  of  potash.  ']1ie  septum  may  be  attacked,  so  that  the  bridge  of  the 
nose  sinks  in  (although,  in  an  adult,  a  great  deal  may  be  lost  without  any  appa- 
rent alteration  in  shape),  or  the  turbinate  bones,  or  the  roof,  and  in  the  latter 
case  there  is  always  the  risk  of  meningitis.  The  symptoms  are  those  of  inflam- 
mation of  the  mucous  membrane,  but  the  discharge  is  always  profuse  and  foetid, 
the  breath  exceedingly  foul,  and  nothing,  so  long  as  any  dead  bone  is  there,  gives 
more  than  temporary   relief.      In    many  cases   the  diagnosis  is   clear  at  the  first 


Fig.  326. — Nasal  Speculum. 

glance  ;  either  there  is  a  perforation  of  the  hard  palate,  or  a  probe  introduced 
into  the  nasal  cavity  strikes  the  .sequestrum  at  once  ;  but  sometimes,  especially 
when  it  lies  toward  the  upper  and  back  part,  detection  is  a  matter  of  very  great 
difficulty. 

Treatment. — The  dead  bone  must  be  removed  as  soon  as  it  is  loose,  careful 
attention  being  paid  at  the  same  time  to  any  constitutional  taint  that  is  present. 
In  most  cases  it  can  be  extracted,  under  an  an?esthetic,  through  the  anterior  nares  ; 
.sometimes  it  is  easier  to  push  it  back  into  the  pharynx  (the  two  forefingers  can 
usually  be  made  to  meet  in  the  inferior  meatus  of  the  nose,  the  one  introduced 
from  the  front,  the  other  from  behind,  when  the  patient  is  anaesthetized),  but  the 
operator  must  be  prepared  for  free,  though  not  usually  serious,  hemorrhage.  Where, 
owing  to  the  size  of  the  fragment,  this  cannot  be  done.  Rouge  s  operation  may  be 
performed,  /.  e.,  an  incision  made  through  the  mucous  membrane,  where  it  is  re- 
flected from  the  under  surface  of  the  upi)er  lip  on  to  the  gum,  the  cartilaginous 
septum  detached  from  the  anterior  nasal  spine,  and,  if  necessary,  from  the  maxil- 
lary crest ;  the  alai  detached  at  the  margins,  ami  the  upper  lip  with  the  nose  lifted 
up  and  reflected  on  to  the  forehead.  The  nasal  cavities  are  thoroughly  opened  up 
to  view  by  this,  the  whole  interior  can  be  examined,  and  then  the  nose  and  lij) 
replaced  without  a  suture  being  re(iuired,  or  a  mark  left. 

If  the  dead  bone,  without  being  loose,  is  fairly  accessible,  as  frequently  hap- 
pens in  hereditary  syphilis,  it  may  be  partially  dissolved  away  by  a  suljjhurous 
acid  spray  (which  also  heljjs  to  check  the  foetor),  and  occasionally  can  be  chipped 
off"  in  little  pieces  with  a  fine  chisel,  but  care  must  be  taken  that  the  instrument 
does  not  slip  and  penetrate  the  roof. 


TUMORS  OF  THE   NASAL   PASSAGES.  755 

OZ^NA. 

By  this  is  understood  a  persistent,  offensive  discharge  from  the  nose,  caused 
either  by  necrosis  (syphilitic,  tuhercuhir,  or  traumatic),  or  by  the  atrophic  form 
of  catarrhal  inflammation.  The  smell,  which  is  often  not  perceptible  to  the  patient 
(differing  in  this  respect  from  ozaena  of  the  antrum),  is  infinitely  more  offensive 
than  that  of  ordinary  putrefaction.  Possibly,  in  necrosis  cases  this  is  due  to  the 
presence  of  dead  bone  (which,  it  is  well  known,  possesses  this  property)  ;  in 
others,  however,  it  must  arise  from  some  si)ecial  kind  of  fermentation,  for  which 
there  is  every  facility. 

Opinions  differ  very  greatly  as  to  the  relative  proportion  of  cases  in  which 
dead  bone  is  present.  According  to  some  it  is  never  wanting,  although  there  may 
be  great  difficulty  in  finding  it  ;  sometimes  it  has  not  been  discovered  until  Rouge's 
operation  has  been  performed.  Probably  it  is  present  in  the  majority,  especially 
as  there  is  very  often  evidence  of  syphilis,  and  certainly  its  absence  should  never 
be  assumed  until  after  the  most  thorough  exploration. 

Treatment. — Constitutional  treatment  is  always  needed  ;  even  when  there 
is  no  necrosis,  there  is  very  frequently  ulceration  depending  upon  some  constitu- 
tional taint,  such  as  syphilis  or  tubercle.  Locally,  the  first  thing  is  to  reduce  the 
foetor  as  far  as  possible  by  means  of  the  nasal  douche,  using  Condy's  fluid  and 
very  dilute  carbolic  acid  af  first,  and,  later,  when  the  patient  is  more  accustomed 
to  it,  chloride  of  zinc  (one-eighth  of  a  grain  to  the  ounce),  and  corrosive  sub- 
limate (i  in  10,000).  The  chief  difficulty  is  to  make  the  lotion  penetrate  into 
the  recesses,  and  this  is  hardly  possible  unless  the  bore  of  the  tube  is  as  large  as 
the  nostril  will  admit.  In  many  cases,  the  spray  and  volatile  antiseptics,  such  as 
iodine  vapor,  sulphurous  acid  and  eucalyptus,  are  more  effectual.  As  soon  as  this 
is  to  some  extent  overcome,  the  interior  of  the  nose  must  be  thoroughlv  examined, 
both  by  sight  and  touch,  from  in  front  and  behind.  If  any  dead  bone  can  be 
found,  it  should  be  removed  or  chipped  away,  so  as  to  reduce  the  size  of  the  offen- 
sive surface  ;  lupoid  ulceration  must  be  thoroughly  scraped  out,  the  bleeding  being 
stopped  with  the  actual  cautery,  and  syphilitic  sores  touched  with  the  acid  nitrate 
of  mercury. 

If  the  disease  is  too  extensive  to  be  dealt  with  through  the  interior  nares,  or 
if  no  cause  can  be  found,  and  the  ozaena  still  persists,  in  spite  of  all  that  can  be 
done,  the  interior  must  be  further  exposed  by  operation.  Not  only  is  the  patient's 
])resence  almost  intolerable  to  others,  but  his  own  life  is  seriously  endangered  by 
the  constant  inhalation  of  the  poisonous  odors.  One  or  both  aire  may  be  re- 
flected without  leaving  any  conspicuous  mark  if  the  line  of  incision  is  carried  along 
the  junction  of  the  nose  with  the  face,  but  in  most  cases  Rouge's  operation  is 
preferable,  as  being  more  thorough  and  leaving  no  deformity. 

Tumors  of  the  Nasal  Passages. 

The  majority  of  tumors  that  grow  in  the  interior  of  the  nose  tend  to  assume 
the  polypoid  shape.  Some  (adenomyxomata,  the  so-called  mucous  or  gelatinous 
polypi)  spring  from  the  submucous  tissue  covering  the  turbinate  bones,  especially 
the  middle,  but  occasionally  the  superior.  Like  the  polypi  that  occur  on  other 
mucous  membranes,  they  are  essentially  local  hypertrophies,  caused  by  constant 
irritation.  Others,  which  are  very  much  more  rare,  are  formed  of  fibrous  or  fibro- 
sarcomatous  tissue  in  varying  proportions,  and  grow  from  the  roof  and  occasion- 
ally the  septum.  These  belong  to  the  same  order  as  the  naso-]jharyngeal  polypi 
which  are  attached  to  the  roof  and  other  parts  of  the  pharynx,  and  spread  from 
them  into  the  nose.  In  addition,  a  few  cases  of  papilloma  and  columnar  epithe- 
lioma are  recorded,  but  they  do  not  require  special  mention. 

Mucous  polypi  are  composed  chiefly  of  mucous  or  myxomatous  tissue,  covered 
over  with  columnar  ciliated  epithelium  ;  but  portions  of  glands  (sometimes  newly 
formed),  cysts,  and  even  widely  dilated  vessels,  giving  them  an  almost  cavernous 


756    D/SEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


structure,  are  met  with  as  well.  They  form  soft,  gelatinous,  semi-translucent 
masses,  pale  pink  or  yellow  in  color,  projecting  from  the  surface  of  the  mucous 
membrane,  and  sometimes  reaching  far  into  the  anterior  and  posterior  nares.  At 
first  they  are  small  and  sessile,  and  in  any  advanced  case  numbers  in  this  stage  can 
be  seen  between  the  larger  ones.  Those  that  project  toward  the  front  can  usually 
be  seen  at  once  (or  if  the  jjatient  expires  forcil)ly),  forming  smooth,  ])edunculated 
ma.sses  very  soft  to  the  touch,  and  moving  up  and  down  with  each  breath.  The 
deeper  ones  may  require  a  speculum,  and  those  that  grow  into  the  posterior  nares 
can  only  be  detected  by  introducing  the  finger  round  the  margin  of  the  soft  palate. 
Occasionally,  when  one  has  been  exposed  to  the  air  for  any  time,  the  surface 
becomes  dry  and  rough,  and  then  it  may  possibly  be  mistaken  for  an  overgrowth 
of  the  mucous  membrane  over  the  inferior  turbinate  bone  ;  otherwise  it  is  difficult 
to  see  liow  such  an  error  can  arise. 

Symptoms. — Chronic  catarrh  is  always  present.  The  breathing  is  obstructed 
(especially  in  wet  weather,  when  the  polypus  swells  up)';  the  mouth  is  held  open  ; 
the  voice  is  altered  and  becomes  nasal ;  the  sense  of  smell,  and  often  that  of  hear- 
ing, is  lost ;  and  nearly  always  there  is  constant  frontal  headache.  In  severe  cases 
the  shape  of  the  nose  may  become  altered  by  the  internal  pressure  ;  the  lachrymal 
duct  obstructed ;  the  septum  displaced  to  one  side ;  and  the  Eustachian  tube 
blocked  up.     As  a  rule,  there  is  no  bleeding  and  no  offensive  discharge,  both 

of  Avhich  symptoms  are  com- 
mon in  the  case  of  malignant 
growtlis. 

Treatment. — There  are 
various  ways  of  removing  po- 
lypi. The  simplest  is  to  grasp 
the  neck  as  high  up  as  possible 
with  a  pair  of  slightly  curved 
forceps,  having  long  serrated 
blades,  and  twist  it  round  and 
round  until  it  comes  away  (Fig. 
327).  Mitchell  Banks  recom- 
mends that  in  bad  cases  the 
patient  should  be  antcsthetized 
upon  a  sofa,  and,  when  fully 
insensible,  brought  to  the  edge 
and  placed  so  that  the  head 
hangs  over.  The  surgeon  then, 
kneeling  on  the  floor,  pulls 
out  whole  masses  of  the  middle  turbinate  bone  with  the  polypi  upon  them.  If 
there  is  a  very  distinct  pedicle,  the  ordinary  wire  ecraseur  may  be  employed,  or 
the  galvano-cautery,  cocaine  being  used  to  allay  the  pain  and  prevent  sneezing. 
Polypi  that  lie  far  back,  in  or  near  the  posterior  nares,  can  only  be  snared  if  the 
forefinger  of  the  other  hand  is  carried  round  the  back  of  the  soft  ])alate  to  guide 
the  loop.  The  bleeding  is  free,  but  stops  at  once  upon  the  ajiplication  of  ice-cold 
water. 

The  chief  dithculty  is  to  make  the  removal  thorough  ;  and  the  operator 
should  not  be  satisfied  until  the  route  between  the  two  nares  is  completely  freed. 
Even  then  many  small  growths  must  be  left  behind,  and  these,  released  from  the 
pressure  of  the  larger  ones,  and,  stimulated  by  the  inflammation  that  follows  the 
operation,  are  almost  sure  to  spring  up  rapidly.  To  prevent  this,  tannic  acid  or 
sulphate  of  zinc  may  be  used  as  snuff,  or  the  cavity  may  be  washed  out  with 
boracic  acid  and  alcohol,  or  with  other  astringents ;  but  constant  care  is  needed. 
In  the  worst  cases  it  may  be  necessary  to  i)erform  Rouge's  operation. 

Naso-pharyngcal  Polypi. — These  include  all  the  varieties  of  fibroma,  sarcoma, 
and  fibro-sarcoma,  which  grow  from  the  roof  of  the  nose,  the  jjharynx,  or  the 
pterygo-palatine  region.     They  are  met  with  chiefly  at  puberty,  and  in  boys,  form- 


FiG.  327. — Method  of  Grasping  Mucous  Polypi 


TUMORS  OF  THE   NASAL   PASSAGES. 


757 


ing  roundish,  lobnlated  masses,  covered  over  with  a  vascular  mucous  membrane. 
Some  grow  slowly  and  are  firm  and  dense;  others  (which  in  all  probability  are 
round  or  spindle-celled  sarcomata)  are  much  softer  and  increase  in  size  very  rap- 
idly. 'I'hey  are  all  exceedingly  vascular  (the  walls  of  the  vessels  being  very  thin), 
so  that  they  bleed  with  the  least  i)rovocation  and  very  profusely  ;  and  they  spread 
in  all  directions,  forming  secondary  attachments  wherever  they  exert  any  pressure 
upon  the  mucous  surface.  The  favorite  locality  is  the  basilar  process,  spreading 
forward  into  the  nose  and  down  into  the  pharynx  ;  but  they  grow  sometimes  from 
behind  the  superior  maxilla  (simulating  a  tumor  of  the  antrum,  except  that  the 
hard  palate  and  the  alveolar  border  are  not  depressed)  ;  from  the  ethmoid  and 
sphenoid  bones  ;  and  even  from  the  sei)tum.  Occasionally  enchondromata  are 
met  with. 

The  symptoms  depend  upon  the  direction  the  polypus  takes.  A  fcetid,  blood- 
stained discharge  is  nearly  always  present,  as  the  surface  of  the  growth  breaks 
down  and  ulcerates;  sometimes  the  epistaxis  is  so  severe  as  to  threaten  life;  the 
nostrils  may  be  obstructed  ;  the  Eustachian  tubes  closed  ;  deglutition  may  be  im- 
peded, and  the  most  repulsive  deformities  (exophthalmos  and  frog-face)  caused  by 
the  displacement  of  the  features.  Sometimes  there  is  constant  headache  with  a 
tendency  to  coma  and  convulsions,  suggesting  that  the  meninges  are  implicated. 
It  is  said  that  naso-pharyngeal  growths  sometimes  atrophy,  and  they  have  been 
known  to  slough  away  of  themselves,  but,  as  a  rule,  progress  is  steadily  from  bad  to 
worse,  the  profu.se  hemorrhage  in  particular  reducing  the  patient's  strength. 

The  only  treatment  is  free  removal  with  thorough  destruction  or  ablation  of 
the  surface  from  which  it  springs.      Otherwise  it  is  certain  to  return. 

Small  growths  might  probably  be  sometimes  caught  and  twisted  off,  with  prop- 
erly contrived  forceps  introduced  through  the  nose,  while  the  finger  directs  them 
from  behind  the  soft  palate.  If  a  loop  of  wire  can  be  adjusted  round  the  neck,  the 
bulk  of  the  growth  can  be  removed  with  the  galvano-cautery,  or,  if  this  is  not  at 
hand,  with  an  ordinary  wire  ecraseur  ;  but  in  either  case  the  base  must,  in  addition, 
be  thoroughly  seared.  Hemorrhage  is  sure  to  be  profuse,  and,  particularly  if  the 
growth  is  a  large  one,  springing  from  the  base  of  the  skull,  there  is  very  consider- 
able risk  of  causing  meningitis. 

Electrolysis  has  succeeded  and  deserves  a  further  trial.  Both  needles  must  be 
inserted  and  a  current  used  as  strong  as  the  patient  can  bear,  with  the  view  of 
causing  sloughing. 

In  most  cases,  however,  a  preliminary  operation  is  required,  in  order  to  get 
sufficient  space ;  the  origin  of  the  growth  is  not  accessible  without.  Where  this 
should  be  done  depends  upon  what  can  be  found  out  with  regard  to  the  position  of 
the  pedicle  and  the  direction  the  growth  has  taken. 

{a)  If  the  polypus  is  situated  low  down  it  may  be  enough  to  divide  the  soft 
palate  in  the  middle  line  (the  flaps  have  been  known  to  unite  together  again  of 
themselves  without  a  subsequent  operation)  ;  or,  if  this  is  not  sufficient,  to  reflect 
the  periosteum  and  mucous  membrane  from  the  under  surface  of  the  hard  palate 
and  remove  some  of  the  bone  as  well.     This,  however,  is  a  serious  addition. 

(l))  When  it  grows  forward  toward  the  nose,  Rouge's  operation  with  free 
division  of  the  septum  might  give  sufficient  room  ;  and  in  a  case  of  frog-face  a 
median  longitudinal  incision  between  the  separated  nasal  bones  has  been  prac- 
ticed. Langenbeck  reflected  upward  the  nasal  bone  and  the  nasal  process  of  the 
superior  maxilla,  using  as  a  hinge  the  skin,  periosteum,  and  mucous  membrane, 
connecting  them  with  the  frontal.  Two  incisions  were  made  through  the  bone ; 
one  vertical  through  the  nasal,  the  other  from  the  anterior  nares  to  the  margin  of 
the  orbit. 

(^)  Retromaxillary  growths  can  only  be  reached  by  excision  or  reflection  of 
part  of  the  upper  jaw.  Excision  of  the  whole  seems  unnecessary  ;  the  orbital 
plate  should  be  left,  a  saw-cut  being  made  through  the  bone  parallel  to  it  and  w^ell 
below  it. 

Temporary  resection  has  been  practiced  in  various  ways,  of  which  the  best 


7 5  8     DISEASES  ANP  INJURIES  OF  SPE  CIA  L  S  TR  UCTURES. 

known  is  that  of  Langenbeck.  It  consists  in  reflecting  inward,  toward  the  middle 
line,  a  flap  consisting  of  part  of  the  malar  bone  and  the  whole  of  the  superior 
maxilla,  bounded  by  the  pterygo-maxillary  fissure  behind,  the  floor  of  the  orbit 
above  and  the  roof  of  the  palate  below,  with  the  soft  parts  covering  it.  The  hinge 
is  the  suture  between  the  sui)erior  maxilla  and  frontal. 

Incisions  down  to  the  bone  are  made:  (i)  from  the  nasal  j^rocess  along 
the  inferior  margin  of  the  orbit  on  to  the  middle  of  the  malar  bone,  or  even  the 
zygoma  ;  and  (2)  from  the  ala  of  the  nose  parallel  to  the  former,  as  far  back,  and 
then  turning  upward  to  join  it.  The  origin  of  the  masseter  must  be  carefully 
detached  as  far  as  exposed.  An  elevator  is  then  pushed  through  the  posterior 
end  of  the  incision  down  to  the  zygomatic  surface  of  the  superior  maxilla,  and 
carried  onward  until  it  enters  the  pterygo-maxillary  fissure,  and  can  be  felt  under 


lOjUu^-' 


Fig.  328. — Plan  of  Incision  for  removal  of  por- 
tion of  upper  jaw.     (After  Esmarch.'S 


Fici.  329. — Plan  of  Bone  Section,  Removal 
of  upper  jaw  and  malar  bone.  (A/ler 
Es7iiarch.) 


the  mucous  membrane  with  the  finger  passed  into  the  mouth.  In  a  case  of 
polypus  there  does  not  appear  to  be  any  difficulty  in  this,  as  the  pressure  of  the 
growth  widens  out  the  fissure.  The  incisions  are  then  made  through  the  bone 
from  behind  forward,  in  the  line  of  the  superficial  ones,  the  upper  passing  through 
the  malar  bone,  the  malar  process,  and  facial  surface  of  the  sui)erior  maxilla  to 
the  inner  angle  of  the  orbit,  the  lower  parallel  to  this  above  the  alveolar  border. 
A  straight,  narrow  saw  must  be  used  for  this,  the  depth  of  the  cut  being  guided 
by  a  finger  in  the  mouth.  As  soon  as  this  is  done  the  included  portion  of  the 
bone,  with  the  soft  parts  covering  it,  is  freed  behind,  above,  and  below,  and  can 
be  levered  out  from  the  pterygo-maxillary  fissure,  turning  on  its  hinge  in  front. 
This  exposes  the  orbit,  the  temporal  fossa,  the  nasal  cavities,  and  the  pharynx, 
into  all  of  which  the  retromaxillary  growth  may  have  advanced  ;  after  the  tumor 
has  been  removed  the  bone  can  be  replaced  and  secured  in  position  with  sutures. 


CLEFT  PALATE.  759 


CHAPTER   XL 

INJURIES  AXD  DISEASES  OF   TIJE  MOUTH  AND  FAUCES. 
MALFORMATIONS. 

Cleft  Palate. 

Cleft  i)alate  is  caused  by  the  imperfect  development  of  the  i)alate  process  grow- 
ing inward  from  the  superior  maxillary.  It  may  involve  the  soft  palate  only,  or 
even  the  uvula  by  itself  (bifid  uvula)  ;  or  the  soft  and  part  of  the  hard  \  or  the 
whole  length  of  both,  and  then  it  is  always  associated  with  hare-lip  on  one  or  both 
sides.  When  the  intermaxillary  portion  is  separate  it  usually  carries  three  incisor 
teeth,  sometimes  only  two;  and  very  often  in  these  cases  there  is  a  pre-canine 
incisor  developed,  more  or  less  perfectly,  on  the  posterior  margin  of  the  cleft. 
Whether  this  is  due  to  the  (possible)  development  of  each  intermaxillary  bone 
from  two  centres,  the  cleft  running  between  them  ;  or  to  a  reversion  under  condi- 
tions of  abnormal  development  to  the  original  number  of  six  incisors  ;  or  whether 
it  simply  indicates  a  general  disarrangement  of  the  dentinal  papillae,  is  uncertain. 
Nothing  is  known  as  to  the  cause  of  the  arrest,  which  must  take  place  at  a  very 
early  period  of  fcetal  life.  It 'is  sometimes  hereditary,  and  it  is  said  that  there  is 
a  distinct  tendency  to  it,  when  one  of  the  lateral  incisor  teeth  is  wanting  in  the 
parent.  It  is,  however,  more  to  the  point  that  the  arrest  is  only  complete  in  a 
very  small  number  of  cases  ;  the  palate  processes  are  seldom  altogether  deficient ; 
very  often  one  side  (usually  the  right)  is  fused  with  the  vomer  ;  and  they  continue 
to  grow  for  the  first  few  years  of  life,  so  that  not  unfrequently  the  cleft  actually 
becomes  narrower,  especially  in  front. 

Syphilis  often  leaves  median  perforations,  both  in  the  hereditary  and  the 
acquired  form  ;  but  the  soft  palate  is  never  symmetrically  defective,  and  there  is 
always  a  large  amount  of  scar  tissue. 

Infants  with  this  defect  are  unable  to  suck  in  the  ordinary  way  ;  sometimes 
they  can  manage  it  if  there  is  a  flap  attached  to  the  teat,  closing  the  aperture  into 
the  nostril,  or  if  the  teat  is  very  large  and  thin  with  a  hole  on  its  under  surface  ; 
in  other  cases  they  must  be  fed  with  a  long-necked  bottle,  so  that  the  fluid  is 
poured  quite  to  the  back -of  the  throat.  After  a  time  the  difficulty  diminishes,  the 
tongue  becoming  hypertrophied  and  somewhat  altered  in  shape.  The  growth  of 
the  palate  and  the  ultimate  success  of  the  operation  may  both  be  seriously  endan- 
gered by  imperfect  feeding  during  the  first  few  months  of  life. 

The  time  for  the  operation  depends  upon  the  extent  of  the  deformity  and  the 
condition  of  the  child  ;  five  or  six  years  is  the  usual  age  ;  by  that  time  the  parts 
are  fairly  well  grown  and  the  child  should  be  able  to  stand  an  operation.  If,  how- 
ever, the  defect  is  unusually  great,  it  is  better  to  wait  a  year  or  two  than  run  the 
risk  of  an  unsuccessful  attempt.  The  soft  palate  is  generally  operated  upon  first, 
but  Smith  recommends  that,  unless  there  is  some  exceptional  difficulty,  the  whole 
should  be  completed  at  once. 

The  patient  is  placed  in  the  dorsal  position  with  the  shoulders  raised  and  the 
head  rather  thrown  back.  An  anaesthetic  is  not  absolutely  necessary,  but  if  care 
is  taken  to  watch  the  breathing  and  prevent  blood  passing  down  into  the  larynx, 
chloroform  may  be  given  through  the  nose  by  means  of  Junker's  apparatus. 
Smith's  gag,  opening  both  sides  of  the  mouth,  and  combining  with  it  a  tongue- 
depressor,  is  the  most  satisfactory,  but  Mason's  or  Coleman's  should  be  at  hand. 
The  rings  of  the  gag  are  held  behind  the  neck  by  a  responsible  assistant,  whose 
sole  duty  it  is  to  attend  to  the  position  of  the  head  and  the  breathing,  especially 
as  the  continued  depression  of  the  base  of  the  tongue  may  cause  a  little  difficulty. 


Fig.  330. — Smith's  Gag  with  Tongue  Depressor. 


760    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

(a)    When    the   soft 
palate    only   is  involved. 
As  soon   as  the  gag  is  in 
position  and   the  patient 
anaesthetized,    the   tip  of 
the  uvula  on  one  side  is 
caught   with  a  long  jjair 
of  mouse-toothed  forceps, 
and  a  flap  cut  from  the 
margin  of  the  cleft  from 
below  upward.  The  other 
side   is   then    seized   and 
pared  in  the  opposite  di- 
rection.     The   whole    of 
the  mucous  edge  must  be 
removed  and  care  taken 
to  obtain  as  wide  a  raw 
surface  as  possible,  espec- 
ially at  the  angle,  where 
union     fails     most      fre- 
quently.    Fine  silver  wire 
or  horse-hair  is  used  for 
the  sutures.     If  the  edges 
fall   fairly   well   together, 
the  former  can  easily  be 
passed  with  one  of  Smith's 
tubular    needles    (Fig. 
^S^).  taking  both  sides  in 
a  single  sweep.     If  horse- 
hair is  preferred,  a  short 
curved    needle    may    be 
threaded    on    each     end 
and  passed  separately  through  each  half  of  the  flap  with 
a  needle-holder  ;  or  Avery's  method  may  be  employed. 
In  this  a  loop  of  silk  is  passed  through  one  side  of  the 
cleft  with  a  needle  on  a  handle,  caught  with  a  pair  of 
forceps,  and  drawn  out  sufficiently  far  to  project  from 
the  mouth.      Then  a  single  horse-hair  is  passed  opposite 
to  this,  through  the  other  side  and   threaded  through  the 
loop.     When  this  is  pulled  back  again  it  draws  the  hair 
through  the  second  side  with  it.      In  the  ca.se  of  the  uvula 
a  rectangular  needle  on  a  handle  can  generally  be  used. 
The  lowest  suture  is  passed  first.     By  drawing  on 
this  the  palate  is  made  tense  and  the  passage  of  the  next 
is  easier ;  the  same  process  can  be  continued  the  whole 
Fig.  332.— Cleft  of  the  Soft  Palate,  way,  the  a.ssistant  keeping  the  ends  of  the  sutures  separate. 

dotted    lines    showing    line    ot    t  r    .■•  j  ^  ^\  j-i  1        <-     ^        •  i. 

incUion.  li  the  cdgcs  come  together  readily,  the  fastening  can  be 


Fig.  331. — Coleman's  Gag. 


Fig.  333 — Smith's  Tubular  Needle. 


CLEFT  PALATE.  761 

completed  at  once  ;  if  not,  the  loops  must  be  just  drawn  together,  so  that  the 
operator  may  see  where  the  tension  is  greatest,  and  lateral  incisions  made  to 
relieve  it.  The  levator  palati  is  the  chief  cause  of  the  difficulty,  but  free 
division  of  the  mucous  membrane,  especially  on  the  nasal  surface  of  the  palate, 
is  almost  equally  essential. 

A  puncture  is  made  with  a  sharp-pointed  knife  (like  a  tenotomy  knife  on  a 
long  handle)  inside  the  hamular  process,  midway  between  the  teeth  and  the  cleft, 
and  on  a  level  with  the  highest  suture.  A  similar 
instrument,  but  with  a  blunt,  rounded  i)oint,  is  then 
passed  through  this,  and  an  incision  made  downward 
and  backward  through  the  tissues  of  the  .soft  palate, 
as  far  as  may  be  necessary.  The  wounds  gape  im- 
mensely at  once,  the  edges  come  together  readily, 
and  the  sutures  can  be  tightened  up,  a  twister  or  a 
pair  of  torsion  forceps  being  used  for  the  wire  ones. 
If  the  tension  is  very  great,  the  incision  may  be  half 
the  length  of  the  soft  palate,  but  a  shorter  one  is 
usually  sufficient.  One  of  the  palatine  branches  is 
always  divided,  but  the  hemorrhage  is  seldom  serious. 

(F)  When  the  hard  palate  is  involved  as  well :   „  c  <■  d  1        .     ^     ■  u  i 

V    /  '  1   •  1  Fig.  334. — Soft  Palate  sutured,  with  lat- 

the    gap  in    this  case  is   closed    by  detaching    the    mu-        eral  incisions  for  the  relief  of  tension. 

I  /-J  T         r   iU  •       ..  In  the  hard  palate,  site  of  puncture. 

cous  membrane  (and  as  much  01  the  periosteum  as  midway  between  teeth  and  edge  of 
will  come  with  it)  from  the  under  surface  and  inner     ,'='^'''-  ^'^^  ""^  of  incision  along  the 

,,.,..  ,        latter. 

side  of  the   palate  process,  and  displacing  it  toward 

the  middle  line.      In  front  and  behind  the   flaps  are  left  attached,  so  that  they 

hang  down  like  two  horizontal  curtains. 

To  separate  these  flaps,  a  puncture  is  made  down  to  the  bone  in  the  centre  of 
one  side  of  the  hard  palate,  midway  between  the  teeth  and  the  cleft,  and  midway 
between  the  anterior  angle  of  the  latter  and  the  posterior  margin  of  the  bone.  A 
curved  raspatory  is  thrust  in  at  this  spot  and  worked  toward  the  middle  line  until 
it  projects  into  the  cleft,  detaching  the  periosteum  before  it.  It  is  then  withdraw^n, 
a  more  curved  one  inserted  into  the  puncture  through  which  it  protruded,  and  all 
the  structures  covering  the  hard  palate,  out  as  far  as  the  puncture,  forward  to  the 
teeth  and  backward  to  the  junction  of  the  hard  and  soft  palate,  completely 
detached.      The  same  thing  is  done  on  the  opposite  side. 

The  next  step  is  to  divide  the  connection  between  the  upper  surface  of  the 
soft  palate  and  the  floor  of  the  nose,  where  the  fascia  is  especially  firm.  Scissors 
curved  on  the  flat  are  used.  The  palate  is  drawn  forward,  one  blade  passed 
between  the  flap  and  the  bone,  the  other  above  the  upper  surface  of  the  palate, 
and  the  mucous  membrane  cut  through  as  far  as  the  wall  of  the  pharynx.  The 
flaps  now  meet  together  easily,  particularly  if  the  palate  is  a  high  one.  Wire 
sutures  are  passed  and  drawn  together,  taking  care  that  the  edges  are  everted  ;  the 
original  puncture  in  the  centre  of  the  hard  palate  is  prolonged  sufficiently  to 
remove  all  tension,  and  then  the  sutures  are  twisted  up. 

Hemorrhage  may  be  free  for  a  moment  or  two,  but  it  generally  stops  of  itself. 
In  the  case  of  the  soft  palate,  it  is  very  rarely  of  any  consequence,  and  sponging 
is  hardly  required  ;  the  more  this  can  be  dispensed  \\\\.\\  the  better,  as  it  delays 
the  operation  and  tends  to  make  the  patient  sick.  If  the  lateral  incisions  bleed, 
the  head  can  be  turned  to  one  side  and  the  mouth  syringed  out  with  ice-cold 
water.  Detaching  the  periosteum  is  occasionally  attended  with  a  good  deal  of 
bleeding,  but  a  sponge  on  a  holder,  pressing  the  flap  against  the  bone,  stops  it  at 
once.  Secondary  hemorrhage  from  the  palatine  arteries,  w-hich  may  be  very 
serious,  must  be  stopped  by  plugging  the  descending  palatine  canal. 

Respiration  requires  careful  watching,  not  only  on  account  of  the  anaesthesia, 
the  position  of  the  head,  and  the  pressure  upon  the  base  of  the  tongue,  but  because 
of  the  danger  of  blood  trickling  down  the  larynx.      Later,  severe  broncho-pneu- 
monia, which  is  almost  fatal  to  union,  may  arise  from  this. 
49 


762     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

After-Treatment. — The  child  must  be  kept  as  quiet  as  possible  after  the 
operation,  and  only  a  few  droi)s  of  ice-cold  water  allowed  for  some  hours,  for  fear  of 
causing  sickness.  All  food  must  be  fluid,  or  semi-fluid,  and  taken  very  slowly.  If 
possible,  the  child  should  be  kept  in  bed,  at  any  rate  for  the  first  few  days;  and 
if  it  is  fretful  and  inclined  to  cry,  small  doses  of  chloral  may  be  given.  The 
mouth  should  not  be  looked  at  for  a  fortnight ;  the  sutures,  if  there  is  no  tension 
upon  them,  may  be  left  longer  still. 

Union  fails  most  frequently  at  the  junction  of  the  soft  with  the  hard  palate; 
sometimes  the  whole  breaks  down,  but  it  rarely  happens  that  the  flaps  slough.  If 
union  is  not  perfect,  a  considerable  time,  six  months  at  least,  should  be  allowed  to 
pass  before  a  second  operation  is  tried.  Occasionally  a  third  or  even  a  fourth  is 
necessary  ;  but  in  many  of  these  a  more  satisfactory  result  can  be  obtained  by 
wearing  an  obturator.  Afterward  no  jjains  should  be  spared  to  improve  the 
articulation  and  educate  the  muscles.  In  the  slighter  cases,  which  admit  of  early 
operation,  phonation  may  be  almost  perfect ;  but  when  the  defect  is  very  consid- 
erable, so  that  the  palate,  even  though  it  is  restored,  forms  merely  a  tense  septum 
extending  partially  across,  the  accent  is  never  lost.  The  fibres  of  the  superior 
constrictor,  extending  from  one  hamular  process  to  the  other,  become  hypertro- 
phied,  so  as  to  close  the  communication  more  completely,  l)ut  the  flap  never  can 
vibrate  properly,  and  not  unfrequently.  after  some  time,  the  cicatrix  contracts 
and  makes  matters  worse  than  they  were  immediately  after  the  operation. 


INJURIES  OF  THE  MOUTH  AND  FAUCES. 

Lacerated  wounds  of  the  tongue  are  of  frequent  occurrence  in  epileptic  fits 
and  from  falls  u])on  the  chin  ;  and  the  hemorrhage  is  sometimes  serious.  The 
wounds  always  heal  by  granulation,  although  the  attempt  may  be  made  to  draw 
the  surfaces  together  by  means  of  deeply  placed  catgut  sutures. 

The  soft  palate,  the  tongue,  or  the  tonsils  may  be  very  seriously  injured  by 
foreign  bodies,  such  as  the  stem  of  a  tobacco-pipe  or  a  piece  of  stick  being 
violently  driven  into  the  mouth.  The  internal  carotid,  or  the  ascending  pharyn- 
geal artery,  has  been  torn  open  in  this  way  with  fatal  consequences.  In  some 
cases  the  extraction  of  the  foreign  body  has  been  followed  by  a  torrent  of  blood  ; 
in  others  suppuration  has  taken  place,  usually  because  of  some  fragment  left 
behind,  and  the  artery  has  not  given  way  for  some  days.  In  the  latter  case  there 
is  nearly  always  a  warning  first.  If  the  bleeding  is  slight  an  attempt  may  be 
made  to  control  it  from  inside  the  mouth  by  means  of  ice,  or,  if  this  fails,  by  tur- 
pentine or  solid  perchloride  of  iron  held  against  the  spot ;  but,  if  it  is  severe  or  if 
it  returns,  ligature  of  the  common  carotid  should  be  performed  at  once.  It  has 
been  proposed  in  these  cases  to  tie  the  external  as  well,  so  as  to  prevent,  as  far  as 
possible,  the  blood  finding  its  way  round  through  that  part  of  the  collateral 
circulation. 

Fish-bones,  pins,  and  other  pointed  structures  are  occasionally  driven  into 
the  mucous  membrane  in  deglutition  ;  and  at  times  they  cause  a  considerable 
amount  of  inflammation.  Very  often  they  can  be  felt  with  the  finger  better  than 
they  can  be  seen. 


DISEASES  OF  THE  MOUTH  AND  FAUCES. 

Inflammatory  Affections, 

Acute  inflammation  of  the  mucous  membrane  of  the  mouth  is  common  in 
infancy  and  childhood,  and  is  occasionally  met  with  later  in  life,  about  the  time 
of  eruption  of  the  molar  teeth.  It  is  often  associated  with  disordered  digestion, 
the  two  being  dependent  to  a  great  extent  upon  the  same  cause  :  and  it  is  espec- 
ially frequent  among  the   children   of  the   poor  and  those   who  live  under  bad 


STOMA  Tins.  763 

hygienic  conditions.  \'arious  forms  of  it  are  described,  but  they  seldom  occur 
independently  of  each  other. 

Catarrhal  stomatitis  K?,  \.\\Q  mildest;  the  mucous  membrane  swells  up  and 
becomes  a  brighter  red  ;  the  epithelium  has  a  sodden  white  appearance,  and  after 
a  time  is  detached  in  patches  ;  the  tongue  is  raw  and  red,  indented  by  the  teeth  ; 
the  gums  are  soft  and  spongy  ;  and  here  and  there  the  surface  is  marked  by  shallow 
erosions.  In  what  is  known  as  follicular  stomatitis  the  orifice  of  each  mucous 
gland  is  marked  by  a  swollen,  bright  red  areola. 

Aphthous  stomatitis  is  difficult  to  distinguish  from  the  last.  It  makes  its  first 
appearance  as  a  group  of  yellowish  vesicles,  which  break  and  leave  superficial 
ulcers,  about  the  size  of  a  pin's  head,  covered  with  a  yellowish  slough  and  sur- 
rounded by  a  bright  red  areola.  Frequently  they  come  out  in  successive  crops, 
so  that  all  stages  can  be  seen  at  the  same  time.  They  are  exceedingly  tender,  and 
if  on  a  part  where  they  are  exposed  to  friction  they  may  seriously  interfere  with 
mastication. 

Aphthous  stomatitis  must  not  be  confused  with  thrush,  which  is  an  entirely 
different  affection. 

Ulcerative  stomatitis,  which  occurs  at  the  same  time  of  life  and  under  the 
same  conditions,  is  more  serious.  The  whole  thickness  of  the  mucous  membrane 
is  involved  (though  not  the, substance  of  the  cheek,  as  in  norma)  ;  it  becomes 
swollen,  dusky-red,  or  even  purple  ;  then  a  foul  grayish  slough  forms  upon  the 
surface  ;  and  later,  when  this  is  detached,  a  distinct  although  superficial  ulcer  is 
left.  Very  often  the  opposing  surface  of  the  gum  or  cheek,  as  the  case  may  be, 
becomes  infected  too,  so  that  various  stages  of  the  disease  may  be  seen  at  the 
same  time. 

The  symptoms  depend  upon  the  severity  of  the  attack  and  the  extent  of  sur- 
face involved.  In  the  catarrhal  form  the  mouth  is  hot  and  dry,  the  breath  offen- 
sive and  every  movement  of  the  tongue  attended  with  pain  ;  there  is  constant  thirst 
and  the  sense  of  taste  is  altogether  lost.  After  a  time  the  secretion  becomes  more 
profuse,  sometimes  excessive,  and  very  tender  spots  make  their  appearance,  corre- 
sponding to  the  places  from  which  the  epithelium  has  been  detached.  In  the 
ulcerative  form  these  symptoms  are  greatly  exaggerated  ;  the  gums  are  swollen  and 
bleed  with  the  slightest  touch  ;  the  teeth  are  exceedingly  tender,  and  movement 
so  painful  that  mastication  is  impossible.  Not  infrequently  there  is  a  consider- 
able degree  of  fever,  and  there  may  be  conspicuous  swelling  of  the  floor  of  the 
mouth,  involving  the  lymphatic  glands  and  the  loose  cellular  tissue  around  ;  but 
there  is  never  the  hard  brawny  feeling  in  the  centre  of  the  cheek  which  marks  the 
onset  of  noma. 

Treatment. — Chlorate  of  potash  rarely  fails  to  effect  a  cure  :  it  should  be 
given  locally  in  the  form  of  a  gargle  or  wash,  and  internally  as  well.  In  younger 
children  borax  with  glycerine  (well  diluted)  may  be  painted  over  the  raw  surface 
several  times  a  day  ;  or,  if  the  case  is  very  obstinate,  alum  or  nitrate  of  silver  .10 
ad  30  c.c.  (gr.  ij  ad  5J)  may  be  used  instead.  The  condition  of  the  bowels  always 
requires  attention — it  rarely  happens  that  they  are  acting  properly  ;  but  mercurials 
should  be  avoided  ;  and  as  soon  as  a  certain  amount  of  regularity  is  established, 
tonics,  iron,  cod-liver  oil  and  quinine  should  be  given  freely.  Partly  as  cause, 
partly  as  consequence,  these  forms  of  stomatitis  are  always  associated  with  debility 
and  malnutrition.     Other  forms  of  stomatitis  are  due  to  specific  causes. 

Thrush  is  a  superficial  inflammation  of  the  mucous  membrane  of  the  mouth 
and  tongue  caused  by  the  growth  in  the  epithelial  cells  of  the  fungus,  the  o'idium 
albicans,  in  all  probability  the  same  as  the  o'idium  lactis.  It  is  met  with  chiefly 
in  children  who  are  brought  up  by  hand,  and  in  adults  suffering  from  exhausting 
illnesses.  The  mucous  membrane  of  the  mouth  and  tongue  is  red  and  swollen ; 
its  secretion  is  acid  instead  of  alkaline  ;  but  the  characteristic  feature  is  the  presence 
at  the  angles  of  the  mouth  of  a  number  of  minute  white  dots,  without  any  red 
areola  as  in  the  case  of  aphthce.  These  enlarge  until  they  meet  and  fuse,  so  that 
sometimes  in  bad  cases  the  whole  of  the  interior,  with  the  pharynx  and  even  the 


764    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

oesophagus,  is  covered  over  with  a  thick  creamy-white  layer.  Diarrhoea  with 
greenish  offensive  stools  sets  in  ;  the  child  is  unable  to  take  any  food  ;  the  emaci- 
ation becomes  extreme  ;  sores  make  their  apjiearance  round  the  anus,  and  the 
result  is  not  unfrecpiently  fatal. 

This  disorder  is  due  to  the  fungus  that  causes  the  acid  fermentation  of  milk, 
and  can  be  produced  anywhere  by  neglect  of  proper  precautions,  especially  scald- 
ing thoroughly  every  time  they  are  used  all  the  vessels  which  contain  food  and 
come  into  contact  with  milk.  In  large  institutions,  such  as  foundling  hospitals,  it 
is  constantly  making  its  ap])earance  unless  special  precautions  are  taken,  and  fre- 
quently helps  to  cause  the  death  of  weakly  children  by  the  digestive  disturbances 
that  accompany  it. 

The  treatment  is  very  simple  :  with  thorough  cleanliness  it  soon  dies  out.  All 
suspicious  spots  within  reach  should  be  brushed  over  with  very  dilute  carbolic 
acid,  or  with  borax  and  glycerine,  and  the  child's  mouth  cleansed  thoroughly 
after  every  meal.  At  the  same  time  the  complications  that  are  present  with  it, 
and  are  in  great  measure  due  to  it,  the  diarrhoea,  loss  of  appetite,  and  disordered 
digestion,  require  the  strictest  attention. 

Mercurial  stomatitis  is  rare  at  the  present  day  :  a  faint  red  line,  or  a  slight 
swelling  of  the  gum  round  the  necks  of  the  teeth,  particularly  where  there  is  an 
accumulation  of  tartar,  is  all  that  is  seen.  It  may  occur  from  inhalation,  inunc- 
tion, or  absorption  from  the  alimentary  tract,  and  no  doubt,  though  the  number 
must  be  very  small,  certain  people  are  peculiarly  su.sceptible.  The  flow  of  saliva 
is  increased  ;  the  gums,  as  already  mentioned,  become  red  and  swollen  ;  the  breath 
is  foul ;  the  tongue  furred  and  a  little  enlarged  ;  the  teeth  feel  too  long ;  and 
mastication  of  anything  hard  is  very  painful.  If  this  is  persisted  in  the  most  fearful 
consequences  may  ensue  ;  the  mucous  membrane  may  slough,  the  gums  ulcerate 
away,  the  teeth  fall  out,  the  bones  perish,  and  the  gangrene  spread  to  the  floor 
of  the  mouth  and  nose,  causing  the  most  terrible  destruction.  In  days  gone  by 
there  is  no  doubt  the  result  was  often  fatal,  partly  from  the  constitutional  disturb- 
ance and  the  inability  to  take  food,  partly  from  the  continued  inhalation  of 
particles  from  the  foul  and  decomposing  sloughs. 

At  the  earliest  sign  the  administration  of  mercury  should  be  stopped,  and 
strong  astringent  gargles  used  frequently.  Usually  this  of  itself  is  enough.  Chlorate 
of  potash  is  said  to  be  of  as  great  service  in  this  as  in  other  forms  of  stomatitis, 
preventing  in  particular  the  peculiar  foetor  of  the  breath. 

S\J>hilitic  Stomatitis. — The  same  forms  of  eruption  that  occur  upon  the  skin 
are  met  with  also  in  the  mouth,  modified  by  the  conditions  under  which  they  exist. 
They  occur  in  the  hereditary  as  much  as  in  the  actpiired  disease,  and  furnish  a 
very  large  proportion  of  the  cases  of  mediate  contagion.  Rhagades  and  the  ex- 
ceedingly painful  fissures  at  the  angles  of  the  mouth  have  been  mentioned  already. 
Superficial  sores,  closely  similar  in  appearance,  are  of  common  occurrence  upon 
the  inside  of  the  lips.  Mucous  plaques  and  tubercles  are  more  frequent  upon  the 
tongue,  the  tonsils,  soft  palate,  and  pillars  of  the  fauces.  Where  the  epithelium 
is  thin,  and  the  friction  smooth  and  constant,  they  are  scarcely  raised  ;  there  is 
simply  a  grayish-white  patch  with  a  smooth  surface,  and  well-defined,  slightly 
reddened  border  ;  or  the  epithelial  covering  has  already  been  detached  and  a  raw 
surface  left.  Symmetrical  jjatches  of  this  kind  are  often  seen  upon  the  margin  of 
the  soft  palate  on  either  side  of  the  uvula,  and  may  be  regarded  as  distinctive.  In 
other  places  they  grow  out  into  warty  or  cauliflower  excrescences,  often  of  some 
size;  and  in  others,  again,  where  they  are  irritated  by  the  teeth,  they  cut  into 
deep  and  angry  ulcers. 

Secondary  tubercular  syjjhilides  are  more  rare  ;  the  epithelium,  which  is  thrown 
off  as  scales  upon  an  exposed  surface,  becomes  soft  and  macerated  in  the  mouth, 
so  that  the  appearance  they  present  is  closely  similar  to  that  just  described.  In 
the  tertiary  stage,  superficial  and  deep  gummata,  involving  the  mucous  membrane, 
the  submucous  tissue,  or  the  periosteum,  are  of  common  occurrence.  Sometimes 
they  are  absorbed  under  treatment,  and  disappear  without  leaving  a  scar  ;  more 


PERIOSTITIS  AND  OSTEITIS.  765 

often  they  break  clown  and  leave  deep  and  irregular  ulcers.  The  favorite  locality 
appears  to  be  the  palate.  Central  gummata,  leading  to  necrosis  and  median  per- 
foration, are  frecjuently  met  with  (the  presence  of  congenital  clefts  in  the  hard  and 
soft  palate,  and  occasionally  of  foramina  in  the  pillars  of  the  fauces,  must  not  be 
forgotten),  and  it  is  not  uncommon  to  find  the  uvula  and  soft  palate  either 
destroyed  altogether  or  united  to  the  posterior  wall  of  the  pharynx  in  such  a  way 
that  there  is  only  a  small  aperture  left. 

The  constitutional  treatment  does  not  present  any  special  features  ;  the  local  is 
very  important.  Gummata  disappear  rapidly  under  iodide  of  potash  ;  ulcers  occa- 
sionally require  the  application  of  acid  nitrate  of  mercury.  Secondary  affections, 
however,  may  prove  very  obstinate.  The  first  thing  is  to  get  rid  of  every  kind  of 
irritant,  whether  it  is  the  sharp  edge  of  a  tooth,  or  tobacco-smoke,  spirits,  or 
highly  seasoned  food.  So  long  as  these  continue  to  act,  it  is  almost  impossil)le  to 
effect  a  cure.  Rhagades  and  exuberant  condylomata  may  be  touched  with  nitrate 
of  silver,  or  brushed  over  with  a  10  per  cent,  solution  of  chromic  acid.  Simple 
mucous  patches  usually  get  well  with  a  wash  of  chlorate  of  potash  and  lotio  nigra, 
or  a  very  weak  one  of  bichloride  of  mercury;  in  more  obstinate  cases  the  inha- 
lation of  calomel  maybe  tried,  or  brushing  the  surface  over,  night  and  morning, 
with  a  solution  of  bicyanide  of  mercury  (gr.  xv  ad  5J),  and  sometimes  iodoform 
lightly  dusted  on  proves  very  beneficial,  the  taste  and  odor  being  concealed  by 
mixing  it  with  freshly  ground  coffee. 

Tubercular  stomatitis  is  not  a  common  affection.  Occasionally,  when  the 
tongue  is  involved,  it  occurs  on  the  under  surface  of  the  soft  palate,  appearing  in 
the  form  of  minute  vesicles  which  enlarge,  break  down,  and  leave  superficial  sores 
with  sharply  cut  edges.  More  rarely  it  begins  independently.  There  is  very  little 
inflammation  as  a  rule;  the  sores  slowly  and  steadily  increase  in  size  and  depth, 
multiplying  and  fusing  together  until  at  length  they  develop  into  irregularly 
shaped  ulcers  with  sinuous  edges,  often  lying  upon  carious  bone.  There  is  no  in- 
duration ;  the  course  at  first  is  very  chronic,  and  there  are  no  large  sloughs  or  necro- 
sis, as  in  syphilis,  but,  in  spite  of  this,  the  destruction  maybe  very  considerable; 
I  have  knowui  the  whole  of  the  soft  palate  eaten  away.  The  prognosis,  especially 
wdien  the  disease  is  secondary  to  mischief  elsewhere,  is  very  unfavorable,  and  the 
course  tow^ard  the  end  often  very  rapid,  in  a  measure  ownng  to  the  pain  on  deglu- 
tition, and  the  difificulty  of  taking  food  ;  but,  occasionally,  a  certain  amount  of 
benefit  is  derived  from  constitutional  treatment  combined  with  scraping,  iodoform, 
lactic  acid,  and  similar  remedies,  and  more  rarely  spontaneous  (but  unfortunately 
only  temporary)  cicatrization  occurs. 

Other  forms  of  stomatitis  are  occasionally  met  with.  Lupus  may  extend 
from  the  lips  to  the  gums  and  palate,  and  has  been  known  to  occur  independently  ; 
in  the  latter  case  the  diagnosis  from  tubercular  disease  must  be  almost  impossible. 
Anaesthetic  patches  occur  in  the  early  stages  of  leprosy,  and  deep  ulceration  is  not 
unfrequently  the  immediate  cause  of  death  in  the  tubercular  form.  A  very  acute 
variety  has  been  described  in  connection  with  gonorrhoea;  in  scurvy,  hemor- 
rhagic stomatitis  is  one  of  the  prominent  symptoms,  and  in  leucoplakia,  when 
the  tongue  is  extensively  diseased,  the  mucous  membrane  of  the  sides  and  floor 
of  the  mouth  is  usually  affected  too. 

Periostitis  and  Osteitis. 

Inflammation  of  the  superior  or  inferior  maxilla  may  be  caused  by  extension 
from  neighboring  structures,  such  as  teeth  ;  by  injury  after  extraction  of  teeth  or 
compound  fracture  ;  by  mercury  or  phosphorus  ;  by  suppurative  disease  in  all  its 
forms  (noma,  acute  suppurative  periostitis,  or,  especially  after  the  acute  exanthe- 
mata, pysemia),  or  by  the  action  of  specific  organisms,  such  as  those  of  actinomycosis, 
syphilis,  tubercle,  or  leprosy.  It  may  be  acute  or  chronic,  ending  in  necrosis  or 
caries,  according  to  the  cause,  the  intensity  of  the  attack,  and  the  character  of  the 
bone.     Necrosis,  for  instance,  is  more  common  in  the  lower  jaw  than  in  the  upper, 


766    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

owing  to  its  peculiar  density  ;  caries  in  children,  in  whom  the  bones  are  more  vas- 
cular and  less  compact.  When  due  to  acute  suppuration,  the  sequestrum  may  be 
detached  within  a  few  days  ;  on  the  other  hand,  in  phosphorus  necrosis,  it  often 
does  not  separate  for  years.  The  amount  of  new  bone  thrown  out  is  usually  very 
small,  but  in  necrosis  of  the  lower  jaw  from  phosphorus  poisoning  it  is  often  enor- 
mous for  a  time,  and  then  disappears  almost  entirely. 

In  acute,  suppurative  osteitis,  whether  arising  from  local  or  constitutional  in- 
fection, the  symptoms  are  exceedingly  severe.  Owing  to  the  vascularity  of  the 
part  and  the  looseness  of  the  tissues  around,  the  swelling  is  usually  excessive, 
spreading  far  over  the  face  and  down  the  neck.  The  fever  is  often  very  high 
and  the  pain  intense,  continuing  until  the  pus  is  let  out  by  incision  or  finds  some 
means  of  exit  for  itself.  Then  the  symptoms  slowly  subside,  the  pus  escapes  ex- 
ternally or  into  the  cavity  of  the  mouth,  and  the  discharge  continues  until  either 
the  bone  recovers  (for  even  extensive  portions  of  the  alveolar  margin  may  be  de- 
tached from  the  periosteum  by  acute  suppuration,  without  necessarily  undergoing 
necrosis)  or  the  secpiestrum  is  cut  off. 

Mercurial  stomatitis  when  carried  far  enough  to  affect  the  bones  is  no  less 
acute,  judging  from  past  accounts,  for  happily  such  cases  are  seldom  seen  at  the 
present  day.  Syphilitic  inflammation,  on  the  other  hand,  is  more  chronic,  and  the 
tubercular  form  more  so  still.  Phosphorus  necrosis  is  peculiar  in  many  ways  :  it 
does  not  affect  those  whose  teeth  are  sound,  but  as  soon  as  a  spot  of  caries  appears 
the  inflammation  spreads  down  into  the  alveolus,  detaches  the  gum,  loosens  the 
tooth,  and  steadily  advances  until  the  whole  ramus  is  involved.  The  symptoms 
are  often  very  severe  :  the  soft  tissues  around  swell  up  and  become  inflamed  ;  there 
is  a  constant  discharge  of  most  offensive  pus  welling  up  around  the  teeth  and 
poisoning  the  breath  ;  fresh  abscesses  are  always  forming  ;  and  partly  from  the 
continued  fever  anci  inability  to  take  food,  partly  from  perpetually  inhaling  and 
swallowing  the  foul  discharge,  the  patient  is  cpiickly  reduced  to  a  condition  of 
extreme  anremia.      (See  Diseases  of  Bone.) 

Treatment. — Syphilitic  periostitis  and  simple  acute  inflammation  are  checked 
at  once  by  iodide  of  potash,  or  by  painting  the  inflamed  surface  of  the  gum  with 
the  liquid  iodine.  If  there  is  the  least  reason  to  suspect  supjiuration,  an  incision 
should  be  made  inside  the  mouth  with  a  sharp-pointed  bistoury,  the  edge  of  which 
is  protected  up  to  within  half  an  inch  of  the  end  by  wrapping  it  round  with  a  strip 
of  plaster.  If  this  is  done  in  time  the  disfigurement  of  an  external  opening  can 
nearly  always  be  avoided.  Even  when  there  is  already  a  soft  fluctuating  swelling 
upon  the  face,  the  incision  should  always  be  made  in  the  groove  between  the  cheek 
and  gum.  Afterward  the  cavity  of  the  mouth  must  be  washed  out  fretjuently  with 
some  hot  antiseptic  solution  (carrying  it  outside  the  teeth  by  means  of  a  rubber 
tube),  and  the  vessels  of  the  skin  made  to  contract  by  keeping  it  constantly  wet 
with  lead  lotion.  When  dead  bone  is  present,  very  little  can  be  done  until  it  is 
loose  enough  to  come  away.  The  teeth  may  be  extracted  if  they  are  detached  and 
surrounded  by  suppuration  ;  incisions  made  to  facilitate  drainage  ;  and  the  mouth 
kept  as  clean  as  possible.  Carious  bone  may  be  scraped,  but  care  must  be  taken, 
especially  wath  children,  not  to  disturb  the  germs  of  the  permanent  teeth.  If  any 
extensive  defect  is  left,  it  must  be  bridged  over  with  a  suitable  plate  so  as  to  pre- 
serve the  outline  of  the  mouth. 

Alveolar  Abscess. — Suppuration  in  connection  with  the  fangs  of  carious  teeth 
is  known  as  alveolar  abscess,  or  parulis.  Throbbing  pain,  with  protrusion  of 
the  tooth  from  thickening  of  the  periodontal  membrane,  and  swelling  of  the  soft 
structures  around  the  jaw,  are  the  chief  features.  If  left,  it  may  discharge  around 
the  tooth  ;  more  often,  it  works  its  way  out  through  the  side  of  the  jaw  on  to  the 
gum  (the  ordinary  form  of  gum-boil)  ;  but,  when  connected  with  the  lateral  inci- 
sors, it  may  spread  back  between  the  layers  of  the  hard  palate,  and  gain  the  sur- 
face first  at  its  posterior  margin,  or  burst  into  the  nose,  and,  especially  when  the 
molars  are  involved,  it  has  a  marked  tendency  to  open  upon  the  face.  In  this 
case  it  is  not  unlikelv  to  leave  a  chronic  sinus,  the  orifice  of  which  is  surrounded 


SUPPURATION  IN  THE  ANTRUM.  767 

by  pouting  granulations.  Sometimes,  owing  to  the  tension,  the  consecjuences  are 
even  worse  ;  necrosis  is  not  uncommon,  and  even  pyaemia  has  l)een  known  to 
occur. 

The  mouth  should  be  washed  out  with  water  as  hot  as  can  be  borne,  and  the 
gums  freely  lanced,  or  leeched.  Poultices  should  not  be  used.  If  this  fails,  and 
the  tooth  is  much  diseased,  it  should  be  extracted,  or,  if  there  is  any  stopping, 
this  should  be  removed  ;  but,  unless  this  gives  free  exit,  or  the  whole  abscess  sac 
comes  away  attached  to  the  diseased  fang,  it  is  advisable  to  make  a  free  incision 
through  the  swollen  portion  of  the  gum,  keeping  the  edge  of  the  knife  turned  toward 
the  bone,  and  open  the  abscess  there.  The  thickening  along  the  side  of  the  sulcus, 
sometimes  extending  under  its  floor,  can  usually  be  made  out  at  once  by  running 
the  finger  round  the  inside  of  the  cheek.  If  a  discharging  sinus  persists,  it  will 
usually  be  found  on  j^robing  that  there  is  either  a  small  .sequestrum,  or,  more 
frequently,  an  old  fang  left,  keeping  up  the  irritation. 

Suppuration  in  the  Antrum. 

This  may  result  from  injury,  from  dental  caries  and  alveolar  abscess  (the 
fangs  of  the  first  molar  project  into  the  cavity,  and  those  of  the  second  bicuspid 
are  only  separated  by  a  thin  plate  of  bone),  or  from  disease  of  the  mucous 
membrane  of  the  nose.  In  this  case  the  teeth  are  sound  and  free  from  pain,  or 
are  only  involved  secondarily,  occasionally  becoming  loose  and  dropping  out  of 
themselves,  from  absorption  of  the  alveoli. 

The  natural  orifice  of  the  antrum  is  rather  high  up  on  the  floor  of  the  middle 
meatus,  and  is  rarely  closed.  Even  when  it  is  the  inner  wall  is  so  thin  that  it 
usually  gives  way  elsewhere.  Sometimes,  however,  the  secretion  is  pent  up ;  the 
tension  rises  ;  suppuration  sets  in,  and  the  attack  becomes  very  acute. 

When  this  occurs  the  pain  is  most  intense  ;  generally  it  is  deep-seated  ;  often 
it  is  referred  to  the  teeth,  and  usually  it  radiates  all  over  that  side  of  the  face  and 
head.  The  walls  of  the  cavity  yield  and  bulge  outward  in  all  directions,  as  in  the 
case  of  rapidly  growing  tumors.  The  side  of  the  face  is  tender  and  swollen  ;  the 
skin  is  reddened  and  pits  on  pressure  ;  the  nostril  is  blocked  up ;  the  teeth  are 
loosened  and  exceedingly  painful,  very  often  they  feel  too  long ;  and  the  floor  of 
the  orbit  maybe  pushed  upward,  until  vision  itself  is  seriously  interfered  with.  If 
the  finger  is  passed  under  the  upper  lip,  the  anterior  wall  can  be  felt  projecting 
into  the  mouth  ;  and  occasionally  the  bony  plate  is  so  thin  that  it  crackles.  Some- 
times there  is  a  rigor,  and  always  there  is  serious  constitutional  disturbance.  Such 
cases,  however,  are  certainly  rare  ;  nearly  always  the  wall  gives  way  at  some  spot, 
and  the  acuteness  of  the  symptoms  is  relieved  at  once  ;  and  it  does  not  seem  un- 
likely that  most  of  the  cases  of  acute  suppuration  of  the  antrum  are  really  deep- 
seated  periosteal  abscesses  in  connection  with  the  roots  of  the  teeth,  and  are  in 
the  thickness  of  the  wall. 

In  chronic  inflammation,  on  the  other  hand,  the  occasional  discharge  of  fluid 
from  the  nostril,  when  the  patient  lies  down  with  the  affected  side  of  the  face 
uppermost,  is  sometimes  the  only  sign.  If  it  is  merely  catarrhal,  associated  with 
polypi,  the  fluid  is  of  a  clear,  watery  character ;  if  there  is  suppuration  it  is  thicker 
and  generally  offensive  ;  but  it  differs  from  ozaena  in  this,  that  the  smell  is  per- 
ceptible to  the  patient,  but  not,  unless  by  blowing  the  no,se  the  cavity  is  emptied  of 
its  contents,  to  the  bystanders.  Moreover,  there  are  no  crusts  of  dried  and  inspis- 
sated mucus.  Occasionally,  the  discharge  finds  its  way  through  the  posterior  nares 
and  is  swallowed. 

In  one  case  quoted  by  Heath,  the  cavity  was  filled  by  thickened  caseous  pus, 
and  the  bone  was  enlarged,  hard,  and  tender,  so  as  to  simulate  a  solid  tumor  of 
the  jaw;  as  a  rule,  however,  there  is  no  distention.  Attacks  of  neuralgia,  with  a 
constant,  dull,  aching  pain,  and  sometimes  frontal  headache,  as,  when  the  frontal 
sinus  is  involved,  are  nearly  always  present.  The  teeth  and  the  bone  around  are 
tender,  and  the  former  may  become  loose  and  drop  out  ;  the  side  of  the  face,  and 


768    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

especially  the  eyelids,  are  swollen  and  puffy  from  time  to  time  ;  and,  not  uncom- 
monly, the  patient's  health  suffers  severely  from  the  constant  swallowing  of  an 
offensive  discharge. 

When  the  suppuration  is  chronic,  the  diagnosis  rarely  presents  any  difficulty, 
though  it  is  i)rol)al)le  many  of  the  cases  are  overlooked  and  regardetl  merely  as 
inflammation  of  the  mucous  meml)rane  of  the  nose.  The  acute  form  resembles 
in  some  respects  a  rapidly  growing  sarcoma,  especially  as  this  is  often  attended 
with  pain  and  a  considerable  rise  of  temperature  ;  but  the  symptoms  are  much 
more  severe.  In  any  case  of  doubt,  an  exploratory  puncture  should  be  made 
under  the  lip. 

The  treatment  consists  in  letting  out  the  pus,  draining  the  cavity  thoroughly, 
and,  if  necessary,  washing  it  out  with  an  antiseptic  or  mild  astringent.  In  some 
cases,  the  cavity  can  be  readily  cleared  from  the  middle  meatus  of  the  nose  by 
means  of  a  Eustachian  catheter.  If  this  does  not  succeed,  an  additional  orifice 
must  be  made  elsewhere.  If  any  of  the  teeth  which  are  ordinarily  in  relation 
with  the  antrum  are  decayed  and  carious,  the  stumps  should  be  extracted,  and,  if 
the  cavity  is  not  opened,  a  trocar  driven  through  the  remaining  i)ortion  of  the 
bone,  care  being  taken  that  it  does  not  slip  in  too  far.  Afterward  a  drainage  tube, 
that  can  be  stopped  at  will,  must  be  inserted  in  the  opening  to  prevent  its  closing 
and  to  keep  the  food  from  passing  up  into  the  cavity,  where  it  would  decompose. 
If,  however,  the  teeth  are  sound,  or  if  they  have  already  been  extracted,  and  the 
alveolar  margin  has  become  thickened  and  dense  from  sclerosis,  the  opening  must 
be  made  either  through  the  anterior  wall,  under  the  upper  li}),  behind  the  canine, 
or  through  the  nose.  The  former  of  these  is  to  be  preferred  when  the  wall  is  at 
all  bulged  or  is  inclined  to  yield  beneath  the  finger.  The  latter  is  better  under 
other  circumstances,  provided  there  is  sufficient  room  in  the  nostril.  The  open ii'^g 
is  most  easily  made  in  the  lower  meatus,  just  under  the  middle  of  the  inferior 
turbinate  bone,  where  the  inner  wall  is  fairly  thin.  There  is  no  difficulty  in  per- 
forating the  bone,  and,  if  there  is  a  necessity  for  it,  the  patient  very  soon  learns  to 
wash  out  the  cavity  through  the  opening,  for  himself.  As  a  rule,  however,  if  a 
second  opening  is  made,  and  the  interior  is  once  thoroughly  cleared  of  its  decom- 
posing contents,  the  secretion  soon  regains  its  natural  character. 

Hydrops  Antri,  or  Dropsy  of  the  Antrum. 

The  facial  surface  of  the  upper  jaw  occasionally  becomes  immensely  distended 
by  a  collection  of  clear  yellowish  serum  containing  a  few  crystals  of  cholesterin. 
The  enlargement  is  very  gradual,  quite  painless,  and  sometimes  involves  the  palate 
and  nasal  surfaces  as  well.  The  bone  becomes  so  thin  that  it  crackles  like  parch- 
ment, and  it  may  even  be  completely  absorbed  in  some  places.  If  the  fluid  is 
evacuated,  the  swelling  subsides,  the  maxilla  resumes  its  normal  relations,  and  the 
opening  very  soon  clcses  in. 

It  was  formerly  held  that  this  dilatation  was  due  to  an  accumulation  of  the 
natural  secretion  of  the  mucous  lining  of  the  cavity,  the  opening  into  the  nose 
having  in  some  way  or  other  become  closed.  According  to  Heath,  however,  it 
is  certain  that  some  of  these  cases,  and  very  probably  all,  originate  as  cysts  in 
the  anterior  wall  of  the  antrum  ;  and  that  either  they  grow  to  such  a  size  as  to  be 
mistaken  for  the  cavity  itself,  or  that  the  intervening  wall  is  gradually  absorbed 
by  the  pressure,  and  the  two  cavities  thus  placed  in  communication  with  each 
other. 

Closure  of  the  Jaws. 

Inability  to  open  the  mouth  may  ari.se  from  muscular  spasm,  from  acute  in- 
flammation of  the  bones  or  soft  structures,  or  from  cicatricial  contraction  and 
other  organic  changes  caused  by  previous  attacks  of  inflammation. 

{a)  Muscular. — The  simplest  example  is  the  contraction  of  the  muscles  of 
mastication,  which  not  uncommonly  attends  the  eruption  of  the  wisdom  teeth ; 


CLOSURE  OF  THE  JAWS.  769 

« 

sometimes  apparently  it  is  hysterical,  and,  occurring  as  trismus,  it  is  one  of  the 
early  symptoms  of  tetanus.  The  contraction  disappears  at  once  under  an  anaes- 
thetic, allowing  the  interior  of  the  mouth  to  be  thoroughly  examined  ;  and  then, 
if  the  wisdom  tooth  is  found  to  be  growing  forward  against  the  next,  or  if  it  is 
covered  in,  steps  may  be  taken  to  release  it.  Generally  it  requires  removal,  but 
occasionally  this  is  impossible,  and  the  next  has  to  be  taken  away  before  it  is 
sufficiently  accessible.  Hysterical  contraction  is  characterized  by  the  peculiar 
manner  in  which  it  returns  after  the  anaesthesia  is  past,  not  slowly  and  quietly, 
beginning  with  the  return  of  consciousness,  but  quite  suddenly,  long  after  all  the 
reflexes,  and  not  until  the  patient's  attention  is  drawn  to  it. 

(/O  Inflamviatory. — All  forms  of  acute  inflammation,  whether  involving  the 
lower  jaw  itself,  the  tonsil,  parotid  gland,  or  other  structures  in  the  neighborhood, 
are  attended  by  a  certain  degree  of  inability  to  open  the  mouth,  partly  owing  to 
the  pain,  i)artly  to  the  mechanical  difficulty  caused  by  the  inflammatory  exudation 
poured  out  in  the  loose  cellular  tissue.  The  treatment,  of  course,  depends  upon 
the  i)rimary  cause. 

{/)  Permanent  Closure. — This  may  arise  from  cicatricial  contraction  of  the 
soft  parts,  consequent  on  noma  or  gunshot  injury  destroying  a  large  portion  of  the 
cheek,  or  from  affections  of  the  joint.  In  one  or  two  instances  the  coronoid  pro- 
cess has  become  ankylosed  to  the  upper  jaw  after  long-continued  inflammation. 
Unreduced  dislocations,  after  a  time,  acquire  considerable  mobility,  although  the 
incisor  teeth  cannot  be  brought  into  apposition. 

If  the  cicatricial  contraction  involves  both  the  mucous  and  cutaneous  sur- 
faces, the  only  satisfactory  way  of  dealing  with  it  is  by  plastic  operation  after  ex- 
cision. Stretching  the  bands  and  simple  division  are  quite  useless.  A  double  flap 
must,  of  course,  be  used — the  inner  one,  if  possible,  being  composed  of  mucous 
membrane.  In  cases  in  which  the  whole  thickness  is  not  involved,  Heath  recom- 
mends that  the  cicatrix  should  be  freely  divided  and  a  metal  plate  or  shield  adjusted 
on  the  teeth  so  as  to  fit  in  between  the  gum  and  the  cheek,  and  prevent  the  for- 
mation of  fresh  adhesions.  A  kind  of  mucous  membrane  is  gradually  developed 
in  the  groove,  but  this  mode  of  treatment  is  naturally  only  practicable  in  a  very 
limited  number  of  cases. 

Ankylosis  of  the  lower  jaw  is  caused  either  by  chronic  suppurative  arthritis 
(consequent  on  injury,  pyaemia,  suppurative  osteitis,  or  tubercular  disease)  or  by  a 
peculiar  form  of  rheumatism,  often  the  relic  of  an  acute  attack,  which  leads  to  the 
production  of  dense  fibrous  adhesions,  and  not  unfrequently  obstinately  returning 
again  and  again,  ends  at  length  in  synostosis.  Naturally,  it  is  a  condition  of  con- 
siderable importance,  not  only  from  the  interference  with  mastication,  but  from 
the  grave  danger  of  asphyxia  in  case  of  vomiting. 

Treatment. — The  joint  may  either  be  excised  or  an  artificial  one  made  in 
front  of  the  fixed  point.  The  former  operation  is  only  of  limited  value.  An 
incision  an  inch  and  a  half  in  length,  not  deeper  than  the  subcutaneous  cellular 
tissue,  is  carried  downward  and  slightly  forward  from  the  supraglenoid  root  of 
the  zygoma.  The  temporo-facial  branch  of  the  seventh  nerve  must  be  found  and 
pulled  downward,  the  lobules  of  the  parotid  gland  pushed  aside,  and  the  neck  of 
the  condyle  divided  with  a  chain  saw,  without  opening  the  buccal  cavity.  The 
head  may  then  be  detached  with  a  chisel  or  cutting-forceps,  and  levered  out ;  but, 
especially  in  those  cases  in  wdiich  the  bones  are  dense  and  sclerosed  as  a  result  of 
chronic  osteitis,  the  operation  is  exceedingly  difficult. 

Linear  osteotomy  has  been  performed  through  the  condyle  itself;  below  this 
through  the  neck ;  further  down  at  the  base  of  the  coronoid  ;  and,  according 
to  Rizzali's  method,  through  the  mucous  membrane,  without  an  external  scar ; 
but  all  of  these  labor  under  the  same  objection,  that  osseous  union  is  almost  certain 
to  occur. 

Esmarch's  operation  (excision  of  a  wedge-shaped  portion  of  the  ramus)  is 
more  satisfactory.  An  incision  is  made  along  the  lower  margin,  in  front  of  the 
angle,  the  soft  parts  separated,  and  a  triangular  portion   of  bone  with  its  apex 


770    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

t 
upward,  and  the  base,  about  an  inch  in  length,  corresponding  to  the  lower  border, 
detached  and  removed.  A  deep  groove  is  cut  on  the  external  surface  with  a  saw 
first,  and  then  the  section  completed  with  cutting  forceps.  Bennett,  who  per- 
formed this  operation  on  both  sides  in  a  case  of  rheumatic  synostosis,  in  which  all 
milder  measures  had  failed  again  and  again,  recommends  that,  at  least  in  cases  of 
this  disease,  the  insertion  of  the  masseter  should  be  detached  from  the  bone  on  the 
distal  side  of  the  incision,  or  the  two  fragments  are  certain  to  be  drawn  together, 
The  patient  recovered  with  very  good  upward  and  downward  action. 


TUMORS. 

I.   In  Connection  with  the  Soft  Structures. 

Navi  are  not  uncommon  ujion  the  gums,  lips,  and  inside  of  the  mouth.  In 
one  case  under  my  care  the  whole  thickness  of  the  cheek  was  involved. 

Congenital  hypertrophy  of  the  gums  is  a  very  rare  affection,  requiring  free 
excision.  It  must  be  distinguished  from  local  hypertrophy,  growing  out  in  a 
polypoid  form,  the  result  of  constant  irritation,  for  which  a  much  more  limited 
operation  will  suffice. 

Papillomata  may  occur  upon  the  gums  in  the  neighborhood  of  the  teeth, 
upon  the  lips,  or  upon  the  inside  of  the  cheek.  In  some  cases  they  are  low  and 
can  scarcely  be  distinguished  from  ordinary  warts  ;  in  others,  however,  they  are 
compound  or  branched  and  covered  over  with  exaggerated  filiform  papillae,  similar 
to  those  that  are  occasionally  seen  in  what  has  been  called  ichthvosis  linguae.  It 
is  probable  that  they  are  the  product  of  constant  irritation  (I  have  known  them 
develop  symmetrically  upon  the  upper  and  lower  lips,  from  perpetual  smoking)  ; 
and  they  should  always  be  freely  removed  for  fear  of  something  worse  developing 
as  age  advances. 

Adenomata  are  rare,  but  they  are  occasionally  found  on  the  lips,  palate,  gums, 
and,  in  short,  in  all  parts  in  which  mucous  glands  are  abundant.  They  form  soft, 
irregularly-shaped,  but  flattened  swellings  under  the  mucous  membrane.  Their 
growth  is  slow,  but  it  is  generally  difficult  to  ascertain  how  long  they  have  been 
present.  In  microscopic  structure  they  present  a  close  resemblance  to  the  gland 
growths  that  are  found  in  the  parotid,  and  sometimes,  like  these,  are  cystic  and 
contain  bone  and  cartilage.  For  the  most  part  they  are  made  up  of  irregular 
masses  of  acini  and  ducts. 

Mucous  cysts  are  often  met  with  upon  the  inside  of  the  lip  (labial)  or  cheek 
(buccal)  developed  from  the  mucous  glands,  and  forming  rounded,  tense  swellings, 
rather  dark  in  color.  The  contents  are  translucent,  but  very  viscid  ;  and  occa- 
sionally undergo  calcareous  degeneration.  It  is  sufficient  to  remove  a  portion  of 
the  wall,  but  in  many  cases  the  whole  can  be  excised  without  difficulty. 

Ranula  is  the  term  applied  to  a  cyst  of  the  floor  of  the  mouth,  in  many 
respects  resembling  those  just  described.  It  forms  a  soft,  lobulated,  fluctuating 
swelling,  usually  of  a  bluish-purple  color,  and  lies  immediately  under  the  mucous 
membrane,  on  one  side  of  the  frsenum  linguae.  When  small  it  gives  rise  to  little 
inconvenience,  but  as  it  grows  it  pushes  the  tongue  on  one  side,  interfering  with 
deglutition  and  articulation,  projects  in  the  submaxillary  region,  and  may  even 
reach  down  into  the  neck.  The  wall  is  composed  of  fibrous  tissue  lined  with 
epithelium  which  is  sometimes  ciliated  ;  and  the  cavity  is  filled  with  a  clear  viscid 
fluid  that  bears  no  relation  to  saliva. 

Ranula  is  probably  developed  from  a  mucous  gland  (that  of  Blandin  or  Nuhn) 
which  is  present  in  this  situation  ;  it  has  nothing  to  do  with  the  duct  that  runs  by 
the  side  of  it.  It  has  been  known,  however,  to  originate  in  connection  with  the 
sublingual  gland,  and  it  is  probable  that  in  many  doubtful  instances  it  is  the 
product  of  cystic  dilatation  either  of  normal  mucous  glands  occupying  this  region 
or  of  outlying  portions  of  the  larger  ones  which  have  been  in  some  way  detached 


TUMORS  OF  THE  MOUTH  AND  JAW.  771 

in  the  course  of  development.  It  is  very  questionable  whether  ranula  in  the 
strict  sense  of  the  term  ever  develops  from  the  sublingual  bursa,  although  it  is 
cjuite  possible  that  this  may  become  cystic. 

The  treatment  of  ranula  is  a  little  difficult 
on  account  of  the  obstinac)'  with  which  it 
returns.  Excision  of  the  whole  cyst  is  a  serious 
operation,  involving  a  considerable  degree  of 
dissection  among  very  vascular  structures. 
Removal    of  a  portion    of  the    wall    only  is 

seldom   of  any  use  unless    further   steps   are    .^yj^— [^^•;,  v  ^on^uc 

taken  to  secure  its  obliteration.  So  much 
may  be  cut  away  that  it  tannot  close ;  the 
interior  may  be  wiped  out  with  caustic,  so  as 
to  excite  a  certain  degree  of  inflammation  ;  a 
V-shaped    flap    may    be   made   and    the   apex 

,».'i.    1    ^A     J„     .,     i.«   i-U       a  •  -ii     Fig.    335. — Ranula,   or    Sublingual    Cyst,   with 

Stitched  down  to  the   floor;  or  a  wire  or  silk  Saiivary  buct  lying  upon  it. 

seton    may   be   used.      The   milder    measure 

should  be  tried  first,  as  severe  inflammation  may  result  if  the  sac  wall  is  made 
to  slough. 

[The  injection  of  Tincture  of  Iodine  is  recommended.  After  the  excision  of 
the  V-shaped  flap  a  hard-rubber  syringe  with  a  long  curved  nozzle  should  be  pushed 
into  the  cavity,  which  should  then  be  filled  to  distention  with  the  iodine.  A 
second  and  even  a  third  injection  is  sometimes  required.] 

Dermoid  Cysts. — Cysts  containing  sebaceous  matter  and  hairs  are  occasionally 
found  in  the  floor  of  the  mouth,  chiefly  in  the  middle  line,  and  in  the  substance  of 
the  tongue.  They  are  always  of  congenital  origin,  although  they  may  not  enlarge 
until  adult  life,  and  are  due  either  to  accidental  implantation,  or  to  the  persistence 
and  cystic  degeneration  of  fcetal  structures,  such  as  the  hyoglottic  canal,  which 
commences  at  the  foramen  ceecum.  Their  position,  the  absence  of  inflammation, 
and  the  exceedingly  slow  enlargement  are  the  chief  diagnostic  features,  but  it  is 
rarely  possible  to  be  certain  without  a  preliminary  puncture. 

Other  forms  of  cysts  are  very  rare,  although  one  or  two  instances  of  hydatids 
are  on  record. 

Epithelioma  (squamous)  is  the  only  form  of  malignant  disease  that  is  at  all 
common.  It  develops  not  unfrequently  from  the  continued  irritation  of  ill-fitting 
plates,  and  requires  the  freest  removal.  The  diagnosis  from  simple  ulceration  is 
not  difficult  if  the  part  is  examined  carefully,  but  the  chief  interest  of  this  disease 
is  the  relation  that  it  bears  to  a  variety  of  cystic  degeneration  of  the  jaws. 

2.  Growing  from  the  Bones  and  Periosteum. 

Partly  owing  to  the  great  variety  of  the  tissues  that  compose  them,  partly  to 
the  constant  irritation  to  which  they  are  subjected,  the  jaws  are  exceptionally  liable 
to  become  the  seat  of  new  growths  and  cysts.  All  the  tumors  that  develop  in 
connection  with  bone  may  occur,  and,  in  addition,  others  that  form  from  the  teeth, 
the  fibrous  tissue  of  the  gum,  and  the  epithelium.  The  term  epulis  is  applied  to 
those  that  grow  from  the  aheolar  margin  at  the  neck  of  the  teeth,  springing  from 
the  periosteum  or  the  periodontal  membrane.  Strictly,  it  should  be  limited  to  the 
hard  fibromata  which  are  common  in  this  region,  and  which  often  extend  so  far 
down  the  socket  of  the  tooth  that  a  considerable  portion  of  the  alveolar  margin 
has  to  be  excised  in  order  to  insure  its  complete  removal. 

Fibromata,  composed  of  peculiarly  dense  fibrous  tissue,  with  often  spicules  of 
bone,  and  sometimes  islets  of  cartilage  in  their  anterior,  are  the  most  common. 
For  the  most  part  they  grow  from  the  periosteum  and  form  pedunculated  tumors, 
projecting  under  the  mucous  membrane.  More  serious  ones,  however,  are  met 
with  occasionally,  springing  from  the  interior  of  the  antrum,  or  from  the  inferior 
dental  canal,  or  from  the  sockets  of  some  of  the  teeth,  and  attaining  an  enormous 


772     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

size.      In  all  cases  they  require  free  removal,  but  providing  this  is  properly  doi.e 
there  is  no  fear  of  recurrence. 

Enclwndromata  are  much  more  rare,  and  many  of  them  become  converted 
into  bone.  Occasionally,  when  they  originate  from  the  antrum,  they  attain  an 
enormous  size,  though  of  very  slow  growth,  and  lead  to  great  tlcformity.  Like  the 
former  they  may  begin  either  in  the  substance  of  the  bone  or  under  the  periosteum, 
and  they  require  free  removal.  It  seems  probable  that  those  which  are  stated  to 
have  recurred  were  either  not  thoroughly  excised,  or  were  in  reality  chondrifying 
sarcomata. 

Ivory  and  cancellous  exostoses  are  occasionally  met  with.  The  former  gener- 
ally grow  either  in  the  antrum  or  from  the  angle  of  the  lower  jaw.  The  latter 
may  be  formed  from  cartilage,  but  very  often  are  covered  in  with  an  unusually  thick 
layer  of  compact  tissue.  Sometimes  they  originate  in  the  interior  of  the  bones, 
and  in  many  cases  they  are  so  ill  defined  that  it  is  impossible  to  draw  a  distinct 
line  between  them  and  that  i)eculiar  form  of  hyperostosis  or  overgrowth  of  the  jaw 
which  is  occasionally  met  with  in  young  peo])le,  and  which  in  its  turn  is  very 
difficult  to  distinguish  from  the  milder  forms  of  leontiasis. 

Exostoses  must  be  carefully  separated  from  bony  outgrowths  due  to  displaced 
or  supernumerary  teeth,  which  are  by  no  means  uncommon. 

Odontomata,  or  tumors  formed  in  connection  with  the  teeth,  may  be  either 
mere  outgrowths  (exostoses  of  the  fangs)  composed  chiefly  of  cement,  or,  much 
more  rarely,  gigantic  misshapen  masses  of  dentine,  enamel,  and  cement,  thrown 
together  with  more  or  less  of  order  and  arrangement.  They  have  only  been  met 
with  in  the  lower  jaw  and  in  young  people  ;  and  in  all  probability  they  spring 
from  the  germs  of  one  or  more  of  the  molar  teeth  which  have  become  displaced 
and  have  grown  out  into  an  irregular  mass,  sometimes  as  large  as  a  turkey's  egg. 
The  symptoms  to  which  they  give  rise  are  very  indefinite.  Unless  the  surface 
protrudes  through  the  gum,  there  is  merely  a  slow  growing  tumor,  causing  immense 
expansion  of  the  lower  jaw  ;  and  it  has  happened  on  several  occasions  that  large 
portions  of  the  bone  have  been  excised  under  the  impression  that  there  was  a 
centrally  placed  malignant  growth.  One  tooth  is  always  absent  from  the  series, 
and  occasionally  the  growth  of  the  neighboring  ones  is  interfered  with  to  such  an 
extent  that  they  remain  buried  in  the  substance  of  the  jaw.  If  the  nature  of  the 
ca.se  is  recognized  there  is  no  difficulty  in  removing  j^art  of  the  wall  of  the  cyst, 
and  detaching  the  mass  from  the  fibro-cellular  membrane  surrounding  it. 

Myeloid  sarcoma  may  develo])  either  in  the  interior  of  the  lower  jaw — forming 
a  rounded,  tense,  and  elastic  swelling,  often  suspiciously  like  a  cyst,  only  of  more 
rapid  growth — or  under  the  periosteum.  In  this  situation  it  is  sometimes  called 
myeloid  epulis,  and  is  distinguished  from  the  ordinary  fibrous  form  by  its  darker 
color,  which  shows  distinctly  through  the  mucous  membrane.  Of  all  the  sarco- 
mata it  is  the  least  malignant,  and  may  never  recur  if  excised  freely.  In  the  upper 
jaw  it  usually  grows  from  the  antrum,  and  is  softer  and  more  vascular,  containing 
frequently  a  very  large  i)roiJortion  of  round  or  spindle  cells. 

Round-celled  and  spindle-celled  sarcomata  are  intensely  malignant.  They  may 
spring  from  the  i)eriosteal  surface  of  either  jaw,  but  their  favorite  seat  is  the  antrum, 
in  which  they  grow  with  great  rapidity,  thrusting  the  walls  out  in  all  directions 
and  extending  into  neighboring  cavities.  The  nostril  becomes  blocked  ;  the  floor 
of  the  orbit  is  raised  and  the  eyeball  protruded  ;  the  hard  palate  is  forced  down  ; 
the  facial  surface  is  thrust  forward  ;  and  the  whole  side  of  the  face  seems  enlarged. 
Then  in  a  short  time  the  growth  spreads  into  the  pharynx,  or  extends  down  the 
sockets  of  the  teeth,  detaching  them  and  forming  a  fungating  mass  on  the  alveolar 
margin  ;  or  it  grows  out  into  the  nose  and  simulates  a  polypus,  or  involves  the 
skin  of  the  face.  Nothing  else  in  so  short  a  time  can  produce  so  great  or  so  gen- 
eral an  enlargement.  Free  removal  of  the  whole  bone  is  essential,  but  very  often 
the  disease  is  already  too  far  advanced  before  the  patient  is  aware  of  the  affection. 
Rapid  recurrence  is  the  rule,  the  secondary  growths  being  generally  softer  and 
more  malignant  than  the  primary. 


TUMORS  OF  THE  JAW.  773 

Sarcomata  growini^^  from  the  jaws,  like  those  of  other  bones,  occasionally 
undergo  partial  chondrification  or  ossification,  forming  what  used  formerly  to  be 
described  as  osteoid  cancer  and  malignant  enchondroma.  Cystic  degeneration  is 
not  uncommon,  esi)ecially  in  the  myeloid  form. 

Primary  carcinoma  does  not  occur  in  the  jaws,  but  secondary  growths,  extend- 
ing in  the  case  of  the  upper  jaw  from  the  nasal  mucous  membrane  (tubular  epithe- 
lioma), or  from  the  palate  surface  (squamous),  are  not  uncommon,  and,  without 
any  great  external  show,  lead  to  complete  destruction  of  the  bone ;  a  probe,  for 
example,  may  pass  through  a  small,  comparatively  insignificant,  opening  in  the 
palate  into  a  great  ulcerated  space.  In  the  case  of  the  lower  jaw,  ingrowths  of 
epithelial  cells  in  the  form  of  columns  are  met  with  in  connection  with  multilo- 
cular  cysts. 

Cysts. — Both  the  upper  and  the  lower  jaws  are  frequently  the  seat  of  cystic 
disease,  which  may  originate  in  connection  with  the  mucous  membrane,  or  the 
teeth,  or  be  dependent  upon  the  degeneration  of  new  growths,  sarcoma  or  epithe- 
lioma. 

Mucous  cysts  are  chiefly  found  in  the  antrum,  developing  from  the  glands 
lying  in  it,  and  are  very  generally  associated  with  the  presence  of  polypi.  The 
mucous  and  submucous  tissues,  as  in  the  nose,  sometimes  undergo  chronic  hyper- 
trophy ;  when  the  fibrous  portion  predominates,  a  polypus  results  ;  when  it  is  the 
glandular  part,  cysts  are  produced.  These  are  usually  multiple,  rarely  attain  any 
very  large  size,  and  contain  a  clear  mucous  fluid.  Sometimes  they  cause  a  certain 
amount  of  absorption  of  the  bone  upon  which  they  rest. 

Dentigerous  Cysts. — Cysts  formed  in  connection  with  the  teeth  are  either 
due  to  an  error  of  development,  or  are  the  result  of  chronic  irritation  and  inflam- 
mation. The  former  are  known  as  dentigerous  cysts.  One  of  the  permanent 
teeth,  generally  the  canine,  remains  buried  in  the  jaw  ;  the  fluid  which  normally 
collects  between  the  enamel  organ  and  the  surrounding  tissues,  as  the  tooth 
approaches  the  surface,  gradually  increases  in  quantity  ;  a  certain  degree  of  ten- 
sion is  caused  ;  and  by  degrees  a  cyst  is  formed  deep  in  the  substance  of  the  bone, 
lined  with  soft  but  thick  membrane.  The  tooth  at  first  is  attached  to  the  wall  at 
one  spot,  but  subsequently  it  becomes  free.  The  diagnosis  rarely  presents  any 
difificulty  ;  the  swelling  is  always  met  with  in  young  adult  life  ;  one  of  the  perma- 
nent teeth  is  missing  from  the  series,  and  very  often  the  temporary  one  has  not 
been  detached  ;  the  outer  side  of  the  jaw  especially  is  expanded  ;  the  surface  is 
perfectly  uniform  and  painless;  and  sometimes,  on  deep  pressure,  a  certain  degree 
of  crackling  can  be  made  out.  Occasionally  they  are  formed  in  connection  with 
the  other  teeth,  and  a  few  instances  are  recorded  in  which  the  temporary  teeth, 
and  even  supernumerary  ones,  were  associated  with  them. 

Subperiosteal  Cysts. — The  other  form  of  dental  cyst  is  met  with  at  any  age, 
and  appears  to  be  the  result  of  chronic  irritation  in  connection  with  the  fangs. 
From  their  situation  under  the  lining  membrane  of  the  alveoli,  they  are  sometimes 
known  as  subperiosteal.  Fluid  collects  around  the  root  of  a  carious  tooth,  the 
bone  is  absorbed,  a  lining  membrane  is  formed,  and  at  length  a  distinct  cyst  is 
produced,  which  may  or  may  not  be  attached  to  the  tooth.  At  first  its  contents 
are  thick  and  semi-purulent;  later,  as  the  pus  undergoes  fatty  degeneration,  they 
become  softer,  cheesy,  and  at  length  serous.  Cholesterin  crystals  are  generally 
present  in  abundance.  These  cysts  are  rarely  larger  than  a  hazel-nut,  but  some- 
times, when  they  are  situated  in  the  anterior  wall  of  the  antrum,  they  encroach 
upon  its  space  to  such  an  extent  that  they  may  easily  be  taken  for  it,  and  it  is  not 
improbable  that  many  of  the  cases  of  so-called  hydrops  antri  are  really  to  be 
accounted  for  either  by  the  presence  of  one  of  these  cysts  in  the  wall,  or  by  one 
having  ruptured  into  the  cavity. 

The  symptoms,  when  the  cyst  is  sufficiently  large  to  give  rise  to  any,  are 
merely  those  of  a  chronic,  painless  enlargement  of  part  of  the  jaw.  As  a  rule,  by 
the  time  it  is  large  enough  to  form  a  projection,  the  wall  over  it  is  absorbed,  and 
there  is  merely  a  thin  crackling  plate  of  bone  which  yields  beneath  the  finger. 


774     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

The  treatment  consists  in  free  incision  of  the  cavity,  exploration  to  make  sure 
there  is  no  persisting  cause,  such  as  a  misplaced  or  supplementary  tooth,  and 
drainage. 

According  to  Heath,  periosteal  cysts  occur  in  the  lower  jaw  without  any 
apparent  immediate  connection  with  the  teeth,  though  very  possibly  some  irrita- 
tion connected  with  those  organs  may  have  been  the  original  cause  of  the  mischief. 

Cysts  that  develop  in  connection  with  myeloid  or  other  sarcomata  rarely 
admit  of  diagnosis,  and  do  not  possess  any  practical  importance. 

Multilocular  cysts,  on  the  other  hand,  the  so-called  cystic  sarcomata,  are  of 
great  interest.  They  are  more  common  in  the  lower  jaw  than  in  the  upper,  and 
originate,  in  most  instances,  in  some  form  of  injury,  or  from  the  irritation  of 
decayed  teeth.  Formerly  they  were  regarded  as  simple  cysts,  but  it  has  been 
shown  that  they  are  really  of  epithelial  origin,  due  to  the  downgrowth  of  columns 
of  cells  from  the  surface  into  the  interior  of  the  bone.  As  a  result,  great  cellular 
spaces  are  formed  inside,  and  the  internal  and  external  plates  are  so  far  separated 
from  each  other  that  in  extreme  cases  the  alveolar  portion  of  the  horizontal  ramus 
is  reduced  to  the  condition  of  a  few  scattered  trabecule,  and  the  teeth  are  com- 
pletely detached.  The  central  cells  in  the  larger  columns  undergo  colloid  degen- 
eration, and  in  this  way  cysts  are  formed,  filled  with  a  thin,  glairy,  or  blood-tinged 
fluid,  and  surrounded  by  imperfect  layers  of  columnar  epithelium.  Their  growth 
is  very  slow,  and,  probably  owing  to  the  bony  capsule  and  to  the  early  degeneration 
of  the  epithelium,  they  have  but  little  tendency  to  implicate  surrounding  structures 
or  the  lymphatic  glands.  In  one  or  two  instances,  however,  sarcomatous  tissue 
has  been  found  associated  with  them,  and  then  the  prognosis  is  not  so  good. 

Owing  to  the  fact  that  the  alveolar  margin  and  the  sockets  of  the  teeth  are 
much  more  involved  than  the  lower,  firmer  portion  of  the  horizontal  ramus,  it  is 
possible,  in  many  cases,  to  excise  the  whole  of  the  growth  from  the  mucous  surface, 
scraping  it  away  freely,  without  removal  of  the  whole  thickness  of  the  bone. 
Whether  this  should  be  done  or  not  depends  chiefly  upon  the  age  of  the  patient 
and  the  amount  of  solid  tissue  present.  In  case  of  any  recurrence,  the  whole 
affected  portion  should  certainly  be  removed. 


OPERATIONS  ON  THE  JAWS. 

Excision  of  the  Upper  Jaw. 

This  may  be  complete  or  partial,  not  removing  the  floor  of  the  orbit.  Where 
possible  the  latter  is  to  be  preferred,  as  it  causes  less  deformity  and  does  not  expose 
the  eyeball  to  the  risk  of  displacement  or  injury.  In  cases  of  sarcoma,  for  which 
this  operation  is  most  frequently  performed,  free  removal  of  every  part  of  the 
bone  is  essential. 

The  patient  is  placed  in  a  semi-recumbent  i)osition  with  the  head  and  shoul- 
ders well  supported.  The  ancesthetic  must  be  administered  by  means  of  Junker's 
apparatus,  the  tube  being  passed  through  the  other  nostril  or  the  mouth,  according 
to  the  convenience  of  the  moment.  A  preliminary  tracheotomy  is  not  necessary, 
although  it  is  a  wise  precaution  when  a  hemorrhage  is  expected,  but  the  adminis- 
trator must  pay  special  attention  to  the  breathing,  and  particularly  to  the  danger 
of  blood  finding  its  way  down  the  larynx. 

The  incision  (usually  known  as  Fergusson's)  runs  down  the  centre  of  the  upper 
lip,  round  the  ala  of  the  nose  to  the  inner  angle  of  the  orliit,  and  along  its  lower 
margin  as  far  as  the  malar  prominence.  The  arteries  of  the  lip  are  the  only  ones 
that  bleed,  unless  the  growth  has  infiltrated  the  skin.  The  flap  is  reflected  far 
enough  to  expose  the  whole  of  the  bone  that  requires  to  be  removed. 

An  incisor  tooth  is  drawn,  and  an  incision  made  with  a  stout  scalpel  along 
the  floor  of  the  nose,  down  the  hard  palate  in  the  middle  line,  and  transversely 
outward  at  its  posterior  margin  toward  the  last  molar.     The  object  is  to  preserve 


OPERATIONS  ON  THE  JAWS. 


775 


the  soft  palate  when  the  bone  is  removed,  the  separation  being  completed  with 
blunt-pointed  scissors.  The  ala  of  the  nose  and  the  ijeriosteum  of  the  orbit  are 
to  be  detached  in  the  same  way. 

The  bones  may  be  partially  divided  with  a  saw  or  cut  through  at  once  with  a 
pair  of  long-handled  bone-forceps.  The  latter  is  the  more  speedy  and  does  not 
really  lead  to  more  splintering.  One  blade  is  passed  into  the  mouth,  the  other 
down  the  nostril,  and  the  hard  palate  divided  with  a  single  cut ;  the  nasal  process 
is  treated  in  the  same  way,  and  then  the  outer  angle  of  the  orbit,  the  line  of  divi- 
sion running  into  the  s])heno-maxillary  fissure,  l^y  this  the  bone  is  ])ractically 
freed,  and  if  gras])ed  with  a  pair  of  lion-forceps,  one  set  of  teeth  fixing  themselves 
in  the  hartl  palate,  the  other  on  the  malar  eminence,  it  can  be  easily  detached  by 
wrenching  it  from  side  to  side,  and  separating  the  soft  structures  as  they  resist  with 
a  pair  of  blunt-pointed  scissors.  There  is  seldom  any  hemorrhage  ;  the  arteries 
divided  are  all  minute,  and  if  torn  across  retract  at  once.  Sometimes,  however, 
when  the  growth  is  very  rapid  and  the  vessels  much  dilated,  it  is  fairly  free  ;  and 
if  the  substance  of  the  tumor  (in  which  the  vessels  are  often  little  more  than  open 
channels)  is  torn,  it  may  be  of  any  extent.  It  must  be  stopped  by  pressing  a 
sponge  firmly  against  the  bleeding  part,  or,  if  this  fails,  with  the  actual  cautery. 


I.  Gensoul. 


2.  Velpeau. 

3.  Syme. 


4.  Malgaigne.  5.   Nelaton. 


6.   Fergusson.  7.  Dieffenbach.  8.  Weber.  9.  v.  Langenbeck. 

Fig.  336. — Incisions  for  Section  of  the  Superior  Maxilla. 


If  the  whole  growth  has  been  removed  and  the  bleeding  stayed,  nothing  further 
need  be  done ;  the  flap  is  simply  replaced  and  fixed  with  two  or  three  sutures,  a 
hare-lip  pin  being  used  for  the  lip.  If,  however,  the  bone  is  crushed  by  the  forceps, 
or  if  the  surface  of  the  growth  presents  a  torn  and  ragged  surface,  the  wound  must 
be  carefully  examined,  and  the  rest  either  removed  with  a  sharp  spoon  or  destroyed 
by  packing  the  cavity  with  lint  covered  with  a  paste  made  of  chloride  of  zinc  and 
starch.  Sometimes  it  is  necessary  to  plug  the  space  with  strips  of  iodoform  gauze 
in  order  to  check  the  oozing  ;  but,  whatever  material  is  used,  it  must  be  withdrawn 
at  the  end  of  twenty- four  hours,  owing  to  the  rapidity  with  which  it  becomes  foul, 
and  partly  for  this  reason,  partly  from  the  pain  it  causes,  it  should  be  avoided 
whenever  it  is  possible. 

The  after-treatment  is  very  simple  and  the  deformity  left  strangely  slight.  The 
lower  eyelid,  however,  may  become  oedematous,  especially  when  the  floor  of  the 
orbit  is  removed,  and  cause  a  very  unsightly  projection  ;  and,  in  cases  in  which  it 
is  necessary  to  remove  the  malar  bone  as  well,  the  prominence  of  the  cheek,  of 
course,  is  lost,  so  that  the  depression  becomes  more  conspicuous. 

Partial  operations  are  much  more  common.  The  floor  of  the  orbit  may  be 
left,  the  bone  being  sawn  across  below  the  infra-orbital  foramen ;  or  the  incision 


776    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

may  be  confined  to  the  side  of  the  nose,  and  the  anterior  wall  of  the  antrum  exposed 
sulificiently  to  allow  a  tumor  to  be  gouged  out  from  the  interior;  or  large  portions 
of  the  alveolar  margin  with  the  teeth  may  be  removed  from  the  inside  of  the  mouth 
in  cases  of  epulis.  Temporary  resections,  in  which  more  or  less  of  the  Ijone  is 
separatetl  from  the  rest  and  reflected,  without  dividing  the  periosteum  or  soft  tissues, 
have  l)een  described  on  i)age  7 58. 

Excision  of  the  Lower  Jaw. 

This  may  be  either  complete,  the  symphysis  being  divided  and  the  condyle 
disarticulated,  or  partial ;  and  it  may  be  performed  altogether  from  the  inside  of 
the  mouth,  or  through  an  external  incision.  The  former  operation,  except  in  the 
case  of  such  diseases  as  phosphorus  necrosis,  is  exceedingly  difficult  and  danger- 
ous from  the  risk  of  wounding  the  facial  and  maxillary  vessels  in  a  part  that  is 
almost  inaccessible    from    the    interior ;    the  latter  involves  a  cicatrix  of   some 


m\% ' 


Fig.  337.  Resection  of  Lower  Half  of  Jaw.  Fig.  338. 

Cutting  the  Skin  and  Sawing  Through  tlie  Bone.  Twisting  from  the  Joint. 


extent  (dei)ending  upon  the  amount  of  bone  that  requires  taking  away),  but  if  the 
red  portion  of  the  lip  is  not  divided,  and  the  incision  is  kept  under  the  horizontal 
ramus  it  is  scarcely  noticeable.  The  facial  artery  must,  of  course,  be  divided, 
but  the  nerve  does  not  suffer  unless  the  incision  is  carried  unnecessarily  high  up 
the  posterior  margin  of  the  vertical  ramus. 

If  one-half  of  the  bone  is  to  be  removed,  a  vertical  incision  is  made  through 
the  lip,  and  a  horizontal  one  at  right  angles  to  this,  along  the  inferior  margin  as 
far  as  the  angle,  and  up  behind  the  vertical  ramus  to  a  level  with  the  lobule  of  the 
ear.  The  soft  tissues  are  dissected  off  the  external  surface  of  the  bone  and  reflected 
upward  ;  the  jaw  divided  near  the  symphysis,  one  of  the  teeth  being  drawn  for  the 
purpose,  and  the  structures  on  the  inner  side  separated  in  the  same  way.  The 
bone  should  be  sawn  nearly  through  and  the  section  completed  with  bone-forceps, 
and  care  should  be  taken  when  the  division  is  near,  and  still  more  at  the  symphysis, 
that  the  tongue  does  not  fall  backward.  The  facial  artery  should,  of  course,  be 
secured  at  once. 


OPERATIONS  ON  THE  JAWS.  ^n 

The  anterior  end  of  the  detached  half  must  now  be  grasped  with  forceps,  and 
pulled  down  to  complete  the  separation  of  the  masseter  and  internal  ijterygoid. 
For  the  latter  the  bone  must  be  everted.  Then,  if  it  is  intended  to  disarticulate, 
either  the  temporal  muscle  must  be  detached  from  the  coronoid  or  this  process  cut 
off  with  bone-forceps  and  left  for  excision  later.  If  it  catches  against  the  malar 
bone  while  it  is  being  depressed  this  must  be  done.  As  soon  as  this  is  effected, 
the  jaw  can  be  depressed  a  great  deal  further,  and  by  keeping  the  point  of  the  knife 
well  against  the  bone  the  long  internal  lateral  ligament  (with  the  inferior  dental 
nerve  and  artery),  the  capsule  and  jiart  of  the  external  pterygoid  can  be  divided. 
The  jaw  then  comes  away  readily,  the  rest  of  the  soft  structures  being  divided,  one 
by  one,  with  blunt-pointed  scissors.  Cireat  care  is  required  not  to  divide  the 
internal  maxillary  artery,  which  lies  outside  the  internal  lateral  ligament,  between 
it  and  the  bone,  or  to  tear  it  by  everting  the  ramus  too  much  and  twisting  it  round 
the  neck  of  the  condyle. 

Partial  excision,  leaving  the  condyle  and  the  coronoid  process,  is  more  easy. 
In  many  instances  slighter  operations  still  are  possible  :  a  segment  of  the  hori- 
zontal famus  only  may  be  removed  (when  this  is  done  the  division  of  the  jaw 
should  be  nearly  completed  in  both  lines  of  section  before  either  is  carried  right 
through,  or  in  making  the  second  the  support  of  the  jaw  is  lost)  ;  or,  as  in  epulis, 
and  occasionally  in  epithelioma,  the  alveolar  portion  may  be  taken  away  and  the 
lower  border  left. 


50 


773    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  XII. 

INJURIES  AND   DISEASES  OF   THE   TONGUE,  SALIVARY  GLANDS  AND 

TONSILS. 

CONGENITAL  AFFECTIONS  OF  THE  TONGUE. 

Tongue-tie  is  caused  by  the  fra^num  being  of  unusual  shape  or  size  ;  it  may  be 
too  broad  or  attached  too  far  forward.  In  the  vast  majority  of  instances  this 
affection  is  imaginary,  but  cases  are  met  with  in  whicli  it  renders  suckbng  very 
difificult,  or,  later,  interferes  with  articulation.  The  mucous  membrane  should  be 
divided  with  a  pair  of  blunt-pointed  scissors,  and  sufficient  sej^aration  effected  by 
tearing. 

The  opposite  condition,  undue  laxity  of  the  frasnum,  so  that  the  tongue  can 
sink  backward,  with  its  dorsum  against  the  wall  of  the  pharynx  and  its  base  over 
the  glottis,  is  much  more  rare.  Several  cases,  however,  are  recorded  in  which  it  is 
stated  to  have  caused  death.  The  same  thing  has  been  known  to  occur  after  very 
complete  division  of  the  frtenum. 

Fixation  to  the  floor  of  the  mouth  by  folds  of  mucous  membrane,  absence  of 
the  tongue  altogether,  bifid  tongue,  and  other  defects  are  very  rare. 

Macroglossia. — One  or  two  examples  of  true  hypertrophy  of  the  tongue, 
involving  all  the  component  structures,  have  been  recorded,  but  by  macroglossia 
is  generally  understood  an  enlargement  of  a  different  character.  It  affects  only 
the  connective  tissue,  lymph  spaces  and  lymphatics,  which  are  enormously  dilated. 
The  blood-vessels  are  occasionally  larger  than  natural,  and  in  some  instances  a 
certain  amount  of  adenoid  growth  has  been  described  ;  but  there  does  not  appear 
to  be  any  increase  in  the  number  or  size  of  the  muscular  elements. 

Macroglossia  is  nearly  always  congenital  and  is  occasionally  associated  with 
hydrocele  of  the  neck  ;  but  it  is  often  not  noticed  for  some  time  after  birth.  In 
the  few  instances  in  which  it  appears  to  have  developed  late  in  life  it  has  followed 
injury,  inflammation,  or  the  acute  specific  fevers,  its  pathology  in  all  probability 
being  essentially  the  same.  The  enlargement  that  is  met  with  in  cretins,  idiots, 
and  others  of  weak  intellect,  is  merely  the  result  of  inflammation  consequent  upon 
repeated  protrusion  and  injury. 

The  appearance  is  characteristic.  The  shape  of  the  tongue  is  more  or  less 
natural,  but  it  protrudes  many  inches  beyond  the  mouth,  and  the  surface  is  covered 
with  enlarged  papillae,  often  bulbous  at  the  ends,  and  .separated  from  each  other 
by  deep  smooth-walled  fissures.  The  general  color  is  paler  than  natural,  and  it 
has  a  delicate  semi-translucent  appearance  on  the  surface.  In  the  slighter  cases  it 
can  still  be  withdrawn  ;  in  those  which  have  lasted  some  length  of  time  this  is  no 
longer  possible  ;  the  mouth  cannot  be  closed  ;  the  saliva  dribbles  away  ;  the  lower 
lip  becomes  everted,  and  the  chin  covered  with  eczema  ;  even  the  lower  jaw  is 
enlarged  and  the  teeth  forced  down  by  constant  pressure  until  they  are  practically 
horizontal.  Then  the  protruded  portion  of  the  tongue  begins  to  suffer.  From 
constant  exposure  the  surface  becomes  hard,  dried  up,  cracked,  and  ulcerated  ; 
repeated  injuries  from  the  teeth,  which  are  always  rubbing  against  its  under  surface 
and  its  sides,  and  other  causes,  lead  to  attacks  of  inflammation,  each  of  which 
brings  a  fresh  amount  of  oedema  and  leaves  the  condition  worse  than  it  was  before  ; 
and  at  length,  partly  from  the  discomfort,  ])artly  from  the  difficulty  of  introducing 
food  (not  so  much  the  swallowing  of  it),  the  patient's  condition  becomes  one  of 
absolute  misery. 

The  only  treatment  that  can  give  permanent  relief  is  the  excision  of  a  V- 
shaped  portion;  and  this  should  be  practiced  in  all  cases  in  which  the  contour  of 


INFLAMMATION  OF  THE  TONGUE. 


■79 


the  lower  jaw  and  the  direction  of  the  teeth  are  becoming  affected.  If  the  thick- 
ness is  very  great  the  natural  shape  of  the  tongue  may  be  partially  restored  by 
excising  a  horizontal  as  well  as  a  vertical  wedge,  the  surfaces  being  brought 
together  by  catgut  sutures  running  through  the  whole  thickness.  In  cases  of 
recent  injury  when  the  tongue  is  more  than  usually  swollen,  soft  linen  moistened 
with  glycerine  may  be  wrapped  round  it  to  reduce  the  oidema,  although  of  course 
it  has  no  effect  upon  the  permanent  hypertrophy. 


Inflammation  of  the  Tongue. 

The  mucous  membrane  of  the  tongue,  like  that  of  the  mouth,  is  liable  to  all 
the  varieties  of  superficial  ulcera- 
tion that  have  already  been  de- 
scribed. Aphthie  may  form  upon 
the  tip  and  edges ;  thrush  may 
occur  in  infants  and  adults  whose 
health  has  broken  down  ;  herpes 
is  occasionally  seen  :  and  ulcera- 
tive stomatitis  sometimes  extends 
on  to  it  from  the  cheek  or  palate. 
In  addition  to  these,  however,  and 
to  the  various  kinds  of  specific 
disease,  such  as  syphilis  and  tu- 
bercle, the  tongue  is  especially 
subject  to  certain  forms  of  chronic 
inflammation,  some  superficial  and 
spreading  over  the  greater  portion, 
others  local  and  ending  in  deep 
ulceration.  These  are  due,  there 
is  no  doubt,  to  the  constant  injury 
and  irritation  to  which  the  surface 
is  exposed  ;  but  they  are  also  very 
largely  dependent  either  upon  in- 
dividual predisposition  or  the 
general  state  of  health.  The 
same  irritant — tobacco  smoke,  for  example — which  may  be  continued  in  one  case 
for  years  without  producing  the  least  effect,  in  another  causes  serious  irritation 
within  a  very  short  space  of  time  ;  and  a  ragged  tooth,  which  may  not  hurt  so  long 
as  the  general  health  is  good,  cuts  into  the  tongue  and  leads  to  ulceration  as  soon 
as  it  begins  to  fail.  It  is  possible  that  in  this  case  the  condition  of  the  tongue 
itself  is  sufficient  explanation  :  it  becomes  enlarged  and  flabby  ;  the  teeth  cut  into 
it ;  and  the  epithelium  covering  it  may  be  more  delicate  than  natural  ;  but  this  is 
certainly  not  satisfactory  in  the  case  of  the  former,  nor  will  it  account  for  the  obsti- 
nate persistence  of  some  of  these  varieties  of  inflammation  when  they  have  once 
commenced. 

Acute   Glossitis. 

Acute  inflammation  of  the  tongue  may  be  caused  by  cold,  mercury,  poisoned 
wounds,  the  presence  of  foreign  bodies,  or  the  stings  of  insects.  It  has  also  been 
known  to  occur  in  the  course  of  erysipelas  and  some  of  the  eruptive  fevers.  The 
mucous  membrane  only  may  be  affected,  or  the  whole  substance  of  the  tongue  ; 
and  it  may  end  in  speedy  resolution,  in  a  circumscribed  abscess,  or  in  a  most  acute 
form  of  diffuse  inflammation,  which  spreads  to  the  floor  of  the  mouth,  involves 
the  aperture  of  the  larynx,  and  not  unfrequently  proves  fatal  from  asphyxia  or 
septic  inflammation. 

There  is  no  difficulty  in  the  diagnosis.  The  surface  is  dark  and  livid,  the 
dorsum  covered  with  fur ;  the  size  increases  so  that  it  is  tightly  pressed  against  the 


Fig.  339. — Macroglossia. 


78o    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

teeth,  and  movement  is  attended  with  severe  pain.  If  the  inflammation  continues 
the  swelling  soon  becomes  enormous;  the  tongue  fills  the  mouth,  ])rotrudes  be- 
tween the  teeth,  presses  up  against  the  palate  and  projects  backward  over  the  glottis. 
The  tissues  at  the  floor  of  the  mouth  become  swollen  and  tense,  so  as  to  raise  it 
further  still  ;  the  mouth  cannot  be  shut ;  the  saliva  pours  away  ;  articulation  and 
deglutition  are  impossible  ;  and  there  is  imminent  danger  of  asphyxia.  'I'he  pain 
in  acute  cases  is  very  great  and  there  is  dreadful  distress,  but  the  temperature  is 
seldom  high.  As  the  inflammation  subsides,  superficial  sloughs  not  uncommonly 
make  their  appearance  where  it  has  pressed  against  the  teeth,  leaving  troublesome 
ulcers  ;  or  this  is  followed  by  a  condition  of  chronic  induration  and  enlargement ; 
or,  in  very  rare  cases,  by  persistence  of  the  sloughing,  until,  if  the  patient  does 
not  succumb  from  septic  poisoning  and  broncho-pneumonia,  the  whole  organ  is 
practically  destroyed. 

The  treatment  depends  upon  the  severity  of  the  attack.  In  the  milder  cases, 
in  which  the  distress  is  not  urgent  and  there  is  no  immediate  fear,  the  bowels 
should  be  opened  freely  with  a  saline  purge,  chlorate  of  potash  given  internally, 
and  the  mouth  washed  out  constantly  with  an  ice-cold  solution  of  carbolic  acid  or 
permanganate  of  potash.  Fragments  of  ice  may  be  sucked  meanwhile.  In  the 
more  severe  ones,  when  the  mouth  is  nearly  filled,  leeches  may  be  applied  behind 
the  angles  of  the  jaws,  and  careful  e.xamination  made  with  the  finger  over  the 
dorsum  of  the  tongue  as  far  as  it  will  reach.  If  a  special  projection  can  be  felt,  or 
even  if  there  is  merely  a  difference  in  con.sistence,  a  puncture  should  be  made  with 
a  scalpel,  either  on  the  dorsum  in  the  middle  line,  or  below,  through  the  floor, 
according  to  its  position,  and  a  further  exploration  made  with  a  steel  director  in 
the  hope  of  finding  a  circumscribed  abscess.  In  the  most  severe  cases,  however, 
nothing  of  the  kind  is  possible,  and  all  that  can  be  done  is  to  make  a  free  incision 
down  the  dorsum  of  the  tongue  on  each  side  of  the  middle  line,  about  half  an  inch 
from  it,  and  offer  a  chance  of  escape  to  the  inflammatory  effusion.  The  depth 
need  not  be  great,  but  the  submucous  tissue  should  be  opened  up.  Afterward  the 
patient  usually  requires  a  prolonged  course  of  tonics.  Acute  glcssitis  rarely  occurs 
except  in  those  whose  health  is  already  broken  down,  and  its  course  is  so  rapid 
and  so  severe  that  death  may  ensue  simply  from  exhaustion.  Tracheotomy  may  be 
required  at  any  moment. 

Simple  Ulceration. 

This  is  usually  caused  by  friction  against  the  edge  of  a  tooth  or  plate ;  but 
the  liability  to  its  occurrence  and  its  severity  depend  very  largely  upon  the  state 
of  health  at  the  time. 

The  sore  is  generally  situated  at  the  side  or  under  the  tip  ;  it  may  be  single 
or  multiple,  according  to  the  cause.  When  quite  recent  there  is  merely  a  super- 
ficial blister  or  excoriation,  surrounded  by  a  narrow  zone  of  redness.  In  older 
cases  and  when  the  irritation  is  severe,  it  is  more  like  a  deep  cut,  extending  into 
the  substance  of  the  tongue,  with  a  sloughy  surface  and  sharply-defined  angry 
edges.  The  dorsum  near  it  is  covered  with  fur  ;  the  mucous  membrane  around  is 
swollen  and  (jedematous,  so  that  the  sore  appears  raised  above  the  level  of  the  rest ; 
the  breath  is  offensive,  and  movement  very  painful.  In  very  chronic  ones  the 
appearance  is  different  again.  The  signs  of  acute  irritation,  the  redness,  swelling, 
and  sloughing  base  are  wanting  ;  and  in  their  place  there  is  an  amount  of  indura- 
tion that  suggests  epithelioma  at  once.  It  is  in  these  that  Butlin's  method  of 
e.xamining  a  scraping  from  the  surface  (if  cocaine  is  used  a  considerable  thickness 
is  easily  obtained)  is  chiefly  useful,  and  it  should  always  be  tried  when  there  is  the 
least  suspicion. 

The  diagnosis  rests  chiefly  upon  the  position,  the  signs  of  inflammation,  and 
the  evidence  of  an  exciting  cause  If  this  can  be  found  and  removed,  either  by 
filing  down  or  extracting  a  tooth,  or  by  covering  over  a  sharp  projection  with  a 
shield  of  vulcanite,  the  irritated  surface  soon  loses  its  redness  and  begins  to  granu- 
late.    Borax,  chlorate  of  potash,  and  a  lotion  of  chromic  acid  (gr.  x.  ad  3J)  are 


INFLAMMATION  OF  THE   TONGUE. 


781 


the  most  useful  applications.  If,  however,  the  sore  is  indurated,  in  a  person  over 
forty  years  of  age,  and  if  improvement  does  not  very  soon  take  place,  a  further 
examination  should  be  made,  and  unless  it  is  perfectly  satisfactory,  there  should 
be  no  hesitation  in  excising  the  whole  affected  area.  Ulcers  of  this  kind 
frequently  leave  fissured  cicatrices  extending  some  depth  in  the  substance  of  the 
tongue. 

Chronic  Superficial  Glossitis, 

The  surface  of  the  tongue  is  liable  to  a  peculiar  variety  of  inflammation  which 
is  of  great  importance,  owing  to  its  obstinacy  and  to  the  tendency  to  pass  on  to 
epithelioma.  It  is  known  by  many  names,  and  assumes  many  forms,  but  there  is 
no  evidence  to  show  that  there  is  any  essential  difference  between  them.  A  single 
patch  is  sometimes  spoken  of  as  leuco?na  ;  the  term  chronic  siipeificial  glossitis  is 
usually  reserved  for  that  condition  in  which  the  whole  surface  is  smooth  and  red- 


I.  The  early  stage,  with 
slight  enlargement. 


Fig.  340. — Chronic  Superficial  Glossitis. 

2.  The  later  stage,  with  dense  coating  of 
epithelium,  cracked  and  fissured. 


dened,  the  papillae  having  disappeared  ;  when  a  large  portion  is  covered  with  a 
thick  milk-white  mass  of  sodden  epithelium,  it  is  called  leucoplakia  ;  a  very  rare 
condition,  in  which  the  filiform  papillse,  over  more  or  less  of  the  surface,  are 
enormously  hypertrophied,  may,  Avith  some  re.servation,  be  spoken  of  as  ichthyosis 
(it  is  not  a  congenital  affection  like  true  ichthyosis,  but  merely  an  inflamed  papil- 
lomatous growth)  ;  psoriasis,  tylosis,  keratosis,  and  other  similar  expressions  are 
not  needed. 

It  is  much  more  common  in  men  than  women,  and  rarely  occurs  under  forty 
years  of  age.  Tobacco  smoking,  raw  spirits,  hot  and  irritating  articles  of  diet, 
and  syphilis  are  usually  regarded  as  the  causes,  and  there  is  no  question  that  in  the 
majority  a  perfectly  definite  history  of  one  or  all  of  these  can  be  obtained  ;  but  it 
is  equally  true  that  it  occurs  sometimes  in  patients  who  have  never  suffered  from 
syphilis  and  who  have  never  smoked  or  drank  to  excess.  In  some  the  whole  sur- 
face soon  becomes  involved,  and  these  must  be  regarded  as  in  some  way  specially 
predisposed  to  it ;  in  others  it  remains  limited  to  small  patches  for  a  great  length 


782    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

of  time,  but  it  always  begins  opposite  some  irritant,  either  a  tooth  or  the  spot  at 
which  the  end  of  a  pipe  rests.  It  is  exceedingly  common  among  dock  laborers  at 
the  l^ast  Knd,  and  I  believe  is  due  chiefly  to  smoking,  and  very  possibly  to  the 
kind  of  tobacco. 

'I'he  appearances  differ  immensely  in  different  stages.  In  the  earliest,  one  or 
more  spots  upon  the  surface  are  smooth,  glossy,  and  redder  than  the  parts  around. 
The  mucous  membrane  is  hyi)eraimic  and  tedematous,  the  horny  layer  of  the 
epithelium  is  detached,  and  the  natural  inequalities  of  the  surface  are  leveled  up. 
The  swelling  is  not  noticeable  unless  a  considerable  portion  of  the  tongue  is 
involved  ;  then  the  increase  in  size  is  shown  by  the  deep  dej^ressions  for  the  teeth 
all  round  the  edge  (Fig.  340).  By-and-by,  as  the  epithelial  layer  continues  to  grow, 
l)luish-white,  semi-translucent  patches  make  their  appearance  here  and  there  ; 
gradually  these  become  thicker  and  more  opacpie  in  the  centre,  and  spread  further 
and  further  round  the  margin,  until  at  length,  if  the  irritation  continues,  the 
whole  surface  is  covered  over  with  a  sodden  layer  like  the  epidermis  of  the  hand 
after  it  has  been  poulticed.  Before  this  stage  is  reached  other  changes  begin. 
The  dense  covering  of  epithelium,  like  sodden  wash-leather  to  look  at,  impedes 
the  movements  of  the  tongue;  its  flexibility  is  lost;  often  it  shrinks  in  size  and 
becomes  hard  and  dense  ;  deep  cracks  and  fissures  form,  arranged  longitudinally 
and  transversely  in  a  symmetrical  pattern  ;  and,  after  a  while,  as  these  become 
more  and  more  worn,  ulceration  follows.  In  severe  cases  the  inflammation  is 
seldom  limited  to  the  tongue  itself;  not  unfrequently  the  white  patches  extend 
over  the  floor  of  the  mouth,  and  on  to  the  lips  and  i)alate  as  well. 

The  ichthyotic  variety  is  very  rare  in  comparison.  It  originates  as  an  inflam- 
matory overgrowth  of  the  papillce  at  one  or  more  i)oints.  They  grow  out  and 
form  rugged  thorn-like  masses  covered  with  sodden  layers  of  epithelium,  but  do 
not  apparently  infiltrate  the  deeper  layers  to  the  same  extent.  It  usually  occurs 
upon  the  tongue,  but  I  have  seen  a  typical  e.xample  upon  the  inner  surface  of  the 
upper  lip  caused  by  persistent  smoking. 

The  symptoms  of  which  the  jiatient  complains  are  very  slight.  There  is  a 
certain  amount  of  discomfort,  but  it  comes  on  so  slowly  that  it  is  scarcely  noticed. 
The  tongue  is  tender  ;  in  the  later  stages  it  feels  uncomfortable  and  stiff,  and  the 
sense  of  taste  is  impaired,  but  unless  the  surface  becomes  ulcerated  opposite  a  tooth 
or  deep  down  in  one  of  the  fissures,  there  is  rarely  any  actual  pain. 

The  prognosis,  except  in  the  slighter  cases,  is  very  unfavorable.  Partly,  no 
doubt,  this  arises  from  the  fact  that  the  same  causes  are  usually  allowed  to  con- 
tinue at  work,  although,  perhaps,  with  a  less  degree  of  intensity  ;  but,  indepen- 
dently of  this,  treatment  has  singularly  little  influence,  if  once  the  epithelium  has 
definitely  become  opaque.  What  proportion  of  these  cases  end  in  carcinoma  is 
very  uncertain  ;  according  to  Butlin,  the  number  is  probably  under-estimated. 
Sometimes  an  ulcer  or  a  fissure  becomes  the  seat  of  malignant  disease,  the  column 
of  epithelium  growing  down  into  the  subjacent  layers,  as  in  other  parts  of  the 
body;  but  not  unfrequently  it  develops  simultaneously  over  a  large  extent  of 
surface  in  ca.ses  in  which  the  leucomatous  condition  of  the  tongue  has  ever  been 
sufficiently  marked  to  attract  attention. 

Treatment. — All  sources  of  irritation  should  be  removed  at  once  ;  diet  must 
be  carefully  regulated,  and  smoking  prohibited  ;  it  is  clearly  impossible  even  to 
procure  relief  if  the  causes  are  allowed  to  continue.  The  rest  is  simply  palliative. 
Mercury  and  iodide  of  potash  very  rarely  effect  any  good.  Local  washes  of  bi- 
carbonate of  potash  or  borax  are  sometimes  beneficial  ;  in  other  cases  chromic 
acid  or  dilute  bicyanide  of  mercury  painted  over  the  surface  once  or  twice  a  week 
answers  better.  Caustic  should  never  be  u.sed,  but  localized  indurated  patches  or 
obstinately  persisting  ulcers  may  sometimes  be  excised,  even  though  there  is  at  the 
time  no  evidence  of  malignant  disease. 


INFLAMMATION  OF  THE  TONGUE.  783 

Syphilitic  Affections  of  the   Tonsruc. 

Primary  chancre  is  very  rare,  but  it  may  occur,  usually  near  the  tip.  'I'he 
induration  is  always  well  marked,  and  this,  together  with  the  age  of  the  patient, 
the  rapid  enlargement  of  the  glands,  and  the  influence  of  treatment,  is  the  chief 
diagnostic  feature. 

Mucous  patches  are  very  common,  and  present  immense  variety.  On  the 
dorsum  they  form  flattened  elevations  of  a  grayish-white  color,  smooth  or  slightly 
papillated  on  the  surface.  There  is  no  red  areola  surroundimg  them  and  they  are 
not  sensitive.  Under  the  tongue  they  grow  out  into  low,  cauliflower-like  projec- 
tions. At  the  tip  and  margin  where  they  are  irritated  by  the  teeth,  they  develop 
intoiJlcers.  Sometimes  these  are  superficial,  but  often,  if  there  is  a  ragged  edge, 
they  extend  deeply  into  the  mucous  and  submucous  tissue,  leaving  irregular 
fissures  and  cicatrices  when  they  heal.  In  many  cases  it  is  very  difficult,  if  not 
impossible,  to  distinguish  these  from  simple  traumatic  ulcers,  except  by  their 
persistence,  and  by  the  slight  degree  of  inflammation  around  them. 

In  the  later  stages  syphilitic  inflammation  is  almost  as  common.  vSometimes 
it  takes  the  form  of  a  rounded  gumma  deep  in  the  substance  of  the  tongue,  form- 
ing a  soft,  ill-defined  swelling,  usually  projecting  on  the  dorsum  in  the  middle 
line.  This  may  be  absorbed  and  disappear  under  treatment,  leaving  a  buried  cica- 
trix which,  without  imi)lica'ting  the  surface,  entirely  destroys  the  shape;  or  it  may 
break,  like  any  other  gumma,  and  form  a  sloughing  cavity  with  overhanging  ragged 
edges.  In  other  cases  the  exudation  is  more  diff'used,  and  numerous  small  tubercles 
are  developed  one  after  the  other,  leaving  irregular  sores  and  radiating  scars. 
Sometimes,  again,  hard  patches  make  their  appearance  in  the  mucous  and  submu- 
cous tissue,  and  grow  larger  and  larger  until  they  form  definite  elevated  plaques, 
the  surface  of  which  loses  the  papillae,  becomes  dense  and  white  and  then  breaks 
down  into  irregular  ulcers  and  fissures  ;  and  occasionally  what  is  known  as  scleros- 
ing glossitis  sets  in  ;  the  substance  of  the  tongue  is  infiltrated  more  or  less  through- 
out ;  the  natural  tissue  elements  are  destroyed,  and  an  uneven,  fissured,  hardened, 
and  distorted  mass  is  left.  As  these  different  forms  rarely  or  never  occur  by  them- 
selves, and  as  they  are  nearly  always  complicated  by  leucomatous  patches  and 
ulcers  caused  by  the  teeth,  the  ultimate  result  in  a  tongue  affected  by  severe  syphilis 
can  hardly  be  described  ;  the  shape  is  altogether  altered  ;  {t\\  or  none  of  the 
papillre  are  left;  deep  fissures  traverse  the  surface  in  all  directions;  hardened 
elevations,  covered  with  dense,  white  epithelium,  project  between,  and  ragged, 
irregular,  and  painful  ulcers  are  scattered  around  the  margins  and  at  the  bottom 
of  the  clefts. 

Diagnosis. — The  induration  in  syphilis  is  rarely  so  dense  or  so  well-defined 
as  in  epithelioma.  Other  signs  are  of  little  value  in  comparison.  Both  diseases 
are  common  at  the  same  time  of  life,  although,  of  course,  syphilis  may  occur 
earlier.  If  the  sore  is  on  the  dorsum,  if  there  is  little  pain  on  pressure  and  little 
salivation,  it  is  probably  due  to  syphilis  ;  but  it  is  impossible  to  say  more,  as  one 
so  often  develops  from  the  other.  If  there  is  the  least  doubt,  a  scraping  from  the 
surface  should  be  examined  under  the  microscope.  Iodide  of  potash  not  unfre- 
quently  causes  a  temporary  improvement  in  typical  malignant  cases  (possibly, 
because  of  the  syphilitic  foundation),  and  care  must  be  taken  not  to  be  misled 
by  this. 

Treatment. — The  constitutional  treatment  of  syphilitic  glossitis  is  most 
important ;  but  at  least  as  much  care  must  be  paid  to  local  conditions.  The 
mouth  should  be  washed  out  frequently  with  a  gargle  of  chlorate  of  potash  and 
lotio  nigra,  or  of  very  dilute  bichloride  of  mercury.  Obstinate  patches  should 
be  painted  over  every  day  with  chromic  acid  (gr.  x  ad  5J),  or  bicyanide  of  mer- 
cury (gr.  XV  ad  3J).  Iodoform,  if  the  patient  can  stand  it,  is  especially  valuable 
for  deep  ragged  ulcers ;  but  caustic,  which  stops  almost  immediately  the  progress 
of  fissures  at  the  angles   of  the  mouth,  should  never  be  used  in  the  case  of  the 


7S4     DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 

tongue.  Smoking  should  be  altogether  left  off;  very  great  attention  must  be 
paid  to  diet ;  all  hot  or  highly  seasoned  articles  of  food,  and  spirits,  avoided  ; 
and  the  teeth  carefully  examined  to  make  sure  that  no  ragged  corners  project 

and  irritate  the  surface. 

Tubercular  Disease. 

Tul)ercular  ulceration  of  the  tongue  may  occur  either  as  a  jjrimary  affection, 
or  be  secondary  to  similar  disease  in  the  lungs  or  larynx.  'I'he  diagnosis  in  the 
early  period  is  exceedingly  difficult.  The  strongest  family  or  personal  history  of 
one  disorder  does  not  exclude  the  possibility  of  another.  It  may  occur  at  any 
age  or  in  either  sex,  although  it  is  more  common,  like  most  other  affections  of 
the  tongue,  in  men.  The  tip  or  the  dorsum  is  the  part  usually  attacked  first ; 
minute  semi-translucent  vesicles  appear  in  the  mucous  membrane  ;  these  grow 
larger  and  larger  until  they  break,  leaving  shallow  ulcers  with  slightly  reddened 
edges.  Then,  by  degrees,  as  the  disease  extends,  fresh  vesicles  form  around,  and 
the  ulcers  grow  deeper  and  deeper,  until  at  length  they  develop  into  ragged  exca- 
vations, with  pale,  flabby  sides  and  bases.  There  is  no  induration,  and  this,  with 
the  age  of  the  patient,  the  history,  and  the  evidence  of  tubercle,  either  in  the 
tissues  around  or  in  other  organs,  is  the  chief  feature  distinguishing  it  from  epi- 
thelioma. The  pain  at  first  is  not  severe,  but  later,  when  the  ulceration  extends 
to  the  deeper  parts,  it  often  becomes  extreme,  and,  by  preventing  the  patient 
taking  food,  materially  hastens  the  progress  of  the  disease. 

The  prognosis,  especially  when  the  affection  is  secondary  to  disea.se  of  the 
lungs  or  larynx,  is  exceedingly  bad  ;  it  nearly  always  indicates  rapid  extension. 
Primary  tubercular  ulceration  is  more  susceptible  of  treatment.  Excision  is  some- 
times possible,  the  wound  healing  readily  ;  if  this  cannot  be  effected,  an  attempt 
may  be  made  to  destroy  the  surface  of  the  sore  by  free  scraping  and  the  actual 
cautery ;  but  if  this  is  done  it  must  be  thorough  ;  half  measures  are  worse  than 
useless.  Lactic  acid  has  been  strongly  recommended,  but  the  application  is  very 
painful.  In  more  advanced  cases  iodoform  with  borax  and  a  minute  quantity  of 
morphia  may  be  dusted  on  by  means  of  an  insufflator.  Constitutional  treatment, 
cod-liver  oil,  iron,  and  nourishing  diet,  are,  of  course,  absolutely  essential ;  and 
every  care  must  be  taken  to  protect  the  tongue  from  sharp  or  rough  edges  of  teeth, 
and  from  irritation  by  hot  or  stimulating  articles  of  diet.  Finally,  when  the  pain 
and  salivation  can  no  longer  be  controlled  by  other  mcoisures,  a  certain  amount  of 
relief  is  obtained  by  division  or  resection  of  the  lingual  nerve. 

Lupus  sometimes  extends  to  the  tongue,  causing  a  form  of  ulceration  which 
can  hardly  be  distinguished  from  this,  and  occasionally  other  varieties  of  inflam- 
mation occur,  due  to  persistent  dyspepsia,  gout,  and  (very  seldom  at  the  present 
day)  mercury. 

Tumors  of  the  Tongue. 

Ncevus  forms  a  smooth,  soft,  lobulated  swelling,  usually  of  a  purplish-red  color, 
with  a  few  brighter  spots  upon  it.  It  can  be  recognized  at  once  by  the  way  in 
which  it  disappears  on  pressure  and  slowly  fills  again,  but  it  rarely  attracts  much 
notice  unless  it  gets  in  the  way  of  the  teeth  ;  then  it  may  lead  to  serious  hemor- 
rhage. Sometimes  it  degenerates,  leaving  a  warty  growth  upon  the  surface.  If  it 
persists  or  continues  to  grow,  it  can  be  cured  by  a  single  application  of  the  cautery. 
A  similar  dilatation  of  the  lymphatics  is  sometimes  seen. 

Dermoid  h'J'/j- occasionally  develop  in  the  tongue  ;  probal)ly,  as  they  are  nearly 
always  in  the  middle  line,  from  the  hyo-lingual  canal.  Mucous  cysts,  similar  to 
those  found  on  the  lips  and  cheek,  may  occur,  especially  on  the  dorsum.  Hydatid 
cysts,  blood  cysts,  and  other  varieties  are  very  rare.  Chronic  abscess,  which  in 
many  respects  closely  recembles  a  cyst,  is  not  so  uncommon. 

Papillomata  are  frequent  at  all  ages.    They  are  distinguished  from  epithelioma 


TUMORS  OF  THE  TONGUE. 


785 


/ 


ji^ 


V 


Fig.  341. — Epithelioma  of  the  Tongue. 


by  the  absence  of  induration,  l)ut  great  care  is  re(niired  in  the  case  of  people  over 
forty  years  of  age.  If  there  is  the  least 
suspicion,  very  free  removal  of  the  base 
as  well  as  of  the  growth,  is  advisable. 
Sometimes  dendritic  condylomata  resem- 
ble them  very  closely. 

Lipomata  and  fibromata,  probably  of 
congenital  origin,  are  occasionally  met 
with,  growing  out  in  polypoid  form,  and 
one  or  two  cases  of  sarcoma  and  adenoma 
are  on  record ;  but  all  these  are  very 
exceptional. 

Squamous  epithelioma,  on  the  other 
hand,  is  exceedingly  common,  especially 
between  the  ages  of  forty  and  fifty-five. 
Before  thirty  it  is  very  rare,  and,  in  com- 
parison, it  is  seldom  met  with  in  women. 

The  immediate  cause  is  unknown, 
although  there  is  no  question  that  it  is  in 
some  way  the  outcome  of  persistent  irri- 
tation. Smoking  and  dram^drinking  un- 
doubtedly assist  in  its  production  ;  in  a 
very  large  proportion  of  cases  it  begins  in 
an  old  leucomatous  patch,  an  irritated 
papilloma,  or  a  chronic  ulcer  on  the  side 
of  the  tongue ;  syphilis  predisposes  to  it 
by  the  sores  and  scars  it  leaves  behind  ; 
it  is  not  uncommon  for  it  to  develop  at  the  seat  of  an  old  gumma,  or  even  directly 
from  a  syphilitic  ulcer  ;  but  not  one  of  these  things,  nor  all  of  them  together, 
offer  a  satisfactory  explanation  for  its  growth.  It  may  spring  from  any  ulcer, 
however  caused,  from  any  scar,  or  any  part  of  the  tongue  that  is  irritated,  whether 
by  a  tooth  or  by  caustic,  and  even  in  some  cases  apparently  from  a  healthy  surface. 

Its  first  appearance  is  equally  variable,  depending  upon  the  condition  of  the 
spot  at  which  it  grows.  There  may  be  merely  a  little  induration  at  the  ba.se  of  a 
papilloma  or  under  the  floor  of  an  ulcer  or  fissure  ;  a  leucomatous  patch  may 
insidiously  become  thick  and  dense,  or  a  nodule  may  form  quietly  without  being 
noticed  in  the  substance  of  the  mucous  membrane.  Naturallv,  from  the  causes 
that  predispose  to  its  occurrence,  it  is  more  common  on  the  edges  and  at  the  tip ; 
but  no  part  is  exempt.  However  it  forms,  when  it  is  first  seen  it  usually  has  already 
assumed  the  shape  of  an  ulcer  ;  the  epithelial  surface  has  broken  down,  and  an 
uneven,  ragged  sore  with  a  sloughing  base,  is  already  developed.  The  only  constant 
feature  is  the  induration  due  to  the  accumulation  of  the  epithelial  growth. 

The  edges  are  irregular,  raised  above  the  surrounding  part,  and  intensely 
hard  ;  the  base  may  be  covered  with  warty  granulations,  may  even  not  be  ulcer- 
ated at  all  (when,  for  example,  it  originates  from  a  papilloma  or  a  superficial  leu- 
coma),  but  it  is  always  hard.  Induration,  in  short,  is  the  distinctive  feature  of 
the  disease ;  the  only  other  affection  that  resembles  it  is  a  primary  chancre,  and 
that  is  very  rare  in  comparison  ;  and  it  is  so  marked  a  characteristic  that  any 
sore  or  warty  growth  in  a  person  over  forty  years  of  age,  that  presents  it  in  the 
least  degree,  should  be  regarded  as  exceedingly  suspicious.  It  may  be  scraped  and 
examined,  or  it  may  be  excised  at  once,  but  under  no  circumstances  should  it  be 
allowed  more  than  a  fortnight's  grace. 

Pain  may  be  present  from  the  first ;  in  the  later  stages  it  is  never  absent, 
radiating  into  the  ear  and  over  the  whole  side  of  the  face  Salivation  is  of  frequent 
occurrence  and  very  distressing,  from  the  movement  of  the  tongue  it  occasions. 
The  glands  become  enlarged  exceedingly  soon,  nearly  always  within  the  first  three 
months,  sometimes  even  earlier.     Sooner  or  later,  according  to  the  position  of  the 


7S6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

growth,  the  disease  extends  to  the  floor  of  the  mouth  or  along  the  arches  of  the 
palate  to  the  tonsil  ;  the  tongue  becomes  fixed,  and  even  the  bone  at  length 
involved.  When  this  stage  is  reached  the  suffering  becomes  intense  ;  sj^eech  and 
swallowing  are  almost  imjiossible  ;  the  pain  never  ceases  ;  salivation  is  profuse  ;  the 
mouth  is  filled  with  a  foul,  sloughing  ulcer,  and  the  strength  fails  rapidly.  Death 
usually  takes  place  in  a  year  or  eighteen  months.  The  constant  pain,  the  want  of 
food  and  sleep,  the  hemorrhage  from  the  ulcers  in  the  floor  of  the  mouth,  and  the 
sujjpuration  and  sloughing  speedily  bring  on  the  most  profound  exhaustion.  Some- 
times this  alone  is  sufficient  ;  in  other  cases  the  immediate  cause  is  an  attack  of 
bleeding  rather  worse  than  usual,  or  what  is  more  common  still,  septic  pneumonia, 
due  to  the  inhalation  of  particles  from  the  foul  and  putrid  surface.  It  is  note- 
worthy that  secondary  deposits,  other  than  those  in  the  glands  and  floor  of  the 
mouth,  are  not  so  common  in  this  variety  of  carcinoma  as  in  many  others. 

The  diagnosis  in  the  early  stages  is  often  very  difficult.  Papillomata,  syphi- 
litic and  tubercular  ulcers,  and  those  due  to  chronic  irritation,  all  liearaclose' 
resemblance  to  carcinoma,  and  not  unfrequently  pass  into  it  ;  while  it  must  be 
always  remembered  that  the  clearest  evidence  of  syphilis  does  not  preclude  in  the 
least  the  presence  of  carcinoma  too  ;  some  would  even  go  so  far  as  to  say  that  it  is 
actually  in  favor  of  it.  If  there  is  the  slightest  induration,  a  scraping  should  be 
examined,  and  unless  the  absence  of  epithelioma  is  proved  the  sore  should  be 
excised.  Small  operations  of  this  kind  are  not  in  any  way  .serious,  while  the  risk 
on  the  other  side  is  fearful.  As  already  mentioned,  no  reliance  can  be  placed  on 
temporary  improvement  under  the  influence  of  iodide  of  potash. 

Treatment. — l*Larly  removal  is  at  present  the  only  hope  of  cure.  It  is  true 
that  the  percentage  of. cases  that  have  lived  for  more  than  a  year  without  recurrence 
is  very  small,  but  when  it  is  recollected  that  hospital  patients  (and  many  private 
ones)  often  do  not  apply  for  treatment  until  months  have  passed,  and  that  then  they 
frequently  will  not  submit  to  operation  until  some  other  remedy  has  been  tried  and 
failed,  the  blame  should  not  be  laid  upon  the  operation.  It  is  certain  that  in  cases 
of  early  and  thorough  removal,  not  only  is  the  immediate  mortality  very  much  less, 
but  the  period  of  immunity  very  much  longer. 

When,  owing  to  the  position  or  extent  of  the  growth,  there  is  no  chance  of 
complete  removal,  or  when  the  carcinoma  has  returned,  much  can  still  be  done  to 
relieve  suffering.  Excision  of  the  growth  is  certainly  justifiable  if  it  offers  a  hope 
of  relief  from  pain  ;  the  stump  of  the  tongue  sometimes  remains  healthy,  even 
when  the  operation  is  too  late  to  intercept  the  glandular  enlargement.  In  excep- 
tional cases  parts  of  the  surface  may  be  destroyed  with  the  actual  cautery,  if  only 
the  painful  spot  is  limited  in  extent ;  but  discretion  must  be  used,  as  ineffectual 
cauterization  only  makes  the  growth  tenfold  more  rapi  d.  The  lingual  nerve  may  be 
divided  ;  this  nearly  always  stops  the  pain  and  salivation  at  once,  although,  unless 
a  portion  is  resected,  the  benefit  is  only  for  a  time.  In  most  cases,  however,  espe- 
cially toward  the  end,  morjjhia  is  absolutely  necessary,  and  if  it  is  given  it  should 
be  given  freely.  Butlin  recommends  dusting  the  surface  with  a  powder  comi)osed 
of  iodoform,  borax,  and  morphia. 

The  fcetor,  which  is  very  distressing,  must  be  checked  with  iodoform,  or  washes 
of  permanganate  of  potash,  dilute  carbolic  acid,  or  other  antiseptics.  A  small 
quantity  of  cocaine  may  be  added  if  the  smarting  is  severe.  Inhalations  of  euca- 
lyptus and  creasote  are  also  very  useful.  If  there  is  any  hemorrhage  it  must  be 
checked  by  local  pressure,  ice,  or  the  application  of  styptics.  The  feeding  of 
])atients  suffering  from  epithelioma  of  the  tongue  in  its  advanced  stages  is  always 
difficult.  Mastication  is  impo.ssible  ;  the  pain  is  so  intense  when  anything  touches 
the  tongue  that  deglutition  can  hardly  be  carried  out ;  and  later  the  larynx  is  often 
insufficiently  protected.  So  long  as  swallowing  is  possible  the  food  should  be 
carefully  prepared  beforehand  ;  but  in  many  cases  the  patients  after  a  little  while 
prefer  to  feed  themselves  by  means  of  a  funnel  and  soft  rubber  tube.  Toward  the 
end  even  this  may  be  impossible,  and  it  may  be  necessary  to  pass  a  tube  through 
the  nostril  or  make  use  of  nutrient  enemata. 


EXCISION  OF  THE  TONGUE.  787 

OPERATIONS  UPON  THE  TONCiUE. 

Removal  of  the  tongue  may  be  accomplished  through  the  mouth,  with  or  with- 
out previous  division  of  the  cheek  ;  or  through  the  floor  after  a  varying  amount  of 
dissection.  Division  of  the  jaw  itself  adds  very  greatly  to  the  gravity  of  the 
operation,  witliout — unless  the  disease  has  involved  the  bone — any  commensurate 
advantage. 

The  choice  of  operation  is  naturally  influenced  chiefly  by  the  seat  of  disease. 
If  the  growth  is  very  recent,  little  more  than  a  suspicious  papilloma,  and  near  the 
tip,  a  very  small  operation  through  the  mouth  may  suffice.  If  it  is  more  advanced, 
the  whole  tongue  can  be  removed  without  external  incision  ;  but  if  either  of  the 
glands  is  involved,  or  it  is  thought  (and  there  can  be  little  doubt  about  it)  that  the 
patient  stands  a  better  chance  by  removing  not  only  the  tongue  itself  but  the 
lymphatic  tissues  on  the  floor  of  the  mouth,  a  submaxillary  incision  is  es.sential. 
Removal  of  the  anterior  half  is  not  necessarily  a  serious  operation  :  removal  of  the 
whole,  whether  through  the  mouth  or  by  means  of  a  submaxillary  incision,  undoubt- 
edly is,  but  there  is  no  evidence  that  the  latter  of  these  two  methods  is  worse  than 
the  former.  An  incision  through  the  cheek  is  only  required  when  the  growth 
extends  down  the  side  of  the  tongue  in  that  direction. 

The  chief  dangers  attendant  on  removal  are' :  hetnorrhage  from  the  lingual 
arteries,  weakening  the  patient  at  the  time  and  causing  broncho- pneumonia  later  ; 
asphyxia,  from  blood  trickling  into  the  lungs,  acute  oedema  of  the  larynx,  or  falling 
back  of  the  stump  when  the  muscles  that  attach  the  tongue  to  the  symphysis  are 
divided  ;  and  especially  broticho-pncumonia.  This,  which  is  by  far  the  most  fre- 
quent cause  of  death,  is  the  result  of  blood,  particles  of  food,  or  septic  material 
from  the  foul  and  sloughing  surface  finding  their  way  down  the  trachea.  Sometimes 
there  is  gangrene  of  the  lung  ;  more  frequently  minute  scattered  points  of  consoli- 
dation, which  do  not  give  rise  to  any  physical  signs,  but  which  can  be  diagnosed 
with  almost  as  great  certainty  from  the  aspect  of  the  patient.  There  may  be  no 
rise  of  temperature,  no  pain,  and  scarcely  any  cough  ;  but  the  patient  does  not 
seem  to  rally  ;  the  face  is  dusky  and  pinched  ;  the  eyes  surrounded  by  dark  rings  ; 
the  pulse  quick  and  very  small ;  and  the  respiration  hurried  and  shallow.  If  it 
occurs  it  is  practically  fatal  ;  but  a  very  great  deal  may  be  done  in  the  way  of 
prevention  by  selecting  suitable  methods  of  operation  and  by  careful  after-treat- 
ment. 

I.   Removal  without  an  External  Incision. 

This  may  be  accomplished  either  with  scissors  (Whitehead's  method)  or  with 
an  ecraseur  (Morrant  Baker's)  ;  the  galvano-cautery  is  practically  abandoned, 
owing  to  the  extensive  sloughing  it  causes. 

{a)  The  scissors  used  by  Whitehead  are  flat  and  straight,  sharp  up  to  the  tips, 
which  are  square  and  blunted.  The  patient  is  placed  under  an  anaesthetic  in  the 
position  that  will  secure  the  best  light ;  chloroform  is  usually  preferred,  given  by 
means  of  a  rubber  ball  syringe  ;  but  even  more  than  the  usual  amount  of  caution 
is  necessary,  and  unless  a  preliminary  laryngotomy  is  performed,  the  administrator 
must  watch  with  the  greatest  care  that  no  blood  trickles  down  into  the  trachea. 
The  hands  may  be  fastened  to  the  side,  but  nothing  should  pass  round  the  chest ; 
and  the  body  should  not  be  fastened  to  the  operating  table,  as  it  may  be  necessary 
at  any  moment  to  roll  the  patient  over  on  to  his  side  and  syringe  out  the  mouth  in 
order  to  free  it  from  blood. 

As  soon  as  the  patient  is  anaesthetized,  Coleman's  or  Mason's  gag  is  placed 
between  the  teeth  on  the  side  opposite  to  the  operator,  and  entrusted  to  an  assistant, 
who  attends  to  this  and  to  the  sponging.  The  lips  can  be  drawn  out  of  the  way 
with  retractors  fastened  to  an  elastic  band,  if  it  is  considered  necessary.  A  double 
silk  ligature  is  then  passed  well  through  the  substance  of  the  tongue  and  given  to  a 
second  assistant. 

The  operator  begins  by  cutting  the  raucous  membrane  that  extends  from  the 


788     DISEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 

tongue  to  the  alveolar  process,  keeping  close  to  the  bone.  The  anterior  pillar  of 
the  fauces  and  the  structures  that  attach  the  tongue  to  the  jaw  come  next,  the 
assistant  meanwhile  keeping  the  tongue  well  forward  ;  then  the  muscles  that  form 
the  base  are  cut  across  by  a  series  of  successive  snips  until  the  entire  structure  is 
separated  on  the  plane  of  the  inferior  border  of  the  lower  jaw,  and  as  far  back  as 
the  safety  of  the  epiglottis  permits.  The  arteries  are  tied  or  twisted  as  they  are 
divided,  and  a  ligature  passed  through  the  remains  of  the  glosso-epiglottic  fold  to 
draw  the  stump  forward,  in  case  of  secondary  hemorrhage. 

Whitehead  has  never  found  any  difficulty  in  securing  the  arteries.  If  there  is 
any  bleeding  it  can  be  controlled  at  once  by  passing  the  finger  behind  the  root  of 
the  tongue,  drawing  it  forward  and  pressing  it  toward  the  opposite  side,  as  Heath 
recommends.  Jacobson,  with  the  view  of  avoiding  it,  merely  cuts  a  deep  groove 
through  the  mucous  membrane  on  the  side  and  dorsum,  and  then  tears  the  soft 
muscular  tissues  with  closed  scissors  until  the  artery  and  nerve  are  seen.  Billroth 
ties  the  linguals  first,  but  those  who  have  followed  out  Whitehead's  directions 
generally  consider  it  unnecessary. 

[The  hemorrhage  is  certainly  and  easily  controlled  by  passing  an  eyed  trans- 
fixion needle  through  the  skin  and  upward  through  the  base  of  the  tongue  in  the 
centre.  A  heavy  ligature  is  now  passed  into  the  eye  to  the  middle  of  the  ligature  ; 
the  needle  is  now  withdrawn,  bringing  the  ligature  with  it,  which  is  cut  to  release 
the  needle,  which  is  then  thrust  through  the  same  skin  opening,  and  pushed  into 
the  mouth  close  by  the  side  of  the  tongue  opposite  the  ligature.  One  of  the  free 
ends  is  now  threaded  into  the  eye  of  the  needle  and  withdrawn  with  it.  The 
needle  is  now  thrust  through  at  the  other  side  of  the  tongue  and  the  remaining  end 
threaded  and  withdrawn.  The  ends  are  now  tied  firmly,  and  both  linguals  are 
securely  comj^ressed.] 

(/;)  When  the  ecraseur  is  used  the  preliminary  steps  are  the  same,  but  two 
ligatures  are  passed  through  the  tongue,  one  through  each  half,  and  the  whole  organ 
divided  down  the  median  septum.  If  the  dorsum  and  tip  are  cut  fairly  deeply  with 
a  straight  blunt-pointed  bistoury,  the  two  halves  can  be  separated  from  each  other 
with  the  forefinger  without  causing  any  material  hemorrhage.  The  mucous  mem- 
brane and  the  muscles  passing  from  the  jaw  to  the  tongue  are  divided  as  before  ; 
and  then,  as  soon  as  the  two  halves  are  thoroughly  freed  as  far  back  as  is  considered 
advisable,  a  loop  of  stout  whip-cord  attached  to  an  ecra.seur  is  passed  over  each. 
The  section  should  be  from  the  middle  line  outward,  and  the  loop  may  be  tightened 
fairly  quickly  at  first,  but  as  soon  as  any  resistance  is  felt  not  more  than  one  turn 
should  be  made  in  the  minute.  Very  frequently  the  vessels,  with,  perhaps,  the 
nerve,  are  dragged  out  in  a  long  loop,  when  they  can  be  easily  secured  and  tied. 
If  the  whole  of  the  structures  that  attach  the  tongue  to  the  jaw  have  been  divided, 
it  is  advisable  to  fasten  the  stump  to  the  mucous  membrane  at  the  side  of  the  mouth 
by  means  of  sutures,  for  fear  of  its  falling  back. 

It  is  very  difficult  to  estimate  the  relative  advantages  of  the.se  methods,  as  they 
both  require  a  considerable  degree  of  skill,  and  operators  are  naturally  inclined  to 
that  which  they  have  practiced  most.  Morrant  Baker's  is  the  easier,  and  if  the 
ecraseur  is  only  used  slowly,  is  practically  exempt  from  bleeding.  On  the  other 
hand,  it  tends  to  make  the  stum])  convex,  although  this  is  concealed  by  the  mus- 
cular contraction,  and  it  is  probable  that  the  amount  of  bruising  is  greater.  Cer- 
tainly this  was  the  case  with  the  old  chain  ecraseur.  Contrasted  with  this,  the 
scissors  are  sometimes  followed  by  serious  hemorrhage,  but  the  operator  can  see  the 
whole  time  what  he  is  doing. 

It  is  still  an  open  question  whether  it  is  ever  advisable  to  leave  half  the 
tongue.  In  most  instances  it  bends  round  upon  itself,  owing  to  the  contraction 
of  the  cicatrix,  and  only  becomes  an  incumbrance  ;  but  occasionally  it  moulds 
itself  into  shape  and  assists  both  in  speaking  and  swallowing. 

Preliminary  laryngotomy  is  advocated  by  many,  and  no  doubt  jjossesses  great 
advantages,  with  slight,  if  any,  additional  risk.  The  fauces  can  be  plugged  so 
that  no  blood  can  possibly  pass  down  ;    the  administration  of  the  anoesthetic  is 


EXCISION  OF  THE  TONGUE.  789 

easier  ;  the  month  can  be  sponged  freely  if  there  is  any  bleeding  :  and  the  operator 
can  proceed  ([uietly  and  deliberately.  As  Jacobson  points  out,  when  scissors  are 
used  the  amount  of  swelling  and  inflammation  after  the  operation  is  so  slight  that 
there  is  no  need  to  retain  the  cannula  after  the  patient  has  rallied  from  the 
anaesthetic. 

If  any  glands  require  removal,  or  if  there  is  any  infiltration  in  the  floor  of  the 
mouth,  a  separate  incision  is  advisable.  The  dissection  in  such  cases  must  neces- 
sarily be  very  thorough  if  it  is  attempted. 

2.  Removal  isv  Sub-maxillary  Incision. 

Of  these,  by  far  the  best  is  that  devised  by  Kocher,  who  performs  it  under  the 
carbolic  si)ray. 

A  preliminary  tracheotomy  is  performed  and  an  ordinary  cannula  inserted. 
Entry  of  blood  is  prevented  by  plugging  the  pharynx  with  a  sponge  soaked  in  car- 
bolic acid.  The  incision  runs  along  the  anterior  border  of  the  sterno-mastoid 
from  the  ear  nearly  down  to  the  middle  of  the  muscle  ;  from  this  it  turns  forward 
to  the  hyoid  bone  and  along  the  anterior  border  of  the  digastric  to  the  symphysis. 
A  flap,  containing  skin,  platysma,  and  fascia  is  reflected  upward  ;  the  facial  artery 
and  vein  tied  ;  the  lingual  secured  on  the  hyoglossus  ;  and  the  sub-maxillary  fossa 
completely  cleared  out,  beginning  from  behind.  All  the  cellular  tissue  is  removed, 
together  with  the  lymphatic  glands,  and  the  sub-maxillary  and  sub-lingual  ones  if 
they  appear  involved.  The  mylo-hyoid  muscle  is  then  separated,  the  mucous  mem- 
brane divided,  and  the  tongue  drawn  through  the  opening.  If  the  whole  thick- 
ness is  removed  the  opposite  lingual  must  be  tied  as  well. 

Before  commencing  the  operation  the  mouth  and  the  nasal  cavities  are  thor- 
oughly washed  out  with  a  solution  of  perchloride  of  mercury  (i  in  2000)  ;  and 
after  it  is  finished  and  the  wound  adjusted  with  sutures  the  surface  of  the  stump 
and  the  pharynx  behind  it  are  covered  over  completely  with  a  sponge  soaked  with 
carbolic  acid.  The  dressings  are  changed  twice  a  day,  advantage  being  taken  of 
the  opportunity  to  pass  an  oesophageal  tube  and  feed  the  patient  ;  for  the  rest 
nutrient  enemata  are  used.  The  operation  is  undoubtedly  more  extensive  than 
the  others,  but  it  is  believed  that  this  is  amply  compensated  for  by  the  thorough- 
ness with  w^hich  the  whole  of  the  affected  tissues  is  removed  and  the  way  in  which 
the  risk  of  septic  inflammation  and  pulmonary  complications  is  avoided.  Kocher 
himself  has  been  very  successful  as  regards  immediate  mortality,  but  the  operation 
does  not  seem  to  have  been  performed  by  other  surgeons  to  any  great  extent. 

The  after-treatment  of  these  cases  requires  even  more  than  ordinary  care. 
Every  endeavor  must  be  used  to  prevent  putrefaction,  which,  owing  to  the  tem- 
perature, moisture,  and  alkaline  reaction,  is  very  prone  to  follow;  the  patient's 
strength  must  be  husbanded  and  maintained  in  everyway;  and  precautions  taken 
to  prevent  food  or  the  discharge  from  the  wound  entering  the  lungs.  With  this 
in  view,  Kocher  fills  the  entire  cavity,  from  the  edge  of  the  wound  back  into  the 
mouth  and  pharynx,  w^th  a  sponge  soaked  in  carbolic  acid  solution,  shutting  off 
the  naso-pharyngeal  cavity  on  the  one  hand  and  the  larynx  and  pharynx  on  the 
other.  The  same  object  may,  however,  be  achieved  much  more  satisfactorily  by 
means  of  a  plan  recommended  by  Barker.  The  whole  wound  is  carefully  cleansed, 
dried,  and  dusted  with  iodoform,  and  the  two  ends  of  the  incision  sutured.  In  the 
middle  a  piece  of  rubber  tubing  is  adjusted,  long  enough  to  reach  well  down  into 
the  oesophagus  ;  and  all  the  space  around  is  carefully  packed  with  antiseptic  wool. 
This  can  be  left  untouched  for  days,  the  patient  being  easily  fed  by  means  of  a 
funnel  as  often  as  it  may  be  required. 

The  ordinary  practice,  when  the  tongue  is  removed  through  the  mouth,  is 
either  to  wash  the  cavity  out  at  frequent  intervals  with  a  dilute  antiseptic,  or  to 
keep  the  surface  of  the  w-ound  as  dry  as  possible  by  means  of  iodoform.  Drainage 
is  not  very  successful ;  a  large  tube  may  be  passed  through  the  floor  of  the  mouth 
and  fixed  at  the  proper  level,  but  it  is  of  little  use  except  to  secure  a  thorough  flow 


790     DISEASES  AND  INJURIES    OF  SPECIAL   STRUCTURES. 

of  the  antiseptic  across  the  surface  of  the  woiiiul.  If  the  first  method  is  preferred 
it  is  a  wise  precaution  to  make  the  i)atient  practice  washing  out  the  mouth  before- 
hand, as  there  is  sure  to  be  a  certain  amount  of  awkwardness  at  first.  Immediately 
after  the  ojjeration  the  surface  of  the  wound  is  brushed  over  with  chloride  of  zinc, 
or  better  with  Whitehead's  varnish  (Friar's  balsam,  in  which  a  saturated  solution  of 
iodoform  in  ether  has  been  substituted  for  rectified  spirit),  and  as  soon  as  the  effects 
of  the  anaesthetic  have  thoroughly  passed  off  and  the  patient  has  rallied,  the  mouth 
is  washed  out  at  frequent  intervals  with  a  dilute  solution  of  carbolic  acid  or  per- 
manganate of  potash,  the  head  being  held  on  one  side  so  that  none  of  the  discharge 
is  swallowed.  In  addition,  the  surface  of  the  wound  may  be  brushed  over  four  or 
five  times  a  day  with  a  solution  of  iodoform,  or  the  patient  may  inhale  eucalyptus 
vapor  or  some  other  volatile  antiseptic. 

In  most  cases,  however,  there  is  no  difficulty  in  keejjing  the  surface  of  the 
wound  dry.  The  simplest  method  is,  at  the  time  of  the  operation,  to  fill  the  cavity 
with  iodoform  (after  sponging  it  out)  and  rub  it  well  into  the  surface,  or  to  use 
Whitehead's  varnish.  The  more  scientific  plan  is  to  prepare  some  gauze  with 
iodoform  (by  means  of  glycerine  and  colophony  dissolved  in  alcohol),  cut  it  into 
strips,  and  pack  the  whole  cavity  with  these,  laying  them  flat  one  upon  the  other, 
with  fresh  iodoform  between  until  the  wound  is  filled.  The  deeper  layers  adhere 
to  the  raw  surface,  from  which  they  cannot  be  separated  until  it  has  begun  to 
granulate  ;  the  superficial  ones,  sodden  with  saliva,  may  be  removed  and  renewed 
from  time  to  time.  At  the  end  of  a  {<i.w^'  days  the  whole  comes  away  of  itself, 
leaving  a  healing  surface  beneath.  Even  this,  however,  will  not  altogether  prevent 
septic  pneumonia.  Probably,  in  those  whose  tissues  are  healthy  and  well- 
nourished,  either  of  these  plans  would  succeed  ;  the  wound  in  the  floor  of  the 
mouth  would  not  slough  to  any  extent  and  the  lungs  would  be  able  to  resist  infec- 
tion. In  those,  on  the  other  hand,  who  are  already  broken  down  by  exhaustion, 
privation,  consciousness  of  the  presence  of  cancer,  and  perhaps  past  intemperance, 
it  is  almost  impossible  to  prevent  sloughing. 

The  general  treatment  re(]uires  an  equal  amount  of  care.  Speaking  must  be 
prohibited  ;  all  foods  given  either  by  means  of  a  soft  rubber  tube  and  funnel 
through  the  mouth  (it  is  well  that  the  patient  should  have  practiced  this  before- 
hand), or  for  the  first  few  days  by  the  rectum  ;  stimulants  in  moderation  are  nearly 
always  beneficial ;  and  of  course  all  food  must  be  liquid.  It  is  not  advisable  to 
relax  a  single  precaution  until  the  surface  of  the  wound  has  begun  to  clean.  The 
patient  should  be  encouraged  to  sit  up  in  bed  as  soon  as  he  can,  the  second  day  if 
possible;  but  care  must  be  taken  to  keep  him  warm  and  to  avoid  anything  of  the 
nature  of  a  draught. 

Operations  on  the  Lingual  Nerve. 

The  lingual  nerve  may  be  stretched,  divided,  or  resected,  to  relieve  the  pain 
and  salivation  in  carcinoma,  and  for  neuralgia  of  the  tongue.  Of  these  operations, 
the  first  has  not  been  performed  a  sufficient  number  of  times  to  enable  an  opinion 
to  be  formed  as  to  its  value  ;  the  second  is  of  undoubted  service,  but  only  for  a 
short  time ;  in  a  month  or  so  sensation  begins  to  return,  and  pain  with  it ;  the 
third  is  more  hopeful. 

The  patient  is  placed  under  an  anaesthetic,  and  the  tongue  forcibly  pulled  out 
of  the  mouth  with  a  broad  pair  of  tongue- forceps  toward  the  oiiposite  side. 
When  this  is  done  the  lingual  nerve  stands  out  beneath  the  mucous  membrane  as  a 
tense  band,  stretching  from  the  margin  of  the  internal  pterygoid  to  the  side  of  the 
tongue.  A  sharp-pointed  hook  can  then  be  placed  beneath  it,  the  tension  on  the 
tongue  relaxed,  and  the  mucous  membrane  over  the  nerve  divided  sufficiently  to 
enable  it  to  be  seen  and  isolated.  The  longer  the  portion  that  is  removed  the 
better. 

Section  is  easily  performed  by  what  is  known  as  Moore's  method.  An  inci- 
sion about  three-quarters  of  an  inch  in  length  is  made  through  the  mucous  mem- 


TONSILLITIS.  79 1 

brane  in  a  line  from  the  last  molar  tooth  to  the  angle  of  the  jaw.  The  finger  is 
passed  down  to  the  bulging  alveolar  border  to  act  as  a  guide  ;  a  curved  bistoury 
is  used  so  as  to  get  in  under  the  projection  ;  and  everything  is  divided  down  to 
the  bone. 

DISEASES  OF  THE  TONSILS. 

The  tonsils  lie  between  the  pillars  of  the  fauces  covered  with  mucous  mem- 
brane. Immediately  outside  is  the  superior  constrictor  of  the  pharynx,  by  which 
they  are  separated  from  the  internal  carotid  and  ascending  pharyngeal  arteries. 
Of  these  the  former  lies  about  half  an  inch  behind  and  to  the  outer  side  ;  but,  if 
it  is  thrown  into  curves,  it  may  approach  nearer.  The  latter  appears  insignifi- 
cant ;  but,  if  wounded,  the  hemorrhage  is  scarcely  less  serious. 

Inflammation. 

{a)  Simple  catarrhal  or  erythematous  tonsillitis  sometimes  occurs  by  itself, 
caused  by  fatigue  or  exposure  to  cold  and  wet ;  but  m.ich  more  often  it  is  merely 
part,  and  the  most  insignificant  part,  of  a  general  disorder,  such  as  acute  rheumatic 
fever,  scarlatina,  or  septicaemia  induced  by  the  inhalation  of  foul  air  or  sewer  gas. 
The  symptoms  under  these  circumstances  naturally  present  no  sort  of  relation  to 
the  affection  of  the  throat ;  there  may  be  a  rigor  with  very  high  temperature,  as  in 
scarlatina,  or,  on  the  other  hand,  the  most  profound  depression,  so  as  to  suggest 
typhoid,  as  in  poisoning  by  foul  air ;  nor  is  there  anything  in  the  throat  itself  by 
which  one  condition  can  be  diagnosed  from  the  other.  The  surface  is  reddened  ; 
there  is  a  slight  amount  of  swelling  involving  the  soft  palate  and  fauces  as  well  as 
the  tonsil ;  the  throat  feels  hot  and  dry  ;  often  there  is  a  tickling  or  aching  sensa- 
tion in  the  ear ;  hearing  is  impaired  ;  swallowing  painful  ;  and  in  severe  cases 
there  is  tenderness  on  pressure  behind  the  angles  of  the  jaw.  If  the  inflammation 
continues,  the  swelling  becomes  more  and  more  prominent  ;  white  specks  formed 
of  sodden  epithelium  mixed  with  mucous  and  leptothrix  filaments  make  their 
appearance  in  the  depressions  of  the  gland,  and  the  follicles  themselves  become 
involved. 

{b)  Follicular  tonsillitis  may  be  acute  from  the  beginning,  when,  for  example, 
it  results  from  catarrhal  inflammation  ;  but  more  frequently  it  is  chronic  and  per- 
sistent, varied  every  now  and  then  by  acute  or  subacute  attacks.  The  swelling 
involves  the  gland  only  ;  the  mucous  membrane  around  is  but  slightly  affected  ; 
the  surface  is  very  uneven  ;  all  the  crypts  and  depressions  are  filled  with  drops  of 
muco-pus,  and  when  these  are  detached  or  squeezed  out  funnel-shaped  ulcers  are 
left.  The  readine.ss  with  which  inflammation  breaks  out  and  the  persistent  ten- 
dency to  sore  throat  in  those  who  suffer  from  this  condition  may  be  traced  to  the 
presence  of  these  foul  decomposing  masses  of  epithelial  debris,  mucus,  fragments 
of  food,  and  leptothrix  filaments.  Each  one  acts  as  a  source  of  infection  for  all 
the  structures  around,  giving  rise  to  an  acute  attack  if,  from  any  cause,  there  is 
the  least  hyperaemia  or  abrasion  of  the  epithelium. 

{c)  Hypertrophy  of  the  Tonsils. — Chronic  enlargement  of  the  tonsils  is  espe- 
cially prone  to  occur  in  children,  owing  in  part  to  the  much  greater  activity  of 
the  lymphatic  tissue  in  the  early  years  of  life,  and  in  many  cases  is  associated  with 
a  similar  enlargement  of  the  submaxillary  glands.  Practically  it  is  the  outcome 
of  constant  irritation,  not  sufficiently  severe  to  cause  either  catarrhal  or  follicular 
inflammation,  though  these  are  often  present  as  complications,  and  it  affects  espe- 
cially the  adenoid  tissue.  It  is  always  bilateral,  though  very  often  one  is  consid- 
erably larger  than  the  other. 

If  the  tonsils  are  not  inflamed,  the  surface  is  pale  and  smooth,  or  reticulated, 
from  the  widely  stretched  orifices  of  the  crypts,  which  are  much  more  shallow  than 
natural ;  but  often  they  are  reddened,  congested,  and,  if  there  is  any  inflamma- 
tion of  the  follicles,  dotted  a'l  over  with  yellowish- white  patches,  each  of  which 


792    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

is  surrounded  by  a  brighter  ring.  There  is  little  or  no  pain,  unless  the  inflamma- 
tion is  acute,  and  no  fever  ;  but  the  voice  is  altered,  assuming  a  nasal  tone  ;  respira- 
tion is  interfered  with,  so  that,  particularly  in  rickety  children,  the  chest  falls  in 
and  becomes  pigeon-breasted  ;  hearing  is  impaired  ;  the  child  is  comjjelled  to 
breathe  through  its  mouth,  and  snores  at  night  ;  the  aspect  becomes  stupid  and 
vacant  ;  active  exercise  is  rendered  difficult ;  the  blood  is  imperfectly  aerated,  and 
the  general  nutrition  is  seriously  affected.  Very  often  attacks  of  subacute  or 
follicular  tonsillitis  occur  as  well,  this  condition  apparently  acting  as  a  predispos- 
ing cause  ;  and  then  the  enlargement  may  become  serious,  and  cau.se  attacks  of 
very  alarming  suffocating  spasm  at  night. 

{d')  Acute  suppurative  tonsillitis,  or  quinsy,  either  commences  in  the  tonsil 
itself,  when,  as  a  rule,  there  are  a  number  of  small  abscesses  side  by  side,  and  the 
symptoms  are  not  of  the  most  severe  type,  or  in  the  cellular  tissue  around  the 
gland.  It  appears  to  be  due  to  the  same  causes  as  follicular  and  erythematous 
tonsillitis,  acting  with  greater  intensity,  or  affecting  tho.se  who  are  broken  down 
in  health  by  over-work  or  other  troubles.  The  periglandular  form  is  practically 
confined  to  adult  life,  and  has  a  marked  tendency  to  return  at  distant  intervals. 
Sometimes  it  affects  the  retro-pharyngeal  tissue  rather  than  the  neighborhood  of 
the  tonsil  itself,  and  it  is  distinguished  by  the  way  in  which  the  tonsil  is  concealed 
from  view  ;  the  arch  of  the  palate  is  enormously  swollen  ;  the  mucous  membrane 
covering  the  anterior  pillar  of  the  fauces  and  the  side  of  the  tongue  and  mouth  is 
a  dusky  red  ;  the  glands  under  the  jaw  are  enlarged,  and,  in  the  worst  cases,  the 
loose  cellular  tissue  that  extends  between  the  jaws  and  fills  up  the  side  of  the  neck 
and  the  floor  of  the  mouth  is  involved  as  well,  so  that  a  huge  swelling  forms  all 
over  that  side  of  the  face,  and  the  teeth  cannot  be  separated  from  each  other  even 
to  allow  the  tip  of  the  tongue  to  protrude.  Fortunately,  this  very  severe  form 
seldom  affects  the  two  sides  at  the  same  time,  and  suppuration  rarely  occurs  in 
both.  The  onset  is  sudden,  with  a  succession  of  severe  chills,  and  the  tempera- 
ture may  rise  to  103°  to  104°  F.  From  the  first  there  is  unusual  depression  and 
anxiety  ;  the  pain  is  very  severe,  especially  in  the  ear,  but  radiating  all  over  the 
face  ;  salivation  is  often  profuse,  and  there  is  a  constant  secretion  of  viscid  muci  s 
at  the  back  of  the  throat,  causing  great  distress  by  exciting  the  reflex  movements 
of  deglutition.  Breathing  is  difficult,  swallowing  almost  impossible  ;  the  jaws  are 
rigidly  fixed,  partly  from  the  pain,  partly  owing  to  reflex  muscular  contraction  ; 
and,  as  pus  begins  to  form,  the  throbbing  becomes  almost  unbearable.  In  the 
slighter  cases — those  which  affect  the  tonsil  itself — a  number  of  minute  abscesses 
are  usually  present,  and  break  one  by  one  into  the  interior  of  the  mouth  ;  in  the 
more  severe  ones,  when  there  is  acute  periglandular  inflammation,  the  pus  may 
burst  in  the  same  direction  at  the  end  of  the  fifth  or  sixth  day,  giving  great  and 
immediate  relief,  or  may  work  its  way  into  the  soft  palate,  or  even  sometimes  down 
into  the  neck,  before  it  can  be  evacuated.  Even  when  the  attack  has  been  of  short 
duration  it  always  leaves  a  condition  of  serious  debility. 

Treatment. — The  constitutional  treatment  of  acute  tonsillitis  depenc's 
naturally  upon  the  disorder  with  which  it  is  associated.  If  none  can  be  found, 
all  that  can  be  done  is  to  meet  the  symptoms  as  they  arise,  giving  quinine,  .sali- 
cylate of  soda,  or  antipyrin  when  the  temperature  is  high  ;  and  tonics,  and  espe- 
cially iron,  after  the  acute  stage  has  subsided.  Chronic  hypertrophy,  on  the  other 
hand,  is  nearly  always  associated  with  that  peculiar  susceptibility  to  inflammation 
which  finds  its  highest  development  in  what  is  known  as  scrofula,  and  must  be 
met  from  the  first  with  tonics,  iron,  cod-liver  oil,  good  food,  and  sea  air. 

The  local  treatment  must  be  guided  by  the  severity  of  the  attack.  In  the 
milder  forms,  which  are  frequently  associated  with  a  relaxed  condition  of  the  mu- 
cous membrane  of  the  palate  and  uvula,  astringent  gargles  (of  alum,  bichloride  of 
mercury  with  decoction  of  cinchona,  etc.)  are  sufficient.  In  more  severe  cases,  in 
which  there  are  numerous  points  of  follicular  inflammation,  the  accumulated  debris 
may  be  removed  by  washing  out  the  mouth  with  hot  salt  and  water,  and  then  the 
surface  thoroughly  brushed  with   nitrate  of  silver  (gr.  xx  ad  3J),  glycerine,  and 


TONSILLITIS. 


193 


tannic  acid,  or  glycerine  and  perchloride  of  iron.  Much  of  the  discomfort  of 
this  proceeding  may  be  removed  by  using  a  sohition  of  cocaine  first ;  but  even 
then  in  children  it  is  often  a  matter  of  great  difficulty.  Sometimes  a  hand  spray 
may  l)e  used,  or  creasote  vapor  inhaled  from  hot  water,  but  the.se  remedies  are 
chiefly  beneficial  from  a  preventive  point  of  view. 

In  chronic  hypertrophy,  when  there  is  a  mass  projecting  inward  behind  the 
anterior  i>illar  of  the  fauces,  nothing  but  excision  is  of  any  avail ;  and  the  same 
treatment  should  be  recommended  for  those  cases  of  follicular  tonsillitis  in  which 
the  patient  is  constantly  suffering  from  recurrent  attacks,  occasioned  by  the  reten- 
tion of  the  decomposing  discharge  on  the  surface  of  the  gland.  Moreover,  it 
seems  probable  that  tonsils  affected  in  this  way  are  more  prone  to  be  attacked  by 
diphtheria  than  others,  the  membrane  beginning  in  the  crypts  and  growing  out 
from  them  over  the  epithelial  surface  ;  and  this  alone  would  be  a  most  efficient 
reason. 

As  an  alternative  the  application  of  the  galvano-cautery  is  sometimes  made 
use  of.  The  throat  must  be  thoroughly  penciled  with  cocaine,  and  the  burner 
applied  while  cold  to  the  surface  of  the  gland  ;  the  current  is  then  turned  on  and 
a  sufficient  amount  of  tissue  destroyed  to  make  sure  of  a  smooth,  dense  cicatrix 
when  the  wound  heals.  The  pain  is  said  to  be  slight,  and  to  be  relieved  by  suck- 
ing small  fragments  of  ice  for  an  hour  or  two  afterward. 

Acute  phlegmonous  inflammation  requires  more  vigorous  measures.  An 
attempt  may  be  made  to  cut  the  attack  short  at  its  onset  by  giving  aconite  (n\^j 

every  half-hour)  until  there  is  a  distinct 

;      '^^  effect  upon   the  pulse ;  but  it  rarely  suc- 

\  \  ceeds.      The    bowels    should    be    opened 

\  \  freely,  while  the  patient  can  still  swallow 

\^  \  without  much  difficulty ;   ice  placed  around 

the    neck,    small    fragments    kept    in    the 

^■\         \  mouth ;    the    patient    induced   to   take  as 

'^.^^       \  much  liquid  food  as  he  can  ;  and  the  surface 

of  the  swelling  explored  with  the  finger, 


Fic.  342. — Tonsillotcme. 

cocaine  being  used  freely  both  to  relieve 
the  pain,  so  that  the  patient  may  be  able 
to  open  his  mouth,  and  to  prevent  the 
spasmodic  contraction  of  the  muscles  of 
deglutition,  produced  by  touching  the 
surface.  If  any  spot  can  be  found  that  is 
softer  or  more  yielding  than  the  rest,  a 
puncture  should  be  made  in  it  with  a  bis- 
toury, the  blade  of  which  is  protected  up  to  within  an  inch  of  the  point  by  means 
of  strapping  wrapped  around  it.  The  tongue  must  be  held  down  out  of  the  way ; 
the  edge  of  the  blade  must  point  upward  and  inward,  and  the  puncture  be  made 
just  through  the  margin  of  the  anterior  pillar  (which  is  forced  prominently  into 
the  mouth),  perfectly  straight  from  before  backward. 

Excision  of  the  tonsil  may  be  performed  with  a  bistoury,  but  it  is  much  more 
satisfactory  to  employ  a  tonsillotome  or  guillotine.     The  simplest  consists  merely 
of  a  ring  to  slip  over  the  projection,  with,  on  its  inner  margin,  a  groove,  carry- 
ing a  blade.      Both  ring  and   blade  are  on  the  same  handle,  one  gliding  on  the 
51 


794    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

other.  A  more  complicated  one  carries  a  forked  spear  as  well :  this,  by  means 
of  a  spring,  transfixes  the  growth  and  draws  it  slightly  inward  toward  the  middle 
line,  making  it  secure,  and  ensuring  sufficient  being  taken  away.  The  assistant 
stands  behind  the  patient,  holding  the  head  so  that  the  light  falls  into  the  mouth, 
and  pressing  with  his  fingers  just  behind  the  angles  of  the  jaws  in  order  to  steady 
the  tonsils.  An  ancesthetic  may  be  used,  but  even  in  children  cocaine  is  sufficient. 
The  operator  stands  in  front,  and  it  is  of  great  advantage  to  him  if  he  can  use  his 
two  hands  equally  well.  As  much  of  the  growth  as  projects  beyond  the  pillar  of 
the  fauces  should  be  removed,  for  although  the  cicatrix  contracts  to  some  slight 
degree,  it  really  produces  very  little  effect  if  the  gland  contains  much  soft  adenoid 
tissue.  When,  owing  to  the  frequency  of  follicular  inflammation,  it  is  denser  and 
more  fibrous,  there  is  less  probal)ility  of  the  growth  recommencing.  Both  tonsils 
should,  if  they  require  it,  be  removed  at  the  same  sitting  ;  the  pain  and  incon- 
venience are  not  materially  greater  than  when  one  is  taken  away,  and  the  cure  is 
effected  in  half  the  time. 

Hemorrhage  that  does  not  stop  on  the  application  of  ice  is  very  rare.  If 
capillary  oozing  continues  to  any  serious  extent,  perchloride  of  iron  or  some  other 
styptic  must  be  employed.  It  has,  however,  been  necessary  to  tie  the  common 
carotid. 

In  addition  to  these  the  tonsil  is  liable  to  be  attacked  by  various  forms  of 
specific  inflammation.  Diphtheria,  for  example,  not  unfrequently  begins  upon  the 
tonsil,  starting  from  an  apparently  simple  attack  of  follicular  tonsillitis  and  spread- 
ing thence  to  the  mucous  membranes  around.  Scarlatinal  ulceration  may  occur, 
and  open  up  the  internal  carotid  by  the  sloughing  it  causes.  The  same  thing  may 
happen  in  severe  cases  of  blood-poisoning,  such  as  result  from  the  inhalation  of 
sewer  gas.  Syphilis  very  often  attacks  them  ;  there  are  very  few  cases  of  primary 
chancre,  it  is  true,  but  a  peculiar  circular  and  sometimes  punched-out  ulcer  is 
nearly  invariable  in  the  early  secondary  stage,  and  very  extensive  ulceration  may 
occur  at  a  later  period,  destroying  the  soft  palate  and  the  pillars  of  the  fauces,  and 
dragging  the  base  of  the  tongue  backward  by  the  cicatrization  it  entails.  Tuber- 
cular disease  is  more  rare,  and  in  the  earlier  stages  is  difficult  of  diagnosis;  later, 
when  the  ulceration  becomes  general,  it  is  scarcely  possible  to  tell  in  what  part  the 
disease  began. 

Tonsillar  calculi  are  not  uncommon,  caused  in  all  probability  by  the  gradual 
inspissation  of  the  masses  of  muco-pus  that  are  found  buried  in  some  of  the  follicles. 
In  composition  they  resemble  the  tartar  that  collects  upon  the  teeth,  and  they  may 
reach  the  size  of  a  pea  or  a  small  bean. 

The  only  tumors  that  occur  with  any  frequency  are  epithelioma  and  lympho- 
sarcoma, and  even  they  are  not  common.  The  former  is  nearly  always  secondary, 
originating  in  the  structures  near  and  gradually  extending  into  it.  The  latter  is 
primary,  but  very  little  can  be  done  for  either.  Sarcomatous  growths  have  been 
shelled  out  after  ligature  of  the  carotid,  with  success  as  far  as  the  immediate 
result  of  the  operation  was  concerned  ;  but  very  rapid  recurrence  took  place  in  all. 


DISEASES  OF  THE  SALIVARY  GLANDS. 

Inflammation'. 

The  parotid  suffers  the  most  often  of  the  three ;  the  sublingual  the  least. 

Acute  parotitis  is  well  known  from  its  occurrence  in  connection  with  mumps. 
It  may,  however,  be  caused  in  many  other  ways.  In  some  epidemics  of  typhoid 
fever,  for  example,  it  is  fairly  common  ;  in  others  it  is  very  rare.  In  pyoemia  it 
is  often  met  with  ;  not  unfrequently,  even  when  there  is  no  suspicion  of  this,  it 
follows  operations  on  the  abdominal  viscera  ;  and  occasionally  it  is  due  to  ptyal- 
ism.  the  passage  of  foreign  bodies  up  the  duct,  syphilis,  tubercle,  and  other  dis- 
orders. 


DISEASES  OF  THE  SALIVARY  GLANDS. 


795 


In  mumps  suppuration  is  rare.  The  gland  on  one  side  suddenly  becomes 
tense  antl  swollen,  assuming  a  characteristic  shape,  and  causing  very  severe  pain, 
especially  when  an  attempt  is  made  to  open  the  mouth  ;  and  then  when  it  is 
beginning  to  subside,  the  opposite  one  usually  behaves  in  the  same  way.  Some- 
times the  submaxillary  gland  is  affected,  together  with  or  independently  of  the 
parotid.  Metastatic  inflammation  of  the  testicle  is  not  by  any  means  uncommon, 
and  is  of  some  importance,  as  it  may  end  in  atrophy.  The  ovaries  and  the 
meninges  of  the  brain  are  also  stated  to  be  occasionally  attacked,  but  this  is  much 
more  rare.  In  the  other  varieties  of  parotitis,  supi)uration  is  of  fre(pient  occur- 
rence and  is  often  attended  with  high  fever,  owing  to  the  tension  of  the  fascia  that 
surrounds  the  gland.  The  i)us  has  been  known  to  work  its  way  into  the  ear  and 
discharge  through  the  external  auditory  meatus  ;  to  descend  under  the  deep  fascia 
of  the  neck  ;  and  even  to  track  upward  along  the  course  of  the  nerves  into  the 
base  of  the  skull  and  set  up  acute  suppurative  meningitis. 

In  front  of  the  ear  over  the  parotid  there  is  a  small  group  of  lymphatic  glands 
which  occasionally  enlarge  and  become  inflamed,  and  there  are  others  in  the  in- 
terior as  w^ell ;  but  the  shape  of  the  swelling  is  so  different  that  there  is  very  little 
risk  of  their  being  mistaken. 

The  treatment  presents  nothing  special.  Suppuration  is  hard  to  detect  until 
the  collection  has  attained  a  considerable  size,  owang  to  the  dense  fascia  over  the 
gland  ;  but  sometimes  it  is  indicated  by  local  cedema  or  by  the  presence  of  one 
especially  tender  spot.  A  grooved  needle  should  be  used  for  exploration,  and  if 
any  pus  is  found  the  abscess  should  be  opened  after  Hilton's  method,  as  it  is  im- 
possible to  say,  under  such  conditions,  in  what  direction  the  very  important  struc- 
tures that  lie  in  the  gland  are  displaced. 

Salivary  Calculi. 

Calculi,  composed  of  phosphate  and  carbonate  of  lime  with  magnesia  and  a 
proportion  of  animal  matter,  are  sometimes  met  with  in  the  duct  of  the  submax- 
illary gland,  and  much  more  rarely  in  that  of  the  parotid. 
The  usual  size  is  about  that  of  a  date-stone ;  small  ones  are 
passed  occasionally,  and  very  large  ones,  the  size  of  a 
pigeon's  egg,  have  been  recorded.  In  most  cases  they  do 
not  give  rise  to  symptoms  of  any  kind  unless  the  duct  is 
blocked  :  then  the  gland  enlarges  and  becomes  distended 
until  it  is  able  to  overcome  the  resistance  in  front  and 
relieve  itself  for  the  time.  Occasionally,  however,  they 
cause  considerable  inflammation  and  lead  to  the  formation 
of  a  mass  of  dense  inflammatory  deposit  extending  through 
the  whole  submaxillary  region.     The  nature  of  the  trouble 

11       J    i      i    J      i  1  •       i.-  •  jj\  n  Fig.  343. — Salivary  Calculus, 

IS  usually  detected  at  once  by  examination  with  one  nnger       weighing 48 grains.  Natural 

in  the  mouth  and  another  under  the  chin,  or  by  passing  a 

probe  down  the  duct.     A  free   incision   should  be  made 

through  the  mucous  membrane  so  as  to  release  it  without  breaking  it ;  if  this 

occurs  the  removal  of  all  the  fragments  is  sometimes  very  tedious. 

Tumors. 

The  parotid  gland  is  occasionally  the  seat  of  a  peculiar  variety  of  new  growth, 
distinguished  from  all  others  as  a  parotid  glatiduiar  tumor.  Sometimes  a  similar 
growth  is  met  with  in  connection  with  the  submaxillary.  It  consists  of  fibrous, 
mucous,  cartilaginous,  and  glandular  tissue  combined  in  varying  proportions,  and 
forms  a  firm,  elastic  mass  of  an  irregularly  lobulated  shape.  Usually  it  is  enveloped 
in  a  dense  capsule  and  buried  in  the  substance  of  the  gland.  Occasionally  it  is 
detached,  lying  on  it,  but  in  all  probability  developed  in  connection  with  it.  It 
has  been  suggested  that  the   presence  of  cartilage  may  be  accounted  for  by  the 


size. 


796     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


Fig.  344. — Submaxillary  Tumor. 


persistence  of  some  portion  of  the  branchial  arches,  the  first  in  the  ca.se  of  the 
parotid,  the  second  for  the  submaxillary. 

Parotid  tumors  of  this  description  are  usually 
met  with  in  young  adults,  and  increase  so  slowly  that 
little  attention  is  paid  to  them.  As  age  advances, 
however,  they  are  liable  to  change  their  characters 
suddenly  and  develop  into  rapidly  growing  adeno- 
sarcomata  ;  and  sometimes  they  assume  this  character 
from  the  first,  ma.sses  of  vascular  gland  ti.ssue  devel- 
oping in  some  parts,  and  soft  sarcomatous  growth  in 
others. 

When  this  occurs  the  tumor  becomes  painful  and 
tender  ;  the  skin  grows  thin  ;  the  surface  is  reddened 
with  dilated  veins;  and  all  the  tissues  near  become 
involved.  In  a  little  while  ulceration  follows ;  the 
covering  breaks  down  ;  gigantic  fungating  masses 
that  bleed  at  the  slightest  touch  protrude  through  the 
opening;  hemorrhage  sets  in  ;  and  partly  from  this, 
partly  from  septic  absorption  and  exhaustion,  the 
result  not  unfrequently  proves  fatal  within  a  few  months. 

Other  tumors  are  seldom  met  with.  Cysts  may  form  either  independently 
or  in  connection  with  other  tumors,  but  they  rarely  attain  any  size.  Mucous  cysts 
are  met  with  in  the  submaxillary,  but  probably  not  in  the  parotid.  Lymphatic 
growths  are  occasionally  found,  and  a  itw  instances  of  fibromata  and  sarcomata 
are  on  record.  It  is  questionable  whether  the  cases  of  cancer  were  not  really 
adeno-sarcomata,  as  the  sarcomatous  tissue  is  very  unevenly  distributed. 

The  only  treatment  is  excision,  but  to  be  successful  it  must  be  done  while  the 
growth  is  small.  The  incision  should  lie  over  the  posterior  border  of  the  gland  ; 
if  necessary  a  second  may  run  forward  from  this  at  right  angles  to  it.  If  the 
capsule  is  opened  freely  the  tumor  can  sometimes  be  shelled  out ;  but  if  it  has  deep 
connections,  running,  for  example,  down  to  the  styloid  process  or  behind  the 
ramus  of  the  jaw,  or  if  the  facial  nerve,  instead  of  lying  beneath  it,  runs  through 
it,  the  operation  becomes  exceedingly  difficult.  It  is  advisable  if  possible  to  keep 
inside  the  capsule  ;  and  if  the  facial  nerve  runs  into  the  tumor  an  attempt  must 
be  made  to  dissect  out  the  chief  branches,  but  the  result  is  rarely  satisfactory. 
Facial  paralysis  invariably  results  if  any  traction  is  put  upon  the  nerve  in  separa- 
ting the  tumor  from  it ;  but,  fortunately,  unless  the  fibres  are  too  much  bruised, 
or  are  cut  away  to  such  an  extent  that  the  ends  cannot  be  brought  together,  the 
muscles  usually  regain  sufficient  power  to  prevent  conspicuous  deformity.  In 
cases  of  accidental  division  the  ends  should  of  course  be  sutured  at  once. 

Excision  of  the  parotid  has  been  performed,  but  never  with  sufficient  success 
to  justify  repetition. 


EXAMINATION  OF  THE   EAR.  if)i 


CHAPTER  XIII. 

SURGICAL    DISEASES   OF   THE   EAR   AND   LARYNX. 
By  T.  Mark  Hovell. 

SECTION  1.— DISEASES  OF  THE  EAR. 

Examination  of  the  Ear. 

To  ensure  this  being  carried  out  thoroughly,  it  is  well  to  adopt  a  definite 
order  for  employing  the  various  tests  to  the  patient's  hearing  and  for  inspecting 
the  ear  and  other  parts.  This  is  best  done  by  grouping  the  methods  of  examina- 
tion which  require  light  and  those  for  which  it  is  unnecessary. 

Any  watch  may  be  used  as  a  test  for  hearing,  provided  the  distance  has  been 
ascertained  at  which  its  tick  can  be  heard  by  a  normal  ear.  This  distance  is 
recorded  as  a  denominator,  and  the  patient's  hearing  power  is  the  numerator. 
Thus,  using  a  watch  that  can  be  heard  at  six  feet  to  test  a  patient  who  hears  at 
thirty-six  inches  with  the  right  ear  and  twenty  inches  with  the  left,  the  result 
would  be  recorded  :   right,  4|- ;  left,  -ff. 

A  vibrating  tu?iiiig-fork,  when  placed  on  the  vertex  of  the  skull  in  the  middle 
line,  should  be  heard  equally  in  both  ears,  and  when  one  meatus  is  closed  with  a 
finger  the  sound  should  be  louder  on  that  side,  on  account  of  the  vibrations  being 
confined  and  consequently  to  some  extent  thrown  back  upon  the  labyrinth.  If, 
therefore,  a  patient  hears  a  tuning-fork,  applied  as  above  mentioned,  louder  in  the 
ear  in  which  the  hearing  is  impaired,  it  maybe  inferred  that  the  conducting  appa- 
ratus is  at  fault,  and  if  it  is  not  heard  as  well  as  in  the  other  ear,  that  the  labyrinth 
or  auditory  nerve  is  affected. 

Malingering  may  be  detected  sometimes  by  using  the  tuning-fork  in  this  way, 
the  impostor  thinking  that  he  ought  not  to  hear  so  well  with  the  ear  closed. 

The  extent  to  which  the  labyrinth  or  auditory  nerve  is  impaired  may  be 
roughly  gauged  by  placing  the  tuning-fork  over  the  mastoid  process  of  the  affected 
side  and  noting  the  number  of  seconds  that  the  vibrations  can  be  heard  by  the 
surgeon  when  the  fork  is  applied  to  his  own  head  after  the  patient  has  ceased  to 
hear  them. 

The  auscultation  tube  is  a  piece  of  rubber  tubing  about  thirty  inches  long, 
having  at  each  end  a  hollow  piece  of  ivory  or  vulcanite  to  fit  the  meatus.  To 
distinguish  the  end  used  for  patients,  one  ear-piece  may  be  made  of  ivory,  the 
other  of  vulcanite. 

By  placing  one  end  in  the  patient's  ear  and  the  other  in  one's  own  the  con- 
dition of  the  Eustachian  tube  can  be  ascertained  whilst  the  tympanum  is  being 
inflated,  by  Valsalva's  or  Politzer's  method  or  by  means  of  a  Eustachian  catheter. 
Thus,  if  there  is  moist  mucus  in  the  tube  or  tympanum  a  bubbling  sound  is  heard, 
or  whistling  if  the  calibre  of  the  tube  is  narrowed.  In  cases  in  which  the  mem- 
brana  tympani  is  perforated  the  injected  air  can  be  felt  by  the  surgeon  striking 
against  his  own  membrane. 

Valsalva  s  jnethod  of  inflating  the  tympanum  consists  in  expiring  forcibly 
through  the  nose  whilst  the  mouth  is  closed  and  the  nostrils  are  compressed  by  a 
finger  and  thumb.  In  a  healthy  ear  the  entrance  of  air  is  accompanied  by  a  feeling 
of  fullness  and  slight  cracking  sound. 

Politzer's  method  cox\%\'i\%  in  holding  a  small  quantity  of  water  in  the  mohth, 
and  then,  whilst  it  is  being  swallowed,  forcing  air  from  an  India  rubber  bag  through 
one  nostril  while  the  other  is  compressed  with  a  finger  or  thumb  to  prevent  the  air 


798     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


escaping.  The  sensation  produced  in  the  ear  is  similar  to  that  caused  by  Valsalva's 
inflation,  but  more  marked. 

The  late  Dr.  Peter  Allen  used  to  force  air  into  both  nostrils  simultaneously 
by  blocking  their  orifices  with  an  India-rubber  pad  through  which  pa.s.sed  two 
jiieces  of  tubing,  one  of  which  enters  each  nostril. 

Instead  of  swallowing  water,  the  naso-pharynx  may  be  shut  off  by  the  patient 
whistling  or  uttering  a  guttural  sound,  such  as  "  buck."  In  children  it  is  unneces- 
sary, as  the  Eustachian  tube  is  more  patent. 

A  Eustachian  catheter  should  not  be  more  than  four  and  one-half  inches 
long,  and  it  is  most  convenient  to  use  one  with  a  diameter  of  small 
size.  Whilst  introducing  it  the  surgeon  should  stand  at  the  patient's 
right  side  with  the  catheter  held  lightly  between  the  thumb  and 
index  finger  of  his  right  hand,  the  beak  or  curved  end  pointing 
downward,  and  allow  it  to  slip  through  the  nostril  until  it  touches 

the  posterior  wall  of  the 
naso-i)harnyx.  It  should 
then  be  withdrawn  half 
an  inch  and  the  beak 
turned  outward  and 
sometimes  slightly  up- 
ward, when  it  will  be 
found  to  be  in  the  ori- 
fice of  the  Eustachian 
tube. 

As  the  dimensions 

of  the  nostrils  vary  very  much,  owing  to  deviations  of  the  septum,  cartilaginous 
and  bony  spurs,  and  other  abnormal  conditions,  there  is  no  fixed  rule  for  the 
position  of  the  catheter  during  its  passage.  It  often  passes  best  if  the  beak  is 
directed  horizontally  outward  beneath  the  inferior  turbinated  bone  as  soon  as  it 
is  well  within  the  nostril,  turning  it  down  again  a  little  as  it  goes  through  the 
choana.  A  catheter  should  always  be  passed  with  the  greatest  gentleness,  and, 
in  many  instances  it  is  best  to  allow  it  to  find  its  own  way.      Should  it  be  impos- 


FlG.  345. — Allen's  Air-pad. 


Fig.  346. — Alr-b.ig  with  Nozzle  to  fit  a  Catheter,  suitable  also  for  Politzer's 
Inflation,  with  a  Teat  slipped  over  it. 


sible  to  reach  the  tube  through  one  nostril,  the  curve  of  the  instrument  must  be 
increased,  and  an  attempt  made  to  do  so  through  the  other.  If  the  catheter  is 
drawn  backward  by  muscular  contraction,  when  the  beak  is  turned  outward  in  the 
naso-pharynx,  it  is  an  indication  that  it  is  l)ehind  the  posterior  lip  of  the  Eusta- 
chian orifice.  A  special  catheter  with  a  distinguishing  mark  should  be  kei)t  for 
syphilitic  cases.  If  a  nostril  is  extremely  sensitive,  it  may  be  sponged  with  a  four 
per* cent,  solution  of  cocaine. 

As  soon  as  the  catheter  is  in  position,  the  little  and  ring  fingers  of  the  left 
hand  should  be  placed  one  on  each  side  of  the  patient's  nose,  the  palm  of  the  hand 


DISEASES  OF  THE   EXTERNAL   EAR. 


799 


being  downward  and  forward,  and  the  outer  end  of  the  instrument  grasped 
between  the  thumb  and  intlex  finger.  J^y  this  means  the  catheter  is  firmly  held, 
and  the  hand  at  the  same  time  well  supported  against  the  patient's  face.  The 
nozzle  of  the  air-bag  should  now  be  introduced,  and  the  thumb  and  index  finger 
of  the  left  hantl  slipped  forward  to  hold  it  in  place.  Air  is  then  forced  into  the 
tympanum  by  compressing  the  air-bag.  Many  aurists  prefer  a  modification 
of  Politzer's  bag,  having  a  piece  of  tubing  between  the  air  re.servoir  and 
the  nozzle,  which  prevents  the  movement  of  the  bag  being  communicated 
to  the  catheter. 

For  examining  the  membrana  tympani,  two  kinds  of  speculum  are  used,  one 
consisting  simply  of  a  funnel  of  metal  or  vulcanite,  the  other  (Brunton's)  of  a 
metal  funnel  with  a  lens  at  the  opposite  end  and  an  aperture  at  the  side  for  the 
admission  of  light.  For  using  the  former  daylight  is  sufficient,  but  for  the  latter 
artificial  illumination  is  necessary.  The  focus  for  a  Brunton's  speculum  should 
be  three-quarters  of  an  inch  from 
the  end  when  the  centre  of  the  cap 
containing  the  lens  is  level  with  the 
larger  extremity  of  the  speculum. 

Before  the  speculum  is  intro- 
duced, any  abnormal  condition  of 
the  outer  part  of  the  ear  should  be 
noted,  and  the  auricle  raised  upward 
and  backward  in  order  to  straighten 
the  canal. 

A  healthy  membrane  is  of  a 
bluish-gray  color,  and  is  placed 
obliquely  across  the  canal,  its  upper 
and  posterior  part  being  more  exter- 
nal than  the  lower  and  anterior.  Passing  downward  and  backward  and  a  little 
inward,  nearer  the  anterior  than  the  posterior  edge  of  the  membrane,  is  a  whitish 
ridge,  the  handle  of  the  malleus,  and  passing  forward  and  downward  from  its 
lower  extremity,  which  is  slightly  enlarged,  and  situated  just  below  the  centre  of 
the  membrane,  is  a  triangular  glistening  surface  called  the  cone  of  light,  having  its 
base  toward  the  periphery.  At  the  upper  part  of  the  handle  of  the  malleus  is  a 
white  projection,  the  short  process  of  the  malleus,  and  stretching  backward  and 
forward  from  the  short  process  to  the  edge  of  the  membrane  are  two  slight  ridges, 
the  anterior  and  the  posterior  folds,  the  latter  being  the  more  clearly  defined. 
Above  these  folds  the  membrana  propria  is  absent,  the  part  being  called  Schrap- 
nell's  membrane.  Not  infrequently  a  whitish  line  (showing  the  position  of  the 
long  process  of  the  incus)  is  seen  behind,  internal  and  parallel  to  the  upper  part 
of  the  handle  of  the  malleus.  Occasionally  the  outer  part  of  the  stapes  can  be 
distinguished. 

After  the  position,  color,  degree  of  transparency,  and  any  abnormal  condi- 
tion of  the  membrane  that  may  exist,  have  been  carefully  noted,  the  nares, 
pharynx,  and  naso-pharynx  should  be  examined. 


Fig.  347. — Brunton's  Auiiscope. 


Diseases  of  the  External  Ear. 

Anomalous  formations  of  the  auricle  are  sometimes  found  ;  they  are  generally 
associated  with  defects  in  the  meatus  or  the  deeper  parts  of  the  ear. 

Accumulation  of  wax  is  due  either  to  increased  activity  of  the  glands,  or  to 
obstacles  interfering  with  the  escape  of  their  secretion.  The  former  condition  is 
often  associated  with  disorders  of  the  external  and  middle  ear,  the  latter  may  be 
produced  by  exostoses,  or  foreign  bodies,  or  by  the  cerumen  being  pushed  into 
the  meatus  during  attempts  to  cleanse  it. 

The  symptoms  vary  according  to  the  size  and  position  of  the  plug.  They 
are,  generally,  deafness,  often  coming  on  or  increasing  suddenly,  tinnitus,  giddi- 


8oo     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

ness,  and  cough  ;  usually  there  is  no  pain.  The  glistening  surface  of  the  wax  has 
been  mistaken  for  the  niembrana  tynipana. 

Treatment. — Syringing  with  w^arm  water  is  generally  sufficient  to  clear  the 
meatus  if  the  stream  is  directed  against  its  floor,  but  should  the  plug  be  hard  and 
near  the  orifice  it  may  be  gently  moved  with  a  spud.  If  the  syringing  causes 
pain,  the  wa.x  may  be  softened  with  the  following  drops: — 

Grammes. 

Sodn?  bicarb., 60 

Cjlycerini, |20 

Aq.  dest.,  ad 32 

If  the  ear  is  tender  a  few  drops  of  liq.  opii  sedativus  may  be  added.  After  the 
wax  has  been  removed  the  meatus  should  be  dried  with  absorbent  cotton-wool  and 
a  piece  kept  in  the  meatus  for  some  hours, 

Othccmatoma,  or  blood-tumor  of  the  auricle  {Jucinatoina  ai/ris),  may  occur 
spontaneously  or  be  due  to  injury  ;  the  former  is  much  more  commonly  found 
among  insane  patients,  and  more  often  in  men  than  in  woman.  It  appears  as  a 
swelling  on  the  outer  surface  of  the  auricle,  produced  by  the  effusion  of  blood 
beneath  the  i)erichondrium.  The  size,  outline,  and  tenseness  of  the  tumor  depend 
upon  the  amount  ;  its  color,  on  the  dei)th. 

Treatment. — If  the  tumor  is  small  and  not  very  tense,  it  may  be  left  to 
subside,  or  the  fluid  may  be  evacuated  and  pressure  applied.  Traumatic  cases  are 
sometimes  attended  by  great  disfigurement. 

Fungi  in  the  external  auditory  meatus  are  usually  found  where  there  has  pre- 
viously been  disease  of  the  parts,  producing  an  accumulation  of  epidermic  scales. 
There  is  usually  tinnitus,  pain,  and  impairment  of  hearing.  On  examining  the 
meatus,  the  fungus  is  seen  on  the  walls  of  the  canal  and  often  also  on  the  tympanic 
membrane. 

Treatment. — The  ear  should  be  syringed  several  times  a  day  w^ith  a  warm 
solution  of  perchloride  of  mercury  (i  in  1000),  or  hyposulphite  of  soda  (5  grains 
to  .^i).  And  then  a  few  drops  of  warm  alcohol  should  be  put  into  the  ear.  This 
should  be  continued  for  several  days. 

Circumscribed  or  furuncular  inflammation  of  the  external  meatus  is  usually 
found  in  the  cartilaginous  portion,  and  is  often  associated  with  deranged  health  ; 
it  may  be  due,  however,  to  local  irritation. 

Symptoms. — If  the  deeper  part  is  affected  fever  and  even  delirium  may 
occur,  especially  in  children.  The  pain  often  radiates  over  the  side  of  the  head, 
and  is  increased  by  movement  of  the  jaw  and  by  making  pressure  over  the  tragus  ; 
it  generally  increases  toward  night,  and  continues  with  but  slight  diminution  until 
the  abscess  bursts  or  is  opened.  Deafness,  when  present,  is  mainly  due  to  the 
obstruction.  Tinnitus  may  be  present.  There  is  often  no  congestion  of  the 
meatus,  but  one  or  more  extremely  tender  swellings  inside.  Recurrence  is  com- 
mon, especially  in  weakly  subjects. 

Treatment. — Leeches  may  l)e  applied  to  the  tragus  ;  plugs  of  gelatine  con- 
taining i'6  grain  (.01)  of  extract  of  ojiium  inserted  into  the  meatus  ;  and  an  inci- 
sion made  into  the  swollen  tissue.  After  the  incision  the  parts  should  be  painted 
with  carbolized  glycerine  or  solution  of  boric  acid.  Hot  i)oultices  should  not  be 
applied  to  the  auricle.  Opium  should  be  given  internally  to  relieve  pain,  and 
attention  paid  to  the  general  health. 

Exostoses  are  generally  multiple  and  sessile,  and  they  vary  in  size  from  slight 
elevations  to  large  rounded  projections.  They  are  often  associated  with  chronic 
catarrh  of  the  middle  ear,  and  are  also  said  to  be  caused  by  gout,  syphilis,  and 
sea  bathing.  They  grow  slowly  and  .should  not  be  interfered  with  unless  they 
close  the  meatus.  They  can  be  removed  with  a  dental  drill.  Pedunculated 
growths  are  sometimes  found  in  cases  of  chronic  suppuration  ;  they  grow  quickly, 
and  are,  as  a  rule,  easily  removed  with  a  pair  of  forceps. 

Foreign  Bodies  in  the  External  Auditory  Meatus. — When  a  yjatient  is  said  to 
have  a  foreign  body  in  the  ear,  the  first  stej)  is  to  ascertain  that  the  statement  is 


DISEASES  OF  THE  MIDDLE   EAR. 


80 1 


correct.  In  the  case  of  a  child,  no  detailed  examination  shoukl  he  attempted 
until  an  anaesthetic  has  been  administered.  A  foreign  body  may  remain  for 
weeks  and  even  months  in  the  meatus  without  doing  much  if  any  harm,  while 
l)ermancnt  injury  may  be  caused  by 
improper  attempts  at  removal.  If 
the  meatus  is  swollen,  and  the  for- 
eign body  is  a  substance  not  acted 
on  by  moisture,  such  as  a  button 
or  bead,  it  is  best  to  make  no  im- 
mediate attempt  but  to  apply  some 
soothing  lotion,  and  wait  until  the 
inflammation  has  subsided.  In 
many  cases  this  course  may  be 
adopted,  even  if  it  is  a  pea  or  bean 
or  other  substance  -known  to  swell 
when  moist.  A  foreign  body  can 
generally  be  removed  by  careful 
syringing,  if  the  stream  of  water  is 
directed  between  it  and  the  wall  of 
the  meatus,  and  it  is  only  in  excep- 
tional cases  that  forceps,  hooks,  etc.,  should  be  used.  When  permanent  impair- 
ment of  hearing  follows,  it  is  more  often  due  to  the  attempts  which  have  been 
made  to  remove  it  than  to  the  effects  of  the  foreign  body  itself. 


Fig.  348.— Ear  Forceps. 


Diseases  of    the  Middle  Ear. 

Acute  inflammation  of  the  middle  ear  is  most  frequently  produced  by  a 
draught  of  cold  air  striking  the  ear  or  the  extension  of  inflammation  from  the 
naso-pharynx,  but  it  may  follow  the  use  of  a  nasal  douche  or  sea  bathing. 

Symptoms. — A  feeling  of  fullness  in  the  ear  is  first  complained  of,  followed 
by  pain  of  a  throbbing  or  stabbing  character,  often  radiating  over  the  side  of  the 
head  and  increased  by  swallowing.  There  is  deafness  and  sometimes  tinnitus, 
with  fever,  especially  in  children.  Tenderness  over  the  mastoid  process,  and 
symptoms  of  naso-pharyngeal  catarrh  are  often  present.  In  the  early  stage  the 
membrane  looks  a  little  dull  and  the  vessels  running  along  the  posterior  border  of 
the  handle  of  the  malleus  are  congested.  As  the  attack  becomes  more  severe  the 
congestion  of  the  membrane  increases  and  vesicles  may  form  on  its  surface. 
The  superficial  epithelial  layers  become  swollen  and  are  thrown  off  in  thick  plates. 
If  mucus  or  pus  collects  in  the  tympanum,  the  membrane  becomes  bulged  out- 
ward, and  unless  a  puncture  is  then  made  in  it,  rupture  will  take  place,  the  escape 
of  the  fluid  giving  almost  immediate  relief  to  the  symptoms.  In  some  cases  the 
symptoms  subside  without  this  stage  being  reached. 

Treatment. — The  patient  should  be  confined  to  the  house,  and  in  an  acute 
case  to  bed.  An  aperient  should  be  given,  and  if  much  pain  is  present  three  to 
six  leeches  should  be  applied  over  the  tragus  and  below  the  meatus,  internal  to 
the  lobule.  Hot  fomentations  and  sedative  drops  may  be  applied  to  the  meatus. 
The  membrane  should  be  punctured  in  the  posterior  inferior  segments  as  soon  as 
it  begins  to  bulge.  When  the  acute  symptoms  have  passed  off,  air  should  be 
gently  injected  into  the  tympanum  through  a  Eustachian  catheter  or  by  means  of 
a  Politzer's-  bag,  at  first  once  daily,  the  interval  being  lengthened  until  the  hear- 
ing is  restored.  If  there  is  any  discharge  from  the  meatus,  finely  powdered  boric 
acid  should  be  insufflated  after  the  ear  has  been  carefully  dried  with  absorbent 
cotton-wool,  or  a  solution  of  boric  acid  dropped  in. 

Chronic  suppurative  inflammation  of  the  middle  ear  is  the  result  of  the  acute 
form  of  the  disease  ;  it  often  continues  for  years  if  not  efficiently  treated,  and 
may  produce  very  serious  complications.  On  examination,  after  the  ear  has  been 
syringed,  the  membrane  is  dull  and  the  handle  of  the  malleus  invisible  on  account 


8o2    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

of  the  swollen  condition  of  the  epithelial  layer ;  but  if  this  is  removed  the  color 
is  more  or  less  red.  If  the  perforation  is  large,  the  inner  wall  of  the  tympanum 
may  be  distinctly  seen,  and  in  some  cases  portions  of  the  ossicula,  the  appearance 
depending  upon  the  amount  of  congestion  and  the  size  of  the  perforation.  The 
hearing  is  more  or  less  impaired,  and  patients  sometimes  complain  of  giddiness, 
but  tinnitus  is  not  often  i)resent. 

Treatment  consists  in  keeping  the  parts  scrupulously  clean.  The  discharge 
should  be  washed  away  several  times  a  day  with  a  disinfecting  lotion,  and  the 
meatus  dried  with  absorbent  cotton-wool  wrapped  round  a  probe,  finely  powdered 
boric  acid  being  insufflated  afterward.  As  the  discharge  lessens,  the  application 
may  be  made  at  longer  intervals.  In  old-standing  cases  the  following  drops, 
warmed,  may  be  used  several  times  a  day:  Sulphate  of  zinc  2  to  8  grains,  tinct. 
opii  3ijj  water  to  %.  Granulations  that  spring  from  the  meatus  or  membrane 
should  be  scraped  away  with  a  sharp  spoon  or  destroyed  with  a  saturated  solution 
of  chromic  acid,  according  to  their  position,  care  being  taken  not  to  injure  sur- 
rounding structures.  Polypi  attached  to  the  tympanic  cavity  should  be  removed 
with  a  snare,  unless  very  small.  The  wire  should  be  pas.sed  as  near  asjjossible  to 
their  root  and  the  loop  then  tightened  until  the  polypus  is  grasped,  when  it  may 
be  dragged  out ;  if  the  wire  is  tightened  too  much,  the  growth  is  cut  and  a  por- 
tion of  it  left  behind.  The  polypus  may  also  be  seized  with  forceps  and  twisted 
out.  Before  removal  a  10  per  cent,  or  15  percent,  solution  of  cocaine  should  be 
dropped  into  the  meatus,  and  afterward  the  root  destroyed  with  a  saturated  solu- 
tion of  chromic  acid,  warmed  alcohol  being  dropped  into  the  meatus  afterward. 

Inflammation  of  t/ie  mastoid  cells  may  be  produced  by  the  extension  of  the 
disease  from  the  tympanum.  The  symptoms  are  deep-seated  pain  and  tenderness 
over  the  mastoid  process,  accompanied  with  more  or  less  fever.  When  the  peri- 
osteum is  affected,  the  tissues  behind  the  ear  are  swollen  and  the  auricle  stands 
out  from  the  head.      If  pus  has  formed,  fluctuation  may  be  detected. 

Treatment. — In  the  early  stages,  three  to  six  leeches  and  hot  fomentations 
should  be  applied  over  the  seat  of  pain,  and  sedative  drops  to  the  meatus.  If 
these  measures  fail  to  give  relief,  an  incision  should  be  made  down  the  mastoid 
process  and  the  periosteum  divided.  If  the  symj^toms  continue  after  this  treat- 
ment, the  mastoid  cells  must  be  opened.  For  this  purpose  a  drill  about  an  eighth 
of  an  inch  in  diameter  is  large  enough  ;  it  should  be  provided  with  a  guard  to 
regulate  its  penetration.  The  opening  should  be  made  at  the  junction  of  a  ver- 
tical line  drawn  a  quarter  of  an  inch  behind  the  meatus  with  another  line  drawn 
horizontally  on  a  level  with  its  upper  border.  The  direction  is  inward,  forward, 
and  a  little  upward.  Relief  may  follow  the  operation,  although  no  pus  is  found 
in  the  mastoid  antrum.  The  thickness  of  the  outer  table  of  the  skull  varies,  but 
it  is  generally  about  a  fifth  of  an  inch  in  this  position.  If,  on  making  an  incision 
on  to  the  mastoid  process,  pus  is  found  to  be  escaping  through  an  opening  in  the 
bone,  it  is  best  to  enlarge  it  instead  of  making  a  fresh  one.  As  soon  as  the  mas- 
toid cells  have  been  reached,  they  should  be  washed  out  with  a  warm  disinfecting 
lotion. 

Caries  and  necrosis  may  attack  the  meatus,  mastoid  process,  and  tympanum. 
When  this  occurs  the  granulations  constantly  return,  even  after  jjersistent  attempts 
have  been  made  to  destroy  them,  and  the  discharge  frequently  remains  offensive. 
Facial  paralysis  may  be  present.  In  children  an  anaesthetic  should  be  adminis- 
tered, and  if  any  caries  is  found  the  diseased  surface  should  be  scraped,  and  any 
sequestra  that  are  present  removed. 

Phlebitis,  when  it  occurs,  generally  affects  the  lateral  sinus  and  the  jugular 
vein,  and  may  }iroduce  pynemia. 

Meningitis  and  cerebral  abscess  may  occur  during  acute  or  chronic  suppura- 
tive inflammation  of  the  middle  ear,  but  are  more  often  found  in  the  course  of  the 
latter.  If  the  i)osition  of  the  abscess  can  be  localized,  the  skull  may  be  at  once 
trephined  and  the  pus  evacuated.  An  exploratory  operation  may  be  made  in  a 
severe  case,  although  the  precise  seat  of  the  abscess  cannot  be  determined. 


EXAMINATION  OF  THE  LARYNX.  803 

Syphilitic  Affections  of  the  Ear. 

Condylomata  and  ulcers  are  sometimes  found  in  the  external  auditory  meatus. 
Acute  catarrh  of  the  middle  ear,  probably  due  to  the  periostitis,  may  occur,  and 
when  chronic  catarrh  is  already  present,  it  runs  a  much  more  rapid  course  than  in 
ordinary  cases,  frequently  leaving  the  patient  extremely  deaf,  in  consecpience  of 
the  internal  ear  having  become  imj)licated.  At  puberty,  subjects  of  inherited 
syphilis  are  liable  to  lose  their  hearing,  in  consecjuence,  it  is  believed,  of  the 
disease  affecting  the  terminal  portion  of  the  auditory  nerve. 


SECTION  II.— DISEASES  OF  THE  LARYNX. 

Examination  of  the  Larynx. 

The  instruments  used  for  examining  the  larynx  are  so  well  known  that  it  is 
unnecessary  to  describe  them.  Before  purchasing  a  frontal  mirror,  it  is  well  to  try 
whether  a  spectacle  frame  or  an  elastic  band  round  the  head  is  the  more  comfort- 
able, because  for  constant  use  a  strong  preference  is  sometimes  felt  for  one  or  the 
other.  The  aperture  in  the  mirror  should  be  elliptical  in  shape  and  not  more  than 
y^  of  an  inch  in  the  longest  diameter  ;  it  should  be  made  in  the  glass  as  well  as  in 
its  metal  back.  A  special  set  of  faucial  mirrors  should  be  kept  for  syphilitic  cases, 
and  distinguished  from  those  in  general  use  by  their  handles  being  of  a  different 
color.  The  mirrors  which  have  been  introduced  with  an  electric  lamp  attached 
are  mere  toys  and  useless  for  continuous  work. 

To  examine  the  larynx  the  faucial  mirror  should  be  warmed  until  the  dimness 
which  appears  as  soon  as  heat  is  applied  has  almost  passed  off.  If  held  over  the 
lamp  until  it  has  quite  disappeared,  the  mirror  is  generally  too  hot.  The  tongue 
should  then  be  protruded  and  firmly  but  gently  held  with  a  napkin  between  the 
thumb  and  forefinger  of  the  left  hand.  Care  should  be  taken  to  keep  the  under 
surface  of  the  tongue  from  touching  the  incisor  teeth  :  this  will  not  occur  if  the 
forefinger  is  held  horizontally  and  the  left  hand  kept  well  raised. 

While  the  tongue  is  held,  the  rays  of  light  reflected  from  the  frontal  mirror 
must  be  focused  on  the  base  of  the  uvula  and  the  faucial  mirror  placed  firmly  but 
lightly  against  the  same  place,  gently  raising  it  so  as  to  lift  the  soft  palate.  If  the 
tip  of  the  uvula  is  reflected  in  the  mirror,  this  must  be  lowered  a  little.  Patients 
should  be  directed  not  to  hold  their  breath  whilst  their  throat  is  being  examined. 
When  much  irritability  of  the  pharynx  exists,  a  4  per  cent,  to  10  per  cent,  solution 
of  cocaine  should  be  sprayed  or  painted  over  the  soft  palate  and  posterior  wall. 
Occasionally  the  larynx  may  be  examined  without  the  tongue  being  protruded  ;  this 
method  is  sometimes  useful  when  the  pharynx  is  very  irritable  and  a  solution  of 
cocaine  is  not  at  hand. 

Inhalation. — Apparatus  for  the  inhalation  of  medicated  steam  should  be  con- 
structed so  that  the  air  may  enter  near  the  bottom  of  the  vessel  and  bubble  slowly 
through  the  whole  depth  of  the  fluid.  Patients  should  be  directed  to  breathe 
slowly,  six  or  seven  times  a  minute  only,  not  to  expire  into  the  inhaler,  and  to  re- 
main indoors  for  twenty  minutes  or  half  an  hour  afterward,  to  avoid  catching  cold. 
Steam  inhalation  should  be  used  at  a  temperature  between  140°  F.  and  150°  F. 

Sedative  inhalations  may  be  composed  of:  tse.  benzoini  co.,  3J ;  acid,  benzo- 
ici,  gr.  iij  ;  kaolin,  gr.  xij,  and  tse.  tolu,  n^^xviii ;  lupulin,  gr.  xxx ;  or  sodae 
bicarb.,  gr.  xx,  and  succus  conii,  gij  ;  a  pint  of  water  at  140°  F.  being  used  in 
each  case  :  stimulating  ones  of  two  or  three  minims  of  oil  of  Scotch  pine,  oil  of 
juniper  or  of  creasote,  with  a  few  grains  of  light  carbonate  of  magnesia,  used  in 
the  same  way. 


8o4     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

Insufflation. — The  patient  should  be  directed  to  hold  his  tongue  well  forward 
with  a  handkerchief,  using  his  right  hand  to  enable  the  operator  to  direct  the 
application  by  the  aid  of  a  mirror  held  in  his  left.  If  a  powder  is  used  the 
end  of  the  insufflator  is  bent  at  a  right  angle  to  the  stem,  and  the  descending  arm 
is  not  more  than  half  an  inch  in  length.  Blowing  down  the  tube  with  the  mouth 
ensures  a  more  accurate  application  than  using  a  ball  syringe.  It  is  convenient  to 
have  the  rubber  tube  which  connects  the  mouth-piece  with  the  instrument  not  less 
than  fifteen  inches  long. 

The  best  spray  producers  are  worked  by  compressed  air,  the  high  tension  en- 
suring the  even  distribution  and  fine  division  of  the  fluid.  There  is  not  then  the 
same  tendency  to  cause  coughing.  Hand  sprays  should  be  fitted  with  two  balls, 
the  anterior  being  used  as  a  reservoir.  By  compressing  the  tubing  between  this 
and  the  bottle  until  the  moment  the  spray  is  used,  the  tension  is  increased  and 
the  fluid  more  finely  atomized. 

Brushes  are  necessary  where  a  particular  portion  of  the  larynx  has  to  be  touched 
with  the  solution  ;  they  should  be  made  so  that  they  readily  come  to  a  point 
directly  they  are  wetted.  If  too  large,  difficulty  will  be  experienced  in  introducing 
them  into  the  larynx.  On  the  Continent  and  in  America  solutions  are  applied  by 
means  of  a  piece  of  cotton-wool  twisted  round  a  piece  of  bent  wire,  instead  of  a 
brush. 

Inflammation  of  the  Larynx. 

Acute  laryngitis  (catarrhal  laryngitis')  is  most  frequently  met  with  in  persons 
whose  vital  powers  have  become  depressed  by  anxiety,  excessive  mental  work  or 
prolonged  physical  exertion,  sedentary  occupation  or  living  in  ill-ventilated  rooms. 
The  commonest  exciting  cause  is  sudden  or  prolonged  exposure  to  a  damp  cold 
atmosphere  or  to  a  draught  of  cold  air  impinging  upon  the  neck  or  an  ear,  especi- 
ally when  the  skin  is  perspiring  freely,  but  an  attack  maybe  caused  by  the  inhala- 
tion of  dust,  fumes  from  chemical  compounds,  or  a  vitiated  atmosphere  heavily 
charged  with  tobacco  smoke.  It  is  sometimes  due  to  the  straining  of  long- 
continued  shouting,  to  paroxy.sms  of  coughing  or  speaking  for  a  length  of  time  in 
an  improperly  pitched  tone  of  voice,  or  to  the  entrance  of  a  foreign  body  into  the 
larynx.  In  many  cases  the  inflammation  extends  from  the  nares  or  pharynx,  and 
occasionally  from  the  trachea.  Errors  in  diet,  and  particularly  the  free  con- 
sumption of  hot  alcoholic  drinks,  may  originate  and  keep  up  catarrhal  laryngitis, 
especially  in  its  subacute  form. 

The  symptoms  vary  according  to  the  stage  and  degree  of  the  attack.  At 
first  there  is  diminution  in  the  amount  of  secretion,  and  this  gives  rise  to  a  sensa- 
tion of  tickling  or  dryness  which  frequently  produces  cough  ;  later  on  the  secretion 
of  mucus  increases,  but  it  rarely  becomes  excessive.  On  making  a  laryngoscopic 
examination,  the  whole  of  the  larynx  is  seen  to  be  extremely  congested,  and  in 
many  cases  an  elliptical  aperture  between  the  cords  is  visible  during  phonation, 
produced  by  imperfect  approximation.  Erosions  on  the  upper  surface  or  inner 
border  of  one  or  both  vocal  cords  are  frequently  met  with,  the  places  denuded  of 
epithelium  generally  being  oval  in  outline  and  lighter  in  color  than  the  sur- 
rounding tissues.  True  ulceration  is  never  met  with  in  laryngitis  unconnected 
with  constitutional  disease.  Occasionally  after  a  violent  fit  of  coughing  blood  is 
seen  on  the  surface  of  the  mucous  membrane  or  extravasated  into  the  submucous 
tissue.  This  condition  has  been  termed  laryngitis  haemorrhagica,  but  it  hardly 
deserves  a  separate  name,  as  it  is  only  a  chance  occurrence.  The  voice  may  be 
merely  hoarse  or  almost  absent,  its  alteration  in  tone  being  dependent  more  upon 
the  paretic  condition  of  the  vocal  cords  or  mechanical  interference  with  their 
movements,  than  the  congestion  or  swollen  condition  of  the  mucous  membrane 
of  the  larynx  itself.  Adults,  as  a  rule,  recover  from  an  attack  of  acute  laryngitis 
in  a  few  days  if  treated  from  the  commencement,  but,  if  neglected,  the  affection 
may  remain  in  the  subacute  form  for  some  time  and  eventually  pass  into  the 
chronic  stage.      In  children  acute  laryngitis  is  a  much  more  serious  matter,  on 


CHRONIC  LARYNGITIS.  805 

account  of  the  interference  with  respiration,  due  partly  to  the  smaller  size  of  the 
glottis. 

Treatment. — The  patient  should  be  kept  in  a  warm  room  on  light  diet, 
without  any  stimulants.  Sedative  inhalations  should  be  given  every  three  or  four 
hours  if  the  case  is  acute,  or  at  longer  intervals  when  less  severe.  A  saline  febrifuge 
should  be  administered,  to  which  may  be  added  a  small  quantity  of  opium  to 
relieve  the  cough  ;  the  form  which  I  prefer  is  a  mixture  of  citrate  of  potash  with 
the  compound  tincture  of  camphor.  One  or  two  drachms  of  the  ammoniated 
tincture  of  ([uinine,  taken  in  water  every  three  or  four  hours,  is  sometimes  useful. 
An  aperient,  especially  a  small  dose  of  calomel,  is  often  beneficial  at  the  com- 
mencement. In  children  the  air  should  be  warmed  and  moistened  by  making  a 
tent  over  the  bed  and  allowing  the  steam  from  a  bronchitis  kettle  or  Lee's  steam 
draught  inhaler  to  enter  it. 

Chronic  Laryngitis. 

This  often  follows  an  acute  or  subacute  attack,  especially  if  it  has  been 
neglected  ;  but  any  of  the  conditions  that  excite  acute  inflammation  may  induce 
it  or  maintain  it  when  it  has  once  commenced.  A  congested  condition  of  the  mucous 
membrane  is  very  common  in  boys  at  puberty,  owing  to  the  hyperaemia  that  accom- 
panies the  sudden  development  of  this  organ  (causing  what  is  popularly  known  as 
"  cracked  voice  ")  ;  and  asimilar  affection  is  present  in  most  cases  of  old-standing 
disease  and  in  chronic  bronchitis.  Men  suffer  more  frequently  than  women, 
owing  in  all  probability  to  more  frequent  exposure ;  children  of  both  sexes  are 
comparatively  exempt. 

The  subjective  symptoms  in  many  cases  are  not  marked,  especially  when  there 
is  no  necessity  to  make  frequent  use  of  the  voice.  Slight  irritation  and  dryness  of 
the  throat,  with  a  tickling  cough,  are  all  that  a  patient  usually  experiences  ;  but 
these  speedily  become  greatly  increased,  if  the  voice  is  used  for  any  length  of 
time,  and  a  pricking  or  burning  sensation  in  the  throat  may  ensue,  accompanied 
by  a  feeling  of  obstruction,  which  the  patient  endeavors  to  relieve  by  constantly 
"  clearing  the  throat." 

The  objective  symptoms  are  hoarseness,  increased  secretion,  and  certain  defi- 
nite changes  in  the  tissues  of  the  parts.  A  marked  feature  of  this  disease  is  that 
in  recent  cases  the  hoarseness  is  most  noticeable  when  the  patient  begins  to  use  the 
voice  after  having  been  silent  for  some  time,  the  natural  tone,  however,  being 
assumed  in  a  few  minutes.  This  phenomenon  is  probably  due  to  the  increase  in 
the  blood  supply  and  nerve  force  to  the  part  consequent  upon  the  vocal  effort.  If 
the  patient  continues  to  use  his  voice  a  feeling  of  fatigue  is  soon  experienced 
and  hoarseness  quickly  supervenes.  When  the  affection  is  less  recent,  the  voice 
may  be  continually  hoarse  or  even  lost.  Sometimes  it  is  natural  unless  attempts  are 
made  to  exert  it,  such  as  by  preaching,  singing,  etc.  In  chronic  laryngitis  there 
is  usually  increased  secretion  of  mucus,  which  may  be  seen  adhering  to  the  interior 
of  the  larynx  and  especially  to  the  vocal  cords,  gluing  the  latter  together.  As  a 
rule  it  is  thick,  grayish  in  color,  and  at  times,  when  expectorated,  streaked  with 
blood.  If  chronic  bronchitis  exists  the  secretion  is  more  profuse  and  less  tena- 
cious in  character.  The  larynx  is  generally  more  or  less  congested,  but  at  times 
the  hyperaemia  is  limited  to  a  particular  part  of  the  cavity,  a  vocal  cord  or  a 
portion  of  one  being  not  infrequently  the  only  seat  of  marked  increased  vascularity. 
At  times  enlarged  blood-vessels  may  be  seen  running  parallel  with  the  length  of 
the  cord  along  its  centre  or  attached  border,  giving  the  part  a  streaky  appearance. 
The  mucous  membrane  is  generally  swollen,  and  in  old-standing  cases  the  sub- 
mucous tissue  also  is  considerably  involved.  This  thickening  produces  to  some 
extent  the  hoarseness  which  accompanies  the  affection,  but  this  symptom  is  at 
times  greatly  aggravated  by  the  swollen  interarytenoid  fold  interfering  with  the 
complete  approximation  of  the  vocal  cords.  As  a  result  of  chronic  laryngitis, 
nodular  excrescences  are  not  infrequently  met  with,  and  the  non-malignant  forms 
of  laryngeal  growth  owe  their  origin  to  long-standing  hyperaemia. 


8o6     DISEASES  AND  INJURIES   OE  SPECIAL   STRUCTURES. 

Chronic  inflammation  of  the  larynx  is  often  attended  with  changes  in  the 
tissues  themselves,  the  subepithelial  portion  of  the  mucosa  being  converted  into 
lymphoid  tissue.  In  aggravated  cases  of  chronic  laryngitis  one  or  both  cords  may 
be  found  f)ersistently  congested  and  the  surface  granular  in  apjjearance,  or  a  por- 
tion of  a  cord  (generally  the  anterior)  may  be  seen  to  be  markedly  increased  in 
size,  in  consequence  of  the  hypertrophied  condition  of  the  connective  tissue  of 
the  part.  Another  feature  noticeable  at  times  in  this  affection  is  a  paretic  condi- 
tion of  some  of  the  intrinsic  laryngeal  muscles,  producing  loss  of  power,  even  if 
not  actual  loss  of  movement,  in  one  or  both  cords,  usually,  however,  only  in  one. 
If  but  one  cord  is  affected,  on  phonation  the  opposite  one  crosses  the  mesial  line 
to  approximate  with  it,  provided  the  raucous  membrane  is  not  too  swollen  to  allow 
of  such  movement.  Erosions  of  shallow  ulcerations,  which  extend  no  deeper  than 
the  epithelial  layer,  are  not  infrequently  seen  in  this  disease,  a  frequent  seat  being 
the  posterior  wall  of  the  larynx  and  the  cartilaginous  portion  of  the  vocal  cords. 
In  some  cases  of  chronic  laryngitis,  especially  those  occurring  in  strumous  jjersons, 
the  subglottic  region  becomes  especially  involved,  giving  rise  to  hoarseness,  which 
is  often  quickly  followed  by  comj^lete  loss  of  voice.  Thickening  of  the  tissues, 
especially  at  the  outer  surface  of  the  vocal  cords,  is  the  condition  which  specially 
attracts  attention  when  a  laryngoscopic  examination  is  made,  the  tumefaction 
often  presenting  the  appearance  of  a  second  vocal  cord  immediately  below  the 
true  one. 

The  surface  of  the  swelling  is  generally  smooth  and  whitish-gray  in  color, 
but  occasionally  it  is  ulcerated  and  touched  with  red. 

In  some  cases  the  disease  appears  to  originate  in  the  cartilage  or  perichon- 
drium, the  structures  below  the  anterior  commissure  of  the  vocal  cords,  or  those 
on  the  inner  surface  of  the  sides  of  the  cricoid  cartilage,  being  most  frequently 
affected — both  situations  in  which  the  mucous  membrane  is  in  direct  contact  with 
the  perichondrium.  In  consequence  of  the  swelling  which  exists  in  these  cases, 
dyspnoea  may  occur  to  an  extent  which  necessitates  tracheotomy.  In  all  cases  of 
long-standing  chronic  laryngitis  the  individual  and  family  history  of  the  patient 
should  be  carefully  inquired  into  and  the  lungs  examined  from  time  to  time. 

With  efficient  local  treatment  a  favorable  prognosis  may  be  given,  provided 
that  (i)  the  disease  is  of  comparatively  recent  date  ;  (2)  is  not  accompanied  by 
any  marked  tissue  changes  ;   (3)  the  exciting  cause  has  been  removed. 

Treatment. — Unless  remedies  are  persistently  employed,  the  aff"ection  will 
remain  stationary,  even  if  it  does  not  progress;  or  the  symptoms  may  disapp)ear 
for  a  time  and  then  recur  with  the  slightest  irritation.  Chronic  laryngitis  affect- 
ing the  subglottic  region  is  much  more  intractable  than  the  ordinary  variety,  on 
account  of  the  difficulty  of  applying  remedies. 

In  cases  of  chronic  laryngitis,  which  are  not  of  long  standing  and  which  pre- 
sent no  marked  tissue  changes,  stimulating  steam  inhalations — pine  oil  or  creasote, 
for  example — are  of  very  great  service,  but  it  is  necessary  to  expire  the  vapor 
through  the  nostrils  as  well  as  draw  it  into  the  larynx,  because  the  pharynx  and 
naso-pharynx  are  usually  also  involved.  The  inhalation  of  fumes  of  chloride 
of  ammonium  is  useful  in  checking  excessive  secretion.  It  is  essential  that 
it  should  be  neutral,  as  an  excess  of  either  hydrochloric  acid  or  ammonia  causes 
irritation. 

In  more  advanced  cases  astringents  may  be  applied  to  the  larynx  with  a  brush, 
or,  better  still,  in  the  form  of  spray.  A  solution  of  chloride  of  zinc  (15  to  30 
grains  to  an  ounce  of  water),  or  perchloride  of  iron  (30  to  120  grains  to  an  ounce 
of  water),  may  be  used  with  a  brush.  Should  spasm  of  the  glottis  result  from  the 
application,  the  patient  should  be  made  to  speak  and  repeat  a  word  until  the  spasm 
subsides!     Solutions  for  application  in  the  form  of  a  spray  should  be  weaker  : — 


Chloride  of  zinc,      2  to  10  gr.  lo  ^  j 

Sulphate  of  zinc, 2  10  10  gr.  to 

Perchloride  of  iron, J4  to  2  gr.  to 

Alum, 1  to  10  gr.  to  ,^  j 


i 


LARYNGITJS.  807 

Where  there  is  much  inspissated  mucus  adhering  to  the  interior  of  the  larynx,  it  is 
well  to  spray  the  cavity  with  a  weak  alkaline  solution  to  soften  the  tenacious  film 
and  allow  it  to  be  got  rid  of  before  any  other  application  is  made.  Should  much 
thickening  exist  the  stronger  astringents  must  be  used,  and  if  these  fail  to  reduce 
the  hypertrophied  tissue,  it  may  be  necessary  to  destroy  it  by  means  of  a  galvano- 
cautery.  Where  there  is  long-standing  hyper^emia  with  diminished  secretion,  car- 
bolic acid  and  glycerine  (^ss-^j  of  pure  carbolic  acid  to  5J  of  glycerine)  may  be 
applied.  Turpentine  is  sometimes  useful  if  the  secretion  is  excessive.  If  paresis 
of  the  laryngeal  muscles  has  supervened,  electricity  must  be  employed  to  the 
interior  of  the  larynx,  a  constant  or  combined  current  being  the  most  efficacious. 
As  long  as  inflammation  exists  in  the  larynx  it  is  obvious  that  the  voice  should  be 
used  as  little  as  possible.  When  congestion  or  relaxation  of  the  pharynx  or  nares 
is  present  it  must  be  treated,  and  any  local  source  of  irritation  removed^  Atten- 
tion should  be  paid  to  the  general  health,  and  tonics  prescribed,  or  change  of  air 
recommended,  as  may  be  required. 

Perichondritis  of  the  larynx  usually  occurs  as  a  sequel  to  some  other  disease, 
such  as  phthisis,  cancer,  syphilis,  typhoid  fever,  or  to  an  injury,  but  it  may  be 
primary.  It  is  generally  found  in  adults,  and  is  more  common  amongst  males 
than  females.  A  dull  aching  pain  in  the  larynx  is  often  experienced,  and  there 
is  generally  more  or  less  congestion,  with  swelling  of  the  tissues  over  the  affected 
part.  Ulceration  may  occur,  and  if  an  abscess  has  formed  and  burst  internally, 
pus  may  be  visible. 

Immobility  of  one  or  both  vocal  cords  may  result  from  the  swollen  condition 
of  the  tissues  around  the  arytenoid  cartilages,  or  from  implication  of  the  recurrent 
laryngeal  nerve.  OEdema  is  generally  present  in  secondary  perichondritis.  The 
cricoid  and  arytenoid  cartilages  are  most  frequently  affected,  the  inflammation 
usually  beginning  in  the  perichondrium.  Beyond  soothing  inhalations  and  scari- 
fication (if  there  is  much  oedema)  little  can  be  done  locally  to  arrest  the  disease. 
Leeches  are  occasionally  useful  in  the  early  stages,  and  sometimes  an  abscess  may 
be  detected  and  opened  with  a  laryngeal  lancet  before  it  has  burst.  Trache- 
otomy is  often  required.  Dilatation  with  hollow  bougies  has  been  recommended 
to  counteract  the  stenosis  which  often  follows  this  affection,  but  the  results  of  this 
method  of  treatment  are  unsatisfactory. 

Lai-yngeal phthisis  is  usually  associated  with  pulmonary  disease,  but  it  may  be 
well  marked  in  the  larynx  without  any  evidence  of  it  in  the  chest,  and  it  is  said 
to  have  proved  fatal  without  any  tubercle  having  been  found  in  the  lungs.  The 
predisposing  causes  are  the  same  as  those  of  pulmonary  phthisis.  Males  are  more 
frequently  aff'ected  than  females,  and  most  cases  occur  between  the  ages  of  twenty 
and  thirty.  Excessive  use  of  the  voice  undoubtedly  hastens  the  development  of 
the  disease. 

Symptoms. — In  the  early  stages  there  is  nothing  characteristic  in  the 
appearance  of  the  larynx  beyond  that  of  chronic  laryngitis,  but  as  the  disease 
advances,  the  mucous  membrane  becomes  thickened  and  infiltrated  by  the  tuber- 
cular deposit,  commencing  over  the  arytenoid  cartilages  or  in  the  interarytenoid 
fold,  and  spreading  as  a  pyriform  swelling  toward  the  epiglottis.  It  may  begin, 
however,  in  the  epiglottis  or  other  parts.  By  degrees  the  other  parts  of  the  larynx 
become  affected,  until  most  if  not  all  of  the  laryngeal  tissues  are  involved.  It  is 
unusual  to  find  extensive  infiltration  confined  to  one  side.  In  the  majority  of 
cases  pallor  of  the  mucous  membrane  is  a  distinguishing  feature  of  this  disease,  but 
as  phthisical  subjects  are  prone  to  catarrhal  affections,  congestion  and  erosions  of 
the  mucous  membrane  are  often  present  at  the  same  time. 

Tubercular  ulcers  have  a  marked  tendency  to  coalesce,  thereby  giving  the 
surface  attached  a  worm-eaten  appearance.  Individual  ones  are  shallow  and  of 
small  size,  their  floor  having  a  granular  appearance.  Not  infrequently  the  epi- 
glottis and  the  neighboring  structures  are  extensively  destroyed.  Paresis  of  one 
or  both  vocal  cords  may  be  present,  due  either  to  tubercular  infiltration  of  the 
laryngeal  muscles,  or  to  the  interference   with  their  movements  that  arises  from 


So8    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  swelling  of  the  laryngeal  tissues.  The  general  debility,  however,  the  loss  of 
tone  in  all  the  muscles,  and  the  extreme  bodily  weakness  induced  by  this  disease 
are  not  without  influence.  The  right  vocal  cord  is  more  frequently  affected  than 
the  left,  in  con.sequence  of  the  recurrent  laryngeal  nerve  on  that  side  being  pressed 
upon  by  pleuritic  e.xudation,  or  as  a  result  of  consolidation  of  the  apex  of  the 
lung.  Pressure  from  enlarged  bronchial  glands  sometimes  acts  in  the  same  way. 
Necrosis  and  caries  of  the  cartilages  may  occur  ;  wart-like  excrescences  are  some- 
times seen  projecting  into  the  interior,  and  in  cases  not  far  advanced  thickening 
of  the  interarytenoid  fold  with  irregular  tooth-like  projections  may  be  seen  similar 
in  appearance  to  those  found  in  chronic  laryngitis. 

Hoarseness  is  often  present  in  the  early  stages  of  the  disease,  but  this  largely 
depends  upon  the  condition  of  the  larynx.  At  times  the  voice  is  almost  lost  in 
consequence  of  the  imperfect  action  of  the  vocal  cords,  or  the  want  of  sufficient 
expiratory  power  in  the  lungs.  Cough  rarely  fails,  but  it  is  not  accompanied  with 
much  expectoration  when  the  laryngeal  changes  are  slight,  unless  the  lungs  are 
decidedly  involved  or  catarrh  is  present. 

In  the  earlier  stages  a  certain  degree  of  pain  on  swallowing  may  be  experienced  ; 
later,  as  the  swelling  extends,  there  may  be  as  well  a  feeling  of  obstruction  to  the 
passage  of  food.  Still  later,  especially  when  the  epiglottis  and  ventricular  bands 
are  involved,  the  greatest  discomfort  is  produced  by  liquids  passing  into  the  larynx. 
Unless  i)erichondritis  is  present  there  is  no  pain  in  the  larynx  except  during 
deglutition.  In  giving  a  prognosis  the  most  important  points  are  the  condition 
of  the  epiglottis  and  arytenoid  cartilages  and  the  extent  to  which  ulceration  has 
advanced. 

Treatment. — In  addition  to  the  usual  constitutional  measures,  local  treat- 
ment is  of  service  in  modifying  the  progress  of  the  disease  and  adding  to  the  com- 
fort of  the  patient.  Lozenges  containing  a  small  quantity  of  opium  or  morphia 
are  useful  for  relieving  cough.  Daring  attacks  of  catarrh,  sedative  inhalations 
give  relief,  and  stimulating  inhalations  may  be  used  when  the  tissues  are  anaemic 
and  not  much  infiltrated.  Lactic  acid  appears  to  arrest  the  spread  of  the  affec- 
tion ;  it  may  be  apj^lied  with  a  brush,  or  injected  directly  into  the  tissues;  a  20 
per  cent,  solution  being  used  at  the  commencement,  and  the  strength  increased  to 
40  or  60  per  cent. 

Astringents  applied  either  with  a  brush  or  by  means  of  a  spray  rarely  do  good, 
and  frequently  cause  irritation.  Considerable  relief,  however,  may  be  obtained 
by  the  application  of  a  20  per  cent,  solution  of  menthol  in  olive  oil.  It  occasion- 
ally happens  that  the  infiltration  of  the  tissues  of  the  larynx  becomes  so  great  as  to 
require  tracheotomy,  but  the  operation  ought  never  to  be  done  merely  with  the 
object  of  giving  rest  to  the  larynx. 

The  pain  in  swallowing  may  be  somewhat  relieved  by  the  application  of 
cocaine  and  by  thickening  the  liquid  nourishment  and  directing  the  patient  to 
swallow  it  in  gulps.  Patients  have  been  recommended  to  lie  in  the  prone  position 
across  a  bed  and  to  suck  up  the  nourishment  through  a  tube. 

Lupus  is  usually  associated  with  evidence  of  the  disease  on  the  skin  or  the 
soft  palate,  but  occasionally  it  is  confined  to  the  throat.  It  is  more  often  found 
in  females  than  in  males,  and  amongst  the  lower  classes  of  society.  Its  charac- 
teristic features  are  hypertrophic  changes  followed  by  slowly  spreading  ulceration, 
the  surface  of  which  has  a  worm-eaten  appearance;  sometimes  the  hypertrophied 
tissues  are  nodulated.  The  mucous  membrane  is  congested  less  than  in  syphilis, 
but  more  than  in  phthisis,  and  its  sen.sibility  is  usually  diminished.  The  epiglottis 
is  frequently  attacked,  and  may  be  completely  destroyed. 

Syphilitic  laryngitis  is  not  an  invariable  accompaniment  of  the  manifestations 
of  the  disease  elsewhere,  and  often  does  not  come  on  until  some  time  after  the 
pharyngeal  symptoms  have  disappeared.  Its  most  constant  feature  is  congestion, 
which  is  usually  difficult  to  remove.  Mucous  patches  and  condylomata  are  pres- 
ent at  times,  and  have  usually  an  oval  or  sometimes  roundish  outline  ;  they  are 
less  persistent  than  in  the  pharynx  and  not  always  symmetrical,  sometimes  occur- 


TUMORS  OF  THE   LARYNX.  809 

ring  on  the  ventricular  bands  and  arytenoid  cartilages  or  edges  of  the  epiglottis. 
Erosions  of  the  mucous  membrane  and  superficial  ulceration  are  not  uncommon, 
and  their  tendency  to  recur  is  a  marked  feature  of  the  affection.  The  degree  of 
hoarseness  is  dependent  upon  the  extent  and  position  of  the  laryngeal  changes, 
and  although  in  most  cases  a  natural  tone  of  voice  for  conversation  is  eventuallv 
regained,  the  singing  voice  frequently  remains  impaired. 

Tertiary  syphilis  of  the  larynx  is  asually  marked  by  deep  ulceration,  but  cases 
occur  in  which  persistent  congestion,  accompanied  by  more  or  less  thickening, 
with  or  without  superficial  ulceration,  is  the  prominent  feature.  The.se  changes 
sometimes  make  their  appearance  many  years  after  the  initial  lesion,  impairment 
of  health  generally  being  the  determining  cause. 

The  epiglottis  is  frequently  the  seat  of  ulceration,  its  lateral  or  upper  border 
being  usually  first  attacked.  In  the  later  stages  of  syphilitic  disease  cedema  is 
often  present.  When  false  excrescences  occur,  they  are  generally  situated  on  the 
interarytenoid  fold  or  anterior  surface  of  the  posterior  wall  of  the  larynx.  Cium- 
mata  are  occasionally  found.  The  cicatrix  produced  by  the  ulceration  may  form 
a  web  between  the  vocal  cords,  and  frequently  causes  stenosis,  rendering  tracheo- 
tomy necessary.  The  thickening  around  the  cricoarytenoid  joint  not  unfrequently 
leads  to  permanent  stiffening  of  the  articulation. 

In  many  cases  only  general  treatment  is  required.  When  there  is  much  con- 
gestion, a  sedative  inhalation,  such  as  benzoin,  is  beneficial,  and,  later,  a  stimu- 
lating inhalation,  such  as  vap.  pini  sylvestris,  will  assist  recovery.  Long-standing 
congestion  should  be  treated  by  astringents,  applied  either  by  means  of  a  spray- 
producer  or  a  brush.  In  cases  of  obstinate  ulceration  great  benefit  is  sometimes 
obtained  by  heating  calomel  in  the  bulb  of  a  glass  tube  and  blowing  it,  whilst  in 
a  state  of  vapor,  on  the  affected  part. 

Leprosy. — The  chief  feature  of  laryngeal  leprosy  is  extreme  thickening  of  the 
mucous  membrane  :  sometimes  papillary  growths  or  tuberous  masses  are  present. 
The  larynx  is  never  affected  unless  the  disease  is  present  in  other  parts  of  the 
body. 

Tumors  of  the  Larynx. 

Carcinoma  is  more  often  found  in  males  than  in  females.  Epithelioma  is  the 
most  frequent  variety,  but  encephaloid  and  scirrhus  are  said  to  occur.  The  sub- 
jective symptoms  vary  according  to  the  stage  of  the  disease  and  the  part  affected. 
Usually  there  is  pain,  confined  at  first  to  the  larynx,  but  radiating  to  the  ears  and 
adjacent  parts  after  ulceration  has  commenced.  Dyspnoea  and  dysphagia  follow 
sooner  or  later.  Hoarseness  is  generally  the  most  prominent  objective  symptom  ; 
it  frequently  precedes  all  others  by  a  considerable  period,  but  the  voice  is  rarely 
entirely  lost.  When  ulceration  has  commenced  the  breath  may  become  exces- 
sively foetid,  and  hemorrhage  may  occur  from  a  vessel  being  laid  open.  The 
glands  are  seldom  affected,  and  then  only  when  the  disease  is  at  an  advanced 
stage.  This  is  due  to  the  lymphatics  being  less  freely  connected  with  the  glandu- 
lar system  than  those  from  most  other  organs,  and  for  the  same  reason  general 
cachexia  and  secondary  growths  in  other  parts  of  the  body  are  rare.  The  disease 
first  appears  as  a  swelling,  situated  most  frequently  on  one  of  the  ventricular 
bands,  although  any  other  part  of  the  larynx  may  be  affected  ;  as  it  increases  in 
size  the  outline  becomes  irregular,  the  color  becomes  red  from  congestion  of  the 
mucous  membrane  (though  sometimes  it  is  a  dirty  gray),  and  ulceration  quickly 
supervenes.     tEdema  is  generally  present  in  the  later  stage. 

Treatment. — All  growths  of  a  doubtful  nature  should  be  removed  by  an 
intra-laryngeal  operation  for  microscopical  examination.  If  found  to  be  cancer- 
ous, two  courses  are  open  :  (i)  to  leave  the  disease  to  run  its  course  ;  (2)  to 
attempt  to  eradicate  it  by  surgical  interference. 

With  a  view  to  the  latter,  thyrotomy,  partial  extirpation,  and  complete  extir- 
pation of  the  larynx  have  been  performed,  but  at  present  the  results  of  these 
operations  are  not  encouraging.  Many  patients  die  from  the  immediate  effects 
52 


8io    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

of  the  operation,  and  the  disease  is  very  liable  to  return,  even  after  what  appears 
to  be  com])lete  removal.  Thyrotomy  cannot  be  recommended,  in  conse(inence 
of  the  difficulty  of  removing  all  the  growth.  The  result  of  total  extirpation  of 
the  larynx  has  been  hitherto  far  from  satisfactory.  The  percentage  of  mortality 
due  to  immediate  effects  of  the  operation  is  very  high,  and  the  jiitiable  condition 
of  the  patients  who  survive,  even  for  a  short  time,  detracts  greatly  from  any 
advantage  which  may  have  been  gained.  The  operation  ought  not  to  be  per- 
formed unless  the  patient's  sanction  is  obtained,  after  all  the  disadvantages  as 
well  as  the  advantages  have  been  fully  detailed  to  him.  More  may  be  said  for 
a  partial  operation,  especially  if  performed  while  the  disease  is  still  recent  and 
apparently  localized. 

When  the  disease  is  allowed  to  run  a  natural  course  the  average  duration 
of  life  is  eighteen  months.  If  symptoms  of  stenosis  arise,  tracheotomy  should  be 
performed  before  the  general  health  becomes  lowered  by  insufficient  aeration. 
Pain  must  be  relieved  by  morphia,  either  injected  hypodermically  or  insufflated 
into  the  larynx,  and  dysphagia  met  by  the  use  of  a  feeding-tube  or  nutrient 
enemata. 

Non-malignant  growths  most  frequently  occur  in  the  larynx  when  congestion 
has  lasted  for  some  time,  as  in  catarrhal  or  exanthematous  laryngitis.  Males  are 
more  frequently  affected  than  females. 

Symptoms  vary  according  to  the  nature,  size,  and  situation  of  the  growth. 
When  it  is  attached  to  one  of  the  vocal  cords,  the  voice  is  generally  altered  in 
tone,  and  if  it  is  of  any  size  dyspncjca  is  usually  present. 

Papillomata  are  the  most  common.  They  are  u.sually  of  a  pink  color,  but 
may  be  white  or  bright  red,  and  are  generally  sessile,  and  often  multiple.  When 
removed  they  have  a  tendency  to  recur  or  to  spring  from  a  part  of  the  larynx  pre- 
viously healthy. 

Fibromata  are  of  a  brighter  red,  and  round  or  oval  in  outline,  though  some- 
times they  grow  out  like  cauliflower  excrescences.  They  are  always  single  and 
usually  pedunculated  ;  and  the  surface  is  generally  smooth,  though  it  may  be 
rough,  irregular,  or  w-avy.  There  are  two  varieties,  (<?)  the  firm  and  {/>)  the  soft. 
The  former  come  next  to  pajtillomata  in  the  order  of  frequency,  and  consist  of 
bundles  of  white  fibrous  tissue  covered  with  several  layers  of  epithelium  ;  the  soft 
are  comparatively  rare,  and  consist  of  fibro-cellular  tissue  with  serous  fluid  diffused 
through  their  substance. 

Cystic  tumors  are  not  often  met  with  ;  they  are  generally  situated  on  the  epi- 
glottis or  spring  from  the  ventricle  of  Morgagni,  and  usually  cause  some  local 
irritation. 

Myxomata,  or  true  mucous  growths,  angciomata,  or  vascular  growths,  and 
lipomata,  or  fatty  growths,  are  occasionally  met  with. 

Treatment. — Most  laryngeal  growths  can  be  removed  through  the  mouth 
by  means  of  forceps  or  a  snare.  If  the  patient  is  an  adult,  before  the  operation 
is  attempted,  the  larynx  and  pharynx  should  be  sponged  with  a  5  or  10  per  cent, 
solution  of  cocaine;  for  a  child  4  per  cent,  is  sufficiently  strong.  When  the  i)arts 
are  thoroughly  ana2Sthetized,  the  patient  should  be  directed  to  hold  the  tip  of  his 
tongue  with  a  napkin  in  his  right  hand.  The  forceps  and  faucial  mirror  having 
been  warmed,  the  mirror,  held  in  the  left  hand,  should  be  placed  in  position, 
and,  as  soon  as  a  view  of  the  grow-th  is  obtained,  the  forceps  introduced,  the 
blades  being  kept  closed  until  the  growth  is  reached.  Unless  the  operator 
is  skilled  in  intra-laryngeal  manipulation,  he  ought  not  to  attempt  to  cut 
or  drag  anything  away  unless  he  has  seen  that  only  the  growth  is  between 
the  blades. 

Growths  which  are  too  tough  to  be  extracted  with  forceps  should  be  snared 
and  slowly  divided  with  the  wire.  Cysts  may  be  crushed  with  forceps  or  laid 
open  with  a  guarded  lancet  attached  to  a  curved  handle.  After  removal  a  solu- 
tion of  perchloride  of  iron,  60  to  120  grains  to  the  ounce,  should  be  applied 
every  two  or  three  days  for  a  week  or  so,  to  prevent  recurrence. 


AFFECTIONS  OF  THE  MUSCLES  OF  THE  LARYNX.       8ii 

It  may  be  necessary  to  anaesthetize  a  child  before  attempting  to  remove  the 
growth.  When  this  is  done  the  child  should  be  seated  in  an  upright  position  on 
a  nurse's  lap,  the  mouth  kept  open  with  a  gag,  and  the  tongue  held  out  by  an  as- 
sistant. The  collection  of  saliva  often  prevents  a  good  view  of  the  interior  of 
the  larynx  being  obtained. 

In  very  e.xceptional  cases  it  may  be  desirable  to  destroy  the  remains  of  a 
growth  with  the  electric  cautery.  When  this  is  the  case,  a  suitable  electrode  hav- 
ing been  selected,  all  the  i)latinum  with  the  exception  of  the  point  should  be 
insulated  by  tying  a  thin  piece  of  ivory  on  each  side  of  it  (vaccine  points  do  very 
well),  and  coating  them  over  with  a  thick  layer  of  gum-arabic.  The  larynx  must 
be  thoroughly  anaesthetized,  and  the  electric  current  not  allowed  to  pass  until  the 
point  is  resting  on  the  surface  which  has  to  be  destroyed. 

An  cxtra-laryngeal  method  of  re inovitig  growths  ought  not  to  be  resorted  to 
unless  the  growth  is  causing  danger  to  life,  and  an  experienced  intra-laryngeal 
operator  is  of  opinion  that  no  other  procedure  will  be  successful.  This  mode  of 
removal  is  sometimes  required  when  a  growth  is  very  large,  has  an  extensive 
attachment,  and  is  of  very  tough  texture,  or  is  situated  where  it  cannot  be  reached 
through  the  mouth.  It  must,  however,  be  remembered  that  the  mere  size,  tough- 
ness, or  extensive  attachment  does  not  justify  an  extra-laryngeal  operation  being 
performed. 

Disorders  of  Sensation. 

Sensory  affections  of  the  larynx  are  occasionally  met  with  associated  with 
some  other  disease. 

Amesthesia  occurs  as  a  sequel  to  diphtheria  and  in  bulbar  paralysis.  When 
present  in  a  marked  degree  there  is  danger  of  pneumonia  being  set  up  by  particles 
of  food  passing  into  the  air  passages. 

Hypercesthesia  very  often  accompanies  inflammatory  conditions. 

Parcesthesia  is  usually  met  with  after  a  foreign  body  has  lodged  in  the  larynx, 
even  when  only  for  a  short  time,  the  sensation  of  its  presence  continuing  for  hours 
and  even  days  after  its  removal.      Sometimes  this  is  associated  with  ill-health. 

Neuralgia  rarely  occurs,  and  when  present  is  merely  a  local  manifestation  of 
a  general  condition. 

Electricity  is  of  use  in  some  cases  of  anaesthesia  and  in  paresthesia,  if  it  per- 
sists ;  but  when  the  latter  has  been  caused  by  a  foreign  body,  sedative  inhalations 
or  a  {&\N  applications  of  an  astringent  to  the  affected  parts  are  usually  sufficient  to 
effect  a  cure. 

Muscular  Paralysis. 

This  may  be  due  either  {a)  to  disease  or  injury  of  the  medulla  oblongata  or 
the  nerves  supplying  the  muscles,  or  {p)  to  affections  of  the  muscles  themselves. 
Among  the  diseases  which  produce  these  results  may  be  mentioned  syphilis,  can- 
cer, lead  poisoning,  rheumatism,  and  exposure  to  cold. 

Pressure  on  a  recurrent  laryngeal  nerve  affects  the  abductor  before  the  adduc- 
tor filaments.  This  injury  is  liable  to  be  produced  by  goitre,  aneurysm,  enlarged 
lymphatic  glands,  or  thickening  of  the  pleura  at  the  apex  of  the  right  lung. 
When  both  groups  of  muscles  are  paralyzed,  the  vocal  cord  on  the  corresponding 
side  remains  fixed  in  the  cadaveric  position.  /.  e.,  midway  between  extreme 
abduction  and  adduction,  and  on  phonation  the  healthy  cord  is  drawn  to,  or  even 
over,  the  middle  line,  compensating  for  the  immobility  of  the  paralyzed  cord. 

Paralysis  of  the  abductor  or  adductor  muscles  may  be  unilateral  or  bilateral. 
When  only  one  abductor  is  affected  the  voice  is  usually  unaltered,  but  there  is 
more  or  less  dyspncea  and  stridulous  breathing.  When  both  abductors  are  para- 
lyzed, the  vocal  cords  lie  almost  parallel,  but  generally  separated  rather  more 
behind  than  in  front.  The  voice  is  usually  but  little  altered  :  expiration  is  free  ; 
but  inspiration  difficult  on  the  least  exertion  and  attended  with  stridor,  which  is 


8i2    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

also  generally  i)resent  during  sleep.  It  usually  occurs  in  adults,  and  is  more 
common  in  males  than  females,  resulting  from  either  neuropathic  or  myopathic 
changes. 

When  only  one  abductor  is  paralyzed,  the  voice  is  hoarse  or  may  be  almost 
lost,  and  laughing,  coughing,  and  sneezing  are  always  altered  in  character. 

Bilateral pa7-alysis  of  the  adductors  (^functional  aphonia)  is  more  frequently 
met  with  in  women  than  men,  and  among  young  women  than  old  ones.  The 
subjects  of  this  affection  are  often  antemic  and  in  a  feeble  state  of  health  ;  occa- 
sionally they  are  found  to  be  suffering  from  some  disorder  of  the  sexual  system. 
It  may,  however,  result  from  catarrh,  rheumatism,  lead  poisoning,  and  other 
causes,  and  is  often  met  with  in  the  second  and  third  stages  of  phthisis.  Although 
the  aphonia  is  usually  constant,  sometimes  a  few  words  are  uttered  in  a  natural 
tone  of  voice,  especially  those  at  the  beginning  of  a  sentence.  A  notable  feature 
is  that  coughing  and  sneezing  are  little  altered  in  character.  On  attempted  pho- 
nation,  although  the  vocal  cords  are  adducted  slightly,  a  considerable  interval  is 
left  between  them  ;  sometimes  one  is  more  affected  than  its  fellow.  The  mucous 
membrane  of  the  larynx  is  usually  pale. 

The  cetitral  adductor  {arytenoideus  propi'ius)  is  often  affected  in  conjunction 
with  the  lateral  adductors,  but  may  alone  be  paralyzed.  When  in  this  condition 
there  is  loss  of  voice,  and  although  the  vocal  cords  approximate  in  the  anterior 
three-fourths  of  their  length,  they  remain  separated  by  a  triangular  opening  in  their 
posterior  fourth. 

The  external  tensors  {crico-thyroidei)  are  occasionally  paralyzed  in  conse- 
quence of  exposure  to  a  draught  of  cold  air  on  the  neck,  but  violent  or  long-con- 
tinued use  of  the  voice,  especially  in  the  open  air,  may  produce  the  same  result. 

The  symptoms  are  :  loss  of  voice,  sometimes  only  gruffness,  and  when  a  finger 
is  placed  on  one  of  the  muscles  during  phonation  no  movement  is  detected. 
When  the  affection  is  bilateral  the  central  portion  of  the  vocal  cords  is  depressed 
during  inspiration  and  raised  in  expiration.  The  glottis  also  has  the  appearance 
of  a  wavy  line. 

The  inter7ial  tensors  {thyro-arytenoidei  interni)  are  not  infrequently  affected 
as  a  result  of  over-fatigue  of  the  voice,  or  strain  from  an  excessive  vocal  effort. 
When  this  has  occurred,  the  vocal  cords  appear  slightly  bowed  outward,  leaving 
an  elliptical  aperture  between  them. 

Treatment. — This  must  depend  upon  the  cause  and  duration  of  the  affec- 
tion. If  congestion  is  present,  sedative  steam  inhalations,  such  as  benzoin, 
should  be  emi)loyed,  and  when  it  has  subsided  the  application  of  electricity  to  the 
muscles  affected  may  be  of  service.  This  is  done  by  attaching  one  jiole  of  a  bat- 
tery to  a  metal  disc  fastened  over  the  affected  muscle  by  a  piece  of  elastic  tied 
round  the  patient's  neck,  and  the  other  to  a  laryngeal  electrode,  contact  being 
made  by  depressing  the  lever  as  soon  as  the  end  of  the  electrode  touches  the 
affected  part  of  the  larynx.  In  cases  of  bilateral  paralysis  of  the  abductors,  unless 
the  aperture  between  the  cords  is  seen  to  enlarge  within  a  short  time  after  treat- 
ment has  been  commenced,  tracheotomy  ought  to  be  performed  without  delay. 
In  many  cases  of  functional  aphonia  the  application  of  a  strong  astringent 
(chloride  of  zinc  30  grs.  to  5J,  or  perchloride  of  iron  120  grs.  to  5J)  to  the  in- 
terior of  the  larynx  is  sufficient  to  restore  the  voice  ;  but,  if  this  fails,  faradism 
applied  to  the  vocal  cords  will  produce  the  desired  result.  Should  the  voice  be 
lost  soon  after  it  has  been  regained,  it  is  better  to  wait  until  the  general  health  is 
improved,  because  the  shock  produced  by  the  constant  application  of  electricity, 
especially  if  a  strong  current  is  used,  frequently  tends  to  retard  the  ultimate  re- 
covery of  the  i)atient.  In  the  treatment  of  laryngeal  paralysis  constitutional 
remedies  are  often  required,  and  in  some  cases  are  more  important  than  local 
measures. 


AFFECTIONS  OF  THE  MUSCLES  OF  THE  LARYNX.       813 

Muscular    Spasm. 

Spasm  of  the  adductors  of  the  vocal  cords  {Millar' s  asthma)  is  most  fre- 
quently met  with  in  children  between  six  months  and  two  years  old,  after  which 
age  the  tendency  decidedly  diminishes.  Males  are  much  more  subject  to  it  than 
females,  and  those  who  are  rickety  are  especially  liable  to  be  attacked. 

Most  cases  are  met  with  during  the  first  itw  months  of  the  year,  in  conse- 
quence of  the  more  excitable  condition  of  the  child's  nervous  system  at  that  time, 
dependent  upon  confinement  to  the  house  during  the  winter  months. 

Difficult  dentition  and  intestinal  irritation,  produced  by  indigestible  food 
or  worms,  are  the  chief  exciting  causes.  Sometimes  the  attacks  occur  during  sleep, 
but  they  may  be  brought  on  by  the  child  crying,  sucking,  or  being  dandled. 

Symptoms. — .\  severe  attack  begins  with  several  short  stridulous  inspira- 
tions, followed  by  a  longer  and  more  noisy  one,  after  which  respiration  ceases, 
the  head  is  thrown  backward,  and  the  spine  bent  in  the  same  direction.  The 
eyes  are  fixed  or  turn  from  side  to  side  ;  the  fingers  are  clenched  over  the 
thumbs  and  the  wrists  flexed  ;  the  feet  are  flexed  and  rotated  slightly  outward, 
and  the  great  toes  adducted.  The  child's  face  becomes  dusky,  and  the  superficial 
veins  distended.  Suddenly  the  spasm  relaxes  and  the  child  recommences  to 
breathe.  Usually  the  attacks  recur  from  time  to  time,  sometimes  at  frequent 
intervals,  but  any  one  of  them  may  prove  fatal.      Pyrexia  is  generally  absent. 

Treatment. — During  the  attack  the  child  should  be  slapped  on  the  back, 
cold  water  thrown  on  the  face,  and  smelling-salts  held  to  the  nose.  When  the 
spasm  has  passed  off  an  enema  should  be  given  and  a  mercurial  purge  administered. 
With  a  view  to  diminish  the  tendency  of  spasms,  musk  (gr.  1-3)  or  bromide  of 
ammonia  or  potassium  should  be  administered  every  three  or  four  hours.  The 
greatest  attention  must  be  paid  to  diet. 


Ii4    DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 


CHAPTER  XIV. 

DISEASES    AND    INJURIES    OF  THE   NECK  AND    THROAT. 
MALFORMATIONS. 

Bran'Chial  Fistula. 

The  Eustachian  tube  is  the  modified  first  branchial  cleft  of  fijetal  life.  The 
others  usually  leave  no  representative,  but  occasionally  a  fistulous  opening  is  found 
at  birth  corresponding  to  one  of  them.  The  second  and  fourth  appear  to  persist 
more  frequently  than  the  third  ;  the  former  opens  in  the  neighborhood  of  the 
lesser  cornu  of  the  hyoid  bone,  and  may  or  may  not  communicate  with  the  pharynx  ; 
the  latter  lies  just  at  the'  inner  margin  of  the  sterno-mastoid  immediately  above  the 
sternum.  Occasionally  it  opens  into  the  trachea  or  pharynx.  They  give  rise  to 
no  symptoms  and  usually  require  no  treatment.  Pedunculated  fibro-cartilaginous 
masses  are  sometimes  found  in  the  neighborhood  of  their  external  orifice. 

Spina  bifida,  which  occasionally  occurs  in  the  cervical  region,  najvi,  hydro- 
cele of  the  neck,  dermoid  cysts,  and  those  developed  in  connection  with  the 
thyreoid  body  and  the  thyroglottic  canal,  congenital  lipomata  and  malformations 
of  the  pharnyx,  are  described  elsewhere. 


INJURIES  OF  THE  NECK. 

Wounds. 

Transverse  incised  wounds  are  frequently  met  with  in  the  front  of  the  neck. 
For  the  most  part  they  are  self-inflicted  ;  many  lie  in  the  suprahyoid  space,  some 
in  the  thyrohyoid,  and  others  over  the  larynx  or  trachea.  Generally  in  right- 
handed  people  they  begin  on  the  left,  high  up,  and  run  obliquely  toward  the 
right,  becoming  less  and  less  deep  ;  and  not  unfrequently  they  are  jagged,  the  skin 
rolling  up  into  folds  before  the  pressure  of  the  knife,  so  that  it  appears  as  if  several 
cuts  had  been  inflicted.  Sometimes  they  extend  from  one  side  to  the  other, 
dividing  the  trachea  and  oesophagus  or  both  the  carotid  arteries,  and  even  notching 
the  vertebral  column  ;  much  more  they  are  superficial,  not  penetrating,  perhaps, 
into  the  deep  fascia.  There  are  various  reasons  for  this  :  the  edge  of  the  knife  in 
many  instances  is  directed  against  the  lower  jaw,  or  the  force  is  spent  against  the 
cartilages  ;  when  the  head  is  thrown  back  the  larynx  is  thrust  forward  and  the 
vessels  recede;  resolution  often  fails  at  the  last  moment,  and  if  the  air-passages 
are  opened  the  sudden  collapse  of  the  thorax,  previously  expanded  to  its  utmost, 
is  sufficient  to  interrupt  the  tension  of  the  muscles  and  break  the  force  of  the  arm. 
In  this  way  the  vessels  escape  unhurt  in  by  far  the  larger  number  of  cases. 

Besides  these,  gunshot  injuries  and  punctured  wounds,  stabs,  for  example, 
from  behind,  penetrating  the  apex  of  the  lung,  or  involving  the  great  vessels  at 
the  root  of  the  neck,  and  even  penetrating  between  the  arches  of  the  vertebrae  into 
the  spinal  canal,  are  occasionally  met  with.  Union  by  the  first  intention  is  the 
exception.  It  is  almost  impossible  to  keep  the  wound  at  rest,  and  partly  owing  to 
the  elasticity  of  the  skin,  partly  to  the  action  of  the  platysma,  the  edges  always 
curl  inward,  so  that  perfect  adaptation  cannot  be  obtained.  Death  may  occur 
almost  instantaneously  from  lo.ss  of  blood,  arterial  or  venous,  from  air  being 
drawn  into  a  wounded  vein,  from  suffocation,  owing  to  a  detached  portion  of  the 
tongue  or  one  of  the  cartilages  falling  into  the  larynx  or  trachea,  or  from  blood 
pouring  into  the  lungs,  or  it  may  follow  later  from  inflammation  or  other  compli- 


WOUNDS  OF  THE   NECK.  815 

cations.  Emi^hysema  is  not  uncommon,  but  is  rarely  of  much  importance  ;  spasm 
and  oedema  of  the  glottis  may  set  in  at  any  moment  ;  food,  dust,  cold  air,  blood, 
or  pus  may  find  its  way  down  to  the  lungs,  and  set  up  bronchitis  or  broncho- 
pneumonia ;  abscesses  may  form  around  the  air  passages,  and  spread  into  the 
tissues  of  the  neck,  and  down  behind  the  cervical  fascia  to  the  pleura  and  pericar- 
dium ;  and  if  these  complications  do  not  prove  fatal,  perichondritis  and  necrosis 
of  the  cartilages  may  set  in  ;  granulations  may  spring  up  and  close  the  larynx  or 
trachea  ;  a  fistulous  orifice  may  be  left,  or  aphonia,  dyspnoea,  or  dysphagia  may 
persist  for  the  rest  of  life,  caused  by  the  cicatrization  that  takes  place  in  the  interior. 

When  the  wound  lies  above  the  hyoid  the  facial  and  lingual  arteries  may  be' 
cut,  the  cavity  of  the  mouth  opened,  and  the  tongue  and  the  epiglottis  hacked  in 
such  a  way  that  they  fall  back  over  the  larynx  and  cause  instant  death.  The 
hemorrhage  is  usually  free  and  the  blood  may  pour  down  into  the  trachea  as  well 
as  escape  externally.  Food  and  saliva  pass  out  through  the  opening  ;  the  move- 
ments of  the  tongue  are  impaired  (sometimes  the  hypoglossal  nerve  is  divided)  ; 
the  elevators  of  the  hyoid  are  cut  across  ;  and  swallowing  and  vocalization  cannot 
be  properly  carried  out.  If  the  thyrohyoid  membrane  is  divided,  the  epiglottis 
and  even  the  arytenoid  cartilages  may  be  detached  and  hang  down  ;  or  the  aryepi- 
glottic  folds  may  be  cut,  and  the  superior  thyroid  artery  and  superior  laryngeal 
nerve  divided. 

When  the  brunt  of  the  force  falls  upon  the  cartilages  the  great  vessels  usually 
escape  ;  they  lie  far  back  in  the  angle,  and  unless  the  incision  begins  under  the 
ear,  or  traverses  the  cricothyroid  space  they  are  generally  well  out  of  the  way. 
The  immediate  risk,  therefore,  is  not  so  great  ;  but  whenever  the  larynx  is 
wounded,  the  danger  of  inflammation,  of  spasm  and  oedema  of  the  glottis,  and 
of  food  passing  down  into  the  air  passages,  owing  to  the  imperfect  way  in  which 
they  are  protected,  is  very  serious.  Dyspnoea  and  a  sense  of  impending  suffocation 
are  always  present;  the  least  attempt  at  swallowing  or  speaking  brings  on  fits  of 
spasmodic  coughing  :  and,  if  the  patient  survives,  permanent  impairment  of  the 
voice  is  not  uncommon. 

Hemorrhage  is  more  frequent  in  wounds  of  the  lower  part  of  the  neck  ;  it 
may  come  from  the  carotid  or  thyroid  arteries  ;  from  the  anterior,  external  or 
internal  jugular  veins,  or  even  from  the  thyroid  gland,  which,  sometimes,  when 
cut  into,  bleeds  profusely ;  and,  if  the  trachea  is  cut  across,  the  blood  may  pour 
down  into  the  lungs  so  as  to  cause  instant  death.  Wounds  of  the  trachea  of  them- 
selves are  not  very  serious  ;  but  when  it  is  divided  the  two  ends  retract  so  that  a 
wide  space  appears  between  them,  the  lower  sinking  down  into  the  thorax  and 
moving  to  such  an  extent  with  each  inspiration  that  it  is  almost  impossible  to  fix 
it.  The  oesophagus  and  the  recurrent  laryngeal  nerve  are  often  wounded  at  the 
same  time.  Punctured  wounds  at  the  root  of  the  neck,  if  they  involve  the  upper 
aperture  of  the  thorax,  are  often  fatal  at  once  from  injury  to  the  great  vessels  ; 
but  instances  are  recorded  in  which  recovery  has  taken  place,  even  when  the  apex 
of  the  lung  has  been  injured  and  the  brachial  plexus  divided. 

Treatment. — Hemorrhage  must  be  stopped  at  once  by  pressure.  If  the 
vessel  is  a  large  one,  the  finger  must  be  inserted  into  the  wound  and  kept  upon  the 
bleeding  point  ;  division  of  one  of  the  carotids  is  generally  fatal  immediately,  but 
instances  are  on  record  in  which  the  hemorrhage  has  been  stayed  temporarily  in 
this  way,  until  better  means  could  be  adopted.  If  the  wound  is  too  large,  or 
there  are  many  bleeding  points,  a  handkerchief,  or  a  sponge,  may  be  used  ;  but 
care  must  be  taken  not  to  compress  the  trachea  or  to  drive  the  blood  down  into 
it.  Then,  as  soon  as  possible,  the  arteries  should  be  secured,  either  by  torsion  or 
ligature  at  both  ends,  and  the  veins  tied.  Complete  division  of  the  internal 
jugular  is  not  necessarily  fatal ;  a  small  lateral  wound  should  be  treated  as  if  a 
branch  had  been  torn  off  from  the  side.  In  deep  punctured  wounds,  behind  the 
angle  of  the  jaw,  when  the  bleeding  is  plainly  arterial,  and  when  it  is  impossible 
to  secure  the  vessel  without  a  long  and  dangerous  dissection,  an  attempt  should  be 
made  to  ascertain  by  pressure  upon  the  external  carotid  whether  it  proceeds  from 


8i6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

one  of  its  branches — and,  if  so,  this  should  be  tied  ;  under  other  circumstances  a 
ligature  should  be  placed  round  the  common  trunk.  Wounds  further  l)ack  in  the 
neck  are  still  more  serious.  The  vertel)ral  artery,  or  some  of  the  main  branches 
of  the  occipital  and  superior  intercostal,  may  be  divided  ;  or  even  the  spinal  cord 
may  be  injured.  If  an  artery  is  severed  an  attempt  must  be  made  to  tie  it  ;  if 
this  fails  the  wound  must  be  jjlugged  from  the  bottom  with  some  antiseptic.  This 
has  succeeded  even  in  the  case  of  the  vertebral. 

In  other  cases  asphyxia  is  a  more  prominent  symptom.  When  it  arises  from 
the  entry  of  air  into  veins,  or  from  blood  pouring  down  into  the  trachea,  help,  as 
a  rule,  is  too  late ;  but  if  a  portion  of  the  tongue  or  of  the  larynx  has  been 
detached,  and  is  hanging  over  the  aperture,  it  is  sometimes  possible  to  lift  it  out 
of  the  way  in  time.  The  subsecpient  treatment  depends  uj^on  the  extent  of  the 
injury.  A  deep  ligature,  for  example,  may  be  passed  through  the  base  of  the 
tongue  to  keep  it  forward  ;  the  epiglottis,  if  extensively  cut  into,  is  better  removed, 
and  this  does  not  seem  to  interfere  with  deglutition  ;  otherwise  it  may  be  .secured 
with  sutures  \  and  the  same  may  be  done  with  the  other  cartilages.  Divided 
nerves,  if  the  ends  can  be  found,  should  always  be  drawn  together  again.  Wounds 
of  the  oesophagus  must  be  closed  with  catgut,  but,  especially  if  they  are  transverse, 
there  is  little  chance  of  primary  union.  When  the  trachea  is  cut  across  an  attempt 
must  always  be  made  to  approximate  the  ends  with  sutures ;  but,  owing  to  the 
extent  of  the  retraction  and  the  movement  of  the  parts,  this  is  by  no  means  easy. 
Finally,  if  blood  has  poured  into  the  trachea,  as  much  as  possible  must  be  removed 
by  means  of  suction  or  by  feathers,  so  as  to  limit  the  area  of  decomposition  and 
inflammation  ;  with  an  extensive  wound  in  the  air  passages  the  patient  cannot 
cough  it  up. 

If  the  incision  is  of  great  length,  sutures  may  be  inserted  at  the  ends  to  draw 
the  edges  together,  but  even  then  they  rarely  unite  by  the  first  intention  :  the 
central  portion,  if  the  air  passages  have  been  wounded  and  cannot  be  .secured  by 
sutures,  should  be  left  open,  so  as  to  afford  free  exit  for  the  discharge,  which  might 
otherwi.se  find  its  w^ay  into  the  lungs.  Gaping  is  prevented,  as  soon  as  the  patient 
is  placed  in  bed,  by  raising  the  shoulders  and  fixing  the  head  with  bandages  in  a 
l)osition  of  moderate  flexion,  taking  care,  of  course,  not  to  force  it  down  so  far  as 
to  interfere  with  respiration.  If  the  larynx  is  badly  injured  it  is  better  to  jjerform 
tracheotomy  at  once  and  insert  a  rubber  tube  ;  it  is  almost  sure  to  be  required  later 
on  for  oedema  or  spasm  of  the  glottis,  to  prevent  the  entry  of  foul  air  or  discharges 
into  the  lungs,  or  from  narrowing  of  the  glottis  owing  to  the  cicatrization  and 
growth  of  granulations. 

A  thin  flat  sponge  wrung  out  of  hot  water  should  be  laid  over  the  wound  to 
prevent  dust  entering  in  ;  and  the  air  of  the  room  must  be  kept  warm  and  moist 
by  means  of  a  steam  kettle.  Bronchitis  is  nearly  sure  to  occur  if  the  air  passages 
are  opened,  and  is  very  likely  to  run  on  to  ])neumonia.  The  patient  is  often 
broken  down  in  health  already,  and  is  in  a  state  of  extreme  depression  ;  he  is 
weakened  still  further  by  hemorrhage  ;  coughing  is  impossible  owing  to  the  position 
of  the  wound  ;  and  even  if  blood  does  not  enter  the  lungs,  and  decomi)ose  there, 
inflammation  is  very  likely  to  extend  down  from  the  seat  of  injury,  or  be  caused 
by  particles  of  food,  or  by  the  air  that  has  been  fouled  in  passing  over  a  septic 
surface.  The  diet  must  be  nutritious,  with  a  moderate  amount  of  stimulants  ;  and 
the  patient  must  be  fed  either  with  enemata  or  by  means  of  a  tube  passed  down 
into  the  stomach.  The  danger  is  greatest  if  the  cesophagus  or])harynx  is  opened  ; 
but  if  the  muscles  of  the  floor  of  the  mouth  are  divided,  or  if  there  is  any  extensive 
injury  to  the  upper  part  of  the  glottis,  the  same  precautions  must  be  taken.  The 
larynx  loses  its  power  of  protecting  itself;  coughing  is  impo.ssible  owing  to  the 
escape  of  air;  and  often  the  sensibility  of  the  mucous  membrane  is  imjiaired. 
A  soft  india-rubber  tube  is  generally  sufiicient ;  it  may  be  passed  either  through 
the  mouth  or  nose  (never  through  the  wound),  and  care  must  be  taken  to  make 
certain  that  it  has  not  accidentally  entered  the  larynx.  Liquid  food  may  be 
poured  down  this  by  means  of  a  funnel  every  four  hours  without  much  incon- 


FRACTURE  OF  THE   IIYOTD  BONE.  Sry 

venience  to  the  patient  and  without  any  risk.  In  all  suicidal  cases  the  patient 
must  be  carefully  watched,  for  fear  of  doing  himself  further  injury  ;  sometimes  it 
is  necessary  to  restrain  the  hands,  but  when  possible  this  should  be  avoided. 
Little  can  be  done  for  the  despondency  that  is  so  often  present ;  if  there  is  sleep- 
lessness or  much  excitement  chloral  may  be  given  ;  bromide  is  too  depressing  and 
opium  is  inadvisable  in  bronchitis.  The  prognosis  in  such  cases  is  much  worse 
than  might  be  expected  from  the  extent  of  the  wound. 

If  (lysi)n(ea  arises  the  wound  must  be  examined  at  once,  and  if  necessary, 
tracheotomy  jjerformed.  Occasionally  this  is  recpiired  at  a  later  period,  owing  to 
irregular  contraction  or  cicatrization  in  the  interior,  or  to  the  presence  of  exuber- 
ant granulations,  which  cannot  be  got  rid  of  by  scraping  or  cauterization.  Qui- 
nine, carbonate  of  ammonia,  ether  and  other  stimulants  must  be  given  freely  if 
pneumonia  sets  in  ;  and  the  side  of  the  chest  may  be  enveloped  in  a  poultice  ;  but 
the  signs  are  often>  too  obscure  until  it  is  well  advanced.  There  is  no  rise  of 
temperature  in  many  cases,  and  expectoration  is  ab.sent ;  the  face  is  pale  and 
dusky,  the  forehead  covered  with  beads  of  pers])iration,  the  respiration  short  and 
jerky  and  the  pulse  small  and  cjuick.  Generally  the  patient  rapidly  falls  into  a 
kind  of  stupor.  Deep-.seated  abscesses  and  cellulitis  of  the  neck  are  usually 
accompanied  by  rigors  and  high  fever  ;  and  the  local  signs  are  well  marked. 
Sometimes  the  inflammation  extends  along  the  outside  of  the  trachea  into  the 
mediastinum,  and  causes  pleurisy  and  even  pericarditis.  If  a  fistulous  opening  is 
left  it  may  be  cured  by  a  plastic  operation,  paring  the  edges  and  bringing  them 
together  with  numerous  points  of  suture  ;  or  even  by  gliding  a  piece  of  skin  over 
it  from  one  side  or  the  other,  provided  that  it  is  certain  that  the  patient  can 
breathe  sufficiently  well  when  it  is  covered  up. 

Fracture  of  the  Hyoid  Bone. 

Owing  to  its  protected  situation  this  is  rarely  broken  except  by  direct  violence, 
such  as  a  blow  or  a  squeeze,  as  in  hanging.  The  greater  cornu  is  the  part  that 
usually  gives  way.  One  or  two  instances,  however,  are  recorded  in  which  it  was 
produced  by  muscular  action  alone. 

The  diagnosis  is  seldom  difficult :  unless  there  is  much  swelling  or  ecchymo- 
sis,  the  fragments  can  generally  be  felt  from  the  outside,  and  always  by  introduc- 
ing the  finger  into  the  mouth.  There  is  intense  pain  on  pressure,  or  on  attempting 
to  speak  or  swallow.  Very  often  the  fracture  is  compound,  one  of  the  ends  having 
perforated  the  mucous  membrane,  and  there  is  a  profuse  secretion  of  saliva  mixed 
with  blood.  Sometimes  the  swelling  extends  to  the  larynx,  so  that  the  dyspnoea 
becomes  serious. 

Treatment. — The  fragments  must  be  brought  into  position  by  manipulation, 
and  the  head  and  neck  fixed,  as  far  as  possible,  by  a  splint  moulded  over  the 
shoulders  and  up  the  back  of  the  head.  Swallowing  is  so  intensely  painful,  and 
sometimes  sets  up  such  an  amount  of  coughing  and  irritation,  that  the  patient  may 
have  to  be  fed  by  enemata  for  a  i^vi  days,  until  the  fragments  are  consolidated,  or 
an  (^esophageal  tube  can  be  used.  If  the  dyspnoea  is  severe,  particularly  if  the 
fracture  is  compound,  and  if,  as  often  happens,  the  wound  becomes  septic  from 
the  entry  of  food  and  other  substances  from  the  mouth,  so  that  there  is  risk  of 
acute  laryngitis  setting  in,  tracheotomy  may  be  required  at  a  moment's  notice. 
Union  generally  takes  place  in  three  or  four  weeks,  but  suppuration,  necrosis, 
oedema  of  the  larynx,  and  septic  pneumonia  are  not  uncommon. 

Dislocation  of  the  hyoid  bone,  or  displacement  consequent  upon  relaxation 
of  the  ligaments  connecting  it  to  the  thyroid  cartilage,  has  also  been  described. 

Fracture  of  the  Cartilages  of  the  Larynx. 

This  may  be  caused  in  the  same  way  ;  even  the  trachea  has  been  torn  across 
by  a  violent  blow  from  the  point  of  an  elbow.     The  thyroid,  owing  to  its  size, 


Si 8    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

position,  and  rigidity,  is  the  one  that  usually  suffers  :  sometimes  the  cricoid  is 
broken  as  well. 

This  accident  may  ])rove  instantaneously  fatal  from  obstruction  or  spasm  of 
the  glottis.  Even  when  there  is  not  much  deformity  the  swelling,  ecchymosis, 
and  emphysema  seriously  narrow  the  rima  glottidis  and  cause  very  alarming 
dyspniea.  In  general  there  is  the  most  intense  tlistress,  with  a  sensation  of 
impending  suffocation,  or  this  may  be  absent  at  first  and  then  come  on  suddenly. 
The  treatment  is  the  same  as  for  fracture  of  the  hyoid,  but  unless  the  portion  of 
cartilage  broken  off  is  very  small  and  altogether  external,  so  as  not  to  involve  the 
mucous  membrane,  tracheotomy  or  laryngotomy  may  be  required  at  a  moment's 
notice.  The  latter  is  preferable,  as  the  opening  can  be  used  to  restore  the  dis- 
placed cartilage  to  its  position  or  to  fix  it  by  sutures. 

Contusion  is  much  more  common,  and  when  severe — as,  for  examijle,  in  gar- 
roting — so  that  there  is  hemorrhage  under  the  mucous  membrane,  may  give  rise 
to  the  same  symptoms.  It  is  said  that  sudden  death  has  been  caused  by  this  or 
by  spasm,  without  any  fracture.  Care  must  be  taken  not  to  mistake  the  crackling 
sensation  that  is  often  felt  when  the  larynx  is  moved  from  side  to  side  upon  the 
vertebral  column  for  cartilage-crepitus. 

Foreign  Bodies  in  the  Air  Passages. 

Irritating  vapors  rarely  penetrate  beyond  the  larynx  :  usually  they  are  driven 
out  at  once  by  coughing,  and  cause  merely  a  transient  hyperemia,  though  this 
may  run  on  to  inflammation.  The  same  with  licpiids,  unless  the  larynx  has  lost 
its  sensitiveness  or  the  muscles  are  paralyzed.  After  diphtheria,  for  example,  or 
when  a  patient  is  under  an  anaesthetic,  or  after  wounds  involving  the  floor  of  the 
mouth  or  the  upper  part  of  the  larnyx,  when  the  mucous  membrane  is  dry  and 
insensitive,  it  is  not  uncommon  for  blood  or  liquid  food  or  material  vomited  up 
from  the  stomach  to  find  its  way  down  through  the  larynx  into  the  trachea  and 
lungs,  and,  decomposing  there,  set  up  broncho-pneumonia.  Solid  substances 
cause  symptoms  of  much  greater  intensity. 

As  a  rule  they  enter  by  the  mouth  ;  occasionally  they  ulcerate  through  from 
the  oesophagus,  especially  in  malignant  disease.  In  the  vast  majority  of  cases 
this  accident  is  the  result  of  the  careless  habit  of  holding  things  in  the  mouth  or 
between  the  teeth,  especially  with  children.  Something  or  other — a  laugh,  or  a 
blow  ui)on  the  back — causes  a  sudden  insi)iration,  and  a  foreign  body  is  sucked 
down  into  the  widely-open  glottis  and  lodged  in  the  air- passages  before  it  is  known 
that  the  hold  on  it  is  lost.  Blow-tubes  and  pea-shooters  are  responsible  for  many, 
the  child  in  filling  its  chest  with  air  drawing  the  projectile  into  the  larynx.  In 
operations  about  the  mouth,  when  the  patient  is  under  an  anaesthetic,  it  has  hap- 
pened many  times  :  sets  of  false  teeth,  or  wedges  used  to  hold  the  mouth  open, 
or  teeth  dropped  from  the  forceps  after  extraction,  in  the  haste  to  grasp  another, 
are  all  recorded  as  having  fallen  into  the  larynx.  The  same  thing  may  occur  in 
the  vomiting  that  follows  anaesthesia.  A  case  of  sudden  death  after  the  adminis- 
tration of  ether  was  found  to  be  due  to  the  skin  of  a  ripe  plum  rolled  up  ;  it  had 
been  vomited,  drawn  into  the  larynx,  and  was  firmly  wedged  in  the  right  bronchus, 
so  that  its  end  fell  over  and  covered  the  orifice  of  the  left.  Round  worms  from 
the  digestive  tract,  vomited  during  sleep,  have  been  known  to  lead  to  the  same 
result. 

Symptoms. — These  vary  according  to  the  i)Osition,  whether  it  is  in  the 
larynx  itself,  in  the  trachea,  or  in  the  smaller  bronchi.  They  may  be  immediate, 
due  to  obstruction  or  irritation,  or  secondary,  caused  by  the  inflammation  that 
invariably  follows  sooner  or  later. 

I.  In  the  Larynx. — If  it  is  large  and  round,  so  as  to  fit  upon  the  rima  glot- 
tidis, or  sharp  and  angular,  so  as  to  cause  spasm,  suffocation  may  be  immediate. 
The  symptoms  are  of  the  most  urgent  description  :  the  patient  starts  up  wildly, 
gasping  for  breath,  and  clutching  at  his  collar  ;  the  face  is  livid,  rapidly  becom- 


FOREIGN  BODIES  IN  THE  AIR  PASSAGES.  819 

ing  cyanpsed  ;  the  veins  on  the  forehead  and  neck  stand  out  like  cords  ;  he  may 
be  (luite  unable  to  speak,  or  if  the  larynx  is  not  (juite  closed,  utters  the  most  dis- 
tressing sounds,  attempting  at  the  same  time  to  push  his  finger  down  his  throat ; 
expiration  and  coughing  become  more  and  more  violent,  until  the  body  becomes 
convulsed,  a  cold  sweat  breaks  out,  and  within  a  minute  he  falls  down  unconscious. 
In  most  cases,  however,  the  immediate  effect  is  not  so  intense  :  if  the  foreign 
substance  is  smooth,  so  that  it  does  not  set  up  much  irritation,  or  if  it  is  lodged  in 
some  place  out  of  the  way,  like  one  of  the  ventricles,  the  symptoms  may  be  com- 
l)aratively  slight,  although  the  patient  is  never  free  from  danger.  The  cough  is 
characteristic  :  it  comes  on  in  spasmodic  fits  of  uncontrollable  violence  and  often 
continues  until  the  patient  is  utterly  prostrate  from  exhaustion.  The  lea.st  change 
of  posture  is  sufficient  to  induce  it.  At  first  it  is  dry  without  expectoration,  but 
afterwards,  when  inflammation  sets  in,  this  may  be  copious,  thick,  and  stained  with 
blood.  Sometimes,  especially  in  children,  the  symptoms  bear  some  resemblance 
to  croup  ;  but  as  a  rule  when  they  are  due  to  a  foreign  body,  expiration  is  more 
difficult  than  inspiration.  Pain,  a  sensation  of  tickling  often  referred  to  the  ear, 
and  a  sense  of  anxiety  or  of  impending  suffocation,  are  nearly  always  j^resent. 
The  voice  may  be  quite  lost  from  the  first,  or,  if  not,  it  always  becomes  hoarse  in 
a  few  hours,  from  the  swelling  and  uidema  that  follow.  Later  on,  if  the  foreign 
body  is  sharp  and  angular,  so  as  to  cause  inflammation  and  ulceration  of  the  mu- 
cous membrane,  death  may  ensue  from  spasm  and  oedema  of  the  glottis ;  necrosis 
of  the  cartilages  may  occur';  the  inflammation  may  spread  to  the  lungs  and  cause 
pneumonia  ;  even  blood-vessels  may  be  ruptured,  or  the  patient  may  die  at  length, 
worn  out  and  exhausted.  A  coin,  on  the  other  hand,  has  been  known  to  lie, 
coated  over  with  mucus,  in  one  of  the  ventricles  for  many  months  without  causing 
urgent  symptoms. 

2.  In  the  Trachea. — If  the  foreign  body  is  fixed,  like  a  puff  dart,  which  lies 
with  its  point  uppermost  and  with  each  expiration  is  driven  further  and  further 
into  the  substance  of  the  trachea,  the  immediate  symptoms  are  not  so  striking. 
There  is  dyspnoea,  but  the  cough  is  more  continuous  and  is  not  of  the  same  spas- 
modic, uncontrollable  character.  Aphonia  is  not  present  until  the  mucous  mem- 
brane of  the  larynx  becomes  swollen  from  the  constant  effort  at  expulsion.  Pain 
is  always  felt  over  the  actual  spot,  and  there  is  constant  soreness  behind  the 
sternum.  Inflammation,  however,  with  ulceration  and  copious  expectoration,  very 
soon  makes  its  appearance  and  extends  rapidly  to  the  lungs.  If,  on  the  other 
hand,  the  foreign  body  is  free,  the  symptoms  depend  chiefly  upon  its  shape  and 
weight.  At  one  moment  it  lies  over  the  bronchi,  generally  the  right,  owing  to 
the  position  of  its  orifice  ;  the  next,  it  is  coughed  up  against  the  larynx,  and 
starts  a  violent  paroxysm.  Sometimes  the  patient  is  so  fortunate  as  to  cough  it 
out,  with  instant  relief;  sometimes,  on  the  other  hand,  it  becomes  impacted  in 
the  rima  glottidis,  or  is  caught  and  held  by  the  muscular  spasm,  and  immediate 
death  ensues.  Often  the  patient  is  conscious  that  it  shifts  its  position.  Some- 
times it  can  be  heard  and  even  felt  from  the  outside. 

3.  In  the  Lungs. — When  a  foreign  body  is  lodged  in  one  of  the  bronchi 
there  is  rarely  the  same  urgency.  Dyspnoea,  cough,  copious  expectoration,  pain, 
and  anxiety  are  all  present,  but  the  distress  is  not  so  extreme,  and  there  is  not 
the  same  sense  of  impending  suffocation.  If  it  lies  in  one  of  the  large  bronchi, 
valuable  evidence  may  be  gained  from  an  examination  of  the  chest.  If  the  ob- 
struction is  only  partial,  the  movement  on  that  side  is  diminished,  the  respiratory 
murmur  is  fainter,  and,  generally,  an  unusual  whistling  sound  is  heard  as  the  air 
rushes  past  the  obstruction,  unless  this  is  drowned  by  the  coarse  rales  caused  by 
the  large  amount  of  secretion  that  is  poured  out.  On  the  other  hand,  should  the 
whole  of  one  lung  or  one  lobe  be  shut  off,  vocal  fremitus  and  the  normal  vesicular 
murmur  are  wanting,  and,  after  a  time,  the  percussion  note  becomes  dull,  while 
the  respiration  in  the  rest  of  the  lung  is  puerile. 

Inflammation,  when  a   foreign   body  is  in   the  lung,  may  be  long  delayed 


820    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

(especially  if  it  is  of  an  unirritating  character),  but  it  always  breaks  out  at  last. 
Suppuration  sets  in,  abscesses  form  and  lead  to  the  destruction  of  the  lung ;  gan- 
grene, hemorrhage,  or  empyema  may  occur  ;  tuberculosis  may  break  out,  and  the 
end  nearly  always  comes  within  a  few  weeks,  though  sometimes  not  for  years. 
Only  exceptionally  ha.s  the  foreign  body  found  its  way  out  at  length  through  the 
wall  of  the  thorax  in  the  pus  of  an  em])yema. 

Diagnosis. — In  the  ai)sence  of  history  this  is  often  impossible;  no  single 
symptom  is  i)eculiar  to  this  accident.  Many  cases  have  occurred  in  which  the 
presence  of  a  foreign  body  has  never  been  suspected  (especially  in  the  lungs)  ; 
and  nearly  as  many  in  which  the  suspicion  has  been  wrong.  In  children  the 
difficulty  is  peculiar  great. 

Asphyxia  may  be  caused  by  a  foreign  body  driven  into  the  ])harynx  ;  but  as 
a  rule,  there  is  no  time  for  exact  diagnosis  ;  if  it  is  not  dislodged  at  once  by  the 
patient's  own  efforts  or  by  the  introduction  of  the  finger  into  the  throat,  instant 
laryngotomy  affords  the  only  hope. 

Inflammatory  affections,  croup,  esjiecially  in  children,  and  laryngitis,  are 
more  clifticult.  The  most  important  feature  is  the  rapidity  of  the  onset,  and  the 
extreme  urgency  of  the  symptoms,  without,  at  first,  any  rise  of  temperature  or  sign 
of  fever.  In  spasmodic  croup,  inspiration  is  more  difficult  than  expiration. 
Hysteria,  reflex  irritation  arising  from  disorders  of  the  digestive  tract,  e.specially 
in  children,  spasm  and  oedema  of  the  glottis,  even  aneurysm  of  the  aorta,  and 
whooping-cough,  occasionally  give  rise  to  difficulty,  especially  if  there  is  a  history 
of  a  foreign  body  having  disappeared  from  the  mouth  at  the  time  of  the  onset.  It 
is  more  common  for  a  foreign  body  to  be  overlooked. 

If  the  symptoms  are  very  acute,  partictdarly  if  there  is  violent  suffocative 
cough  recurring  in  spasms,  it  is  probable  the  foreign  body  is  in  the  larynx,  or  else 
that  it  is  loose  in  the  trachea,  and  is  coughed  up  against  it.  When  they  are  severe 
at  first,  and  subside  without  expulsion,  it  has  probably  either  become  lodged  in 
one  of  the  ventricles  or  has  passed  down  in  the  bronchi. 

Treatment. — In  some  cases  the  symptoms  are  so  urgent  that  laryngotomy 
(as  being  the  most  speedy)  must  be  done  at  once  with  anything  that  is  at  hand. 
Even  when  the  pulse  can  no  longer  be  felt  at  the  wrist,  this  may  succeed  with  the 
help  of  artificial  respiration.  When  not  so  urgent,  and  when,  as  usually  happens, 
the  patient  is  seen  for  the  first  time  after  the  immediate  paroxysm  has  subsided,  the 
first  thing  is  to  ascertain  the  position. 

If  it  is  in  the  larynx  it  may  be  extracted  by  means  of  the  laryngoscope  and 
laryngeal  forceps.  A  5  per  cent,  solution  of  cocaine  brushed  once  or  twice  over 
the  mucous  membrane  renders  it  white  and  perfectly  insensitive,  so  that  thorough 
examination  can  easily  be  carried  out  without  fear  of  spasm.  Or  the  same  effect 
may  be  produced,  though  not  nearly  so  well,  by  the  prolonged  application  of  ice, 
by  the  inhalation  of  chloroform  vapor,  or  by  injecting  a  small  quantity  of  morphia 
just  over  the  superior  laryngeal  nerve,  at  the  greater  cornu  of  the  hyoid  bone.  If 
this  fails,  the  choice  lies  between  subhyoid  jjharyngotomy,  laryngotomy  (or 
laryngo-tracheotomy,  if  more  space  is  recpiired)  and  vertical  division  of  the 
thyroid  cartilage,  according  to  the  nature  and  position  of  the  foreign  body.  Then 
it  must  either  be  extracted  through  the  wound  or  pushed  up  from  below.  In  no 
case  should  a  patient  be  left  without  assistance  if  there  is  a  foreign  body  in  the 
larynx  or  floating  in  the  trachea,  especially  if  there  has  been  already  a  severe 
attack  of  spasmodic  dyspnoea. 

When  it  has  passed  beyond  the  larynx,  and  is  fixed  either  in  the  trachea  or 
in  the  lungs,  there  is  not  the  same  degree  of  urgency  or  of  immediate  risk  to  life. 
Tracheotomy,  however,  is  usually  advisable.  It  is  true  that  it  has  been  shown  by 
statistics  that  in  a  very  large  proportion  of  cases  expulsion  takes  i)lace  without  ; 
and,  still  further,  that  the  percentage  of  deaths  in  those  cases  in  which  trache- 
otomy has  been  performed  is  higher  than  those  in  which  it  has  not  ;  but  I  think  it 
will  be  granted   that,  given  any  individual  ca.se,  the  chance  of  safe  expulsion  is 


SCALD  OF  THE  GLOTTIS. 


821 


B'iG.  349. — Golding-liird's  Dilator. 


much  greater  after  the  trachea  has  been  oiiened,  and  that  the  risk  to  life  is  not 
appreciably  increased  by  the  operation.  No  cannula 
should  be  inserted  ;  retractors,  easily  made  with  a 
piece  of  bent  wire,  should  be  fixed  in  the  tracheal 
opening  and  fastened  around  the  neck  with  an  elastic 
band,  so  as  to  keep  up  a  certain  degree  of  tension 
upon  the  orifice,  or  Golding-Bird's  dilator  may  be 
used.  Sometimes  expulsion  is  immediate,  or  the 
foreign  body  is  coughed  up  so  that  it  projects  in  the 
tracheal  wound,  or  it  is  dislodged  by  inversion  com- 
bined with  compression  of  the  thorax,  especially  if 
it  is  round  in  shape  and  of  some  weight ;  emetics 
and  sternutatories  have  been  successful,  but  no  reli- 
ance can  be  placed  upon  them  ;  or  it  may  not  happen  for  some  days.  There  are 
many  instances  in  which  a  cannula  has  been  inserted  and  worn  for  some  time,  and 
then,  quite  unexpectedly,  perhaps  from  changes  it  undergoes  itself,  or  from 
ulceration  around  it,  the  foreign  body  has  suddenly  become  detached  and 
been  expelled. 

If  this  does  not  take  j)lace  within  the  first  four  or  five  days,  the  air-passages 
must  be  explored  with  probes,  hooked  at  the  end,  tracheal  forceps  (either  Gross's, 
w^iich  are  made  of  German  silver,  so  that  they  can  be  bent  to  any  shape,  or  Mac- 
kenzie's or  Durham's  which  are  so  contrived  as  to  open  only  at  the  extremities), 
and  even  with  the  finger.  All  these  attempts  cause  violent  expiration,  and  some- 
times in  this  way,  sometimes  by  being  actually  hooked  up,  foreign  bodies  have 
been  extracted  even  from  the  right  bronchus.  Care  must  be  taken,  however,  not 
to  mistake  the  rigid  angle  between  the  bronchi  for  one.  Much  depends  upon  a 
knowledge  of  the  shape ;  tubular  bodies  may  be  laid  hold  of  at  the  margin,  or 
drawn  up  by  passing  both  blades  of  a  pair  of  forceps  inside,  and  then  separating 
them  ;  the  worst  of  all  are  puff-darts,  which  become  firmly  wedged  in. 

Afterward  the  same  precautions  must  be  taken  as  after  tracheotomy  ;  the  pa- 
tient must  be  confined  to  his  room,  the  air  kept  warm  and  moist,  the  wound 
covered  wath  moistened  gauze,  and,  so  long  as  there  is  any  fear  of  spasm  or  oedema 
of  the  larynx,  the  cannula  should  be  retained  and  the  patient  fed  by  an  oesopha- 
geal tube.  A  certain  amount  of  thickening  and  irritation  of  the  mucous  mem- 
brane, wdth  profuse  expectoration,  and,  possibly,  the  growth  of  granulations,  is 
very  likely  to  persist  for  some  time. 

In  older  cases,  when  some  length  of  time  has  elapsed  since  the  entry  of 
the  foreign  body,  the  question  of  surgical  interference  must  be  guidied  mainly 
by  the  condition  of  the  lungs. 


Scald  of  the   Glottis. 

In  gas  explosions  and  fires  the  pharynx  is  occasionally  burnt,  from  the  heated 
air  or  flame  being  drawn  into  the  mouth  ;  scalding  is  more  common,  especially  in 
young  children,  from  trying  to  drink  out  of  the  spout  of  a  kettle.  In  either  case 
the  chief  danger  arises  from  the  injury  to  the  upper  part  of  the  larynx,  which  may 
be  badly  hurt  from  the  flame  or  steam  being  sucked  down  into  it  by  the  inspira- 
tion which  precedes  a  scream.  The  ojsophagus  usually  escapes,  unless  there  is  a 
determined  attempt  to  drink  the  fluid,  and  it  is  thrown  at  once  to  the  back  of  the 
mouth. 

Unless  the  accident  is  seen,  or  there  is  other  external  evidence,  the  diagnosis 
must  usually  be  made  from  the  sudden  onset  of  extreme  dyspnoea.  The  lips  and 
mouth  may  be  blistered,  but  they  often  escape,  as  the  fluid  passes  right  to  the 
back  and  is  ejected  through  the  nose.  There  is  constant  screaming,  until,  partly 
from  exhaustion,  partly  from  swelling  and  oedema,  the  voice  is  completely  lost, 
and  nothing  can   be  heard  but  a  hoarse,  croupy  inspiration.      Dyspnoea  may  be 


82  2    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


Fig 


-Qidema   of  the  Glottis, 
behind. 


present  from  the  first  ;  often  it  sets  in  with  much  greater  severity  after  a  few  hours, 

especially  toward  evening;  the  pain  is  very  se- 
vere ;  swallowing  is  almost  impossible  ;  and  even 
in  children  there  is  the  most  terril)le  apprehen- 
sion. If  the  finger  is  introduced  into  the 
mouth  the  epiglottis  can  be  felt  hard  and  shriv- 
eled, and,  pa.ssing  back  from  each  side  of  it, 
__^  7T^'«M      ^^^^  smooth  rountled  bodies,  which   project  up- 

if  ;  JSSMx^^^a^l  fli'l'     ward  on  either  side  of  the  aperture  of  the  larynx 

\.  ^  >mlKK^^^m(\- M  '■\i     and  almost  clo.se  it.     These  are  the  aryepiglot- 

tic  folds,  which  become  cedematous  and  swell 
up  to  such  an  extent  that  when  the  tongue  is 
depres.sed  they  may  be  seen  as  shining,  rounded, 
semi-translucent  mas.ses,  reaching  nearly  to  the 
middle  line.  In  severe  cases  the  mucous  mem- 
brane at  the  base  of  the  epiglottis,  the  false 
vocal  cords,  and  even  the  larynx  below  the 
rima  glottidis,  are  more  or  less  in  the  same  con- 
dition. 

Death  may  occur  from  asphyxia  within  a 
few  minutes  of  the  accident  ;  more  often  the 
n  from  tlyspncca  becouics  worse  and  worse ;  the  voice 
is  comi)letely  lost ;  inspiration  is  hoarse  and 
croupy,  the  lower  ribs  sinking  inward  at  each 
attempt ;  and  the  child  sits  propped  up,  perfectly  quiet,  with  its  chest  thrown 
forward  and  its  chin  upward,  so  as  to  secure  the  greatest  muscular  aid.  The  face  is 
pale  and  cyano.sed,  the  lips  dusky,  the  forehead  covered  with  beads  of  perspiration 
— in  short,  there  are  all  the  signs  of  imminent  suffocation.  Later,  if  spasm  of 
the  glottis  does  not  set  in  and  prove  immediately  fatal,  death  may  occur  from 
exhaustion,  from  broncho-pneumonia  due  to  extension  of  the  inflammation,  or 
from  collap.se  of  the  lungs.  P>en  in  the  slightest  case  the  prognosis  is  very  un- 
favorable. 

Treatment. — The  first  object  is  to  prevent  the  inflammation  spreading,  and 
to  protect  the  mucous  membrane.  When  this  is  inflamed,  and  the  cavity  of  the 
glottis  already  narrowed,  the  slightest  irritant,  one  that  under  ordinary  conditions 
would  merely  cau.se  a  transient  cough,  may  bring  on  an  attack  of  fatal  spasm. 
The  air  must  be  kept  warm  and  moist,  without,  however  placing  the  child  in  a 
steam  bath  ;  ice  must  be  placed  round  the  neck  by  means  of  a  collar  ;  leeches 
may  be  applied  outside  ;  and  the  child  must  be  kept  perfectly  quiet,  sitting  up. 
In  adults,  the  hyperemia  and  .sensitiveness  of  the  mucous  membrane  may  be  kept 
in  check  by  constantly  sucking  ice.  Small  doses  of  calomel  (gr.  j  to  gr.  ij)  every 
hour  until  there  are  free  bilious  evacuations,  or  very  small  ones  of  antimony  or 
aconite,  may  be  given  in  vigorous  children  if  the  fever  is  setting  in  with  severity  ; 
and  if  there  is  much  secretion,  an  emetic — alum  for  example,  which  does  not  cause 
de])ression  afterward.  If,  however,  the  dyspnoea  continues  to  increase,  jmrticu- 
larly  if  there  are  recurrent  attacks  of  si)asm,  and  if  the  chest-wall  is  beginning  to 
fall  in,  there  is  no  choice  but  free  scarification  of  the  aryepiglottic  folds,  intuba- 
tion, or  tracheotomy.  The  first  of  these  is  easily  carried  out  with  an  ordinary 
bistoury,  the  edge  of  which  is  guarded  up  to  within  a  third  of  an  inch  of  the  point 
with  a  spiral  piece  of  strapping  ;  the  forefinger  of  the  left  hand  acts  as  a  guide, 
and  free  incisions  may  be  made  without  danger.  I  have  known  this  followed  by 
considerable  relief,  but  as  a  rule  it  is  only  temporary. 

Intubation  is  more  difficult  to  carry  out,  and  requires  sjjccial  appliances,  such 
as  MacEwen's  or  O'Dwyer's  tubes  ;  but  this  or  tracheotomy  must  be  resorted  to. 
unless  scarification  affords  distinct  and  lasting  relief.  It  is  true  that,  especially  in 
children,  opening  the  trachea  is  a  serious  operation,  and  adds  an  additional  cause 
for  the  broncho-pneumonia  which  so  commonly  sets  in  ;    but,  it  enables  the  child 


DIFFUSE  INFLAMMATION  OF  CELLULAR  TISSUE.        Zit, 

to  breathe  freely,  for  a  time  at  least ;  it  prevents  exhaustion  and  the  continued 
battling  for  air  ;  it  stops  the  collapse  of  the  lung  and  the  danger  of  hepatization  ; 
and  it  is  the  only  effectual  protection  against  spasm.  If  it  is  reserved  to  the  last, 
and  only  performed  in  cases  that  are  already  desperate,  the  ill-success  that  attends 
it  should  not  be  laid  entirely  to  the  credit  of  the  operation. 


INFL.AMMATORY  AFFECTIONS. 

Owing  to  their  exposed  position,  all  the  tissues  of  the  neck  are  very  liable  to 
be  attacked  by  inflammation  ;  the  spine,  for  example  may  become  the  seat  of  tu- 
bercle, syphilis,  or  osteo-arthritis  ;  the  muscles  may  be  attacked  by  rheumatism  ; 
gummata  may  develop  in  them  (especially  in  the  sterno-mastoid)  ;  or  the  sheaths 
of  the  nerves  may  become  involved  ;  but,  with  the  exception  of  the  cellular  tissue 
and  the  lymphatic  glands,  separate  description  is  not  required. 

Diffuse  Inflammation  of  the  Cellular  Tissue. 

This  is  especially  serious  from  the  arrangement  of  the  cervical  fascia.  It  may 
be  caused  by  poisoned  wounds  (either  of  the  skin  or  the  mucous  surfaces)  ;  by  in- 
fection through  the  blood-stream,  as  in  pyaemia,  or  by  extension  from  some  neigh- 
boring focus  of  disease,  alveolar  abscess  for  example,  suppuration  in  the  floor  of 
the  mouth  following  operation,  tonsillar  abscess,  and  especially  the  periglandular 
inflammation  that  occurs  in  scarlatina  and  diphtheria.  The  intense  depression 
characteristic  of  these  disorders,  lowering  the  vitality  and  the  power  of  resistance 
of  the  tissues,  is  probably  the  cause  why  it  spreads  with  such  rapidity  and  so 
widely 

The  symptoms  are  very  grave  from  the  first  ;  often  there  is  a  rigor  ;  the  tem- 
perature rises  rapidly  ;  the  pulse  is  quick  and  feeble  and  delirium  soon  sets  in. 
The  pain  is  intense  ;  the  head  is  fixed  ;  the  tongue,  if  the  sub-maxillary  region  is 
involved,  forced  up  into  the  mouth  ;  the  jaws  hardly  able  to  move  ;  and  swallow- 
ing almost  impossible.  The  skin  is  swollen  and  puffy ;  the  superficial  veins  are 
distended,  and  all  the  tissues  of  the  neck  hard  and  tense.  If  left  to  itself,  the 
fascia  may  yield  and  allow  the  exudation  to  make  its  way  toward  the  surface  and 
point  by  the  side  of  the  neck  ;  but  the  inflammation  is  more  likely  to  spread,  in- 
volving one  layer  after  another,  until  either  the  patient  dies  from  acute  blood- 
poisoning,  or  the  mediastina  are  implicated,  and  pleurisy,  pericarditis,  or  retro- 
sternal suppuration  is  added  to  the  rest. 

Early  and  free  incision  is  the  only  course.  The  patient  should  be  placed 
under  an  anaesthetic  ;  an  incision,  an  inch  and  a  half  or  two  inches  in  length, 
made  over  the  most  prominent  part  of  the  swelling,  the  deep  fascia  divided  to  the 
same  extent  upon  a  director,  and  if  this  does  not  give  sufficient  relief,  the  point 
of  the  director  thrust  into  the  middle  of  the  swelling,  and  followed  up  after  Hilton's 
method,  with  dressing  forceps.  Afterward  a  large  drainage  tube  should  be  inserted, 
and  the  discharge  encouraged  as  much  as  possible.  The  direction  of  the  incision 
must  be  parallel  to  that  of  the  main  vessels,  and  it  must  be  very  carefully  made, 
as  it  is  not  always  possible  to  ascertain  how  far  they  are  displaced. 

Even  when  the  inflammation  is  not  so  severe  as  this,  extensive  destruction  is 
by  no  means  uncommon ;  and  sometimes,  especially  after  scarlatina,  profuse 
hemorrhage  occurs  about  the  time  that  the  sloughs  are  separating.  If  it  comes 
from  the  carotid  or  the  jugular,  an  attempt  must  be  made  to  find  the  bleeding  point 
and  isolate  it  for  ligature,  tracing  it  for  some  little  distance  up  or  down,  as  the 
case  may  be,  so  as  to  get  clear  of  the  sloughing  part ;  but  if,  as  usually  is  the  case, 
this  is  impossible,  all  that  can  be  done  is  to  apply  styptics  and  pressure.  The 
cavity  must  be  cleansed  and  dried  as  thoroughly  as  possible,  well  covered  with 
iodoform,  and  then  plugged  with  iodoform  gauze  ;  but  the  prognosis  is  very  grave. 


824    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Inflammation  of  the  Lymphatic  Glands. 

The  cervical  glands  are  especially  liable  to  attacks  of  inflammation.  Eczema 
capitis  in  infancy,  and  the  eruption  of  the  teeth  and  affections  of  the  throat  in 
childhood  and  youth,  maintain  in  many  cases  a  certain  degree  of  chronic  hyper- 
ajmia.  Usually  this  subsides  when  the  cause  is  removed  ;  but  sometimes,  before 
this  can  be  done,  other  irritants  make  their  appearance  on  the  scene,  and  find'in 
the  impoverished  and  weakened  gland  tissue  the  soil  that  suits  them  best. 

The  pyogenic  micrococci,  for  example,  may  gain  access  to  them  through 
abrasions  of  the  mucous  surface.  If  they  are  in  sufficient  number,  or  the  tissue 
resistance  is  sufficiently  enfeebled,  suppuration  follows,  without  much  energy  or 
constitutional  disturbance,  if  the  general  nutrition  is  good  ;  but  with  the  utmost 
virulence,  leading  to  sloughing  phagedsena,  or  diffuse  cellulitis,  if  the  vitality  is 
depressed  by  any  form  of  blood  poisoning,  scarlatinal,  diphtheritic,  or  septicaemic. 

In  other  cases  the  tubercle  bacilli  are  the  irritant,  entering  in  the  same  way. 
The  glands  slowly  enlarge,  caseate  in  the  centre,  and  then  break  down.  The 
capsule  gives  way,  the  caseous  fluid  penetrates  into  the  circumjacent  cellular  tissue, 
infecting  it  wherever  it  spreads,  and  at  length,  after  traveling  long  distances  in  all 
directions  under  the  deep  fascia,  it  makes  its  way  out  through  this  at  some  point 
and  discharges  on  the  surface,  leaving  behind  it  typical  scrofulous  sinuses. 

Syphilitic  inflammation  is  characterized  by  the  sudden  enlargement  of  all  the 
cervical  glands  at  the  same  time,  the  onset  of  the  secondary  period.  Suppuration 
is  very  rare,  but  complete  resolution  is  often  long  delayed,  and  the  least  cause — 
mere  exposure  to  a  draught — is  enough  to  bring  back  the  swelling  and  make  them 
tender  and  painful.  Slight  enlargement  of  this  character  is  one  of  the  most  com- 
mon causes  of  stiff  neck. 

Other  forms  of  specific  inflammation,  occurring  in  connection  with  leprosy, 
plague,  glanders,  or  actinomycosis  are  too  rare  to  deserve  special  mention. 

Diagnosis. — Acute  inflammation  rarely  presents  any  difficulty  ;  the  pain, 
heat,  and  tenderness  on  pressure  are  sufficient  to  indicate  what  is  taking  place, 
although  it  is  impossible  to  say  whether  the  mischief  is  commencing  in  the  gland 
itself,  or,  what  is  more  frequent,  in  the  cellular  tissue  round  it.  The  distinction 
is  not  material,  as  in  either  case  the  treatment  is  the  same  ;  if,  after  the  cause  has 
been  removed,  the  inflammation  does  not  subside  with  rest  and  cold,  if  the  swell- 
ing continues  to  increase,  and  particularly  if  the  skin  becomes  cedematous,  an 
incision  must  be  made  through  the  superficial  structures  and  a  director  used  to 
explore,  after  Hilton's  plan. 

Chronic  inflammation  is  distinguished  by  the  lobulated,  chain -like  character 
of  the  swelling,  and  seldom  gives  rise  to  any  difficulty,  except  in  the  case  of  some 
of  the  varieties  of  lymphoma  and  lymphadenoma.  Tubercular  infiltration  is 
marked  by  the  slow,  painless  enlargement,  involving  one  gland  after  another,  and 
by  the  gradual  softening  and  breaking  down  ;  syphilitic  disease  by  the  firm,  hard 
outline,  the  retention  of  the  natural  shape,  and  the  very  slight  tendency  to  infil- 
trate or  adhere  to  the  tissues  around.  The  treatment,  as  detailed  already,  is 
entirely  dependent  upon  the  cause. 

Torticollis. 

Wry-neck  is  due  to  irregular  contraction  of  the  muscles  twisting  the  head. 
The  sterno-mastoid  is  the  one  usually  in  fault,  sometimes  the  only  one,  but  the 
others  and  the  cervical  fascia  often  aggravate  the  evil.  It  may  be  primary,  caused 
by  disease  of  the  muscle  itself  (this  is  usually  distinguished  as  the  congenital 
variety)  ;  or  secondary,  arising  from  inflammation  of  some  of  the  structures  near 
(the  joints,  vertebras,  lymphatic  glands,  etc),  or  from  a  disordered  condition  of 
the  nervous  system. 

{a)  Congenital  torticollis  is  rarely  noticed  until  some  time  after  birth.  This 
arises  partly  from  the  shortness  of  an  infant's  neck,  partly  from  the  fact  that  the 


TORTICOLLIS.  825 

deformity  itself  is  not  nearly  so  well  marked  at  this  time  of  life  as  it  is  later.  How- 
it  originates  is  uncertain.  Probably  it  is  due  to  partial  rupture  of  the  muscle  at 
the  time  of  parturition  ;  at  least  a  tender,  ovoid  mass  is  not  unfrequently  found, 
shortly  after  birth,  in  the  sternal  head  of  the  sterno-mastoid,  just  where  the  tendi- 
nous and  muscular  fibres  meet,  and  in  several  cases  wry-neck  is  known  to  have 
been  present  later  in  life. 

The  back  of  the  head  is  drawn  down  ;  the  chin  is  directed  toward  the  oppo- 
site side,  so  that  the  face  looks  somewhat  upward,  and  the  muscle  itself  stands  out 
like  a  tense  cord,  with  a  hollow  in  front  and  behind.  The  sternal  portion  is 
usually  the  chief  offender,  and  in  bad  cases  the  mastoid  process  may  be  dragged 
down  so  far  as  to  lie  immediately  over  and  scarcely  an  inch  from  the  sterno- 
clavicular articulation.  As  a  result,  the  cervical  vertebrae  become  twisted  and 
deformed  ;  secondary  curves  make  their  appearance  in  the  back  ;  the  under  side 
of  the  face  does  not  grow  in  proportion  to  the  rest,  the  line  of  the  eyes  becomes 
oblique,  and,  if  the  condition  is  not  remedied  before  puberty,  even  the  breast  fails 
in  its  development. 

If  the  deformity  is  detected  in  time,  an  attempt  may  be  made  to  prevent  it 
by  massage  and  passive  motion,  but  nearly  always  tenotomy  is  required  sooner  or 
later.  The  only  rule  is  to  divide  everything  that  prevents  the  full  range  of  move- 
ment, both  heads  of  the  sterno-mastoid  nearly  always,  and  very  often  the  cervical 
fascia  as  well,  taking  care,  however,  to  avoid  injuring  the  great  vessels  of  the  neck, 
which  are  frequently  displaced.  An  anaesthetic  is  always  advisable.  The  assistant, 
as  in  other  cases  of  tenotomy,  should  hold  the  head  so  that  the  bands  are  relaxed 
while  the  tenotome  is  being  passed  behind  them,  and  tightened  up  when  the  blade 
is  in  position.  Separate  punctures  should  be  made  wherever  necessary  ;  the  divi- 
sion of  both  heads  of  the  muscles  through  one  opening  is  only  to  be  preferred  when 
it  is  less  dangerous  than  doing  it  through  two,  and  a  blunt-pointed  tenotomy  knife 
should  always  be  used  after  the  preliminary  puncture  has  been  made.  The  usual 
situation  is  about  half  an  inch  above  the  clavicle,  but  that  spot  should  be  selected 
at  which  the  fibres  stand  out  most  distinctly,  and  the  division  should  always  be 
from  behind  forward. 

The  little  wounds  should  be  sealed  with  iodoform  or  collodion,  and  the  head 
brought  as  far  as  possible  into  a  straight  line  at  once.  The  extent  to  which  this  is 
possible  depends  partly  upon  the  completeness  of  the  division,  partly  upon  the 
alteration  in  the  cervical  spine.  If  the  patient  is  sufficiently  old  to  appreciate  the 
importance  of  the  result,  mechanical  contrivances  can  usually  be  dispensed  with ; 
friction,  shampooing,  passive  motion,  carrying  a  weight  in  the  hand,  and,  above 
all,  the  use  of  a  looking-glass,  generally  suffice  not  only  to  secure  the  desired  effect, 
but  to  prevent  relapse.  In  the  case  of  children,  however,  and  where,  owing  to  the 
altered  shape  of  the  vertebrae,  there  is  fear  of  recurrence,  it  may  be  necessary 
either  to  make  use  of  a  spinal  support  with  a  jury-mast,  so  as  to  secure  oblique 
traction,  or,  what  is  nearly  as  efficient  when  properly  looked  after.  Little's  arrange- 
ment of  strapping.  One  broad  band  is  fastened  horizontally  round  the  head,  a 
second  round  the  waist,  and  a  strong  webbing  strap  with  a  rubber  accumulator 
attached  behind  the  ear  on  the  sound  side  and  below  in  the  opposite  nipple  line. 
In  old  cases  a  second  operation  is  often  required  to  divide  the  bands  of  cervical 
fascia. 

(Ji)  Acquired  torticollis  may  be  due  to  rheumatism  or  exposure  to  cold,  or  it 
may  be  symptomatic  of  inflammation  of  the  lymphatic  glands,  the  vertebra,  or 
other  structures  in  the  neck,  the  muscles  (for  in  this  case  the  splenius  and  others 
are  in  a  state  of  tonic  spasm  as  well)  contracting  to  save  the  affected  part.  In 
many  of  these  cases  the  diagnosis  of  the  exciting  cause  is  exceedingly  difficult,  and 
very  great  care  is  required,  as  cervical  caries  is  by  no  means  uncommon.  Tonic 
torticollis  of  this  character  can  always  be  distinguished  from  the  congenital  variety 
by  its  relaxing  completely  under  an  anaesthetic,  and  by  the  absence  of  any  short- 
ening of  the  cervical  fascia. 

The  other  variety  of  acquired  torticollis — that  which  occurs  in  connection 
S3 


826    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

with  disease  of  the  central  nervous  system — is  seldom  met  with  until  late  in  life, 
and  is  distinguished  by  the  clonic  character  of  the  convulsions.  The  head  can 
only  be  kept  at  rest  by  means  of  some  external  support ;  as  soon  as  it  is  left  the 
muscles  are  seized  with  clonic  spasms,  which  grow  worse  and  worse  as  the  patient 
attempts  to  control  them.  Sometimes  one  side  only  is  affected  ;  more  fre(iuently 
both,  and  in  many  instances  other  muscles  as  well.  Massage,  galvanism,  counter- 
irritation,  faradization  of  the  opposing  groups,  and  many  other  remedies  have 
been  tried  without  much  benefit.  Occasionally  relief  is  obtained  by  bromide  of 
potash,  but  it  seldom  lasts  long.  Neurectomy  of  the  spinal  accessory  holds  out  a 
better  prospect  when  only  the  sterno-mastoid  is  involved,  especially  if  a  large  por- 
tion of  the  nerve  and  its  connections  with  the  cervical  plexus  are  removed  ;  but 
in  most  instances  the  other  muscles  are  affected  as  well. 


Tumors  of  the  Neck. 

A  very  large  number  of  the  tumors  of  the  neck  are  of  congenital  origin, 
although  they  may  not  begin  to  enlarge  or  become  prominent  until  late  in  life. 

Nccvoid  growths  are  fairly  common.  In  most  cases  they  consist  of  nothing 
but  dilated  veins  and  capillaries  (the  so-called  blood-cysts  of  the  supra-clavicular 
region)  ;  but  not  unfrequently  they  are  associated  with  a  variable  amount  of 
fibrous  and  fatty  tissue,  or  w'ith  hydrocele  of  the  neck — in  all  probability  a  similar 
affection  of  the  lymphatics.  They  can  usually  be  recognized  by  the  effect  of 
gentle  pressure  ;  but,  if  there  is  much  solid  tissue,  or  many  phleboliths,  and  if  the 
history  is  vague,  the  diagnosis  is  simply  a  matter  of  conjecture.  The  only  satis- 
factory treatment  is  excision  ;  but  as  they  may  extend  long  distances  under  the 
muscles  (in  one  case  of  a  mixed  nasvoid  and  lipomatous  grow^th  under  my  care, 
the  supra-clavicular  and  subscapular  regions  w^ere  completely  dissected),  and,  not 
unfrequently,  communicate  with  the  jugular  veins,  the  operation  should  not  be 
lightly  undertaken. 

Hydrocele  of  the  neck,  co/ige/iitai  cystic  hygroma,  or  lymphaJigeioma  cxsticiim, 
has  already  been  described.  It  may  jje  present  at  birth,  or  may  not  cause  any 
conspicuous  enlargement  until  adult  life.  Sometimes  it  occurs  under  the  jaw, 
more  frequently  in  the  supra-clavicular  region,  extending  into  the  axilla.  It  may 
be  unilocular  (the  term  hydrocele  of  the  neck  is  sometimes  re.served  for  this)  or 
composed  of  numbers  of  cysts  of  all  sizes,  mixed  with  fibrous  or  fatty  tissue. 
Generally  the  fluid  they  contain  is  clear  and  serous,  but  it  may  be  red,  chocolate- 
brown,  or  green,  according  to  the  amount  of  blood  mixed  with  it  and  the  changes 
it  has  undergone.  Naturally,  therefore,  the  degree  of  translucency  is  very  vari- 
able. These  growths  not  unfrecjuently  extend  very  deeply  into  the  neck  ;  they 
may  pass  the  middle  line,  reach  down  into  the  thorax,  surround  the  great  vessels, 
and  even  extend  ujiward  into  the  occipital  region.  Oenerally  i)art  of  them  is 
superficial  and  the  diagnosis  easy,  but  sometimes  they  are  altogether  buried  behind 
the  trachea,  or  in  the  mediastinum,  so  that  it  is  impossible  to  ascertain  what  their 
nature  is.  In  some  instances  a  fatal  result  has  been  caused  by  pressure  upon  im- 
portant organs ;  in  others,  it  has  followed  from  deep-seated  suppuration ;  dis- 
api)earance,  without  operation,  is  very  unusual. 

The  treatment  must  be  very  cautious.  Simple  cysts  may  be  tapped  and 
drained,  and  the  same  thing  may  be  done  in  the  case  of  individual  ones  of  larger 
growth  ;  but,  though  this  gives  temporary  relief,  they  often  refill.  Injections  of 
iodine  and  setons  have  succeeded,  but  in  many  cases  they  have  caused  diffuse 
attacks  of  inflammation,  and  even  death  has  occurred.  Excision  is  only  possible 
when  the  growth  is  small  and  superficial.  Repeated  incision  and  drainage,  care- 
fully avoiding  suppuration,  offer  the  best  prospect. 

Hyo-lhigiial  Cysts. — Another  variety  originates  in  connection  with  the  hyo- 
lingual  canal.  This  extends  in  the  foetus  from  the  foramen  caecum  to  the  hollow  of 
the  hyoid,  and  thence  onward  to  the  pyramidal  process  of  the  thyroid  body.  Part 
is  developed  from  the  stomatodreum   (the  lingual   portion   probably   only),  part 


TUMORS  OF  THE   NECK.  827 

from  the  liypo-pharyngeal  diverticulum,  around  which  tlie  thyroid  originates.  In 
the  infant  the  former  often  persists;  the  rest  usually  disap])ears  or  remains,  as  the 
levator  glanduh\2  thyroidea:,  the  pyramidal  lobe  itself,  the  ligament  extending  from 
it,  or  the  cysts  that  are  so  frecpiently  developed  near  its  a}jex.  Some  of  the  cysts 
that  are  formed  from  this  are  dermoid,  containing  sebaceous  matter  and  hair  (the 
lingual  canal  itself  is  epiblastic)  ;  others  are  simple  and  unilocular,  filled  with 
serum  ;  in  others  again,  papillomatous  and  villous  growths  make  their  appearance 
(these  are  usually  regarded  as  accessory  thyroids,  and  may  occur  in  the  larynx 
and  trachea),  and  sometimes  again,  they  undergo  malignant  degeneration,  and 
pass  into  a  form  of  cystic  epithelioma. 

Brancliial  Cysts. — Congenital  cysts,  growing  down  to  and  involving  the 
sheath  of  the  great  vessels,  may  develop  from  the  lining  of  the  branchial  clefts  at 
the  side  of  the  neck.  Sometimes  they  are  associated  with  branchial  fistula.  Their 
contents  (they  may  be  sebaceous  or  mucous)  vary  according  to  the  character  of 
the  epithelium  from  which  they  spring. 

In  addition  to  these  growths  of  congenital  origin,  tumors  of  all  kinds  origi- 
nate in  connection  with  the  various  tissues  and  structures  in  the  neck.  Sarcoma, 
lipoma,  fibroma,  and  even  enchondroma,  may  develop  in  the  cellular  or  fibrous 
tissue  (the  last-named  possibly  from  rudiments  of  the  branchial  cartilages)  ;  exos- 
toses, enchondromata,  and  myeloid  sarcomata  from  the  bones  ;  fusiform  and  sac- 
culated aneurysms,  arterio-venous  aneurysm  and  aneurysmal  varix  from  the  vessels, 
and  molluscum,  sebaceous  cysts,  papilloma,  and  epithelioma  from  the  skin. 

The  lymphatic  glands  present  still  greater  variety.  In  addition  to  lymphoma, 
lymphadenoma,  and  sarcoma  (growths  originating  in  them),  and  to  the  various 
forms  of  specific  inflammation  (tubercle,  syphilis,  glanders,  leprosy,  etc.),  which 
affect  them  and  cause  them  to  enlarge  to  such  an  extent  that  they  are  often  desig- 
nated tumors  (in  spite  of  their  inflammatory  origin),  they  are  liable  to  be  the 
seat  of  secondary  malignant  growths  of  all  kinds.  Epithelioma  of  the  lip  and 
tongue  affect  the  submaxillary  ones  ;  sarcoma  of  the  tonsil,  those  along  the  carotid 
sheath ;  scirrhus  of  the  breast,  the  supraclavicular  chain ;  and  epithelioma  of  the 
oesophagus,  the  deeper  ones  that  run  down  to  the  mediastinum.  Carcinoma  of 
the  larynx,  on  the  other  hand,  does  not  extend  to  them  until  late  in  the  course  of 
the  disease.  Epitheliomatous  glands  in  the  neck,  especially  behind  the  angle  of 
the  jaw%  are  peculiar  in  often  becoming  cystic,  the  central  mass  undergoing 
caseation  and  liquefaction.  When  this  occurs,  they  increase  rapidly  in  size,  the 
skin  over  them  becomes  red  and  thin,  and,  not  unfrequently,  they  burst  and  give 
way,  discharging  a  mixture  of  caseous  debris,  blood  and  serum.  Sometimes  the 
hemorrhage  is  very  serious. 

Tumors  in  connectioJi  with  the  thyroid  body  (which  are  described  separately) 
are  distinguished  by  their  rising  and  falling  with  the  trachea  in  deglutition.  Bur- 
sal cysts,  which  may  occur  over  the  thyroid  cartilage,  or  the  thyro-hyoid  membrane, 
are  known  by  their  chronic  character,  by  the  age  at  which  they  occur,  and  by  the 
thinness  of  their  walls  and  the  character  of  their  contents. 

Hernia  of  the  pharynx  i^pharyngocele)  or  oesophagus  (a  protrusion  of  the 
mucous  membrane  through  a  defective  portion  of  the  wall,  causing  a  great  sac  to 
develop  behind  the  carotid  vessels)  may  be  diagnosed  by  its  position,  the  variation 
in  its  size  from  time  to  time,  and  the  pa.ssage  of  a  sound.  It  may  be  congenital 
or  acquired  ;  but  if  it  gives  rise  to  inconvenience,  the  only  course  is  to  excise  it. 
Tracheocele  (a  similar  protrusion  between  the  cartilages  of  the  larynx  or  trachea) 
is  distinguished  by  its  containing  air,  and  by  the  variation  in  its  size  on  forced 
expiration  ;  usually  it  projects  in  front. 

Gummata  may  occur  in  the  muscles,  especially  the  sterno-mastoid,  or  masses 
of  bone  may  develop  in  them  as  a  result  of  osteo-arthritis,  or  after  strains.  The 
sterno-mastoid  induration  of  infants  is  probably  traumatic,  due  to  partial  rupture 
and  coagulation  of  the  blood  inside  the  sheath. 


828     DISEASES  AND  INJURIES    OE  SPECIAL   STRUCTURES. 

Operations  on  the  Air  Passages. 

Larxngotomx  is  performed  in  the  crico-thyroid  space.  It  is  not  suitable  for 
children,  and  only  for  adults  in  cases  of  emergency  or  when  a  tube  has  to  be  used 
for  a  short  time,  during  an  operation,  for  example.  The  space  is  much  too  small 
(unless  the  cicro-thyroid  and  lateral  crico-arytenoid  muscles  are  incised)  to  admit 
of  the  removal  of  a  foreign  body  or  a  i)apilloma. 

The  question  of  an  anaesthetic  depends  upon  tlic  urgency  of  the  operation. 
The  patient's  head  is  thrown  back  as  far  as  possible,  while  the  neck  rests  upon  a 
firm  support,  and  the  crico-thyroid  space  identified.  A  longitudinal  incision  is 
made  exactly  in  the  middle  line  over  this,  and  the  larynx  opened  by  dividing  the 
membrane  transversely  immediately  above  the  cricoid  cartilage.  The  crico-thyroid 
arteries  are  seldom  injured,  but  if  there  is  any  hemorrhage  the  bleeding  points  can 
be  secured  at  once  with  Wells'  forceps.  A  laryngeal  cannula,  which  is  shorter 
than  an  ordinary  tracheal  one  and  flattened  from  above  downward,  can  then  be 
fitted  in  at  once. 

Tracheotomy  x'i  required  much  more  frequently.  It  may  be  performed  for  the 
relief  of  obstruction,  whether  it  is  temi)orary  (as  in  croup,  diphtheria,  oedema  of 
the  glottis,  or  muscular  spasm)  or  permanent  (as  in  syphilitic  stenosis)  ;  for  the 
removal  of  foreign  bodies  ;  to  give  rest  to  the  larynx  in  cases  of  painful  ulceration  ; 
or  as  a  precaution  in  operations  in  order  to  prevent  the  entry  of  blood. 

The  trachea  may  be  opened  either  above  or  below  the  isthmus  of  the  thyroid  ; 
but,  unless  there  is  some  special  indication  to  the  contrary,  the  former  should 
always  be  selected.  The  anterior  jugular  and  inferior  thyroid  veins  are  in  close 
relation  with  the  lower  part.  The  innominate  artery  bifurcates  almost  on  it,  and 
sometimes  reaches  far  up  into  the  neck.  The  thyroidea  ima  may  cross  it.  It  lies 
very  much  fiuiher  from  the  surface  and  is  much  more  easily  displaced  to  one  side. 
In  infants,  too,  the  thymus  may  cause  a  certain  amount  of  difficulty. 

Except  in  cases  of  great  emergency,  an  anaesthetic  should  always  be  given. 
Chloroform  is  better  than  ether,  as  it  is  less  irritating  :  very  little  is  required, 
especially  in  the  case  of  children,  as  it  is  not  necessary  to  induce  absolute  anaes- 
thesia. The  recumbent  position  is  the  most  convenient,  the  head,  if  the  breathing 
will  allow  it,  being  thrown  back,  and  the  neck  supported  by  a  small  but  firm  pillow 
or  sand-bag.  As  there  is  sometimes  a  little  difficulty  in  identifying  the  cricoid 
cartilage,  a  careful  examination  must  always  be  made  first. 

The  incision  must  be  two  inches  in  length,  beginning  on  the  margin  of  the 
cricoid  cartilage  (unless  it  is  wished  to  include  this,  as  in  laryngo-tracheotomy), 
dividing  the  skin  and  exposing  the  anterior  layer  of  the  deep  fascia.  If  the 
assistant  holds  the  head  perfectly  straight  and  the  surgeon's  hand  is  a  light  one, 
there  is  no  need  to  fix  the  trachea  yet.  The  skin  can  be  made  sufficiently  tense 
by  drawing  it  down  upon  the  sternum.  The  next  step  is  to  identify  the  white  line 
that  marks  the  interval  between  the  muscles.  At  this  level  they  are  not  in  contact, 
and  the  only  structure  in  front  of  the  trachea  (with  the  exception  of  veins)  is  the 
cervical  fascia  that  passes  across  from  one  to  the  other.  To  see  this  clearly  the 
edges  of  the  incision  must  be  gently  separated  with  the  forefinger  and  thumb  of 
the  left  hand,  steadying  the  trachea  without  compressing  it.  Retractors  held  by 
an  assistant  nearly  always  displace  it. 

The  next  proceeding  varies  according  to  the  operator.  Carefiil  dissection 
with  a  scalpel  until  the  rings  of  the  trachea  are  thoroughly  exposed  used  to  be  the 
invariable  rule,  but  now  there  are  many  modifications.  Whitehead  advocates 
splitting  the  fascia  from  above  downward  with  a  raspatory  (even  a  steel  director 
may  tear  the  veins)  until  the  isthmus  is  reached.  This  is  pushed  down,  and  the 
trachea  laid  bare  at  once.  Parker  only  makes  two  incisions,  one  to  expose  the 
white  line,  the  other  from  below  upward,  through  it  into  the  trachea.  Bose 
recommends  a  transverse  incision  through  the  fascia  on  the  cricoid  cartilage  ;  a 
blunt  hook  is  then  introduced  into  the  slit  and  passed  down  behind  the  thyroid, 
and  everything  that  lies  in  front  pulled  toward  the  sternum  until  the  first  three 


TRA  CHE  O  TO  MY. 


829 


rings  are  exposed.  This  has  been  called  the  bloodless  method,  and  may  be  prac- 
ticed when  there  is  a  large  plexus  of  distended  veins,  so  placed  that  it  would  be 
difficult  to  avoid  injuring  them  in  any  other  way. 

Parker's  method  undoul)tedly  shortens  the  o])eration,  avoids  shock,  and 
lessens  the  size  of  the  wound  and  the  absorbing  surface  (a  matter  of  great  moment), 
but  it  can  hardly  be  recommended  unless  the  operator  is  thoroughly  experienced. 
In  actual  practice  each  case  must  be  judged  upon  its  own  merits  :  in  some,  it  may 
be  advisable  to  open  the  trachea  at  once  ;  occasionally  it  must  be  done,  as  respi- 
ration may  cease  with  the  shock  caused  by  the  first  incision  ;  but  in  all  alike  it  is 
necessary  to  expose  and  recognize  the  interval  between  the  muscles,  to  keep  exactly 


P'iG.  351. — Trachea  Dilator. 

in  the  middle  line,  to  avoid  wounding  the  veins,  and  to  make  the  deep  incision 
from  below  upward.  Undoubtedly  it  is  safer  not  to  open  the  trachea  until  it  is 
thoroughly  exposed  ;  and  this  should  be  the  rule  ;  but,  on  the  other  hand,  tedious 
dissection  is  equally  to  be  avoided. 

The  isthmus  of  the  thyroid  gives  very  little  trouble  :  it  can  be  pressed  up  or 
down  by  the  finger  without  difficulty.  [Some  operators  prefer  to  divide  the 
isthmus  between  a  double  ligature.]  Great  care  must  be  taken  to  open  the  trachea 
exactly  in  the  middle  line.  The  upper  three  rings  should  be  divided,  but  not  the 
cricoid.     As  soon  as  this  is  done  the  edges  of  the  tracheal  wound  should  be  held 


Fig.  352. — Parker's  Suction  Apparatus.     The  cylinder  is  filled  with  antiseptic  cotton-wool. 


open  with  dilating  forceps  until  the  immediate  disturbance  consequent  on  the 
change  of  breathing  has  subsided.  Sometimes  respiration  ceases  altogether,  the 
abundant  supply  of  oxygen  causing  apnoea.  Sometimes  rapid  expiratory  efforts 
are  made  :  coughing,  of  course,  is  impossible.  In  cases  of  croup  or  diphtheria 
advantage  may  be  taken  of  this  to  clear  out  any  false  membrane  that  can  be  seen. 
Parker  recommends  sweeping  round  the  interior  of  the  windpipe  with  a  feather 
dijjped  in  a  solution  of  soda  or  borax  in  order  to  detach  and  bring  away  as  much 
as  possible ;  and,  if  this  does  not  succeed,  suction  either  by  means  of  a  ball- 
aspirator  or  a  properly  guarded  mouth-tube  (Fig.  352).  The  immediate  applica- 
tion of  the  mouth  to  the  wound  must  be  absolutely  condemned. 


830    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

The  size  c^  the  trachea  differs  even  at  the  same  age,  and  this,  of  course, 
determines  the  diameter  of  the  cannula;  its  shape  must  depend  upon  the  part  of 
the  windpipe  opened.  Durham's  and  Parker's  (Figs.  353  and  354)  are  the  most 
satisfactory,  the  latter,  however,  owing  to  the  absence  of  a  guide,  is  occasionally  a 
little  difficult  to  introduce.  Quarter-circle  and  bivalve  tubes  should  never  be  used. 
Morrant  Baker'srubber  ones  answer  exceedingly  well  when  the  wound  has  assumed 
a  definite  shape,  the  amount  of  discharge  often  beginning  to  diminish  at  once.  In 
most  cases  a  double  tube  is  necessary  for  purposes  of  cleansing  (Parker  dispenses 
with  it  when  there  is  a  well-trained  nurse),  and  the  inner  one  should  project  slightly 
beyond  the  outer,  so  that  the  latter  may  not  l)ecome  clogged.  In  addition,  the 
collar  of  the  tube  should  be  movable,  that  it  may  accommodate  itself  to  the  action 
of  the  trachea  in  swallowing. 

There  need  not  be  any  hurry  about  the  introduction  of  the  tube  ;  the  wound 
can  be  held  open  with  dilating  forceps  for  a  minute  or  two,  the  trachea  thoroughly 
cleared,  search  made  for  a  foreign  body  (in  this  case  it  is  sometimes  advisable  to 
fix  the  edge  of  the  trachea  temporarily  to  the  skin),  or  a  suture  passed  through  the 
lower  part  of  the  wound  ready  to  fasten.  Then  the  cannula  may  be  quietly  intro- 
duced on  a  pilot,  if  its  construction  admits  of  it,  and,  the  guide  being  withdrawn, 
secured  by  means  of  a  tape  round  the  neck.     In  this  way  there  is  no  fear  either  of 


Fig.  353. — Durham's  Cannula  with  Pilot. 


Fig.  354. — Parker's  Cannula. 


passing  the  tube  between  the  trachea  and  the  fascia  or  of  leaving  it  in  its  proper 
position,  but  blocked  with  false  membrane. 

No  operation  in  surgery  is  so  frequently  bungled  as  tracheotomy  ;  easy  as  it 
appears  on  the  dead  subject,  on  a  child  with  a  short,  fat  neck,  suffering  from 
extreme  dyspnoea,  it  is  entirely  different.  Waste  of  time  should,  of  course,  never 
be  permitted,  but  hurry  is  a  great  deal  worse.  The  cricoid  cartilage  has  been 
mistaken,  the  trachea  pushed  to  one  side  and  missed  altogether  (it  is  very  easy 
in  a  child),  the  opening  hacked  or  made  on  one  side,  the  posterior  wall  cut 
into,  important  veins  wounded,  and  the  carotid,  the  innominate,  and  even  the 
sac  of  an  aneurysm  laid  open.  This  cannot  hai)pen  if  the  head  is  held  straight, 
the  incision  made  of  sufficient  length  and  exactly  in  the  middle  line,  and  if  the 
operator  feels  from  time  to  time  what  he  is  doing.  If,  after  the  first  incision,  he 
presses  the  skin  on  either  side  backward  with  his  thumb  and  forefinger,  the  trachea 
is  fixed  in  the  middle  between  them  without  being  compressed,  and  is  kept  well 
up  in  the  wound. 

Hemorrhage  occasionally  is  unavoidable.  If  an  artery  is  cut  its  end  should 
be  clamped  at  once,  and  a  large  vein  may  be  treated  in  the  same  way.  Generally, 
however,  the  source  cannot  be  detected  ;  it  comes  from  the  small  vessels  of  the 
plexus  betw^een  the  layers  of  the  fascia,  all  of  which  are  distended,  owing  to 
the  dyspnoea.  In  these  circumstances  it  is  often  advisable  not  to  wait,  but  to 
open  the  trachea  at  once ;  as  air  enters  and  the  right  side  of  the  heart  becomes 
relieved,  the  veins  empty  themselves  and  the  hemorrhage  ceases.     Holding  the 


TRA  CHE  O  TOM  Y.  831 

trachea  slightly  forward  with  the  dilating  forceps  helps  to   compress  them  and 
prevents  the  blood  entering  the  lungs. 

When  tracheotomy  is  i)erforme(l  as  a  precautionary  measure  to  prevent  the 
entry  of  blood  into  the  lungs  during  the  course  of  an  operation,  the  incision  and 
various  steps  are  the  same,  but  a  tami)on  is  inserted  instead  of  a  simple  trache- 
otomy tube.   The  two  best  known  are  Trendelenberg's  and  Hahn's. 
Each  consists  of  a  tracheal  tube,  but  in  the  former  a  dilatable  rub- 
ber collar  is  used  to  block  the  space  around  it,  between  it  and  the 
mucous  membrane,  in  the  latter  compressed  sponge.     Of  the  two 
this  appears  to  be  the  better  ;  it  is  not  so  likely  to  slip  or  give  way, 
but  in  all   operations,  except   those  on  the  larynx  itself,  a  simple 
tracheotomy  tube  with  a  sponge  (attached  to  a  string),  to  block 
the  upi)er  aperture  of  the  larynx,  answers  equally  well,  and  is  not 
nearly  so  likely  to  get  out  of  order.  p,^.  355— Hahn's 

After-treatment. — This  varies  naturally  with  the  cause  :  it  Tampon  cannula 

,  ,  111  1  '     1  1  •  covered    with     com- 

must  always  be  remembered  that  tracheotomy  only  reheves  a  symp-  pressed  sponge  im- 
tom  or  prevents  one  ;  the  original  trouble  still  remains.  form"^'"^  *"''  '°'^°' 

{a)  In  the  simplest  case — chronic  laryngeal  stenosis,  for 
instance,  in  \vhich  there  is  no  pulmonary  complication — all  that  is  needed,  pro- 
vided the  tube  fits,  is  something  to  warm  and  moisten  the  air  before  it  enters  the 
lungs,  and  a  dry  absorbent  dressing  around  the  orifice  to  diminish  the  amount  of 
discharge  and  lessen  the  risk  of  broncho-pneumonia  and  cellulitis.  The  patient 
should  be  kept  as  quiet  as  possible  in  a  semi-recumbent  position,  and  well  pro- 
tected from  draughts.  A  bronchitis  kettle  may  be  used,  but  it  is  better,  for  a 
time,  at  least,  to  protect  the  orifice  with  a  thin,  flat  sponge,  wrung  out  of  hot  water, 
so  as  to  filter  the  air  thoroughly.  The  wound  should  be  powdered  with  iodoform, 
and  the  flanges  of  the  cannula  prevented  from  pressing  upon  it  by  little  pads  of 
absorbent  wool.  The  frequency  with  which  the  tube  requires  changing  depends 
upon  the  amount  of  irritation  it  causes ;  a  rubber  one  can  often  be  introduced  on 
a  proper  dilator  by  the  second  day.  In  cases  such  as  these,  there  is  very  little  of 
that  tenacious  mucus  which  is  so  troublesome  in  croup  or  diphtheria. 

For  the  first  itw  days  the  patient  should  be  fed  through  the  rectum  ;  the 
movements  of  the  trachea  in  swallowing  are  very  painful  (cocaine  sprayed  over 
the  wound  prevents  this  to  some  extent),  and  there  is  great  risk  of  fluid  trickling 
down  the  larynx  and  pa.ssing  by  the  side  of  the  tube  into  the  lungs.  This  may 
happen  even  after  the  cannula  has  been  removed,  if  the  larynx  has  not  thoroughly 
recovered,  but  usually  there  is  no  danger  after  the  wound  has  healed,  and  the 
patient  has  grown  accustomed  to  the  change  of  respiration  and  learned  how  to 
cough.  If  the  rectum  becomes  irritable  or  thirst  is  distressing,  an  oesophageal  tube 
should  be  used  instead. 

Tracheotomy  tubes,  if  worn  permanently,  should  be  frequently  changed  and 
carefully  inspected  from  time  to  time.  Their  duration  of  life  varies  very  much, 
and  instances  have  been  known  of  their  breaking  and  of  the  end  falling  down 
into  the  bronchi.  It  is  always  as  well  to  protect  the  orifice  with  a  suitable  respi- 
rator. 

(A)  In  diphtheria  the  after-treatment  requires  even  greater  care.  The  air  must 
be  warmed  and  moistened,  and  the  cot  surrounded  by  screens,  but  the  top  should 
be  left  open.  The  tube  must  be  kept  clean  by  means  of  feathers  dipped  in  a 
solution  of  bicarbonate  of  soda  or  potash  (soda  bicarb.,  gr.  xx  ;  glycerini,  jss  ; 
aq.  ad  5J),  and  if  there  is  any  membrane  heard  or  seen  floating  in  the  trachea  or 
larynx  it  must  be  cleared  away  in  the  same  manner.  Parker  recommends  that  the 
solution  should  be  sprayed  from  time  to  time  over  the  wound  to  prevent  the  viscid 
mucus  collecting  and  drying  around  the  orifice.  The  frequency  with  which  the 
inner  cannula  requires  changing  depends  upon  the  success  with  which  this  is  carried 
out.  At  first  it  may  need  it  almost  every  hour,  but  it  must  be  remembered  that 
the  process  is  an  exhausting  one,  and,  for  a  time,  very  alarming  to  a  child,  so  that 
every  endeavor  must  be  made   to  keep  the   passage  free  without.     Each  cannula 


832    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

sliould  have  a  double  set  of  inner  tul)es,  so  that  when  one  is  removed  and  a  feather 
has  been  passed  down  the  outer  to  make  sure  it  is  clear,  the  second  can  be  intro- 
duced without  delay.  The  outer  need  only  be  removed  once  a  day.  To  clear 
them  they  should  be  ])laced  in  a  hot  solution  of  soda  and  well  scrubbed. 

How  long  the  tube  should  be  continued  depends  u])on  the  course  of  the  dis- 
ease ;  but,  in  any  case,  the  metal  cannula  should  be  replaced  as  soon  as  possible 
by  a  rubber  one  (it  can  usually  be  done  by  the  third  or  fourth  day)  and  this  should 
not  be  worn  longer  than  is  absolutely  necessary.  Before  leaving  it  off  an  attempt 
must  be  made  to  educate  the  larynx  again,  and  to  reduce  the  amount  of  air  jjassing 
through  the  tube,  by  using  one  that  is  perforated  on  the  convexity  or  very  much 
shortened.  The  child,  of  course,  must  be  watched  night  and  day  by  some  one 
who  can  use  dilating  forceps  and  replace  the  cannula  at  once  if  there  is  any  real 
danger. 

Instances  of  very  great  difficulty  are  met  with  every  now  and  then  ;  dyspntea 
comes  on  as  soon  as  the  tube  is  removed,  and  the  child  seems  absolutely  imal)le  to 
breathe  through  its  larnyx.  In  a  few  cases  this  is  due  to  a  mechanical  impediment, 
cicatricial  stenosis,  or  the  growth  of  granulations  from  the  mucous  membrane, 
caused  by  the  irritation  of  the  cannula  ;  but  in  the  majority  no  reason  of  this  kind 
can  be  found,  nor  can  more  than  a  small  proportion  be  accounted  for  on  the 
hypothesis  of  diphtheritic  paralysis.  Probably  it  arises  not  so  much  from  any 
structural  alteration  as  from  the  inability  of  the  child  to  direct  its  efforts  with 
sufficient  energy,  and  from  actual  fright.  Most  cases  recover  as  the  child  grows 
stronger  by  patiently  trying  again  and  again  ;  sometimes  galvanism  is  of  service, 
but  in  a  few  nothing  succeeds,  and,  then,  if  no  organic  obstruction  can  be  found, 
the  only  course  left  is  intubation — passing  a  tube  into  the  larynx,  through  the 
mouth  or  through  the  wound,  and  retaining  it  there.  Either  O'Dwyer's  or  Mc- 
Ewen's  can  be  used  ;  the  essential  point  is  that  the  lower  end  should  be  just  Ijelow 
the  level  of  the  tracheal  opening.  A  tube  of  this  kind  can  be  left  without  being 
removed  for  twenty-four  hours  or  longer  ;  but  if  it  becomes  blocked,  so  that  it 
cannot  be  cleared  by  coughing,  or  if  symptoms  of  exhaustion  come  on  owing  to 
the  distress  it  causes,  it  must  be  removed  at  once,  and  under  no  circumstances 
may  the  child  be  left  alone  for  a  moment. 

Prognosis. — Care  must  be  taken  to  distinguish  between  the  consequences  of 
the  operation  and  those  of  the  disease  for  which  it  is  performed.  Much  depends 
upon  the  age  of  the  patient ;  in  an  infant  it  is  always  serious,  the  structures  involved 
are  so  small  and  delicate,  and  there  is  such  great  risk  of  pulmonary  complications, 
independently  of  croup  or  diphtheria.  If  the  lungs  are  already  collapsed  and  par- 
tially consolidated,  if  the  patient  is  exhausted  by  prolonged  battling  against  immi- 
nent asphyxia,  or  if  he  is  dying  from  the  diphtheritic  poison,  the  operation  can 
do  no  good  ;  it  must  not  be  blamed  for  the  result,  but  it  may  hasten  the  end.  If 
it  is  to  be  of  any  real  service,  or  if  the  wound  is  to  be  used  not  merely  to  relieve 
a  symptom  but  to  attack  the  disease  by  removing  false  membrane  and  giving  the 
patient  pure  air,  not  that  which  has  been  befouled  by  i^assing  over  a  poisoned  sur- 
face, it  must  be  performed  while  there  is  still  a  reasonable  hope. 

Inflammation  of  the  cellular  tissue  of  the  neck  is  the  most  common  complica- 
tion. There  is  always  a  little  at  the  first,  causing  a  certain  amount  of  swelling 
and  cedema  around  the  wound,  but  it  is  seldom  serious  unless  the  parts  have  been 
much  disturbed  in  the  oi)eration  or  the  vitality  of  the  tissues  is  greatly  impaired. 
Usually  it  subsides  in  the  course  of  a  few  days  ;  sometimes,  however,  it  forms  an 
abscess  around  the  trachea  (especially  if  the  tube  has  missed  the  opening  when  it 
was  being  introduced),  and  occasionally  it  leads  to  diffuse  suppuration,  which 
may  even  spread  down  to  the  mediastina  and  involve  the  pleura  or  pericardium. 
Care  must  be  taken  that  the  tape  fastening  the  cannula  is  not  too  tight. 

Irritation  of  the  mucous  membrane  of  the  trachea  may  be  caused  by  the  end 
of  the  cannula.  Usually  this  is  due  to  the  fact  that  it  does  not  fit.  Ulceration  of 
the  anterior  wall,  leading  to  perforation,  w^as  a  common  result  when  quarter-circle 
tubes  were  used,  and  though  this  is  much  more  rare  at  the  present  time,  masses  of 


INTUBATION  OF  THE  LARYNX.  833 

granulations  due  to  the  constant  friction  of  the  end  are  not  unfrc(juent.  Slight 
cases,  if  the  growth  is  easily  accessible,  may  he  relieved  l)y  means  of  an  alum  sjjray, 
or  by  painting  it  with  an  astringent  solution  ;  more  severe  ones  may  require  an 
enlargement  of  the  wound  and  the  ap])lication  of  the  cautery  or  a  curette.  In  a 
few  very  rare  instances  the  trachea  remains  irritable,  even  when  a  rubber  tube  is 
worn,  without  any  perceptible  cause. 

Diphtheria  very  seldom  attacks  the  wound.  It  may  l)ecome  foul  and  sloughy 
from  the  constant  irritation,  l)ut  it  is  rare  to  find  a  definite  adherent  membrane. 
If  it  forms  it  must  be  destroyed  at  once. 

I'hiiphysema  is  sometimes  met  with,  especially  when  the  cervical  fascia  is 
opened  up  irregularly,  and  it  is  said  that  the  air  may  spread  in  the  tissues  until  it 
reaches  and  fills  the  pleura. 

In  addition  to  these  there  is  always  the  risk  of  bronchitis  and  broncho-pneu- 
monia, caused  by  the  entry  of  cold  or  dry  air,  foreign  bodies,  dust,  food,  blood, 
or  the  secretion  of  the  wound ;  and,  of  course,  all  the  ordinary  complications  of 
irritated  wounds,  such  as  sloughing,  erysipelas,  etc.,  may  occur  as  well. 

Larytigo-trachcotomy. — In  this  operation  the  cricoid  is  divided  as  well  as  the 
upper  rings  of  the  trachea.  It  may  be  required  in  the  ca.se  of  children  with  very 
short  necks,  or  be  advisable  w^hen  there  is  a  growth  or  a  foreign  body  in  the  larynx. 
Under  other  circumstances  it  should  not  be  performed,  as  it  is  liable  to  lead  to 
serious  impairment  of  the  voice. 

Subhyoid  pharyngotomy  (opening  the  pharynx  through  the  thyro-hyoid  mem- 
brane) has  been  performed  for  the  removal  of  growths  and  foreign  bodies  in  the 
larynx.  It  should  only  be  resorted  to  in  cases  in  which  extraction  by  the  aid  of 
the  laryngoscope  has  failed  or  is  unsuitable. 

Thyrofomy. — Median  longitudinal  division  of  the  thyroid  cartilage  may  be 
required  under  similar  circumstances.  Laryngo-tracheotomy  is  performed  first 
and  a  tracheal  tube  inserted  ;  in  the  case  of  papillomata,  which  are  often  very 
vascular,  a  tampon  is  advisable  to  prevent  any  blood  trickling  down  the  trachea. 
In  some  cases  this,  or  the  division  of  the  crico-thyroid  membrane,  is  sufficient ;  if 
not,  the  incision  is  carried  upward  and  the  two  halves  of  the  thyroid  cartilage 
separated.  The  greatest  care  must  be  taken  to  keep  exactly  in  the  middle  line, 
and  if  possible  avoid  wounding  the  anterior  commissure  of  the  cords.  In  children 
and  young  adults  the  incision  may  be  made  with  a  scalpel,  and  it  may  not  be 
necessary  to  divide  the  whole  length  ;  the  elasticity  of  the  parts  is  so  great  that 
sufficient  room  can  be  obtained  without.  In  old  people  this  is  not  possible,  and 
in  many  instances  a  fine  saw  must  be  used.  After  the  growths  have  been  removed 
and  the  base  from  which  they  spring  seared  with  chromic  acid,  the  margins  of  the 
cartilage  must  be  accurately  adjusted  and  secured  with  wire  sutures  passed  through 
the  perichondrium.  The  tracheal  tube  should  be  left  for  some  days,  until  all 
danger  of  inflammation  is  past  and  the  parts  are  fairly  well  united.  The  patient 
must  in  the  meanwhile  be  kept  perfectly  quiet ;  talking,  and  especially  coughing, 
prevented  as  far  as  possible  ;  and  all  sources  of  irritation  avoided.  The  voice  is 
very  likely  to  be  impaired  :  not,  perhaps,  so  much  from  inaccurate  adjustment  as 
from  the  subsecjuent  cicatrization  and  contraction. 

Intubation  of  the  Larynx. 

This  method  of  treating  temporary  occlusion  of  the  glottis  has  recently  been 
revived  by  MacEwen  (for  adults)  and  O'Dwyer.  The  former  employs  long  cylin- 
drical tubes  after  the  pattern  of  gum-elastic  catheters,  introducing  them  through 
the  mouth  and  changing  them  every  twelve  hours  ;  the  latter  much  shorter  ones, 
which  (if  not  coughed  up)  may  be  left  in  situ  for  a  fortnight,  resting  upon  the 
ventricular  bands  without  i)assing  through.  The  shortest  are  an  inch  and  a  half 
in  length  ;  the  longest  three.  At  the  upper  end  is  a  diamond-shaped  head  flat- 
tened in  front  and  provided  with  a  small  eye  to  carry  a  thread.  Below  is  a  neck 
which  expands  into  a  fusiform  enlargement.     Each  tube  is  provided  with  a  jointed 


834     DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

guide,  which  can  be  screwed  on  to  an  introducer.  This  consists  of  a  stem  set  on 
a  handle  and  carrying  a  sliding  tube,  so  arranged  that  when  the  cannula  is  in 
position  it  can  be  pushed  off  the  guide  and  left  as  the  latter  is  withdrawn.  Finally, 
there  is  an  extractor  for  the  purpose  of  getting  the  cannula  out  again.  The  can- 
nula and  guides  are  made  in  five  sizes,  the  smallest  being  suital)le  for  a  child  under 
two  years  of  age. 

The  child  must  be  well  wrapped  up  in  a  blanket  and  held  by  the  nurse  in  a 
sitting  position  on  her  lap,  so  that  the  occiput  rests  against  her  left  shoulder.  The 
assistant  stands  behind  and  steadies  the  child's  head.  A  suitable  tube  is  selected, 
threaded  with  a  long  loop  of  silk,  and  fitted  on  a  guide.  This  is  then  screwed  on 
to  the  introducer  and  a  gag  placed  in  the  mouth  on  the  left  side.     The  operator 


Fig.  356. — O'Dwyer's  Tubes,     i.   Moulh  Gag.     2.  Introducer.     3.  Scale.     4.  E.\tracter. 


now  hooks  the  loop  attached  to  the  tube  round  the  little  finger  of  his  left  hand, 
and  passes  the  index  finger  over  the  tongue  on  to  the  epiglottis,  following  it  up 
closely  with  the  end  of  the  tube  in  his  right.  Then  he  either  simply  hooks  the 
epiglottis  forward,  and  slips  the  tube  over  it,  when,  if  suddenly  turned  down  and 
kept  in  the  middle  line,  it  must  pass  into  the  larynx  ;  or  he  passes  over  it  on  to 
the  arytenoid  cartilages  and  guides  the  cannula  in.  In  either  case  it  must  follow 
the  palmar  surface  and  glide  in  under  the  tip.  The  moment  it  is  in  position,  the 
sliding  tube  should  be  shot  forward,  the  guide  drawn  back,  and  the  cannula  pushed 
on  with  the  finger.  The  object  of  the  loop  of  silk  is  to  withdraw  it,  should  it 
have  missed  the  proper  opening  or  passed  into  the  pharynx. 

The  immediate  effect  is  a  violent  fit  of  coughing,  during  which  a  large  amount 


EXCISION  OF  THE  LARYNX.  835 

of  ropy  mucus  is  expectorated.  As  soon  as  this  ceases  the  loop  may  be  cut,  the 
silk  drawn  out  (taking  care  not  to  displace  anything),  and  the  tube  left. 

Extraction  is  more  difficult  and  may  require  an  anaesthetic.  The  forceps  are 
introduced  closed,  and  the  jaws  separated  from  each  other  by  touching  a  lever. 
The  serrations  are  on  the  outer  surface,  so  that  there  is  no  difficulty  in  holding 
the  tube  if  it  is  once  gras])ed. 

In  America  intubation  has  apparently  met  with  great  success  ;  those  who 
advocate  it  affirm  that  there  is  no  shock  of  hemorrhage,  and  that  the  relief  is 
complete.  In  England,  so  far,  very  few  cases  are  on  record,  and  its  merits  in 
different  diseases  are  not  accurately  known.  In  acute  oedematous  laryngitis, 
whether  arising  from  scald  of  the  glottis  or  other  causes,  it  is  probably  preferable 
to  tracheotomy  ;  and  after  tracheotomy,  when  the  tube  cannot  be  dispensed  with, 
a  laryngeal  cannula  has  on  several  occasions  been  used  with  advantage ;  but 
whether  it  can  take  the  place  of  tracheotomy  in  diphtheria  is  very  doubtful. 

The  operation  is  certainly  not  so  easy;  in  practiced  hands  the  introduction 
or  removal  of  a  laryngeal  cannula  may  not  be  of  much  moment,  even  under  cir- 
cumstances such  as  these  ;  but  it  would  lie  almost  impossible  to  those  who  have 
not  had  receipt  experience  in  manipulation.  The  larynx  itself  seems  to  tolerate 
the  tube  very  well ;  they  have  been  w^orn  a  fortnight  without  any  ill  consequence  ; 
nor  is  there  any  tendency  for  them  to  slip  down,  though  they  are  often  coughed 
up.  It  is  a  distinct  draNvback  that  they  cannot  be  replaced  by  a  nurse.  It  is 
said  that  the  discharge  from  the  trachea  is  freely  coughed  up  through  them,  in 
spite  of  their  narrow  calibre.  On  the  other  hand,  feeding  a  child  is  very  difficult. 
An  oesophageal  tube  may  be  tried,  or  the  patient  may  be  laid  upon  his  back  with 
the  head  hanging  well  down  (so  that  everything  falls  of  its  own  weight  over  the 
upper  aperture  of  the  larynx)  ;  but  neither  of  these  proceedings  is  easy,  and  in  a 
large  proportion  of  cases  fluids  find  their  way  down  by  the  side  of  the  cannula 
into  the  lungs  and  set  up  broncho-pneumonia.  Moreover,  there  is  great  risk  that 
the  cannula  may  force  down  some  membrane  in  front  of  it,  and  block  the  trachea 
at  once  ;  and  this  is  so  important  that  even  those  who  recommend  intubation 
advise  that  the  tracheotomy  instruments  should  be  immediately  at  hand.  If  intu- 
bation is  to  be  employed  in  cases  in  which  parents  refuse  their  consent  to  trache- 
otomy, this  is  a  matter  of  serious  moment.  Finally,  it  does  not  allow  the  trachea 
or  larynx  to  be  cleared  in  any  way  except  by  the  natural  efforts  at  expulsion 
through  the  narrowed  opening. 

Excision  of  the   Larynx. 

Excision  of  the  larynx  may  be  complete  or  partial.  The  former  implies  the 
removal  of  the  whole  of  the  cartilages,  with  sometimes  part  of  the  trachea,  pharynx, 
hyoid  bone,  and  circumjacent  structures,  and  with  rare  exceptions  is  the  only 
measure  that  can  be  adopted  in  the  case  of  malignant  growths  of  extrinsic  origin. 
The  latter  aims  merely  at  removing  the  seat  of  disease,  and  is  only  applicable  to 
intrinsic  tumors,  that  is  to  say,  those  springing  from  the  vocal  cords,  true  or  false, 
and  the  parts  immediately  around  them. 

Excision  has  been  performed  for  obstinately  recurring  and  extensive  papillo- 
mata,  for  lupus,  perichondritis,  and  even  for  stenosis  ;  but  with  very  i^\s  excep- 
tions, too  few  to  take  into  consideration,  it  is  never  called  for  except  in  the  case  of 
malignant  disease.  In  sarcoma  it  has  proved  fairly  successful  ;  in  epithelioma,  on 
the  other  hand,  total  extirpation  is  exceedingly  fatal,  in  great  measure  from  the 
direct  effect  of  the  operation.  Partial  excision,  however,  shows  a  much  better 
result,  and  it  seems  probable,  as  the  importance  of  the  early  diagnosis  and  early 
removal  of  carcinoma  is  more  widely  recognized,  it  will  become  better  still.  In 
other  words,  in  extrinsic  malignant  disease,  with  very  few  exceptions,  only  pallia- 
tive measures  are  advisable  ;  and  the  same  must  be  said  of  those  cases  of  intrinsic 
disease  in  which  the  growth  has  advanced  so  far  as  to  render  complete  extirpation 


836    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

necessary  ;  with  tracheotomy,  cocaine,  and  morphia,  the  remainder  of  the  patient's 
life  must  be  made  as  tolerable  as  possible ;  the  chance  of  his  surviving  such  an 
extensive  operation  is  too  small  to  justify  its  jjerformance  ;  and  even  if  it  were 
successful,  recurrence  in  such  advanced  disease  is  almost  certain.  Limited  in- 
trinsic growths,  on  the  other  hand,  should  be  removed  freely  and  without  delay. 

With  regard  to  the  diagnosis  of  the  character  of  an  intra-laryngeal  growth,  it 
has  been  pointed  out  by  Semon  that,  if  in  the  case  of  a  person  who  has  passed 
the  age  of  thirty-five,  a  small  warty  growth  makes  its  appearance  upon  one  of  the 
vocal  cords,  causing  hoarseness  or  aphonia  ;  if  the  cord  to  which  it  is  attached 
becomes  congested  at  an  early  period,  and  still  more  of  its  mobility  is  imi)aired  ; 
if  there  are  signs  of  irritation  around  ;  or  if  the  growth  reappears  very  soon  after 
partial  or  total  destruction — it  becomes  at  once  the  object  of  grave  suspicion.  It 
is  the  peculiarly  limited  character  of  intra-laryngeal  carcinoma  in  its  earlier  stages 
that  renders  the  diagnosis  of  malignant  disease  so  difficult  and  at  the  same  time  so 
important.  Moreover,  it  must  always  be  remembered  that  if  the  result  of  the 
microscopic  examination  of  a  fragment  is  negative  it  proves  nothing,  so  far  as  the 
presence  of  malignant  disease  is  concerned. 

{a)    Complete  Excision. 

Preliminary  tracheotomy,  to  prevent  the  entry  of  blood,  is  advisable,  though 
it  has  not  always  been  performed.  By  keeping  close  to  the  cartilages  and  by 
operating  with  the  patient's  head  hanging  down,  this  complication  can  be  avoided 
until  the  trachea  has  been  divided  and  a  full-sized  tube  inserted.  In  any  case  the 
external  portion  of  the  cannula  should  be  bent  down  by  the  side  of  the  neck,  and 
should  be  long  enough  to  admit  of  an  anaesthetic  being  given  without  inconveni- 
ence to  the  operator.  If  the  disease  is  far  advanced  and  the  patient  exhausted 
from  dyspnoea,  the  tracheotomy  should  be  performed  a  week  at  least  before  ;  if,  on 
the  other  hand,  the  disease  is  limited,  it  should  be  done  at  the  same  time  and  the 
same  incision  made  use  of. 

The  patient  may  either  be  placed  in  the  ordinary  position,  the  incision  being 
made  from  above  downward  ;  or  the  dorsal  spine  may  be  so  raised  that  the  head 
is  dependent  and  the  separation  from  the  trachea  effected  first.  The  latter  is  cer- 
tainly preferable  if  a  tampon  is  not  used. 

The  incision  runs  vertically  down  the  middle  line  from  the  hyoid  to  the 
second  ring  of  the  trachea.  A  transverse  one  is  usually  required  as  well.  The 
soft  parts  over  the  cartilages  are  detached  on  either  side,  lifting  up  the  perichon- 
drium from  them  by  means  of  a  raspatory  or  a  pair  of  blunt-pointed  scissors,  and 
the  separation  carried  back,  first  on  one  side  and  then  on  the  other,  until  the  con- 
strictors are  reached,  the  superior  laryngeal  artery  being  secured  by  a  double 
ligature  and  divided  between.  The  trachea  is  then  separated  from  the  cricoid 
cartilage  and  carefully  stitched  to  the  skin,  the  tampon  being  removed  and  a  large 
tube  of  vulcanite  or  lead  inserted  in  its  place.  The  larynx  is  drawn  forward  from 
below,  and  the  separation  from  the  oesophagus  and  pharynx  behind  carried  gradu- 
ally upward,  leaving,  if  possible,  the  mucous  membrane  that  lines  them  untouched. 
The  thyro-hyoid  membrane  is  then  divided,  the  condition  of  the  epiglottis  exam- 
ined, and  the  separation  completed. 

The  operation  naturally  requires  numerous  modifications.  Enlarged  glands 
may  have  to  be  dissected  out,  necessitating  removal  of  the  soft  structures  outside 
the  larynx  too  ;  portions  of  the  lateral  and  anterior  ])arts  of  the  jjharynx  may  be 
involved  ;  the  whole  of  the  epiglottis  and  part  of  the  hyoid  bone  may  have  to  be 
taken  away  ;  or,  on  the  other  hand,  it  may  be  possible  on  one  side  or  both  to 
leave  the  cornua  of  the  thyroid  cartilage  ;  it  is  recommended  to  do  this  at  the 
time  of  the  operation,  and  if  neces.sary  dissect  them  out  afterward,  as  it  lessens  the 
risk  of  hemorrhage.  Opinions  as  to  the  propriety  of  leaving  the  cricoid  are 
divided  ;  according  to  Hahn  it  is  better  removed,  as  it  interferes  with  deglutition. 


EXCISION  OF  THE  LARYNX. 


837 


All  bleeding  points  are  then  secured  ;  the  cut  edges  of  the  pharynx  sutured 
to  the  skin,  and  the  cavity  thoroughly  packed  with 
an  absorbent  dressing  covered  with  iodoform. 
When  the  wound  is  sound  an  artificial  larynx  (either 
Gussenbauer's  or  Irvine's  modification)  may  be  in- 
troduced. Deglutition,  if  the  pharynx  has  not 
been  opened,  is  very  satisfactory  ;  if,  however,  it 
has  been  necessary  to  remove  much  of  the  anterior 
wall,  so  that  the  wound  cannot  close,  an  oesopha- 
geal tube  will  be  rei^uired  for  the  rest  of  life. 

(J))  Partial  Excision. 

This  operation  naturally  varies  in  its  details 
even  more  than  the  former.  There  are,  however, 
two  well-characterized  methods — the  unilateral  and 
the  subchondral. 

(i)  Unilateral  excision  is  performed  in  the 
same  way  and  with  the  same  precautions  as  the 
complete,  but  the  transverse  incision  (which  runs  along  the  lower  border  of  the 
hyoid)  is,  of  course,  only  on  one  side.  Half  the  hyoid  and  the  epiglottis  may  be 
removed,  but  if  possible  the  superior  cornu  of  the  thyroid  should  be  left.  The 
condition  of  the  patient  after  a  partial  operation  such  as  this  is  much  more  satis- 
factory ;  deglutition  is  not  interfered  with,  and  very  fair  power  over  the  voice  is 
regained. 

(2)  Subchondral  excision  has  been  proposed  by  Butlin,  on  the  ground  that 
malignant  growths  only  involve  cartilage  very  slowly,  and  that  it  would  be  possi- 
ble in  early  cases  to  open  the  larynx  and  remove  the  whole  of  the  diseased  part 
with  sufficient  freedom  without  destroying  or  even  seriously  interfering  with  the 
framework. 


Fig. 


357-- 
rynx 


Gussenbauer's  Artificial  L3- 
("  Phonetic  Cannule"). 


838     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  X\\ 

DISEASES  OF  THE   THYROID. 

The  thyroid  gland  consists  of  a  number  of  separate  sacs  lined  with  a  single 
layer  of  nucleated  cubical  cells,  and  surrounded  by  exceedingly  vascular  adenoid 
tissue.  Colloid  degeneration,  affecting  the  contents  of  the  sacs  and  attended  with 
atrophy  of  the  cellular  lining,  is  of  such  common  occurrence  as  almost  to  be  con- 
sidered normal.  Nothing  is  known  with  regard  to  its  function,  beyond  the  gen- 
eral fact  that  the  activity  of  growth  and  nutrition  of  all  jjarts  of  the  body  (inclu- 
ding the  brain)  is  intimately  connected  with  its  integrity.  In  women  it  frequently 
enlarges  and  becomes  tender — at  puberty,  during  the  menstrual  period,  and  dur- 
ing pregnancy.  Cretinism  is,  in  all  probability,  due  to  its  imperfect  development ; 
removal  during  childhood  causes  a  similar  condition,  and,  in  a  large  proportion 
of  cases,  removal  of  the  whole  gland  is  followed  by  myxoedema,  if  performed  on 
adults.  The  temperature  falls  ;  the  oxygenating  capacity  of  the  blood  dimin- 
ishes ;  leucocytosis  sets  in  ;  the  coagulability  is  lessened  ;  the  skin  and  subcuta- 
neous tissue  undergo  a  peculiar  transformation  ;  nervous  symptoms  (tremors, 
paresis,  paresthesia,  etc.)  make  their  appearance,  and,  at  length,  a  cretinoid  con- 
dition, with  imbecility  and  coma,  follows.  When  this  does  not  take  place,  it  is 
probably  owing  to  the  fact  that  the  whole  gland  has  not  been  removed,  or  that 
accessory  thyroids  (which  are  of  very  common  occurrence)  have  undergone  com- 
pensative hypertrophy.  Sometimes  it  follows  with  great  rapidity  shortly  after 
the  operation  ;  sometimes,  on  the  other  hand,  slowly  and  gradually.  In  a  few 
instances  the  immediate  onset,  after  a  period  of  apparently  perfect  health,  has 
been  brought  on  by  exposure  to  cold. 


Inflammation  of  the  Thvroid. 

Inflammation  may  be  acute  or  chronic,  and  in  resolution  or  in  suppuration 
and  sloughing,  according  to  the  cause  and  the  addition  or  not  of  pyogenic  irritants. 

The  symptoms,  when  the  attack  is  acute,  are  very  alarming,  often  beginning 
with  a  rigor  and  high  fever.  Owing  to  the  way  in  which  the  gland  is  bound  down 
by  the  cervical  fascia,  the  pain  is  very  severe  ;  the  tissues  of  the  neck  are  hard 
and  rigid,  the  superficial  veins  distended,  the  trachea  and  o-'sophagus  compressed 
against  the  spine,  and  even  cerebral  symptoms  caused  by  the  obstruction  to  the 
cranial  circulation.  In  most  cases  resolution  sets  in  after  forty-eight  hours,  and 
the  acute  symptoms  begin  to  subside,  but  often  the  improvement  is  only  partial; 
the  diffuse  enlargement  disappears,  but  one  or  more  local  swellings  remain  ;  the 
skin  becomes  red  and  cedematous,  and  at  length  fluctuation  is  apparent.  Death  may 
occur  from  pressure  upon  the  trachea,  from  pus  finding  its  way  down  into  the  lungs, 
or  from  pyaemia  or  .septicajmia.      In  one  or  two  instances  the  gland  has  sloughed. 

The  treatment  must  be  energetic.  At  the  first  onset  aconite  or  antimony 
may  be  given  internally  in  small,  frequently  re])eated  doses,  until  a  distinct  effect 
is  produced  upon  the  arterial  tension.  Ice-cold  compresses  should  be  placed  upon 
the  neck,  the  superficial  veins  pricked  to  relieve  the  circulation,  and  leeches  ap- 
plied to  the  sui)ra-clavicular  region.  Venesection  (either  from  the  arm  or  the 
external  jugular)  may  be  advisable,  if  the  patient  is  young  and  the  inflammation 
sthenic.  If  signs  of  suppuration  make  their  appearance,  the  superficial  structures 
must  be  carefully  divided,  layer  by  layer,  and  a  director  used  for  exploration  after 
Hilton's  method.  A  drainage  tube  must  be  inserted  to  prevent  the  opening 
becoming  valvular. 


GOITRE.  839 

Simple  Enlargement,  or  Goitre. 

All  forms  of  enlargement  of  the  thyroid  that  are  not  the  result  of  inflamma- 
tion'or  malignant  disease  are  groii])ed  together  d&  goitre.  The  blood-vessels  only 
may  be  affected,  and  the  change  limited  to  the  gland  {pulsathtg  bronchocele)  ;  or 
this  may  be  associated  with  other  symptoms  referable  to  the  vascular  system  {ex- 
ophthalmic goitre,  or  Graves'  disease).  The  vesicles  or  the  interstitial  connective 
tissue,  or  both  together,  may  be  hypertrophied  without  any  change  in  structure 
and  without  any  considerable  alteration  in  proportion  [parenchymatous  (jx  follicu- 
lar enlargement).  This  may  be  complicated  by  various  forms  of  degeneration. 
The  follicles  may  enlarge  into  colloid  cysts,  while  the  interstitial  tissue  atrophies 
and  wastes  until  neighboring  cavities  fuse  together  and  form  huge,  irregular  spaces 
{cystic  goitre).  Sometimes  the  contents  remain  clear  and  gelatinous  ;  sometimes 
they  become  blood-stained  and  mixed  with  debris  from  the  walls  and  vessels,  until 
scarcely  a  trace  of  the  original  character  is  left.  In  many  cases  proliferating  vil- 
lous growths,  consisting  almost  entirely  of  blood-vessels  with  a  thin  layer  of  epi- 
thelium over  them,  make  their  appearance,  springing  from  the  inner  wall  of  the 
vesicles,  and  filling  them  with  a  soft,  almost  erectile  mass.  In  others  the  fibrous 
tissue  is  the  part  chiefly  affected  ;  diffuse  or  localized  bands  are  developed  in  all 
directions  among  the  vesicles,  and  grow  larger  and  harder  until  the  whole  struc- 
ture becomes  solid  {fibrous  goitre).  Finally,  in  most,  the  degeneration  is  not 
limited  to  any  one  tissue,  but  involves  them  all  in  varying  proportion,  so  that  masses 
of  soft,  va.scular,  interstitial  substance,  vesicles,  cysts  with  all  kinds  of  contents, 
and  dense  fibrous  tissue  are  mixed  up  together,  and  rendered  still  more  complex 
by  calcareous  degeneration  of  the  walls  and  capsule. 

An  attempt  has  been  made  to  distinguish  simple  hypertrophy  from  adenoma, 
reserving  the  latter  for  those  cases  in  which  there  are  either  distinct  separate 
tumors  or  isolated  portions  growing  out  in  an  atypical  form  ;  but  it  is  very  doubt- 
ful if  this  can  be  maintained.  A  few  cases  are  recorded  in  Avhich  secondary  growths, 
pulsating  and  resembling  the  normal  thyroid  in  structure,  have  occurred  in  the 
bones  of  the  skull  and  other  parts  of  the  body.  In  some  of  these  an  apparently 
simple  goitre  was  present ;  but,  in  others,  there  was  scarcely  any  increase  in  size. 

Symptoms. — These  depend  upon  the  nature  and  rapidity  of  the  enlarge- 
ment.     Certain  features  are,  however,  common  to  all  alike. 

The  swelling  may  involve  the  whole  gland  and  accurately  follow  its  shape,  or 
it  may  be  confined  to  one  side,  or  to  the  isthmus ;  but,  whatever  part  it  involves, 
it  always  moves  up  and  down  with  the  larynx  in  swallowing.  This  is  due  to  the 
arrangement  of  the  cervical  fascia,  and  is  the  distinctive  feature  of  thyroid  tu- 
mors. They  may  be  smooth  and  uniform  in  outline,  or  covered  with  irregular 
bosses,  or  pedunculated  and  hanging  by  a  stalk  over  the  sternum.  Sometimes 
the  enlargement  consists  almost  entirely  of  vessels  or  of  cysts  filled  with  masses  of 
vascular  outgrowths,  so  that  the  swelling  is  soft  and  elastic,  and  pulsates  almost 
like  an  aneurysm,  with,  in  many  cases,  a  thrill.  Sometimes,  on  the  other  hand, 
only  the  fibrous  tissue  is  concerned,  and  the  tumor  is  nodular,  dense,  and  firm. 

Other  symptoms  are  due  to  pressure.  Large,  slowly-growing  tumors,  that 
project  in  front  and  become  pedunculated,  do  not  offend  in  this  way.  Small  ones, 
on  the  other  hand,  that  lie  in  the  isthmus  or  extend  around  the  trachea  between  it 
and  the  oesophagus,  and  dense  nodules  that  are  sometimes  scarcely  apparent  on 
the  surface,  are  often  much  more  serious,  especially  if  their  growth  is  rapid.  The 
trachea  may  be  flattened,  bent,  or  displaced  to  one  side  of  the  neck.  The  cartil- 
ages may  be  absorbed,  the  recurrent  laryngeal  nerve  paralyzed,  the  movement  of 
the  oesophagus  interfered  with,  and  the  great  vessels  and  ner\'es  stretched  or  flat- 
tened. Sometimes  goitrous  thyroids  suddenly  enlarge  ;  they  are  exceedingly 
vascular,  and  excitement  or  violent  exertion  may  lead  to  such  intense  congestion 
as  to  cause  instant  death. 

Acute  goitre  is  very  rare  in  England,  although  it  is  described  as  occurring  in 
an  epidemic  form  among  troops  in  France.   There  is  a  certain  amount  of  evidence 


840    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

connecting  it  with  the  rheumatic  diathesis,  but  the  cause  is  as  obscure  as  that  of 
the  common  variety.  The  swelling  is  rapid  and  painful,  the  neck  cannot  be  bent, 
the  skin  is  tense  and  white  ;  usually  there  is  considerable  dyspnijea  with  hoarseness, 
and  sometimes  a  rather  high  degree  of  fever.  It  has  been  suggested,  on»  the 
analogy  of  mumjjs,  that  it  is  really  a  form  of  sjjecific  intlammation,  but  it  has  not 
been  shown  to  be  contagious. 

The  hypera;mia  that  occurs  during  the  menstrual  period  and  at  pregnancy  is 
usually  transient,  and  merely  causes  a  feeling  of  fullness  and  tenderness  in  the 
neck.  In  a  few  cases,  however,  the  swelling  never  subsides  completely,  and  it  may 
be  followed  by  fibro-cystic  degeneration. 

Pulsating  bronchocele  may  occur  as  part  of  Graves'  disease  or  independently. 
In  the  former  case  the  whole  gland  is  uniformly  enlarged,  all  the  blood-vessels  are 


Fig.  358. — Pareiiciiymatous  Enlargement  of  the   Tliyroiil. 

dilated,  the  pulsation  is  equally  marked  over  the  whole  surface,  and  the  solid 
tissues  do  not  hypertrophy  until  the  disease  has  lasted  some  time.  In  addition, 
the  enlargement  of  the  gland  is  associated  with  other  symptoms  which  have  been 
assigned  (although  on  very  inadequate  evidence)  to  a  lesion  of  the  sympathetic. 
In  the  latter  case  the  primary  affection  appears  to  be  the  development  ot  exceed- 
ingly vascular  intra-cystic  growths,  although,  of  course,  the  blood  supply  of  the 
whole  gland  is  increased  as  well.  The  surface  is  covered  with  bosses,  some  of 
which  pulsate  so  strongly  that  they  may  be  mistaken  for  aneurysmal  dilatation  of 
the  carotid  or  subclavian,  and  the  amount  of  stroma  and  solid  tissue  is  considerably 
and  irregularly  increased.  Many  of  the  cysts  are  filled  with  broken-down  blood- 
clot  and  tissue  debris,  and  the  changes  these  undergo  in  course  of  time  add  con- 
siderably to  the  varied  character  of  the  morbid  appearance.     Disease  of  this  kind 


GOITRE.  841 

may  remain  unchanged  for  years,  sometimes  growing  larger — when  the  patient  is 
out  of  health — and  then  again  diminishing,  without  apparently  ])roducing  any 
constitutional  effect.  In  one  or  two  cases,  however,  secondary  deposits  of  a  simi- 
lar character  have  made  their  appearance  in  distant  parts  of  the  body,  as  if  the 
primary  growth  had  in  some  way  infected  the  blood  stream. 

Fibroid  and  fibro-cystic  goitres  may  attain  an  immense  size.  Generally  one 
element  is  very  greatly  in  excess  of  the  other,  but  they  rarely  occur  entirely  by 
themselves.  The  shape  and  density  of  the  swelling,  and  the  symptoms  it  causes 
by  pressing  upon  neighl)oring  organs,  naturally  differ  according  to  its  character 
and  direction. 

Diagnosis. — All  thyroid  swellings  move  up  and  down  with  the  larynx  in 
swallowing.     Accessory  thyroids  (which  sometimes  undergo  a  similar  transforma- 


^'! 


-...-■     \ 

Fig.  359. — Cystic  Bronchocele. 

tion  and  develop  into  gigantic  tumors)  present  the  greatest  ditticulty.  They  may 
occur  in  any  part  of  the  neck,  naturally  most  often  in  front,  but  sometimes  under 
the  mucous  membrane  of  the  trachea  or  larynx,  or  below  the  upper  border  of  the 
sternum.  Bursal  cysts  develop  in  connection  with  the  thyro-hyoid  space  ;  con- 
genital cysts  and  such  rare  tumors  as  tracheoceles,  can  hardly  be  mistaken. 

Treatment. — A  very  great  deal  may  be  done  for  recent  parenchymatous 
goitres  and  for  some  forms  of  pulsating  bronchocele.  Even  when  fibroid  or  cystic 
degeneration  has  set  in,  the  size  of  the  swelling  can  be  considerably  reduced,  but 
the  prospect  of  perfect  resolution  is  not  nearly  so  good.  Graves'  disease,  in  which 
the  affection  of  the  thyroid  occurs  as  part  of  a  general  disorder,  stands  on  a  differ- 
ent basis. 

Nothing  is  of  much  use  so  long  as  the  patient  lives  in  a  goitrous  district. 
54 


842    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

^^'hatever  may  l)e  the  reason,  there  is  no  question  that  goitre  occurs  endemically 
in  certain  localities  ;  that  otherwise  healthy  peoi)le  moving  into  them  are  often 
affected,  and  with  somewhat  acute  symptoms  (possibly  the  ejtidemics  among  troops 
in  France  are  due  to  this),  and  that  if  they  remove  in  sufficient  time  the  swelling 
is  very  likely  to  disappear  again.  The  only  precaution  is  never  to  drink  the 
water  of  the  district  in  any  form  ;  but  it  has  not  been  proved  that  this  will  prevent 
the  disease. 

In  recent  goitre  %\.\ovl%  iodine  liniment  or  iodide  of  potash  ointment  applied 
to  the  skin  of  the  neck  often  effects  considerable  im])rovement ;  and  the  iodide 
may  be  given  internally  with  iron  and  other  tonics.  Hydrofluoric  acid  is  said  to 
be  I)eneficial,  but  although  I  have  tried  it  in  a  large  number  of  cases  I  have  failed 
to  detect  any  result.  It  must  be  remembered  that  goitres  of  all  kinds  are  very 
variable  in  size ;  not  merely  after  injury  or  when  a  person  is  out  of  health,  but  for 
entirely  unknown  reasons,  they  have  been  known  to  disappear  suddenly  of  them- 
selves;  so  that,  unless  the  improvement  is  decided  and  permanent,  it  cannot  be 
taken  as  evidence  of  the  value  of  the  drug.  Biniodide  of  mercury  ointment,  as 
applied  in  England,  does  not  appear  to  succeed. 

If  this  fails,  or  if  the  thyroid  is  already  in  a  state  of  fibroid  enlarge7nent,  hard, 
irregular  and  dense,  injections  of  a  solution   of  iodine  in  alcohol  (one  part  in 

twelve)  may  be  tried.  About  half  a  drachm 
is  injected  into  different  i)arts  of  the  gland 
once  or  twice  a  week,  according  to  the 
severity  of  the  reaction  that  follows.  Care 
must  be  taken  that  the  ])oint  of  the  needle 
is  really  in  the  gland  (this  may  be  shown 
by  making  the  patient  swallow),  not  in  the 
cellular  tissue,  and  particularly  to  avoid  the 
veins.  The  seat  of  the  injection  becomes 
slightly  red  and  swollen,  and  the  patient 
may  comj^lain  of  vague  sensations  of  pain 
^^^-«ij«>^^  in  the  neck,  but  anything  more  serious  very 

seldom    follows.      Suppuration    may    occur, 
but  it  is  very  rare,  and  eml)olism  has  been 
Fig.  36o.-Coiioid  Degeneration  of  Thyroid.       knowu  to  happen,  SO  that  the  i)rocedure  is 

not  entirely  devoid  of  risk. 
Cystic  goitre  xwdiyhQ  treated  by  aspiration,  drainage,  enucleation,  or  injection. 
Of  these  the  first  is  of  little  avail,  except  as  a  temporary  expedient  in  an  urgent 
case,  or  as  a  preliminary  to  other  measures.  The  fluid  must  be  drawn  off  very 
slowly,  or  hemorrhage  may  occur  from  the  delicate  vessels  in  the  walls  of  the  sac 
and  fill  it  even  more  tensely  than  it  was  before. 

Drainage  and  enucleation  are  more  successful.  A  linear  incision  is  made 
through  the  superficial  structures,  and  the  capsule  of  the  gland  freely  exposed.  If 
there  is  a  large  single  cyst  it  can  usually  be  enucleated  by  careful  dissection,  clamp- 
ing and  dividing  between  two  ligatures  every  vessel ;  solid  adenomata  may  be 
treated  in  the  same  way.  If  this  is  im])racticable,  the  cavity  can  be  laid  open  and 
the  contents  cleared  out,  but  the  operator  must  be  prepared  for  smart  hemorrhage. 
Plugging  with  iodoform  gauze  may  be  necessary  if  it  does  not  stop  at  once.  It 
does  not  appear  to  be  necessary  to  fasten  the  edge  of  the  cyst  to  the  skin  or  the 
cervical  fascia;  according  to  Clutton,  if  the  superficial  structures  are  not  disturbed 
or  displaced,  there  is  very  little  risk  of  inflammatory  infiltration.  If  there  is  a 
number  of  small  cysts  closely  packed  together,  it  is  better  to  excise  the  part,  so 
long  as  it  is  not  too  large,  ligaturing  the  vessels  one  by  one  as  they  appear  and 
taking  especial  care  of  the  recurrent  laryngeal  nerve. 

Injection  with  perchloride  of  iron  (25  per  cent,  solution)  is  very  strongly 
advocated  by  Morell  Mackenzie  with  the  view  of  exciting  limited  suppuration 
without  hemorrhage.  The  cyst  is  tapped,  partially  or  comj)letely  emptied,  accord- 
ing to  its  size,  and   injected  with  a  drachm   or   two  of  the  solution,  avoiding 


GOITRE.  843 

manipulation  as  far  as  possible.  The  syringe  is  then  withdrawn,  the  cannula 
plugged  and  left  ///  situ  for  about  three  days.  At  the  end  of  that  time  the  contents 
are  allowed  to  escape,  and  if  they  are  thin  and  serous,  or  if  there  is  much  blood 
— if,  in  other  words,  suppuration  does  not  appear  probable — a  second  injection  is 
made.  Poultices  are  applied  to  encourage  this,  and  the  cannula  is  retained  as  a 
drainage  tube  until  there  is  no  longer  any  fear  of  the  opening  becoming  valvular. 
This  plan  is  not  devoid  of  risk  l)y  any  means  ;  suppuration  may  be  acute  with  high 
fever,  and,  although  it  is  usually  successful,  the  inflammation  may  cause  serious 
misgivings  for  a  time. 

Electrolysis  has  been  used  with  considerable  success  in  vascular  goitre,  even 
when  there  were  definite  exophthalmic  symptoms.  Duncan  recommends  a  current 
of  from  40  to  80  milliamperes,  and  relies  chiefly  upon  the  destructive  action 
of  the  negative  pole,  moving  it  about  freely  from  side  to  side  as  soon  as  it  has 
produced  a  decided  effect. 

Under  certain  circumstances  operative  treatment  becomes  imperative.  The 
trachea  may  be  compressed  or  distorted,  causing  marked  tracheal  stridor  and 
dyspnoea  on  the  least  exertion.  The  recurrent  laryngeal  nerve  may  be  irritated  or 
stretched  ;  if  this  occurs  on  both  sides  the  condition  at  once  becomes  very  critical. 


Fig.  361. — Cystic  Degeneration  of  Thyroid. 


A  firm  growth  may  extend  downward  between  the  trachea  and  the  sternum,  or 
embrace  the  trachea,  or  grow  backward  against  it  so  as  to  compress  it ;  or  there 
may  have  been  already  an  attack  of  suffocative  dyspncea  due  to  sudden  enlargement 
of  the  gland. 

The  choice  lies  between  tracheotomy,  division  of  the  isthmus,  enucleation  of 
the  grow'th,  and  ligature  of  the  arteries  supplying  the  gland. 

Tracheotomy,  of  course,  is  only  palliative,  it  may  be  necessary  on  the  spur 
of  the  moment,  a  special  tube,  or,  if  this  is  not  at  hand,  a  gum-elastic  catheter, 
being  passed  down  the  trachea  through  the  constricted  part.  The  difficulty  of 
such  an  operation  can  hardly  be  exaggerated  ;  low  tracheotomy  is,  of  course,  out 
of  the  question — even  the  upper  part  of  the  trachea  may  be  concealed  or  pushed 
to  one  side,  or  flattened,  so  that  it  presents  a  sharp  edge,  or  so  covered  with 
dilated  vessels  and  portions  of  the  growth  as  to  be  almost  inaccessible.  Bose's 
method  (transverse  division  of  the  cervical  fascia,  and  pulling  all  the  structures 
forward  and  downward  from  off  the  front  of  the  trachea)  may  be  the  only  one 
practicable. 

Division  of  the  isthmus,  on  the  other  hand,  is  exceedingly  successful,  and,  in 
a  large  proportion  of  cases,  has  been  followed  by  the  unexpected  diminution  in 


844     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

bulk  of  the  rest  of  the  gland.  To  some  extent  this  may  be  (lue  to  the  recession 
of  the  lateral  lobes,  but  certainly  this  will  not  account  for  the  whole,  'i'he 
incision  is  vertical,  in  the  middle  line;  the  skin  and  superficial  fascia  are  divided  ; 
then  the  layer  connecting  the  sterno-hyoid  and  sterno-thyroid  muscles  (which  are 
usually  much  flattened  out)  ;  the  veins  that  lie  on  the  front  carefully  detached, 
and  the  isthmus  sei)arated  from  the  trachea  by  means  of  the  finger  and  a  director. 
A  double  ligature  is  then  passed  round  the  isthmus  and  the  intervening  tissue 
excised  ;  or  the  median  part  may  simply  be  divided,  and  allowed  to  retract.  This 
operation  has  been  performed  in  exophthalmic  goitre,  for  the  relief  of  the 
dyspnoea;  the  lateral  lobes  were  considerably  reduced  in  size  before  the  patient's 
death,  some  time  after,  from  cerebral  symptoms. 

No  definite  directions  can  be  laid  down  for  enucleation  :  it  may  be  practiced 
either  in  the  case  of  cysts  or  solid  adenomatous  growths,  and  sometimes  consider- 
able portions  may  be  removed  in  this  way  (the  part  left  undergoes  hypertrophy,  so 
that  the  operation  is  practically  free  from  the  risk  of  myxoedema,  unless  the  amount 
taken  away  is  very  large)  ;  but  the  greatest  care  is  necessary  if  the  growth  lies  any- 
where near  the  recurrent  laryngeal  nerves.  On  several  occasions  one  has  been 
divided,  and  in  many  others  their  function  has  been  seriously  impaired  by  the 
inflammation  that  followed. 

Ligature  of  the  thyroid  arteries  has  been  tried  ;  but,  at  the  best,  it  can  only 
be  palliative,  and  the  result  has  not  been  sufficiently  good  to  justify  the  risk. 

Malignant  Disease  of  the  Thvroid  Gland. 

Sarcoma  and  carcinoma  are  both  known  to  occur,  but  they  are  not  common. 
The  former  may  be  either  round-celled  or  spindle-celled,  and  may  be  recognized 
by  the  rapidity  of  its  growth,  and  (when  the  cervical  fascia  has  yielded  before  it) 
by  its  soft,  almost  fluid,  consistence.  The  latter  is  stated  to  be  either  encephaloid 
or  scirrhus.  It  does  not  occur  until  late  adult  life,  and  usually  as  a  complication 
in  goitre,  the  thyroid  suddenly  beginning  to  enlarge  and  become  painful.  The 
diagnosis  cannot  be  made  until  the  lymphatic  glands  or  the  neighboring  tissues  are 
involved  ;  and  removal  is  out  of  the  question.  It  is  probable  that  the  secondary 
pulsating  growths,  similar  in  structure  to  a  cystic  proliferating  thyroid,  and 
occurring  in  distant  parts  of  the  body,  are  really  carcinomatous. 


INJURIES  OF  THE  (ESOPHAGUS.  845 


CHAPTER  XVI. 

INJURIES  AND  DISEASES  OF  7 HE  PHARYNX  AND  (ESOPHAGUS. 

Malformations. 

Congenital  occlusion  of  the  pharynx  is  due  to  the  invagination  that  forms  the 
mouth  failing  to  open  into  the  anterior  end  of  the  primitive  intestine.  In  con- 
genital stricture  the  defect  is  the  same,  but  less  marked. 

Diverticula  may  originate  in  the  same  way.  Some  of  these  are  acquired 
(pharyngoceles)  :  a  part  of  the  wall  is  weakened  by  inflammation  or  injury  to  such 
an  extent  that  the  mucous  membrane  bulges  out  through  the  opening  ;  the  larger 
ones,  however,  and  especially  those  that  occur  in  the  region  of  the  inferior  con- 
strictor, are  congenital  in  origin.  When  small  they  are  not  noticed  ;  as  they 
increase  in  size  they  form  a  pear-shaped  swelling  by  the  side  of  the  neck,  pressing 
upon  the  great  vessels,  displacing  the  larynx,  and  often  causing  dyspnoea  and  vio- 
lent fits  of  spasmodic  coughing  from  pressure  upon  the  sui)erior  laryngeal  nerve. 
The  nature  of  the  sac  is  easily  recognized  from  the  variations  in  its  size  at  different 
times,  and  from  the  way  in  which  its  contents  (air  and  sodden  food)  are  returned 
into  the  mouth  when  it  is  subjected  to  external  pressure,  or  squeezed  by  the  mus- 
cles around  it.  As  it  enlarges  it  displaces  the  oesophagus,  becoming  more  vertical 
and  drawing  nearer  the  middle  line,  until  the  natural  passage  is  thrust  entirely  out 
of  its  axis.  In  one  of  these  cases  Wheeler  laid  open  the  tumor  from  the  outside, 
excised  it,  and  successfully  secured  the  margins  of  the  opening  with  catgut 
sutures. 

Congenital  dilatation  of  the  cesophagus  has  also  been  described  as  affecting 
its  whole  length,  but  this  is  still  more  rare.  A  minor  degree  of  the  same  disorder 
sometimes  results  from  fatty  degeneration  of  the  muscular  wall.  As  a  rule,  hyper- 
trophy and  narrowing  occur  above  a  stricture. 

Injuries  of  the  Oesophagus. 

The  cesophagus  may  be  wounded  from  the  outside  in  cases  of  cut-throat,  or 
from  inside  by  corrosive  fluids  or  hard  and  sharp-pointed  foreign  bodies.  In  rare 
instances  rupture  has  taken  place  during  vomiting,  but  probably  only  when  the 
walls  have  been  weakened  beforehand  by  inflammation  or  fatty  degeneration. 

Swallowing  corrosive  fluids  is  nearly  always  done  with  suicidal  intent,  the 
liquid  (usually  a  mineral  acid  or  a  very  strong  alkali)  being  thrown  quite  to  the 
back  of  the  pharynx,  so  that  the  lips,  mouth,  and  tongue  are  often  not  touched. 
[I  have  seen  some  cases  where  children  produced  cesophageal  stricture  by  the 
swallowing  of  "  Concentrated  Lye."]  The  immediate  effect  is  profound  collapse 
with  intense  burning  pain,  followed  by  vomiting  of  mucus,  blood,  and  sloughing 
shreds  of  epithelium,  mixed  with  the  contents  of  the  stomach.  If  the  result  is 
not  immediately  fatal  from  perforation  or  collapse,  the  severity  of  the  symptoms 
gradually  subsides  ;  there  is  less  blood  and  more  mucus  and  pus  in  the  fluid  that 
is  brought  up ;  the  pain  becomes  less  severe ;  the  swelling  and  thickening  around 
the  oesophagus  diminish,  and  the  febrile  symptoms  abate.  Swallowing,  however, 
causes  very  great  pain,  and  if  more  than  the  epithelial  surface  has  been  destroyed, 
it  rapidly  becomes  more  and  more  difficult,  until  at  length  a  traumatic  stricture  is 
established.  The  wall  of  the  oesophagus  contracts  spasmodically  on  the  irritant 
before  it  is  vomited  back,  and  thus  it  may  happen  that  the  whole  of  the  tube, 
from  the  cricoid  almost  down  to  the  cardiac  orifice,  is  more  or  less  eaten  away. 
In  cases  of  long  standing:  the  walls  become  enormously  thickened  from  inflamma- 


S46    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

tory  deposit  and  fused  witli  the  structures  around.  The  interior  is  rough  and 
irregular,  marked  by  sloughs  and  cicatrices  in  all  directions,  and  here  and  there 
the  cavity  may  be  completely  obliterated,      [(ireat  emaciation  follows.] 


Foreign  Bodies  in  the  Pharynx  and  CEsophagus. 

False  teeth,  i)ieces  of  unmasticated  food,  coins,  fish-bones,  pins,  and  the  like, 
are  not  uncommonly  impacted  in  the  oesophagus — generally  where  it  is  narrowest, 
at  the  level  of  the  cricoid  cartilage — but  sometimes  immediately  behind  the  arch 
of  the  aorta  or  the  left  bronchus. 

The  symj)toms  depend  chiefly  upon  the  size  and  shape.  \i  it  is  large  and 
smooth,  instant  death  may  occur  from  its  pressing  upon  the  aperture  of  the  larynx, 
or  from  spasm  of  the  glottis ;  if  pointed  and  irregular,  there  may  be  dysphagia 
(and  the  feeling  of  soreness  i)ersists  long  after  the  foreign  body  has  been  removed) 
or  complete  obstruction.  Tenderness  in  the  side  of  the  neck,  soreness  behind  the 
sternum,  dyspnoea,  and  a  constant  discharge  of  saliva  and  mucus,  are  often  pre- 
sent as  well.  Later,  if  the  case  is  left  to  itself,  inflammation  sets  in.  Sometimes 
this  leads  to  spontaneous  expulsion,  as  the  foreign  body  becomes  loosened  ;  more 
frequently  it  makes  matters  worse  by  extending  into  the  tissue  around.  Abscesses 
may  form  under  the  deep  cervical  fascia  and  spread  into  the  pleura  or  i)ericardium. 
The  walls  of  the  carotid,  and  even  of  the  aorta  itself,  may  give  way.  The  foreign 
body  may  ulcerate  through  into  the  trachea,  and  be  coughed  up,  or  it  may  be 
driven  into  the  pericardium  and  even  into  the  substance  of  the  heart. 

When  the  foreign  body  is  a  large  one  there  is  seldom  any  difficulty  in  the 
diagnosis.  The  finger  can  explore  the  whole  of  the  upper  part  of  the  pharynx, 
from  the  level  of  the  soft  palate  down  to  the  back  of  the  arytenoid  cartilages,  and 
in  children  even  lower ;  and  the  mucous  membrane  may  be  thoroughly  inspected 
by  means  of  a  laryngoscope  mirror  ;  but  when  it  is  situated  below  this,  and  is  of 
small  size — a  fish-bone,  for  example — its  presence  is  often  only  a  matter  of  infer- 
ence. In  many  cases  the  sensation  persists  long  after  the  offending  substance  has 
been  dislodged. 

Treatment. — A  foreign  body  must  always,  if  possible,  be  extracted  through 
tlie  mouth  ;  if  it  cannot  be  done  it  may  be  pushed  on  into  the  stomach,  removed 
through  a  side  opening,  or  left  to  itself,  according  to   its  nature   and  situation. 

Sometimes  it  is  ejected  dur- 
ing the  retching  and  vomit- 
ing that  accomjjany  ex- 
ploration of  the  fauces,  but 
emetics  should  never  be 
given  for  the  purpose.  The 
"SiiClih"'  I    I     ■        tjesophagus   has  before  now 

been  ruptured  by  violent 
vomiting.  Long-handled, 
curved  forceps,  such  as  are 
used  for  extracting  similar 
bodies  from  the  larynx,  are 
the  most  useful,  especially 
if  it  happens  to  be  some- 
thing small  and  rough.  Pins 
and  fish-bones  may  be 
caught  by  an  exjianding  or 
umbrella  probang  (Fig. 
362),  but  care  must  be  taken 
not  to  drive  them  further  in  ;  they  may  easily  be  forced  into  the  carotid  or  i)eri- 
cardium.  If  smooth  and  firm  and  low  down,  the  obstructing  body  can  sometimes 
be  pushed  onward,  especially  as,  after  a  i&w  hours,  it  becomes  coated  over  with 
mucus  j  and  in  the  case  of  meat  it  has  been  proposed  to  soften  the  surface  by 


Fig.  362. — Horseh.Tir    Probang,  expanded  and  unexpanded. 


Fir,.  363. — Coin-catcher 


DISEASES  OF  THE  (ESOPHAGUS.  847 

means  of  dilute  acids.  Irregular  structures,  such  as  false  teeth,  may  be  laid  hold 
of  by  what  is  known  as  a  coin-catcher  (Fig.  363),  a  blunt,  flat  hook  attached  to  a 
probang  by  a  thin  stri|)  of  steel,  so  that  it  can  glide  past  an  obstacle  and  then 
catch  against  it  as  it  is  withdrawn  ;  and  considerable  force  may  be  used.  If  this 
fails,  and  if  the  foreign  body  is  impacted  in  an  accessible  part  of  the  fjesojihagus, 
it  must  be  removed  by  operation. 

Unless  there  is  some  special  reason — such,  for  example,  as  the  projection  of 
the  foreign  body  distinctly  to  be  felt — o^sophagotomy  is  always  ])erformed  on  the 
left  side.  The  head  is  turned  in  the  opposite  direction  and  an  incision  three 
inches  long  is  made  at  the  inner  margin  of  the  sterno-mastoid.  The  superficial 
structures  are  divided,  the  deep  fascia  slit  up  on  a  director,  and  the  muscle  pulled 
well  toward  the  outer  side,  so  as  to  expose  the  sheath  of  the  great  vessels.  The 
dissection  is  then  carried  carefully  between  this  and  the  trachea,  avoiding  the 
thyroid  arteries  and  veins,  the  thyroid  gland,  and  the  inferior  laryngeal  nerve, 
until  the  (esophagus  and  the  lower  part  of  the  pharynx  are  exposed.  If  the  omo- 
hyoid muscle  gets  in  the  way  it  may  be  divided,  and  any  veins  that  cannot  be 
drawn  to  one  side  must  be  secured  either  by  ligature  or  by  pressure  forceps,  so  as 
not  to  obscure  the  deeper  parts.  Generally  a  sufficient  surface  can  be  brought  into 
view  by  pulling  the  trachea  one  way  and  the  great  vessels  and  the  sterno-mastoid 
the  other  ;  Imt  sometimes  part  of  the  sterno-hyoid  or  sterno-thyroid  requires  divi- 
sion. If  the  foreign  body  can  be  felt  from  the  outside,  a  longitudinal  incision 
may  be  made  over  it  and  the  finger  introduced  so  as  to  ascertain  its  position  more 
accurately.  If  this  cannot  be  done,  a  sound  is  passed  through  the  mouth  and 
made  to  project  into  the  wound.  Afterwards  the  opening  may  be  enlarged  to  a 
sufficient  extent,  and  the  foreign  body  withdrawn  with  appropriate  forceps.  If 
the  impaction  is  recent  and  the  wound  in  the  oesophagus  not  bruised,  the  edges 
may  be  sewn  together  with  catgut,  the  sutures  being  inserted  only  in  the  muscular 
wall,  leaving  the  mucous  membrane  untouched.  Under  other  circumstances  it  is 
better  to  leave  the  whole  open,  with  a  large  drainage-tube  in  the  superficial 
wound.  For  the  first  few  days  the  patient  should  be  fed  with  nutrient  enemata 
only  ;  afterward  an  oesophageal  tube  may  be  used  until  the  wound  is  sound.  The 
thirst  can  be  relieved,  as  Southam  suggests,  by  allowing  the  patient  to  drink  a 
boracic  acid  mixture  (gr.  x  ad  5J).  Most  of  it  flows  out  through  the  wound  (if 
it  is  not  sutured),  and  helps  to  keep  it  clean.  A  fistulous  opening  often  persists 
for  a  time,  but  in  most  cases  it  closes  without  requiring  anything  further. 

When  the  foreign  body  is  low  down  the  question  is  more  difficult.  Southam 
performed  oesophagotomy  successfully  in  a  case  in  which  a  plate  of  false  teeth  was 
impacted  three  inches  below  the  upper  border  of  the  sternum.  In  other  cases  the 
stomach  has  been  opened  and  the  foreign  body  dragged  onward  or  pushed  back,  as 
seemed  best  at  the  time. 

Gastrotomy  may  be  required  if  it  has  passed  the  oesophagus  and  is  lodged  in 
the  stomach.  Sometimes  the  foreign  body  can  be  felt  through  the  wall  of  the 
abdomen  ;  if  this  is  impossible  its  presence  can  usually  be  ascertained  with  a  suit- 
able probang.  In  most  cases,  however,  if  it  has  once  reached  the  stomach  it  is 
able  to  pass  on  through  the  pyloric  valve  without  further  trouble,  although  it  may 
lodge  again  just  above  the  external  sphincter.  Purgatives  should  never  be  given  ; 
vegetable  [such  a&  mashed  potatoes]  and  farinaceous  diet  is  the  best,  owing  to  its 
bulky  character. 

Diseases    of    the  CEsophagus. 

Inflammation  of  the  mucous  membrane  may  arise  from  injury  (as  already 
mentioned)  or  from  specific  causes,  such  as  tubercle,  syphilis,  thrush,  or  diph- 
theria; but,  with  the  exception  of  the  first  of  these,  the  symptoms  are  vague,  con- 
sisting merely  of  pain  in  swallowing,  and  rarely  attract  attention  unless  the 
ulceration  is  so  extensive  as  to  lead  to  the  formation  of  a  cicatricial  stricture. 

Paralysis  of  the  muscular  coat  of  the  pharynx  or  tesophagus  is  occasionally 
met  with  after  diphtheria,  and  may  in  rare  instances  be  due  to  alcoholic  or  lead 


84S    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

poisoning.  Dysphagia  is  always  present,  but  it  differs  from  that  which  occurs  in 
stricture,  in  that  solids  are  swallowed  more  easily  than  fluids.  Sometimes  the 
food  collects  and  is  ejected  after  a  time  by  coughing  or  vomiting. 

Hysterical  pafalysis  is  much  more  common,  the  patient  being  convinced 
either  that  there  is  a  foreign  body  in  the  oesophagus,  or  that  there  is  a  stricture 
(usually  after  having  seen  a  case),  and  being  unable  to  will  the  act  of  deglutition. 
It  is  chiefly  met  with  in  young  women  who  present  other  hysterical  symptoms, 
but  it  may  occur  in  men.  The  suddenness  and  incongruous  nature  of  the  symp- 
toms, the  history  and  a  few  days'  careful  watching,  are  sufficient  to  prevent  a 
mistake.  The  greatest  difficulty  is  in  connection  with  foreign  bodies;  a  fish-bone 
perhaps  has  been  actually  swallowed  and  scratched  the  mucous  surface  ;  and  the 
sensation  arising  from  this,  and  intensified  whenever  anything  passes,  down,  is  a 
sufficient  stimulus  to  keep  up  the  suggestion  of  dysphagia  in  the  patient's  brain. 
It  rarely  happens,  however,  that  there  is  any  collection  of  food  above  the  obstruc- 
tion ;  either  the  patient  keeps  it  in  the  mouth  without  attempting  to  swallow  it, 
or,  if  it  does  pass  over  the  larynx,  it  is  immediately  ejected  again,  often  with  an 
unnecessary  display  of  energy. 

Closely  akin  to  this,  and  occurring  under  the  same  conditions,  is  a  form  of 
muscular  spasm  which  affects  the  pharynx  rather  than  the  oesophagus.  It  varies 
from  merely  a  slight  stammering  of  deglutition,  such  as  might  arise  from  simple 
nervousness,  to  violent  ejection  of  the  contents  of  the  pharynx  through  the  mouth 
and  nose.  In  neither  of  these  conditions,  however,  whether  paralysis  or  spasm  is 
the  prominent  feature,  is  there  marked  emaciation  or  craving  for  food  ;  the  patient 
is  usually  fairly  well  nourished,  though  always  complaining  (differing  in  this 
respect  altogether  from  those  who  persistently  refiise  to  take  any  food),  and  not 
unfrequently  it  is  found,  on  making  inquiry,  that  it  has  already  lasted  many  years, 
off"  and  on,  long  enough  to  negative  absolutely  organic  contraction. 

Many  of  these  cases  are  cured  at  once  by  faradization  or  the  passage  of  a 
bougie,  but  unless  the  morbid  state  of  the  nervous  system  is  in  some  way  relieved, 
or  the  exciting  cause  of  the  hysteria  removed,  they  nearly  always  relapse. 

Tumors  of  the  CEsophaous. 

With  very  few  exceptions,  the  only  form  of  new  growth  that  occurs  in  the 
cesophagus  is  squamous  epithelioma.  It  is  chiefly  met  with  in  men,  very  rarely 
under  forty  years  of  age,  and  forms  an  annular  and  rapidly  contracting  stricture. 
The  surface  ulcerates  away,  but,  as  in  the  intestine,  the  infiltration  into  the  sub- 
mucous, and  later  into  the  muscular  coats,  increases  so  fast  and  contracts  so  rapidly 
that  the  calibre  very  quickly  becomes  narrowed.  Later  it  involves  the  fibrous 
tissues  and  the  other  structures  around  (the  trachea  for  example),  spreading  into 
them  by  direct  extension,  and,  if  it  does  not  prove  fatal  fom  starvation  or  pneu- 
monia, forms  secondary  deposits  in  the  glands  and  elsewhere. 

The  seat  of  election  is  behind  the  carotid  cartilage  or  where  the  left  bronchus 
forms  a  ridge  in  the  mucous  membrane — the  places,  in  other  words,  in  which  the 
calibre  is  smallest  and  the  walls  most  rigid.      No  part,  however,  is  exem])t. 

The  chief,  and  for  some  time  the  only  symjjtom  of  which  the  patient  com- 
plains, is  the  rapidly  increasing  difficulty  in  swallowing,  first  for  solids  and  then 
for  liquids.  Emaciation  speedily  follows,  but  fortunately  the  sense  of  hunger, 
especially  in  the  later  stages,  is  seldom  very  distressing.  Vomiting  may  occur, 
the  saliva,  with  a  certain  amount  of  mucus,  particles  of  food,  and  sometimes  a 
little  blood,  collecting  on  the  face  of  the  stricture.  Pain  is  rarely  severe,  although, 
particularly  when  the  tissues  around  the  cesophagus  are  infiltrated,  attempts  at 
swallowing  or  passing  a  bougie  cause  great  discomfort.  No  external  tumor  can  be 
felt,  with  rare  exceptions,  and  often  there  is  no  distinct  glandular  enlargement 
until  comparatively  late. 


STRICTURE  OF  THE  (ESOPHAGUS. 


849 


p:  •  1 


Stricture  of  the  (Esophagus. 

Organic  stricture  may  be  congenital  or  acquired.  The  former  is  exceedingly 
rare  ;   the  latter,  which  is  very  common,  may  be  simple  or  malignant. 

Simple  stricture  arises  nearly  always  from  the  swallowing  of  corrosive  fluids. 
The  mucous  membrane  sloughs  and  cicatricial  contraction  follows.  Sometimes 
almost  the  whole  length  is  obliterated  in  this  way,  but  the  effect  is  always  greatest 
at  the  commencement.  In  very  rare  instances  it  may  arise  from  some  form  of 
specific  inflammation,  such  as  tubercle  or  syphilis. 

Malignant  stricture  is  always  the  result  of  squamous  epithelioma,  and  is  usually 
annular,  tlie  muscular  coat  above  being  considerably  hypertrophied. 

Symptoms  and  Diagnosis. — Pain  and  difficulty  in  swallowing  are  the 
prominent  symptoms.  The  former  is  exceedingly  severe  at  the  beginning  in  cases 
of  traumatic  stricture  (in  great  measure  owing  to  the  inflammation  around  the 
cesophagus),  and  gradually  becomes  less  as  the  cicatricial  tissue  becomes  firmer. 
The  latter  is  usually  the  only  thing  of  which  a  patient  complains  when  it  is  due 
to  epithelioma.  It  may  come  on  comparatively  suddenly,  an  unobservant  person 
not  noticing  any  difficulty  until  the  narrow  channel  is  blocked  by  the  impaction  of 
a  larger  or  harder  fragment  than  usual,  or,  more  frequently,  it  is  gradual  from  the 
first,  solids  causing  difficulty  before  there  is  the  least  obstruction  to  the  passage  of 
liquids.  In  a  few  instances  deglutition  is  rendered  almost  impos- 
sible by  fits  of  spasmodic  coughing. 

The  diagnosis  can  only  be  made  certain  by  the  passage  of  a 
bougie  ;  but,  as  dysphagia  occurs  in  other  affections  in  which  a 
proceeding  of  this  kind  is  not  unattended  with  danger,  an  attempt 
must  always  be  made  to  exclude  them  first. 

(«)  Muscular  spasm  or  paralysis  may  simulate  true  stricture. 
There  may  even  be  a  history  of  some  foreign  body  having  been 
swallowed  ;  but  it  is  never  the  kind  that  causes  traumatic  stricture. 
Nor  is  there  really  any  likelihood  of  mistaking  spasmodic  contrac- 
tion for  malignant  disease,  for  while  the  latter  rarely  occurs  except 
in  men,  and  never  under  the  age  of  forty,  the  former  is  almost  con- 
fined to  young  women,  and  is  always  marked  by  the  peculiar  incon- 
gruity of  its  symptoms.  In  diphtheritic  paralysis,  which  is  very 
rare,  the  food  usually  passes  slowly  down  for  some  time  before  it 
stops,  and  solids  are  swallowed  more  easily  than  liquids. 

(J))  Compression  of  the  CEsophagus. — Dysphagia  arising  from 
this  is  exceedingly  common,  and  although  the  cause  is  usually  suffi- 
ciently prominent,  this  is  not  always  the  case.  Aneurysms  of  the 
aorta  ;  tumors  of  all  kinds  growing  from  the  vertebrae,  lymphatic 
glands,  cellular  tissue,  or  other  structures  near  the  oesophagus  ;  enlarged  or 
accessory  thyroids ;  gummata  (especially  retro-pharyngeal)  ;  abscesses,  connected 
with  the  vertebrae  or  not,  and  other  conditions,  may  give  rise  to  it.  Aneurysms 
have  been  ruptured  before  now  by  the  passage  of  a  bougie,  and  that,  too,  without 
an  excessive  amount  of  force  having  been  used. 

{/)  In  a  few  cases  dysphagia  has  been  traced  to  the  presence  of  a  pharyngo- 
cele  dragging  the  orifice  of  the  oesophagus  out  of  its  true  axis. 

The  diagnosis  of  simple  from  malignant  stricture  rarely  gives  rise  to  diffi- 
culty. Practically,  unless  there  is  a  very  clear  history  of  a  gumma  or  of  tubercular 
disease,  a  stricture  that  develops  after  the  age  of  forty  without  injury  is  malig- 
nant. 

If  the  presence  of  an  external  tumor  pressing  upon  the  oesophagus  is  negatived, 
a  bougie  must  be  passed,  not  only  to  verify  the  existence  of  a  stricture,  but  to  ascer- 
tain its  locality,  and,  perhaps,  its  diameter.  The  patient  should  be  seated  on  a 
straight-backed  chair  and  the  head  supported  by  an  assistant.  It  should  rather 
be  made  to  poke  forward  than  upward,  in  order  to  straighten  out  the  cervical 
spine ;  if  it  is  thrown  back  the  bougie  strikes  against  the  bodies  of  the  vertebras. 


Fig.  364.  —  Malig- 
nant Stricture  of 
ffi<;ophagus  laid 
open. 


850    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

A  medium-sized  gum-elastic  one  (equal  to  No.  24  or  27  catheter  on  the  French 
scale)  should  be  chosen  to  begin  with,  warmed  by  dipping  in  hot  water,  and  well 
lubricated  with  glycerine.  The  point  should  be  bent  down  a  little.  The  oper- 
ator then,  standing  in  front  of  the  patient,  runs  the  forefinger  of  the  left  hand  over 
the  tongue,  and  guides  the  bougie,  which  is  held  in  the  right,  over  the  base  to  the 
back  of  the  throat.  If  protected  like  this,  it  cannot  pass  up  into  the  naso-pharynx 
or  enter  the  larynx.  Nearly  always  it  causes  a  certain  amount  of  spasm  as  soon  as 
it  touches  the  mucous  membrane,  and  when  it  comes  near  the  cricoid  it  is  not 
unfrequently  gripped  tightly  and  then  forcibly  ejected  by  retching,  or  suddenly 
pulled  out  by  the  patient.  To  some  extent  this  can  be  prevented  by  a  cocaine 
spray,  or  by  brushing  the  surface  of  the  mucous  membrane  over  with  a  two  per 
cent,  solution,  but  nearly  always,  except  in  the  case  of  very  ignorant  men,  it 
can  be  overcome  by  patience,  No  force  may  be  used  under  any  circumstances  ;  I 
have  more  than  once  known  pneumonia  develop  suddenly  after  a  bougie  had  been 
passed. 

If  the  end  is  definitely  arrested  but  not  gripped,  it  must  be  withdrawn  and  a 
smaller  one  selected  ;  in  some  cases  only  a  catgut  will  pass.  Measured  on  a  bougie, 
the  cricoid  cartilage  is  approximately  seven  inches  from  the  teeth,  the  left  bronchus 
eleven,  and  the  opening  in  the  diaphragm  fifteen. 

Other  methods  of  examining  the  oesophagus  are  of  very  little  value.  Auscul- 
tation (the  stethoscope  being  placed  by  the  side  of  the  spine,  while  the  patient 
drinks  some  water)  may  be  tried,  but  it  rarely  gives  any  indication  that  can  be 
interpreted.  The  condition  of  the  lungs,  especially  the  amount  of  bronchial  irri- 
tation caused  by  the  passage  of  a  bougie,  and  the  state  of  the  cervical  glands, 
whether  enlarged  or  not,  are  very  important  factors  in  the  prognosis. 

The  treatment  of  stricture  of  the  oesophagus  depends  upon  the  cause, 
whether  it  is  traumatic  or  cancerous.  In  the  former  case  the  walls  are  usually  very 
much  thickened  (although  it  may  be  a  long  time  before  the  sloughing  in  the  interior 
ceases),  the  patient  is  often  young,  and  there  is  no  danger  but  that  of  starvation  ; 
in  the  latter,  if  the  patient  lives  sufficiently  long,  ulceration  always  gains  the  upper 
hand  and  causes  perforation,  and  even  if  starvation  and  pneumonia  are  success- 
fully prevented,  the  result  must  inevitably  prove  fatal  within  a  few  months  from  the 
malignant  cachexia. 

(i)  Traumatic  Stricture. — In  any  case  in  which  the  interior  of  the  oesophagus 
has  been  seriously  injured,  contraction  must  be  prevented  by  the  use  of  bougies. 
Treatment  should  commence  as  soon  as  the  sloughs  have  separated  and  cicatriza- 
tion is  beginning,  the  greatest  care,  of  course,  being  used.  Special  instruments 
with  rubber  tips,  one  or  two  inches  in  length,  so  as  to  ensure  thorough  flexibility, 
and  about  the  size  of  a  No.  24  or  27  catheter,  are  the  most  useful.  At  first  they 
must  be  pa.ssed  every  day,  then,  if  the  tendency  to  contract  is  not  very  marked,  at 
gradually  increasing  intervals  ;  but,  as  it  may  be  necessary  to  make  use  of  them  for 
the  rest  of  life,  the  patient  should  learn  as  soon  as  possible  how  to  pass  them  for 
himself.     The  food  must,  of  course,  be  suitably  prepared  throughout. 

In  old  cases,  in  which  the  stricture  has  been  allowed  to  contract,  the  difficulty 
is  very  much  greater.  Gradual  dilatation  is  the  most  successful  method,  using 
slightly  conical  instruments.  It  may  be  necessary  to  l)egin  with  catgut,  if  the  con- 
striction is  very  narrow,  leaving  it  in  situ  for  twenty-four  hours,  or  making  use  of 
it  as  a  guide  on  which  a  fine  rubber  tube  can  be  slid  down  ;  the  patient  can  always 
swallow  liquids  by  the  side  of  it.  Internal  oesophagotomy  (division  of  the  stric- 
ture from  within)  is  a  very  risky  operation,  and  as  the  stricture  must  be  a  perme- 
able one  to  allow  of  its  being  done,  can  very  seldom  be  advised.  In  exceptional 
instances  an  artificial  opening  has  been  made  in  the  neck  below  the  stricture 
(oesophagostomy),  and  the  stomach  has  been  opened  and  the  stricture  dilated 
through  the  cardiac  orifice.  Practically,  if  dilatation  fails  gastrostomy  must  be 
performed.  The  results,  compared  with  those  of  the  same  o]>eration  for  malignant 
disease,  show  a  far  higher  percentage  of  success,  but  it  is  not  probable  that  all  the 
unsuccessful  cases  have  been  published. 


STRICTURE  OF  THE  (ESOPHAGUS.  851 

(2)  MaUi:;nant  Stricture. — Excision  of  the  growth  has  been  ])racticed  with 
success,  an  artificial  opening  into  the  (esophagus  being  left  at  the  root  of  the  neck  ; 
but  cases  in  which  such  a  proceeding  is  i)ossible  are  very  seldom  met  with.  As  a 
rule,  all  that  can  be  done  is  to  make  an  artificial  opening  below  the  stricture, 
either  in  the  (esophagus  or  stomach,  or  to  maintain  the  patency  of  the  canal  by 
means  of  tubes  or  bougies. 

{a)  GLsophagostomy. — This  can  only  be  performed  when  it  is  certain  that 
the  growth  is  limited  to  the  very  commencement  of  the  oesophagus — a  condi- 
tion practically  impossible  to  prove.  The  incision  is  the  same  as  for  oesophago- 
tomy,  but  lower  down,  and  as  the  tube  is  collapsed  and  empty,  covere(d  with 
important  vessels  and  in  close  relation  with  the  pleura  and  thoracic  duct,  it  is  evi- 
dently more  dangerous. 

(Ji)  Gastrostomy. — The  results  of  gastrostomy  for  malignant  disease  of  the 
oesophagus  are  e.xceedingly  bad.  It  is  true  that  they  have  improved  to  a  certain 
extent  in  recent  years,  and  that  in  all  probability  if  the  operation  were  i)erformed 
earlier  in  the  course^  of  the  complaint,  before  the  patient  was  exhausted  by  starva- 
tion and  the  growth  of  the  malignant  disease,  they  would  improve  much  more. 
But  it  must  be  remembered  that  gastrostomy  is  only  a  palliative,  not  a  radical 
operation  ;  it  does  not  pretend  to  cure  the  patient,  but  only  to  relieve  him,  and 
that,  therefore,  if  the  same  results  can  be  obtained  in  other  ways,  it  is  not  justifi- 
able to  run  the  risk.  Symonds  has  divided  the  course  of  the  disease  into  two 
periods :  before  and  after  the  signs  of  bronchial  irritation  have  set  in.  Of  these 
the  symptoms  that  occur  in  the  former  can  be  relieved  as  well  by  tubage  (in  all 
ordinary  cases)  as  by  gastrostomy;  for  those  of  the  latter  neither  is  of  any  real 
avail.  If  ulceration  has  once  opened  up  a  communication  between  the  (jesophagus 
and  the  bronchi,  or  trachea,  food  can  be  prevented  from  passing  down  into  the 
lungs,  but  nothing  can  prevent  the  entry  of  mucus,  saliva,  blood,  and  particles  of 
the  growth  detached  by  ulceration,  ^d  these  will  inevitably  cause  a  speedily  fatal 
broncho-pneumonia.  In  a  few  exceptional  cases  gastrostomy  may  still  be  neces- 
sary, and  then  it  should  be  performed  as  early  as  possible,  while  the  patient  still 
retains  his  strength  ;  but  it  rests  with  those  who  advocate  it  to  show  -that  the 
immediate  dangers  attending  tubage  are  more  serious  than  those  of  gastrostomy, 
or  that  tubage  tends  to  make  the  progress  of  the  disease  more  rapid  by  irritating 
the  growth. 

{c)  Tubage. — Symonds'  tubes  are  from  four  to  six  inches  in  length,  and  are 
made  of  gum-elastic  upon  a  silk  web,  the  outside  and  inside  being  as  smooth  as 
possible.  The  upper  end  is  funnel-shaped  so  as  to  rest  upon  the  face  of  the  stric- 
ture and  slightly  flattened  on  one  side  that  it  may  not  press  unduly  against  the 
back  of  the  cricoid,  and  the  margin  is  perforated  in  two  places  for  the  attachment 
of  a  silk  thread.  The  other  end  is  hollow,  with  a  lateral  opening.  The  tube  can 
be  introduced  upon  a  bougie,  but  it  is  more  easily  managed  with  a  proper  whale- 
bone guide  set  in  a  suitable  handle.  The  exact  site  of  the  stricture  is  ascertained 
first  and  marked  upon  the  guide  ;  the  greatest  gentleness  must  be  used,  and  as 
soon  as  the  point  enters  the  narrowed  part  the  tube  is  slowly  pushed  onward  until 
the  resistance  to  the  funnel  is  felt ;  the  guide  is  then  withdrawn,  and  the  silk  thread 
attached  to  the  tube  tied  round  the  ear  or  fastened  with  strapping. 

A  tube  of  this  kind  can  be  left  for  two  or  three  months  without  being 
changed,  the  patient  swallowing  liquid  food  through  it.  As  a  rule,  however,  it  is 
necessary  to  remove  the  first  after  three  or  four  days,  as  the  stricture  always  dilates 
to  some  extent,  and  sometimes  this  must  be  repeated.  Even  if  it  sh  uld  slip 
through,  it  will  pass/^r  anum  or  remain  lodged  in  the  stomach  withoo  incon- 
venience. 

Compared  with  gastrostomy  this  method  possesses  very  great  advantages. 
There  is  little  risk  to  life  ;  the  presence  of  the  tube  does  not  appear  to  increase 
the  rapidity  of  the  ulceration,  although  in  one  or  two  instances,  it  is  said  to  have 
caused  circumcesophageal  suppuration  ;  the  discomfort  is  not  greater,  if  so  great, 
and  a  sufficient  amount  of  food  can  be  taken  quite  as  easily.     In  either  case  the 


852     DISEASES  AND  INJURIES   OF  SPECIAL  STRUCTURES. 

end  is  the  same  ;  as  soon  as  lironchial  irrital)ility  becomes  a  prominent  feature,  as 
soon  as  the  ulceration  extends  into  the  air  passages,  debris,  mucus,  and  foreign 
matter  of  all  kinds  will  make  their  way  into  the  lungs  and  set  up  broncho-pneu- 
monia (all  the  more  raj)idly  because  of  the  malignant  disease),  whether  a  short 
tube  is  worn  or  gastrostomy  has  been  performed. 

When  this  final  stage  is  reached  the  only  course  left  is  the  introduction  of  a 
long  tube  made  of  thin  rubber,  so  as  to  exclude,  as  far  as  possible,  all  fluid  from 
the  oesophagus.  Krishaber's  are  too  hard,  and  very  soon  cause  ulceration  at  the 
back  of  the  larynx  from  the  constant  friction.  Soft  red  rubber  ones  may,  however, 
be  used  for  a  considerable  time.  In  ordinary  cases,  in  which  the  malignant  growth 
is  situated  high  up,  life  may  be  prolonged  in  this  way  for  a  further  period  ;  but 
when  the  disease  is  opposite  the  left  bronchus,  the  thin  partition  very  soon  ulcer- 
ates through,  pneumonia  is  sure  to  follow,  and  even  gangrene  of  the  lung  may 
occur. 


INJURIES  OF  THE  CHEST.  853 


CHAPTER  XVII. 

INJURIES  AND  DISEASES  OF  THE  CHEST. 

INJURIES   OF  THE  CHEST. 

Fractures  and  dislocations  o'f  the  ribs  or  sternum,  contusions  of  the  wall  of 
the  thorax,  and  wounds  involving  the  nerves,  muscles,  or  vessels,  may  occur  with 
or  without  injury  to  the  subjacent  viscera.  In  some  cases  it  can  be  seen  at  once 
whether  they  have  escaped  or  not;  in  others,  it  is  a  matter  of  the  greatest  diffi- 
culty ;  but,  if  there  is  the  least  doubt,  the  case  should  be  treated  as  if  the  graver 
injury  were  proved,  and  no  attempt  must  ever  be  made,  by  probing  or  otherwise, 
to  determine  one  way  or  the  other.  The  finger  may  be  used  to  explore  for  foreign 
bodies,  or  to  ascertain  the  depth  and  extent  of  a  penetrated  wound,  not  to  find 
out  whether  it  penetrates  or  not. 

Injuries  of  the  Wall  of  the  Thorax. 

Contusions  are  very  common,  and  are  rarely  attended  by  serious  consequences. 
The  shock,  however,  may  be  severe  (it  is  said  to  have  proved  fatal  by  itself,  with- 
out visible  injury  of  any  kind),  and  the  extravasation,  when  it  takes  place  in  the 
deep  planes  of  loose  cellular  tissue  beneath  the  muscles,  is  sometimes  very  exten- 
sive, and  is  likely  to  be  followed  by  suppuration.  In  many  cases  the  muscles  are 
badly  bruised  ;  occasionally  they  are  torn  as  well,  especially  the  pectoralis  major, 
which  may  be  pulled  in  two  by  a  sudden  catch  at  something  as  the  body  is  falling. 
When  this  occurs  the  signs  are  very  definite  ;  a  great  gap  appears  at  once,  involving 
particularly  the  sternal  part  of  the  muscle  ;  there  is  very  extensive  hemorrhage, 
and,  when  this  subsides,  the  torn  ends  retract  as  far  as  they  can,  and  waste  away. 
Nothing  can  be  done  for  it  when  the  muscles  and  fascia  are  torn  completely 
through,  but,  if  the  injury  is  not  quite  so  severe,  a  fibrous  cicatrix  forms  and  ties 
the  ends  down  to  the  wall  of  the  thorax,  so  as  to  make  a  new  attachment. 

The  deeper  structures  do  not  always  escape  when  the  external  injury  is  ap- 
parently slight  ;  the  pleura  may  be  bruised  and  become  inflamed  ;  there  may  be 
a  contusion  of  the  lung  with  hemorrhage  into  the  substance,  causing  pneumonia 
and  even  traumatic  gangrene ;  or,  without  the  pulmonary  pleura  being  torn,  the 
air  vesicles  may  be  ruptured,  and  the  air  forced  into  the  cellular  tissue  of  the  lung 
until  it  appears  at  the  root  of  the  neck  {interstitial  emphysema)  ;  and  in  young 
patients  particularly,  when  the  ribs  are  still  elastic,  and  the  wall  of  the  chest  can 
yield  without  breaking,  the  lung  and  pleura  may  be  lacerated,  so  as  to  cause  pneu- 
mothorax or  hfemothorax,  without  there  being  external  injury  of  any  kind  ;  even 
the  pericardium  and  the  heart  may  be  crushed  and  torn. 

Fracture  of  the  Ribs. 

The  ribs  may  be  broken  by  direct  or  by  indirect  violence.  In  the  former 
case  the  position  of  the  fracture  depends  upon  the  force,  and  the  fragments  are 
driven  inward,  for  the  moment  at  any  rate.  In  the  latter,  if  the  chest  is  coni- 
pressed  from  before  backward,  they  generally  give  way  at  the  widest  part  of  their 
curve — in  the  axillary  line — and  the  ends  are  forced  outward,  so  that  there  is  less 
risk  of  the  lung  being  wounded  ;  but  this  is  very  far  from  invariable.  In  rare 
cases  the  fracture  results  from  muscular  action. 

The  first  rib  can  only  be  broken  by  direct  force,  and  then  it  is  scarcely  pos- 
sible unless  the  clavicle  gives  way  as  well.     The  last  two  escape,  from  their  small 


854    DISEASES  AND  INJURIES   OE  SPECIAL   STRUCTURES. 

size  and  free  mobility.  Those  that  suffer  the  most  frecjiiently  are  the  long  ones, 
attached  at  both  their  ends.  One  only  may  give  way,  or  several  may  be  broken 
on  both  sides,  or  they  may  be  broken  in  more  i)laces  than  one  ;  but  this,  owing 
to  their  elasticity,  is  unusual.  In  children,  fracture  is  not  common,  and  some- 
times, when  it  does  occur,  it  is  incomplete.  As  age  advances,  and  the  thorax 
becomes  more  rigid,  the  liability  becomes  more  marked.  In  old  people  they  break 
very  readily,  and  this  also  occurs  in  general  paralysis  of  the  insane  and  in  some 
other  forms  of  lunacy,  owing,  in  all  probability,  to  a  change  in  the  chemical  com- 
position of  the  tissue.  Erosion  by  an  aneurysm,  or  a  secondary  deposit  of  car- 
cinoma, may  occasion  so-called  spontaneous  fracture. 

Symptoms. — Except  in  the  case  of  the  first  rib,  or  in  very  stout  people, 
there  is  rarely  any  difficulty.  Sometimes  a  sudden  snap  is  heard  at  the  moment 
of  fracture  ;  the  i)ain  is  immediate  and  severe,  coming  on  with  sharp  stabs  at 
every  breath,  so  that  respiration  is  shallow  and  carried  on  mainly  by  the  abdomi- 
nal muscles.  Coughing  and  local  pressure  make  it  tenfold  worse.  Close  inspec- 
tion sometimes  shows  that  one  side  of  the  thorax  moves  less  than  the  other.  Dis- 
placement in  simple  fracture  without  comminution  is  rare,  but  occasionally  one 
side  is  depressed,  the  splintered  end  catching  against  the  irregularities  on  the 
other  half  and  holding  it  down.  Crepitus  is  usually  present.  Sometimes  when 
it  cannot  be  felt  it  can  be  heard  with  a  stethoscope.  Laying  the  hand  on  the  side 
of  the  thorax  while  the  patient  draws  a  deep  breath  is  sufficient  in  most  cases  ; 
if  this  does  not  succeed,  pressure  may  be  made  with  the  two  hands  alternately, 
one  on  either  side  of  the  supposed  fracture.  Sometimes  the  loss  of  sjjring  can  be 
detected  in  this  way.  Fracture  is  very  probable  when  pressure  upon  a  distant 
portion  of  a  rib  always  causes  pain  at  the  same  si)ot. 

Union  generally  takes  place  readily;  sometimes  the  amount  of  callus  thrown 
out  is  excessive,  so  that  several  ribs  become  joined  together  by  bridges  of  bone 
(Fig.  365)  ;  occasionally  it  is  fibrous  only,  or  a  bony  ring  is  thrown  out  round 
the  ends,  holding  them  together,  without  there  being  any  true  union  at  all. 

The  costal  cartilages  may  be  fractured  in  the  same  way  as  the  ribs;  or  they 
may  be  torn  away  from  the  bone  or  dislocated  from  the  sternum  or  from  each  other. 

Union  generally  takes  place  by  bony  callus 
/n^^A  thrown  out  round  the  ends  ;  if  they  overlap, 

the  angle  is  filled  up  by  it,  especially  on  the 
pleural  surface  ;  but  fibrous  tissue,  and  oc- 
casionally bone  and  new-formed  cartilage, 
have  been  found  between  them. 

Dislocation  of  the  ribs  from  the  verte- 
iv^^r::;^     br?e  sometimes  occurs  in  severe  injuries  of  the 
;     spine,  but  hardly  admits  of  diagnosis. 

Complications. — These  may  be  im- 
mediate, due  to  injury  to  some  adjacent 
structure,   or  remote,    the  conseciuences  of 

Fig.  365. — Fmcturc   of    Ribs  Welded  Together  by    •     ri  ^-  ^ni       .-  •        1     j  j 

Callus.  innammation.      1  he  former  include  wounds 

of  the  skin,  with  or  without  the  entrance  of 
foreign  bodies;  rupture  of  muscles  (the  intercostals  always,  sometimes  the  pecto- 
rals and  the  serratus  magnus  too)  ;  laceration  of  the  pleura  ;  wound  of  the  lung 
(with  emphysema,  haemoptysis,  pneumothorax,  or  haemothorax)  ;  wound  of  the 
heart  or  pericardium  ;  wound  of  the  diaphragm,  with  the  liver,  spleen,  or  intes- 
tine ;  or  rupture  of  the  internal  mammary  or  intercostal  arteries,  or  of  some  of 
the  great  ve.ssels  in  the  thorax.  The  latter,  so  long  as  the  fracture  is  simple,  are 
of  rare  occurrence,  though  I  have  known  suppuration  even  under  these  conditions  ; 
when  the  injury  is  more  severe,  j^leurisy,  pneumonia,  and  inflammation  of  other 
structures  are  not  uncommon. 

Fractures  of  the  ribs  may  be  serious,  especially  in  old  people,  from  shock,  or 
from  bronchitis  and  broncho-pneumonia  ;  as  a  rule,  unless  several  are  broken,  or 
some  grave  complication   is   present,  there  is  no  cause  for  anxiety.     When  the 


^: 


INJURIES  OF  THE  CHEST.  855 

fracture  is  on  one  side  only,  great  relief  is  given  by  restricting  the  movement  of 
the  thorax.  The  patient  must  empty  his  chest  as  far  as  possible,  and  then  strips 
of  plaster  must  be  placed  round  it  from  the  spine  to  the  sternum,  commencing 
below,  and  arranging  them  so  that  each  covers  at  least  half  the  jjrecetling  one. 
Over  this  may  be  placed  a  flannel  roller,  which  is  prevented  from  slipping  down 
by  means  of  a  brace  over  the  shoulders.  When,  however,  several  are  broken, 
especially  if  they  are  on  both  sides,  compression  is  not  unlikely  to  increa.se  the 
patient's  discomfort.  In  this  case  a  sheet  of  gutta-jjercha  may  be  carefully  moulded 
to  the  sides,  or  the  patient  may  simj^ly  be  placed  in  bed,  propped  uj)  with  a  bed- 
rest, so  that  the  breathing  shall  be  interfered  with  as  little  as  possible,  and  kept 
perfectly  quiet.  In  severe  cases  this  i>lan  should  always  be  adopted.  Nothing 
can  be  done  to  remedy  displacement.  The  air  in  the 
room  should  be  kept  warm  and  moist,  so  as  not  to  cause 
any  irritation  ;  the  diet  should  be  light  and  the  bowels 
kept  open  ;  stimulants  are  rarely  required.  If  there  is 
not  much  expectoration,  but  merely  constant  irritation 
and  tickling,  small  doses  of  compound  tincture  of  camphor 
or  of  chlorodyne  may  be  given  ;  but  when  the  respiration 
is  difficult  and  embarrassed  from  the  amount  of  expectora- 
tion, opium  is  better  withheld,  and  replaced  by  iodide  of 
potash,  carbonate  of  ammonia,  and  stimulating  expecto- 
rants. 

If  the  dvspnoea  is  verv  severe,  and  cyanosis  setting  „       ^^    _        .     -   c 

■  r--         '  ■  \  r  1         r       1  1  1         1  1  Fig.  366.— Strapping  in  Fracture 

in  ;  if  It  is  evident  from  the  frothy,  blood-stained  sputa  of  Ribs, 

and  the  presence  of  moist  rales,  etc.,  over  the  chest,  that 

the  pulmonary  congestion  is  becoming  severe,  and  if  the  pulse  is  hard  and  rapid, 
there  should  be  no  hesitation  in  having  recourse  to  venesection,  though  this  is 
more  often  required  when  the  lungs  themselves  are  injured.  [In  case  of  exten- 
sive emphysema,  incision  at  the  points  of  fracture  and  in  various  places  through 
the  distended  skin  may  be  tried.] 

Injuries  of  the  Sternum. 

The  sternum  may  be  broken  by  direct  violence,  as  in  gunshot  injuries  ;  by 
indirect,  as  in  extreme  flexion  of  the  spine,  when  the  chin  is  driven  down  on  to 
the  manubrium,  and  the  vertebrae  dislocated  ;  or  by  muscular  action  combined 
with  over-extension  of  the  back,  as  in  parturition,  when  the  two  ends  .seem  literally 
to  be  pulled  asunder.  In  the  first  case  the  fracture  may  be  transverse,  longitu- 
dinal, or  comminuted,  according  to  the  kind  and  direction  of  the  force ;  in  the 
two  latter  the  line  of  separation  is  usually  transverse,  and  lies  near  the  junction 
of  the  manubrium  with  the  gladiolus,  and  there  may  be  either  dislocation  or  frac- 
ture. If  there  is  a  well -developed  joint  between  the  two  portions,  with  a  soft 
central  space,  almost  arthrodial,  the  former  will  occur ;  if  the  two  are  firmly 
united,  the  separation  may  take  place  above  or  below.  The  displacement  is  nearly 
always  the  same,  the  lower  fragment  carried  in  front  of  the  upper. 

The  diagnosis  as  a  rule  is  easy,  owing  to  the  marked  character  of  the  de- 
formity. Reduction  can  sometimes  be  eff'ected  at  once  ;  more  often  it  is  a  matter 
of  very  great  difficulty  and  sometimes  quite  impossible ;  and  it  very  rarely  hap- 
pens, when  the  fragments  have  been  restored  to  their  normal  relation,  that  they 
can  be  prevented  from  slipping  back  again.  The  prognosis,  so  far  as  the  fracture 
is  concerned,  is  good  ;  but  the  shock  is  often  extreme,  and  laceration  of  the 
l)leura  or  pericardium,  rupture  of  the  internal  mammary  vessels,  compression  of 
the  heart,  and  other  grave  complications,  are  not  unfrequently  present. 

Non-penetrating  Wounds. 

Non-penetrating  uwunds  are  rarely  serious.  If  the  muscles  are  divided,  or  if 
a  large  artery,  such  as  the  subscapular,  is  torn  across,  there  may  be  free  hemor- 


S56    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

rhage  for  a  time,  but  it  is  easily  checked.  Sometimes,  however,  in  punctured 
wounds  a  large  ha^matoma  forms  in  the  loose  cellular  tissue  under  the  scapula 
and  proves  dangerous  from  inflammation,  and  the  same  thing  may  occur  with 
lacerated  and  gunshot  wounds,  which  often,  owing  to  the  resistance  of  the  ribs 
and  the  yielding  character  of  the  tissues  that  cover  them,  extend  much  further 
than  is  at  first  sight  apparent. 

The  greatest  care  must  be  taken  not  to  convert  them  by  needless  examination 
into  penetrating  ones.  In  most  cases  the  question  can  be  settled  without  touch- 
ing the  wound,  its  extent  and  the  character  of  the  weapon  making  it  certain  at 
once  ;  but  sometimes  the  diagnosis  is  difficult,  and  I  have  known  a  considerable 
degree  of  emphysema  caused  by  injuries  which  certainly  did  not  penetrate,  where, 
for  instance,  the  spike  of  some  iron  railings  ran  obliciuely  upward  beneath  a  boy's 
scapula.  Foreign  bodies  must  be  removed,  even  if  they  are  fixed  in  the  ribs,  and 
the  bleeding  stopped  as  soon  as  possible.  If  the  muscles  are  divided,  catgut 
sutures  may  be  passed  through  the  fascia  investing  them,  in  the  hope  of  drawing 
them  together,  and  the  greatest  attention  must  be  paid  to  position,  so  that  there 
may  be  no  strain  upon  them ;  but  usually  they  unite  either  to  the  skin  or  to  the 
tissue  beneath.  Drainage  is  very  important,  especially  where  the  deep  planes  of 
cellular  tissue  are  opened  up ;  and  the  chest  should  either  be  strapped  or  fixed  as 
far  as  possible,  or,  owing  to  the  want  of  rest  and  the  constant  movement  of  the 
ribs  in  respiration,  union  is  very  likely  to  be  delayed. 


Injuries  of  the  Thoracic  Viscera. 

Rupture  of  the  Pleura. 

Rupture  of  the  costal  pleura  by  itself  probably  occurs  in  every  case  of  frac- 
tured rib  or  severe  contusion  of  the  thorax,  but  owing  to  the  skin  being  unbroken 
the  injury  is  repaired  at  once,  with  only  a  transient  or  local  pleurisy  at  the  most ; 
and  though  such  complications  as  haimothorax  from  rupture  of  an  intercostal  or 
internal  mammary  artery  and  pneumocele  may  occur,  they  are  very  rare.  When 
there  is  an  external  wound  the  pleura  alone  may  be  injured,  without  the  lung,  if 
the  weapon  is  blunt  and  enters  the  thorax  slowly,  so  that  it  pushes  the  lung  in 
front  of  it,  or  if  the  wound  is  in  the  tenth  or  eleventh  interspace ;  for  though  the 
pleura  usually  extends  as  low  as  the  last  rib,  the  lung,  unless  it  is  emjihysematous, 
only  reaches  the  tenth.  In  this  case,  however,  the  diaphragm  and  the  subjacent 
viscera  are  very  likely  to  suffer. 

Other  complications  depend  upon  the  size  and  extent  of  the  wound.  If  it  is 
merely  a  puncture  or  a  small  incision  the  diagnosis  is  often  never  made  ;  but  if  it 
is  extensive  the  lung  may  protrude  without  injury  through  the  opening  {hernia)  ; 
it  may  collapse  and  fall  back,  leaving  the  pleura  full  of  air  {pneumothorax)  ;  the 
cavity,  as  already  mentioned,  may  be  partly  filled  with  blood,  and  the  air  may 
either  pass  in  and  out  freely  through  the  wound  {traumatopmva),  or  it  may  be 
forced  into  the  cellular  tissue  under  the  skin,  and  spread  over  a  considerable  area 
{emphysema).  This,  however,  is  .seldom  extensive  unless  the  lung  is  wounded. 
Finally,  at  a  later  period,  pleurisy  may  set  in,  and  even  run  on  to  empyema. 

Injuries  of  the  Lung. 

These  may  occur,  as  already  mentioned,  from  mere  contusion  or  compression 
of  the  thorax  ;  they  are  very  common  as  a  result  of  fractures  of  the  ribs  :  and  oc- 
casionally they  are  met  with  as  a  result  of  external  wounds,  penetrating  from  the 
outside.  The  wound  may  be  superficial  or  deep,  it  may  be  punctured,  incised, 
or  lacerated,  with  or  without  the  entrance  of  foreign  bodies,  and  it  may  be  so 
trivial  that  it  is  never  diagnosed,  or  it  may  cause  instant  death.  The  simpler 
forms  of  wound  heal  at  once  by  the  first  intention,  without  any  inflammation  and 
with  very  great  rapidity.     Severe  contusion,  owing  to  the  extravasation  into  the 


INJURIES  OF  THE  THORACIC  VISCERA.  85 7 

air  vesicles,  is  attended  with  a  greater  amount  of  consolidation  and  witii  rusty, 
blood-stained  sputa  for  several  days,  hut  the  dullness  rarely  extends  and  there  is 
little  or  no  fever.  If,  however,  the  extravasation  is  very  great,  or  there  is  an 
external  wound,  so  that  the  blood  decomposes,  intense  septic  pneumonia  and  even 
gangrene  may  follow;  but  there  is  always  such  an  amount  of  pleural  effusion,  and 
the  lung,  as  a  rule,  in  these  cases  is  so  collapsed  and  compressed  against  the  back 
of  the  thorax  that  the  physical  signs  are  very  obscure. 

Symptoms. — The  two  characteristic  signs  of  wound  of  the  lung  are  hemor- 
rhage and  the  escape  of  air. 

The  former  may  take  place  into  the  bronchi,  so  that  the  sputa  consists  either 
of  pure  blood  or  of  a  frothy,  bright  red  mixture,  which  in  a  day  or  two  becomes 
rusty  and  black  ;  or  it  may  collect  in  the  cavity  of  the  pleura  (hsemothorax)  and 
gradually  soak  into  the  surrounding  tissues,  so  that  the  skin  on  the  loins  becomes 
dark  and  ecchymosed  ;  or  it  may  escape  externally,  mixed  with  air,  or  almost 
pure.  So  with  the  air.  In  very  rare  instances,  where  the  vesicles  alone  are  torn 
without  the  pleura  being  injured,  it  may  escape  into  the  cellular  tissue  of  the  lung 
and  make  its  way  along  the  outside  of  the  bronchi  into  the  mediastinum,  and  so 
gain  the  root  of  the  neck  ;  or  it  may  collect  in  the  pleural  cavity,  entering  at  each 
expiration,  until  it  distends  the  thorax  to  its  utmost  and  compresses  the  lung 
against  the  back  ;  or,  what  is  far  more  common,  without  entering  the  pleura  at  all, 
it  finds  its  way  across  into  thecellular  tissue  and  gives  rise  to  surgical  emphysema  ; 
or,  finally,  if  there  is  a  large  open  wound,  it  is  sucked  in  and  out  of  the  chest  at 
each  respiration,  mixed  more  or  less  with  blood. 

Besides  these,  other  symptoms  are  usually  present.  The  shock  of  such  an 
injury  is  severe  and  sometimes  fatal,  even  when  the  amount  of  bleeding  is  not 
great;  anxiety  and  distress  are  always  marked  ;  sometimes  the  dyspnoea  is  slight, 
but  usually  it  is  severe,  and  if  the  lung  becomes  rapidly  collapsed  it  may  be 
extreme  ;  there  is  a  constant  sense  of  irritation  and  tickling  in  the  throat,  with  an 
intense  desire  to  cough,  but  the  deep,  fixed  pain  in  the  chest  prevents  it,  and  if 
the  hemorrhage  is  severe  the  patient  may  sink  rapidly  into  a  state  of  collapse. 

Wounds  of  the  Heart. 

In  comparison  with  the  lungs,  the  heart,  as  might  be  expected,  is  very  rarely 
injured.  The  pericardium,  however,  may  be  torn,  the  valves  ruptured,  and  even 
the  substance  of  the  heart  rent  across  in  violent  compre.ssion  of  the  thorax  ;  the 
sternum  or  the  costal  cartilages  may  be  broken  and  driven  down  into  it,  or  it  may 
be  wounded  from  the  outside  by  stabs  or  gunshot  injuries.  In  a  very  few  cases 
the  pericardium  only  has  been  injured,  or  the  surface  of  the  heart.  Much  more 
frequently  one  of  the  cavities  (the  right  ventricle  especially)  is  laid  open.  Besides 
this,  the  pericardium  and  even  the  heart  may  be  wounded  by  foreign  bodies,  fish- 
bones, etc.,  driven  through  the  wall  of  the  oesophagus. 

Death  may  take  place  immediately  from  shock  or  from  blood  collecting  in 
the  pericardial  space  and  stopping  the  action  of  the  heart.  If  the  patient  escapes 
these,  secondary  consequences — continued  hemorrhage,  and,  later,  inflammation 
— are  almost  sure  to  prove  fatal.  Recovery  is  stated  to  have  taken  place  in  about 
fifteen  per  cent.,  but,  probably  from  the  interest  attaching  to  such  cases,  this  esti- 
mate is  too  high,  even,  for  civil  practice.  Foreign  bodies,  however — even  bullets 
— have  been  found  post  mortem  embedded  in  the  substance  of  the  heart,  or  pro- 
jecting into  one  of  its  cavities  ;  and  fibrous  cicatrices,  with  a  thickened  and 
adherent  pericardium,  have  been  demonstrated  in  many  cases.  Wounds  of  the 
auricle  appear  to  be  more  fatal  that  those  of  the  ventricle. 

Signs. — In  the  absence  of  an  external  wound,  the  only  signs  are  extreme 
shock  with  very  great  distress,  and  rapid,  sometimes  almost  instantaneous  failure 
of  the  circulation.  Dyspnoea  is  very  common,  possibly  pointing  to  pericardial 
hemorrhage  and  compression  of  the  heart.  Sometimes  it  is  immediate,  at  others 
it  does  not  come  on  for  some  minutes.  Pain  is  very  variable ;  it  may  be  acute, 
55 


858    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

or  it  may  he  masked  completely  by  the  shock  and  distress.  The  heart  sounds  are 
usually  inaudible,  but  in  a  few  cases  splashing  and  other  abnormal  ones  have  been 
heard.  When  there  is  an  external  wound  the  blood  may  pour  out  in  a  stream  that 
is  almost  immediately  fatal,  or,  especially  in  stabs  where  the  opening  is  small  or 
valvular,  and  when  the  wound  in  the  heart  is  in  the  direction  of  the  fibres,  there 
may  be  very  little. 

The  only  treatment  that' is  likely  to  be  of  any  avail  is  absolute  rest,  cold,  and 
opium  ;  venesection  has  been  recommended  to  relieve  the  heart,  but  it  can  very 
rarely  be  necessary.  The  external  wound  may  be  closed  in  the  hope  of  arresting 
hemorrhage  ;  but  it  must  not  be  forgotten  that  accumulation  of  blood  in  the  peri- 
cardium is  one  of  the  common  causes  of  death.  On  one  occasion  I  attempted 
to  close  the  wound  with  sutures. 

The  great  vessels  may  be  injured  in  the  same  way  ;  and,  as  a  rule,  accidents 
of  this  kind  are  even  more  rapidly  fatal.  Punctures  of  the  aorta  inside  the  peri- 
cardium, through  the  second  intercostal  space,  and  wounds  of  the  coronary  artery, 
end  by  allowing  the  blood  to  accumulate  around  the  heart  and  compress  it.  In- 
juries to  the  other  viscera  in  the  thorax  are  more  rare.  A  very  few  cases  are 
recorded  in  which  the  oesophagus  has  been  wounded  from  the  outside.  It  is  not 
uncommon  to  find  foreign  bodies  driven  through  its  wall  from  the  inside,  into  the 
pleura,  pericardium,  and  aorta.  The  thoracic  duct  has  been  divided,  leading  to 
a  profuse  flow  of  milk-like  fluid  during  digestion  ;  and  it  has  also  been  ruptured 
without  external  wound,  so  that  the  pleural  cavity  became  distended  with  chyle. 

Rupture  of  the  diajjhragm  is  sometimes  met  with,  on  the  left  side,  from 
extreme  compression  ;  and,  of  course,  it  may  be  injured  anywhere  by  stabs,  gun- 
shot wounds,  or  fragments  of  ribs  driven  in.  In  most  cases  the  neighboring 
viscera  are  fatally  injured,  but  sometimes  they  escape,  and  the  stomach  or  intes- 
tines may  be  squeezed  up  through  the  opening  into  the  thorax,  leading  to  great 
distress,  with  vomiting  and  dyspnoia.  When  the  rent  is  small,  they  may  be  stran- 
gulated at  once.  If  this  does  not  happen,  traumatic  diaphragmatic  hernia  persists 
for  the  rest  of  life,  as  the  wound,  if  it  is  of  any  size,  is  never  repaired.  It  may 
be  distinguished  from  the  congenital  form  by  its  situation  and  by  the  absence  of  a 
peritoneal  covering. 

Primary  Co)nplications — Hemorrhage. 

This  may  come  from  arteries  in  the  wall  of  the  thorax  (the  intercostals  or  the 
internal  mammary),  from  the  lung,  or  from  the  heart  and  great  vessels,  and  the 
blood  may  escape  either  internally  (into  the  pleura,  pericardium,  or  mediastinum) 
or  externally.  To  diagnose  one  from  the  other,  it  has  been  recommended  that  a 
folded  card  should  be  introduced  deep  into  the  upper  angle  of  the  wound  with 
its  concavity  outward  ;  blood  from  a  wounded  intercostal  will  escape  along  the 
channel  of  the  card,  that  from  the  thorax  will  pour  out  behind  it. 

{a)  External  Hemorrhage. — The  intercostal  arteries  for  the  most  part  of  their 
course  are  so  protected  under  the  margins  of  the  ribs  that  they  are  rarely  injured  ; 
at  the  back,  however,  they  cross  the  interspaces  obliquely.  When  they  are  divided 
in  gunshot  injuries  or  in  resecting  portions  of  ribs,  the  amount  of  hemorrhage  is 
seldom  large,  but  a  few  cases  are  on  record  in  which  it  appears  to  have  been  very 
serious.  If  the  wound  leads  down  to  a  rib,  the  bleeding  point  should  be  well 
exposed,  and  an  incision  made  on  to  the  lower  margin  of  the  bone  to  ensure  the 
artery  being  completely  divided  ;  then  the  soft  structures  ma)-  be  j^ushed  to  either 
side  with  the  finger-nail,  so  that  the  vessel  may  have  a  chance  of  retracting,  and 
firm  pressure  may  be  kept  up  with  the  finger  for  a  few  minutes.  If  this  does  not 
succeed,  the  periosteum  may  be  dissected  back,  carrying  the  artery  with  it,  or  for- 
cipressure  may  be  used,  or  as  a  last  resource  the  wound  may  be  plugged  either 
with  a  dilatable  india-rubber  ball  or  by  laying  over  it  a  piece  of  antiseptic  gauze, 
filling  the  centre  of  this  with  pledgets  of  cotton,  and  forcing  it  into  the  wound,  so 
that  when  it  is  slightly  drawn  out  it  expands  in  all  directions,  and  compresses  the 
vessel  against  the  rib.      Passing  a  ligature  around  the  rib,  close  to  its  inner  surface, 


INJURIES  OF  THE  THORACIC  VISCERA.  859 

and  resecting  a  portion  of  the  bone,  have  l)een  recommended  when  the  hemor- 
rhage could  not  be  checked  in  any  other  way. 

Wound  of  the  internal  mammary,  owing  to  the  size  of  the  vessel  and  the  free- 
dom of  its  anastomoses,  is  much  more  serious,  and  in  many  cases  has  proved  fatal 
either  at  once  or  later  from  secondary  hemorrhage,  even  when  no  complications 
were  present.  The  blood  may  escape  externally,  or  into  the  mediastinum  or 
pleura ;  and  the  only  effectual  method  for  arresting  the  flow  is  to  cut  down  upon 
it  and  tie  both  ends,  removing,  if  necessary,  a  portion  of  the  costal  cartilages  or 
of  the  margin  of  the  sternum.  In  the  first  three  spaces  this  is  fairly  easy,  but 
lower  down  it  becomes  more  difficult,  until  in  the  fifth  and  sixth  it  is  almost 
impossible. 

When  external  bleeding  comes  from  a  wound  in  the  lung,  the  diagnosis  is 
generally  only  too  easy ;  usually  it  means  that  a  large,  and  therefore  deep,  vessel  is 
torn  across ;  air  rushes  in  and  out  at  the  same  time,  and  cough,  dyspnoea,  haemop- 
tysis, haemothorax,  and  great  distress  are  present  as  well.  The  external  wound 
mu.st  be  carefully  but  quickly  cleansed  ;  any  accessible  foreign  body  removed  ;  and 
then  the  opening  must  be  closed,  the  patient  laid  upon  his  injured  side,  and  the 
most  absolute  rest  enforced,  in  the  hope  that,  as  the  blood  collects  and  the  heart 
beats  more  feebly,  a  coagulum  may  form  and  block  the  vessel.  Tight  constric- 
tion of  the  thorax  is  not  well  borne,  but  the  injured  side  should  be  immobilized 
as  far  as  possible.  Stimulants  should  never  be  given  ;  inhalation  of  turpentine, 
or  subcutaneous  injections  of  morphia  and  ergotine,  may  be  tried  ;  and  apparent 
benefit  has  been  derived  from  giving  ten  minims  of  tincture  of  ergot  every  hour, 
but  the  power  of  these  remedies  is  not  very  great.  Venesection  was  extensively 
practiced  in  the  Crimea  for  the  purpose  of  procuring  collapse,  but  since  then  has 
been  almost  abandoned.  If  the  patient  survives,  the  amount  of  food  and  drink 
for  the  next  few  days  should  be  reduced  to  the  barest  possible.  If  the  pleura  is 
filled  with  blood,  so  that  the  lung  is  collapsed  against  the  posterior  wall  of  the 
chest,  and  if  the  dyspnoea  is  very  extreme,  the  wound  may  be  opened,  and  the 
blood  (or  if  it  has  coagulated,  the  serum)  allowed  to  escape  ;  but  this  can  very 
rarely  be  required,  and  it  must  be  remembered  that  it  may  always  lead  to  fresh 
hemorrhage. 

{b)  Internal  Hemorrhage.  Hcenwthorax. — Pleural  extravasation  nearly  always 
comes  from  the  lung  ;  exceptionally  it  may  proceed  from  the  arteries  in  the  wall, 
or  from  the  heart  or  great  vessels.  The  blood  i)ours  down  at  once  to  the  lowest 
part  of  the  cavity  (depending,  therefore,  upon  the  position  of  the  patient,  whether 
he  is  sitting  up  or  lying  down)  and  soon  coagulates.  If  the  quantity  is  small  and 
no  air  is  admitted,  it  is  absorbed  again,  and  except  for  slight  dullness  and  diminu- 
tion of  the  breath  sounds  at  the  base,  there  is  no  way  of  diagnosing  it.  If,  on 
the  other  hand,  the  amount  is  large,  and  if  air  gains  access  to  it  (pneumo-hsmo- 
thorax),  inflammation,  with  a  great  increase  in  the  pleural  effusion,  and  suppura- 
tion, are  almost  sure  to  follow.  When  the  air  is  filtered  through  the  lung,  instead 
of  entering  directly  through  an  opening  in  the  thorax,  this  danger  is  not  so  great. 

When  the  extravasation  is  large,  there  are  always  symptoms  of  severe  hemor- 
rhage, in  addition  to  the  physical  signs.  The  face  and  lips  are  white,  the  skin 
cold  and  moist,  the  patient  sits  propped  up,  rocking  himself  backward  and  for- 
ward, or  throwing  his  arms  from  side  to  side,  gasping  for  breath,  and  on  the  verge 
of  syncope.  The  pulse  is  small  and  thready,  too  quick  to  be  counted  ;  there  is 
intense  thirst,  the  pupils  are  dilated,  and  often  there  are  attempts  at  vomiting.  In 
such  cases  death  may  ensue  at  once,  partly  from  the  loss  of  blood,  partly  from  the 
difficulty  of  respiration,  or  after  a  time  the  severity  of  the  symptoms  may  diminish 
and  the  pulse  gradually  recover.  Generally,  when  this  is  the  case,  ecchymosis 
makes  its  appearance  in  the  loins  after  a  few  days,  due  to  the  blood-color  soaking 
through ;  sometimes  the  whole  is  absorbed,  but  more  frequently  the  temperature 
begins  to  rise  ;  perhaps  there  is  rigor,  the  area  of  dullness  increases,  the  dyspnoea 
becomes  more  marked,  and  it  is  clear  that  inflammation  is  setting  in. 

The  early  treatment  of  haemothorax  is  not  materially  different  from  that  of 


S6o     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

wound  of  the  lung  with  external  hemorrhage.  The  first  indication  is  to  stop  the 
bleeding.  If  it  can  be  proved  that  this  arises  from  one  of  the  intercostal  arteries 
or  from  the  internal  mammary,  exploration  would  be  justifiable,  but  hjemothorax 
under  such  conditions  must  be  very  rare.  There  is  nothing  at  first  but  rest,  cold, 
opium,  ergot,  and  restricted  diet;  gallic  and  sulphuric  acids  and  acetate  of  lead 
also  enjoy  a  certain  amount  of  reputation.  Where  the  dyspncca  is  extreme,  and  it 
is  evident  that  it  is  due  to  collapse  of  the  lung,  relief  may  be  given  by  inserting  a 
fine  cannula  and  allowing  some  of  the  serum  to  escape  slowly,  so  as  not  to  relieve 
the  pressure  on  the  wounded  vessel  too  suddenly  ;  but  though  this  is  not  unfre- 
quently  necessary  in  pneumo-hajmothorax,  it  is  very  rarely  required  where  there  is 
only  blood.  Later,  after  three  or  four  days,  if  the  effusion  shows  any  signs  of 
increasing,  or  if  there  is  any  rise  of  temperature,  this  method  of  treatment  is  of 
very  great  service.  It  is  very  improbable,  after  such  a  lapse  of  time,  that  the 
increasing  dullness  is  due  to  hemorrhage  ;  much  more  likely  it  is  the  result  of  pleural 
effusion,  consequent  upon  the  tension  ;  and  allowing  some  of  the  fluid  to  escape 
under  its  own  pressure  not  only  diminishes  the  amount  {\i  it  is  going  to  suppu- 
rate) but  assists  the  absorption  of  the  rest  by  allowing  the  lymphatics  to  act  again. 
This  may  be  repeated  on  several  occasions,  as  the  blood  coagula  slowly  breaks 
down,  but  no  force  may  be  used  to  draw  the  fluid  out. 

Accumulation  of  blood  in  the  pericardium  or  in  the  mediastinum  is  very  much 
more  rare  ;  the  former  is  nearly  always  associated  with  wound  of  the  heart  or  the 
first  portion  of  the  aorta,  the  latter  with  injury  to  the  internal  mammary  artery  or 
the  great  vessels  at  the  root  of  the  neck. 

Hczmoptysis. — If  a  large  vessel  is  injured  this  may  be  jjrofuse,  the  blood  pour- 
ing out  from' the  mouth  and  nose  in  gushes,  until  the  patient  sinks  into  a  state  of 
syncope.  When  profuse,  it  always  points  to  injury  of  the  lung,  but  the  blood 
must  be  intimately  mixed  with  the  air,  and  bright  red  in  color,  for  it  to  be  con- 
clusive. If  it  is  not,  it  may  have  come  from  the  larynx,  or  even  have  trickled 
down  from  the  nose  or  some  other  part,  and  been  coughed  up  again.  After  a  day 
or  two  it  becomes  rusty  and  dark,  more  like  the  sputum  of  croupous  pneumonia. 

Pneumothorax. 

Air  may  enter  the  pleural  cavity  either  from  without  through  an  external 
wound,  or  from  within  through  a  rupture  of  a  lung  or  the  bursting  of  a  cavity  in 
its  substance.  In  the  former  it  enters  during  inspiration,  in  the  latter  during 
expiration,  the  air  being  driven  out  of  the  lung  into  the  pleural  cavity  so  long  as 
the  tension  in  it  is  less  than  that  of  the  trachea,  but  neither  can  occur  unless  the 
wound  is  of  some  size  or  very  irregular.  The  adhesive  force  between  the  two 
layers  of  the  pleura  is  such  that,  in  spite  of  the  elasticity  of  the  lung,  it  requires 
some  pressure  to  separate  them.  In  incised  wounds  of  the  chest  the  pulmonary 
pleura  has  been  seen  in  contact  with  the  costal,  gliding  on  it  as  the  lung  expanded 
or  shrank,  but  not  separating  from  it ;  and  in  punctures  from  ril)s,  where  emphy- 
sema of  the  subcutaneous  cellular  tissue  is  exceedingly  common,  pneumothorax  is 
exceedingly  rare. 

If  there  is  an  external  wound  the  diagnosis  of  pneumothorax  is  evident  at 
once ;  when  due  to  penetration  or  rupture  of  the  lung,  the  physical  signs  are  the 
same  as  when  it  is  produced  by  the  rupture  of  a  tubercular  cavity.  The  chest  on 
the  injured  side  becomes  over-distended,  the  intercostal  s])aces  are  bulged  out,  and 
the  viscera  displaced,  the  ribs  remain  motionless  in  respiration,  there  is  tympan- 
itic resonance  over  the  whole  of  the  front,  but  often,  owing  to  the  effusion  of  fluid, 
slight  dullness  at  the  base  behind  ;  and  breath-sounds  are  entirely  wanting  unless 
they  are  transmitted  along  the  wall  of  the  other  lung.  On  shaking  the  patient, 
metallic  tinkling  and  splashing  may  be  heard,  if  there  is  any  fluid  present  as  well 
as  air,  and  when  a  coin  is  placed  upon  the  skin  and  struck  with  another,  a  clear, 
bell-like  sound  is  transmitted  to  the  ear  placed  on  the  opposite  side. 

The  treatment  depends  upon  the  amount  of  distress.     Dyspnoea  is  always 


INJURIES  OF  THE  THORACIC  VISCERA.  86 1 

severe,  but  if  it  is  not  extreme,  the  patient  should  merely  be  kept  perfectly  quiet 
in  bed,  propped  up  in  the  easiest  position,  until  the  air  is  absorbed.  The  rent  in 
the  lung  becomes  very  small  when  it  is  colla})sed  ;  repair  takes  place  readily,  the 
air  soon  disappears,  and  the  lung  quietly  expands  again.  If,  however,  the  dififi- 
culty  of  breathing  becomes  very  great,  especially  if  signs  of  congestion  of  the 
opposite  lung — frothy  blood-stained  sputa  and  moist  rales — make  their  apj^ear- 
ance,  a  fine  cannula  should  be  introduced,  and  some  of  the  air  allowed  to  escape 
under  its  own  tension  ;  and  this  may  be  repeated  as  often  as  required.  Venesec- 
tion is  seldom  necessary.  Later,  as  already  mentioned  in  hajmothorax,  if  there 
is  fluid  mixed  with  air  at  the  bottom  of  the  cavity,  as  much  of  it  as  possible  should 
be  allowed  to  flow  away  in  the  same  manner. 

Ej7iphysetna. 

In  wounds  of  the  thorax  air  may  find  its  way  into  the  subcutaneous  cellular 
tissue,  and  be  driven  further  and  further  by  the  movement  of  the  muscles,  until  it 
spreads  all  over  the  body,  and  renders  the  features  perfectly  unrecognizable,  the 
scalp,  the  palms  of  the  hands,  and  the  soles  of  the  feet  alone  being  exempt.  The 
looser  the  skin  the  more  distended  it  becomes,  but  it  remains  soft  and  white,  and 
when  it  is  touched  there  is  a  fine  crackling  sensation  as  the  bubbles  of  air  are 
driven  through  the  meshes  of  the  areolar  tissue.  The  same  thing  apparently  is  met 
with  in  decomposition  from  incipient  putrefaction,  but  the  other  conditions  are 
very  different. 

Surgical  emphysema  may  be  caused  in  various  ways,  but  there  is  only  one, 
when  it  is  due  to  the  ribs  being  broken  and  driven  into  the  substance  of  the  lung, 
in  which  it  attains  any  importance. 

1.  It  may  occur  in  the  case  of  a  simple  valvular  wound  of  the  skin. 

2.  From  wound  of  the  pleura  only,  when  air  is  sucked  in  during  inspiration, 
and,  owing  to  the  obliquity  of  the  opening,  is  unable  to  escape  freely  in  expira- 
tion. 

3.  From  rupture  of  the  air  vesicles,  without  the  pleura  being  torn.  This, 
which  is  distinguished  as  interstitial  emphysema,  is  more  likely  to  occur  from 
injury  to  the  apex  of  the  lung,  whether  from  external  contusion  or  from  violent 
compression  of  the  thorax.  The  air  gradually  finds  its  w^ay  into  the  mediastinum, 
and  from  there  to  the  root  of  the  neck. 

4.  From  fracture  of  the  ribs.  Owing  to  the  cohesion  of  the  pleural  surfaces, 
the  air,  without  ever  really  entering  the  pleural  cavity,  is  forced  across  it  by  each 
act  of  expiration  into  the  cellular  tissue,  and  is  driven  further  and  further  until  it 
may  extend  over  the  whole  body.  Pneumothorax  very  rarely  occurs  \  the  wound 
in  the  pulmonary  pleura,  as  it  glides  backward  and  forward,  corresponds  twice  in 
every  breath  to  that  in  the  costal,  and  the  air  passes  directly  from  one  to  the 
other. 

Emphysema  can  be  recognized  at  once  by  the  peculiar  crackling  sensation 
when  the  skin  is  pressed.  Generally  it  is  limited  to  the  region  of  the  wound  ; 
those  instances  in  which  it  is  extensive  are  of  comparatively  rare  occurrence.  As 
a  rule,  it  requires  no  treatment ;  the  air  soon  becomes  absorbed  ;  when  it  is  caus- 
ing great  inconvenience  small  punctures  may  be  made  in  the  skin,  or  pressure  may 
be  used  to  try  and  restrain  it ;  but  this  is  not  very  successful,  and,  fortunately,  is 
seldom  required.  It  is  said  to  have  proved  fatal  from  interference  with  the 
respiration.^ 

Hernia  of  the  Lung. 

Pneumocele,  hernia,  or  prolapse  of  the  lung  is  an  occasional  but  rare  compli- 
cation of  injuries  of  the  thorax.     It  may  be  either  immediate  or  secondary.     In 

[*  A  case  of  fracture  of  two  rilis  with  emphysema  from  lung  rupture  was  admitted  into  the 
United  States  Marine  Hospital,  Chicago,  189I.  Death  resulted  on  the  third  day.  The  skin  over 
the  neck  was  distended  until  it  was  completely  separated  from  the  underlying  fascia.] 


S62    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  former  case  there  is  generally  a  wound  of  some  extent  in  the  parietes,  and  the 
lung  is  forced  out  through  it  hy  a  violent  effort  at  expiration  when  the  glottis  is 
closed.  It  may  be  injured  itself  or  it  may  not,  but  as  soon  as  it  is  S(iueezed  out 
through  the  rent  it  expands  so  that  it  cannot  return,  and  rapidly  becomes  con- 
gested. In  extreme  cases  it  may  be  strangulated.  If  seen  shortly  after  the 
accident  an  attempt  may  be  made  to  return  the  protrusion,  and,  if  necessary,  the 
wound  may  be  slightly  enlarged  for  the  pur])0se  ;  but  if  some  time  has  elap.sed, 
and  the  tissue  is  very  much  congested,  it  is  better  left  where  it  is  to  slough  off 
and  granulate  over  ;  or  its  separation  may  be  a.ssisted  by  ligature  or  actual  cautery. 
.V  very  few  instances  are  recorded  in  which,  owing  to  extensive  injury  of  the 
thorax,  an  immediate  prolapse  of  the  lung  has  occurred  without  an  external  wound. 
The  consecutive  variety  may  not  make  its  appearance  until  some  considerable 
time  after  the  receipt  of  the  injury,  and  if  there  has  been  a  wound  it  must  have 
healed  first.  It  forms  a  soft  circumscribed  tumor  ])rojecting  through  the  wall  of 
the  thorax  under  the  skin,  swelling  out  on  expiration  and  shrinking  on  inspiration. 
On  coughing  there  is  a  distinct  impulse ;  if  it  is  pressed  upon  it  collapses  readily 
with  a  feeling  of  soft  crepitation,  and  the  margins  of  the  opening  can  be  plainly 
felt.  It  is  resonant  on  percussion,  and  the  respiratory  murmur  is  loud  and  coarse 
in  comparison.  In  some  cases  it  is  the  result  of  extensive  rupture  of  the  inter- 
costal muscles  ;  in  others,  where  its  formation  is  very  gradual,  it  is  pro1)ably  due 
to  chronic  inflammation  weakening  the  wall  of  the  thorax  at  one  spot,  and  allowing 
the  lung  slowly  to  force  its  way  through.  The  ^only  treatment  required  is  a  belt 
or  truss,  according  to  the  size  and  situation  of  the  protrusion,  to  restrain  it  and 
protect  it  from  injury. 

Foreign  Bodies. 

Bullets  and  other  weapons  impacted  in  the  wall  of  the  thorax  present  no 
special  peculiarity  ;  they  should  be  removed  as  soon  as  convenient,  but  it  must  be 
remembered  that  doing  so  may  give  the  first  proof  that  the  injury  involves  the 
cavity  of  the  chest  as  well  as  its  wall.  If  the  foreign  substance  is  lodged  in  the 
pleura,  it  may  either  (as  in  the  case  of  fragments  of  clothing,  wadding,  splinters, 
etc.)  remain  in  the  neighborhood  of  the  external  wound,  or  if  it  is  heavy,  like  a 
bullet,  sink  down  to  the  bottom,  and  rest  upon  the  surface  of  the  diaphragm,  near 
the  spine.  Occasionally  under  these  circumstances  it  becomes  encysted  ;  much 
more  frequently  acute  inflammation,  running  on  to  suppuration,  sets  in,  and  the 
foreign  substance  is  discharged  through  the  opening  made  to  evacuate  the  pus. 

The  same  thing  occurs  when  it  is  lodged  in  the  lung.  Instances  are  recorded 
in  which  bullets,  fragments  of  bone,  or  of  metal,  and  other  similar  substances, 
have  remained  quiet  for  years,  becoming  surrounded  by  fibrous  tissue  and  encysted, 
or  at  length  have  caused  a  certain  amount  of  chronic  suppuration,  leading  to  their 
discharge  either  externally  or  through  one  of  the  bronchi.  As  a  rule,  however, 
the  termination  is  not  so  successful :  either  acute  septic  pneumonia,  running  on  to 
gangrene,  occurs,  or  chronic  inflammation,  ending  in  phthisis,  follows. 

The  question  of  extraction  depends  entirely  on  whether  the  foreign  body  is 
accessible  or  not.  No  attemj)t  should  be  made  to  remove  it  from  the  pleura, 
unless  there  is  a  distinct  indication  as  to  locality  ;  and  in  the  case  of  the  lung  the 
greatest  caution  must  be  exercised  ;  fatal  hemorrhage  sometimes  follows  the  ex- 
traction of  a  weapon,  but  if  there  is  a  reasonable  suspicion  that  anything  is  left 
the  external  wound  should  not  be  closed. 

Seco7idary   Complications. 

The  secondary  troubles  that  occur  after  injuries  of  the  chest  are  for  the  most 
part  the  result  of  inflammation,  which  may  involve  the  walls  of  the  thorax,  the 
pleura,  pericardium,  lungs,  or  heart. 

Extra-mural  Suppuration. — Abscesses  may  form  as  the  result  of  contusions, 
either  in  the  superficial  tissue  or  deeper  under  the  muscles,  when  they  often  spread 


INJURIES  OF  THE  THORACIC  VISCERA.  863 

for  long  distances  before  they  point.  In  all  cases  they  should  be  opened  at  once  ; 
the  deeper  ones  can  often  be  reached  from  the  axilla,  along  the  margins  of  the 
muscles,  but  if  this  cannot  be  done  the  opening  must  be  made  wherever  the  drain- 
age is  likely  to  succeed  best.  If  there  is  any  doubt  as  to  the  existence  of  pus,  or 
the  direction  of  important  vessels,  Hilton's  method  should  be  employed. 

Necrosis  of  the  ribs  or  sternum  is  not  unfrequently  assigned  to  injury.  Some- 
times it  may  be  due  to  this  alone,  but  in  most  of  the  cases  in  which  this  comjjli- 
cation  is  present  there  is  a  distinct  history  of  tubercle  or  syphilis. 

Abscesses  sometimes  form  between  the  pleura  and  the  ribs,  or  in  the  medias- 
tinum. The  former  are  generally  associated  with  necrosis  and  soon  point  exter- 
nally, though  they  have  been  known  to  burst  into  the  i)leura.  The  latter  may 
attain  a  very  large  size  and  cause  comi)ression  of  the  vessels  and  severe  constitu- 
tional disturbance  before  their  nature  can  l)e  determined.  Usually  they  i^oint 
just  to  the  left  of  the  sternum,  and  if  pulsation  is  communicated  to  them  from  the 
heart  they  may  easily  be  taken  for  aneurism  ;  in  other  cases  they  work  their  way 
out  through  the  bone,  or  pass  upward  into  the  neck,  or  downward  along  the 
internal  mammary  artery ;  or  extend  into  the  pleura  or  pericardium.  No  time 
should  be  lost  in  opening  them  as  soon  as  the  diagnosis  is  made. 

Pleurisy  and  Empyema. — In  fracture  of  the  ribs  and  in  most  cases  of  severe 
contusion  of  the  thorax,  a  certain  amount  of  effusion  is  thrown  out  by  the  costal 
pleura,  leading  to  thickening- of  the  membrane  and  sometimes  to  the  formation  of 
adhesions  between  the  two  surfaces.  If,  however,  there  is  a  large  extravasation  of 
blood,  or  if  air  or  other  foreign  substance  finds  its  way  in,  the  inflammation  is 
more  severe  ;  and  if  the  irritation  is  kept  up,  or  if  it  is  of  a  very  intense  character, 
it  ends  in  suppuration  (empyema  or  pyothorax). 

When  this  occurs  the  suppuration  may  be  very  acute,  ushered  in  by  rigors  and 
high  fever ;  or  it  may  be  chronic,  the  effusion  gradually  increasing,  and  becoming 
more  and  more  purulent,  as  when  empyema  succeeds  serous  pleurisy.  In  most 
cases  it  is  general,  but  it  may  be  local  at  first. 

The  physical  signs  are  usually  well  marked.  If  there  is  no  wound  the  side 
of  the  thorax  is  enlarged  and  the  neighboring  viscera  displaced,  the  breath  sounds 
are  either  altogether  lost  over  the  lower  part  of  the  chest  on  that  side,  or,  if  the 
effusion  is  not  so  great,  they  are  replaced  by  weak  and  distant  bronchial  breathing. 
Over  the  same  area  there  is  absolute  dullness,  the  level  rising  day  by  day,  and 
varying  a  little  with  the  position  of  the  patient  ;  and  sometimes  jegophony  can  be 
heard  at  the  upper  margin.  When  there  is  an  open  wound  the  pleura  is  filled  to 
a  great  extent  with  air,  and  there  is  a  profuse  discharge  of  fluid,  sometimes  pure 
pus,  sometimes  broken-down  blood-clot,  according  to  the  amount  of  hsemothorax 
that  preceded  the  empyema  and  the  length  of  time  since  the  accident. 

The  pleurisy  that  occurs  in  connection  with  simple  fracture  nearly  always 
gets  well  of  itself;  if  fluid  does  collect,  and  is  not  absorbed,  it  may  be  withdrawn 
with  an  aspirator.  If  suppuration  sets  in,  the  first  consideration  is  to  ensure  per- 
fect drainage,  so  that  the  pus  cannot  be  pent  up  and  decompose.  When  there  is 
an  external  wound  it  must  be  enlarged,  carefully  examined,  and  explored  with 
the  finger  to  ascertain  if  there  is  a  foreign  body  which  has  been  overlooked,  or 
any  other  cause  ;  and  in  most  cases  it  is  advisable  to  make  a  second  opening  at 
once.  When  there  is  no  wound  aspiration  may  be  tried  ;  but  if  the  fluid  is  of 
such  a  character  that  it  cannot  be  evacuted  in  this  way  (if,  for  example,  it  consists 
largely  of  blood-clot  that  has  not  yet  become  liquid)  ;  or  if,  after  a  certain  amount 
of  success,  the  cavity  begins  to  fill  again,  it  must  be  drained.  If  it  is  done  at 
once,  before  the  pleura  has  become  condensed  and  thickened,  the  lung  will  ex- 
pand again  and  become  adherent  to  the  wall  of  the  thorax. 

Pneumojiia. — Simple  wounds  of  the  lung,  as  already  mentioned,  generally 
heal  by  the  first  intention,  with  very  little  consolidation  or  effusion.  If,  however, 
there  has  been  much  contusion  or  extravasation  ;  if  there  is  an  external  wound  ; 
and  particularly  if  a  portion  of  some  foreign  substance,  such  as  clothing  or  wad- 
ding, has  been   carried  in,  or  has  entered  through  the  larynx,  decomposition  may 


864    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

set  in,  and  excite  intense  intlainmatic^n  and  suppuration.  Sometimes  even  then  it 
ends  in  a  local  abscess,  the  pus  suddenly  hurstinj;  into  one  of  the  bronchi,  or 
working  out  through  the  wall,  along  the  track  of  the  original  wound,  or  even  dry- 
ing up  and  ultimately  becoming  caseous  or  calcareous  ;  but  much  more  often  it 
runs  on  until  the  greater  jjortion  of  the  lung  or  of  one  of  the  lol)es  is  involved  ; 
and  occasionally  it  is  so  acute  as  to  end  in  gangrene. 

The  locality  of  the  pneumonia  depends  upon  the  seat  of  injury.  The  i>hysi- 
cal  signs,  when  they  can  be  made  out,  are  the  same  as  those  of  the  ordinary 
croupous  form,  but  they  are  usually  obscured  by  the  presence  of  empyema,  pneu- 
mothorax, or  other  comjjlications.  The  sputa  may  be  rust-colored,  even  when 
there  is  no  inflammation  from  traumatic  hemorrhage  into  the  air  vesicles.  High 
fever,  however,  following  a  severe  injury  to  the  lung,  renders  its  presence  practi- 
cally certain.  The  prognosis  depends  upon  the  amount  of  lung  involved  and 
upon  the  cause. 

Very  little  can  be  done  in  the  way  of  treatment  ;  constant  inhalation  of 
moist  air  impregnated  with  some  volatile  antiseptic,  may  be  tried  to  limit  the 
amount  of  decomposition  ;  but  if  the  condition  of  the  breath  indicates  that  gan- 
grene has  set  in,  almost  the  only  hope  lies  in  incision  and  drainage.  Too  often, 
however,  the  condition  of  the  patient  is  practically  hopeless.  For  the  rest,  all 
that  can  be  done  is  to  maintain  the  strength  of  the  patient,  and,  if  there  is  exten- 
sive pleural  effusion,  relieve  the  breathing  by  tapping. 

Diseases  of   the  Chest  Wall. 

Chronic  Abscess. — This  may  arise  from  a  suppurating  hasmatoma,  or  follow 
the  caseation  of  a  tubercular  deposit.  Very  often  it  originates  in  connection  with 
a  carious  rib.  The  symptoms  are  usually  distinctive,  but  care  should  always  be 
taken  to  prove  that  the  sac  has  no  communication  with  the  thorax.  The  cavity 
should  be  laid  open  freely  to  allow  the  contents  to  escape,  explored  with  the 
finger,  washed  out  with  perchloride  solution,  and  drained.  The  tube  reepiires  re- 
moving upon  the  second  day  ;  after  that  the  wound  may  be  covered  with  wood- 
wool and  left  until  it  is  sound. 

Tubercle  may  affect  the  subcutaneous  tissue,  leaving  long  sinuses  lined  with 
pale,  flabby  granulations  (in  one  case  under  my  care  they  extended  across  the 
front  of  the  chest  from  one  axilla  to  the  other),  or  it  may  commence  in  the  sub- 
periosteal layer  of  the  bones.  It  should,  in  any  case,  be  thoroughly  scraped  out, 
and  the  wound  well  powdered  with  iodoform.  Fortunately  the  pleura  becomes 
so  thick  that  there  is  very  little  risk  of  an  empyema  following. 

Ginnmata  are  of  frequent  occurrence  upon  the  sternum,  leaving  deep,  circular, 
punched-out  sores,  with  the  bone  beneath  bare  and  rough. 

In  addition,  all  forms  of  tumors  that  develop  in  connection  with  fibrous  or 
connective  tissue,  bone,  or  cartilage,  are  met  with  ujjon  the  thorax.  The  treat- 
ment, of  course,  depends  upon  their  character;  in  some  cases  their  removal  is 
comparatively  simple  ,;  in  others  it  may  be  necessary  to  excise  the  subjacent  bone 
and  expose  the  pleura  or  even  the  pericardium.  Sarcomata  can  sometimes  be 
shelled  out,  but  great  care  must  be  taken  to  ascertain  whether  they  have  any  deep 
connection. 

OPERATIONS  UPON  THE  THORAX. 

Paracentesis. 

Paracentesis  of  the  pleura  is  performed  either  for  exploration  (to  ascertain 
the  presence  or  the  nature  of  fluid),  or  to  relieve  the  tension  in  the  cavity,  so  that 
the  lung  may  expand  again,  and  the  balance  between  absorption  and  secretion  be 
once  more  restored. 

For  purposes  of  exploration  a  large  hypodermic  syringe  is  the  most  suitable 


OPERATIONS  UPON  THE  THORAX.  865 

instrument.  Care  should  be  taken  that  it  is  absohitely  clean  (it  is  not  sufificient 
to  draw  even  a  strong  carbolic  solution  through  the  needle  ;  all  cannulae  before 
using  should  be  boiled  in  licjuor  potassii:  ;  nothing  else  will  ensure  freedom  from 
putrid  grease  in  the  interior),  and  unless  it  is  intended  to  emjjty  the  cavity,  only 
a  small  amount  should  be  withdrawn.  It  is  very  easy  by  means  of  reiteated  punc- 
tures to  convert  a  simple  pleurisy  into  an  empyema.  The  locality  selected  de- 
pends upon  the  physical  signs,  but  the  thinnest  part  of  the  chest  wall  that  is  avail- 
able should  be  chosen  ;  the  skin  should  be  pulled  a  little  to  one  side,  so  that  the 
opening  may  be  valvular  ;  and  care  should  be  taken  to  pass  in  over  the  upper 
border  of  a  rib. 

If  it  is  intended  to  withdraw  the  fluid  an  aspirator  should  be  used,  adopting 
the  same  precautions,  and  keeping  up  a  uniform  but  slight  amount  of  suction. 
The  operation  may  be  required  for  hasmothorax  ;  for  jileurisy,  if  the  effusion  is  so 
large  as  to  interfere  with  the  action  of  the  opposite  lung  or  with  the  heart,  or  if, 
though  it  is  not  large  enough  for  this,  it  fails  to  diminish  under  other  methods  of 
treatment ;  for  hydrothorax  occurring  on  both  sides  (as  sometimes  in  Rright's 
disease)  ;  and  for  empyema. 

The  usual  situation  is  in  the  seventh  or  eighth  space,  just  in  front  of  the  angle 
of  the  scapula.  An  anaesthetic  is  not  required  ;  if  the  patient  is  very  nervous  the 
ether  spray  may  be  used.  The  semi-recumbent  position  is  the  most  convenient  ; 
the  patient  cannot  lie  upon,  the  sound  side  on  account  of  his  respiration,  but  a 
finger  must  be  kept  upon  the  pulse,  as  sometimes  syncope  occurs  if  a  large  quan- 
tity of  fluid  is  withdrawn,  or  if  it  comes  away  rapidly,  probably  from  the  viscera 
being  unable  to  accommodate  themselves  at  once  to  the  altered  conditions.  A 
small  incision  should  always  be  made  through  the  skin  with  a  scalpel ;  the  walls  of 
the  thorax,  even  when  it  is  full  of  fluid,  are  apt  to  yield  a  little  ;  the  trocar,  how- 
ever sharp  it  may  be,  does  not  penetrate  readily ;  and  if  it  does  not  enter  smartly 
it  may  jjush  the  thickened  pleura  in  front  of  it,  and  fail  to  reach  the  cavity.  At 
the  same  time  it  must  be  guarded  with  the  thumb,  so  that  it  may  not  be  driven 
across  the  pleura  when  the  resistance  ceases. 

The  quantity  of  fluid  withdrawn  must  naturally  be  guided  by  the  circum- 
stances of  the  case,  but  no  attempt  should  ever  be  made  to  empty  the  cavity,  and 
if  the  pulse  becomes  weak,  or  any  blood  appears  in  the  aspirator,  or  the  patient 
begins  to  cough,  the  needle  should  be  withdrawn  at  once,  and  the  puncture  sealed 
with  collodion.  It  very  rarely  happens  that  any  serious  consequences  follow,  but 
syncope,  embolism  (from  the  pulmonary  veins),  and  oedema  of  the  lung  (owing 
in  all  probability  to  the  paralysis  of  the  walls  of  the  vessels,  caused  by  prolonged 
ansemia)  have  been  known  to  occur  ;  and,  owing  to  the  feeble  nutrition  of  the 
tissues  and  the  inflammation  already  present,  there  is  distinct  danger  of  the  fluid 
becoming  purulent. 

Drainage. 

Drainage  of  the  pleura  is  very  rarely  required  except  for  empyema.  In  the 
traumatic  variety  (that  which  is  caused  by  a  foreign  body  entering  the  bronchi,  by 
haemothorax,  or  by  the  rupture  of  a  cavity)  it  is  nearly  always  necessary.  On  the 
other  hand,  when  an  empyema  follows  simple  pleurisy,  aspiration  maybe  tried  first, 
unless  it  is  already  pointing.  In  children,  in  particular,  it  is  often  successful,  and 
although  the  chance  is  less  in  the  case  of  adults,  it  is  always  worth  the  attempt. 
The  cavity,  of  course,  is  not  emptied,  and  the  residue  of  the  pus  must  be  removed 
by  absorption. 

In  addition  to  the  physical  signs  pointing  to  fluid  in  the  pleural  cavity,  the 
presence  of  pus  is  indicated  by  rigors,  hectic,  or  oedema  of  the  skin  ;  but  it  should 
always  be  suspected,  especially  in  the  case  of  children,  if  after  any  of  the  acute 
specific  fevers  or  an  operation,  or,  indeed,  any  serious  illness,  recovery  is  unaccount- 
ably delayed,  and  the  patient,  instead  of  improving,  begins  to  fail  and  go  back. 
If,  under  such  circumstances  as  these,  there  is  any  indication  of  fluid  in  the  pleura, 
there  should  be  no  hesitation  in  using  an  exploring  syringe. 


866     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

The  chances  of  an  empyema  getting  well  of  itself  are  very  remote  ;  nearly 
always  it  continues  to  increase  until  either  the  skin  or  the  lung  gives  way  and  the 
contents  are  discharged  externally  or  into  the  bronchi.  In  rare  cases  the  pus 
works  its  way  down  behind  the  diaphragm  and  bursts  into  the  stomach  or  intestines, 
or  enters  the  psoas  and  i)oints  first  in  the  groin.  The  longer  it  is  left  the  more 
collajjsed  the  lung  becomes  and  the  thicker  the  pleura,  until  at  last,  in  an  old- 
standing  case  that  has  been  allowed  to  break  of  itself  or  has  not  been  opened  until 
late  in  the  course  of  the  disease,  the  pleura  is  dense,  almost  cartilaginous  in  its 
hardness,  and  perhaps  an  inch  in  thickness,  while  the  lung  is  compressed  and 
bound  down  against  the  vertebral  column  in  such  a  manner  that  expansion  is 
hopeless. 

Death  may  occur  suddenly  from  synco])e  ;  the  heart  is  so  much  displaced  and 
its  cavities  so  compressed,  that  at  the  best  it  can  only  work  at  a  grave  disadvantage, 
and  the  least  exertion  may  suddenly  turn  the  scale  ;  from  asphyxia,  owing  to  oedema 
of  the  opposite  lung,  or  from  the  pus  being  discharged  into  the  bronchi  in  such 
quantity  that  it  cannot  be  coughed  up ;  or  from  gradual  exhaustion.  If  the  em- 
pyema bursts  it  may  prove  fatal  from  acute  septicaemia,  the  contents  of  the  cavity 
becoming  putrid  (this  is  less  likely  to  occur  when  the  opening  is  into  the  lungs  than 
when  it  is  external)  ;  or,  after  many  weeks  or  months,  from  hectic  and  albuminoid 
disease.  If  the  lung  cannot  expand,  the  chest  wall  falls  in  (causing  a  lateral 
curvature,  concave  on  the  affected  side,  with  compensatory  curves  above  and 
below)  ;  the  heart  and  the  other  lung  are  displaced,  and  the  diaphragm  is  forced 
up.  Sometimes,  between  them,  the  cavity  is  obliterated  ;  the  lymph  upon  the 
costal  pleura  adheres  to  that  upon  the  lung,  and  the  sac  disappears  as  such,  leaving 
a  deformity  which,  especially  in  the  case  of  children,  diminishes  to  a  certain  extent 
in  course  of  time.  Much  more  often,  if  the  lung  is  once  tied  down  and  the 
pleura  thickened,  sufficient  displacement  is  impossible  (the  upper  part  of  the  thorax, 
where  everything  is  more  rigid,  is  always  the  last  to  contract)  and  a  sinus  is  left, 
leading  to  what  is  practically  an  old  abscess  sac.  If  this  is  small  and  the  opening 
straight,  the  discharge  may  be  so  trifling  as  to  cause  practically  no  inconvenience  ; 
more  frequently  the  prolonged  drain  tells  at  length  upon  the  health,  and  albumi- 
noid degeneration  sets  in. 

An  anaesthetic  is  advisable,  although  special  care  is  required,  and  chloroform 
is  to  be  preferred  to  ether.  The  position  of  the  patient  is  the  same  as  for  aspira- 
tion. In  children  and  recent  cases,  and  in  small  localized  empyemata,  a  single 
incision  may  suffice ;  under  other  conditions  two  should  always  be  made,  as  it  is 
impossible  for  such  a  cavity  as  the  pleura,  when  the  lung  is  contracted,  to  drain 
efficiently  through  one.  The  usual  site  is  in  the  axillary  line  (in  front  of  the 
latissimus  dorsi  in  the  seventh  or  eighth  space)  and  the  two  may  be  close  together. 
It  is  better,  however,  to  have  one  of  them  higher  up  in  the  fourth  or  even  the 
third,  as  the  lower  part  of  the  pleural  cavity  often  becomes  obliterated  in  a  few 
days,  so  that  the  tube  is  forced  out.  If  there  is  an  old  sinus  or  the  pus  is  localized, 
the  question,  of  course,  is  entirely  different ;  and  it  may  even  be  necessary  to 
open  the  cavity  behind  the  scapula,  though  this  should  be  avoided  if  possible,  not 
only  on  account  of  the  depth,  but  because  of  the  obliquity  of  the  intercostal  arteries. 
The  position  of  the  intended  opening  should  always  be  marked  out  upon  the  skin 
before  the  arm  is  abducted  from  the  side. 

A  vertical  incision  an  inch  and  a  half  in  length  should  be  made  through  the 
skin  and  the  superficial  fascia,  down  to  the  intercostal  muscles,  and  then  either  the 
scalpel  itself  (with  the  blade  turned  i)arallel  to  the  ribs)  or  a  shari)-pointed  steel 
director  thrust  through  the  wall  into  the  fluid  beyond.  The  opening  can  then  be 
enlarged  to  a  sufficient  extent  with  a  pair  of  dressing- forceps.  If  the  intercostal 
artery  bleeds  it  is  usually  because  it  is  punctured,  not  divided. 

In  ordinary  cases  a  drainage  tube,  as  large  as  the  space  between  the  ribs  will 
admit,  should  be  introduced  at  once  ;  a  second  opening  made  if  it  is  thought  ad- 
visable ;  the  cavity  allowed  to  empty  itself  as  the  patient  comes  round  from  the 
anaesthetic,  and  then  the  side  covered  in  with  many  layers  of  wood-wool  or  some 


OPERA  TIONS  UPON  THE  THORAX.  867 

other  absorbent  dressing.  By  degrees  the  margins  of  the  ribs  become  aljsorljed  by 
the  pressure  of  the  rubber,  so  that  there  is  no  fear  of  its  being  nijjped  and  com- 
pressed, even  if  the  thorax  collapses.  When,  however,  there  is  an  old  sinus  to  deal 
with  and  the  ribs  are  already  pressed  clo.sely  together,  overlapping  like  the  slates  on 
a  roof;  or  when  it  is  thought  advisable,  owing  to  the  presence  of  a  foreign  body  or 
from  other  causes,  to  e.xplore  the  interior  with  the  finger,  this  is  not  sufficient.  In 
the  former  case  a  circle  may  be  cut  out  from  the  bony  cuirass  with  a  trephine, 
removing  portions  of  two,  or,  perhaps,  three  ribs  ;  in  the  latter,  a  definite  segment 
of  one  may  be  excised.  The  superficial  incision  should  be  sufficiently  long  to 
expose  it  thoroughly  ;  the  periosteum  divided  along  the  convexity  of  the  bone  and 
detached  from  it  (with  especial  care  where  the  lower  border  is  concerned),  and  the 
two  ends  of  the  exposed  portion  severed  with  curved  force])s  or  a  fine  saw.  The 
deep  layer  of  the  periosteum  and  the  pleura  can  then  be  torn  through  at  the  bottom 
of  the  wound.  The  broken  rib  undoubtedly  increases  the  pain  for  the  first  few 
days,  but  in  a  very  short  time  it  becomes  welded  by  callus  to  those  on  either  side 
of  it. 

Except  in  the  case  of  foreign  bodies  or  of  localized  empyemata,  there  is  no 
object  in  the  introduction  of  the  finger  ;  and  probing  the  cavity  should  be  avoided, 
as  it  makes  the  walls  lileed  and  tends  to  separate  recent  adhesions.  Washing  out 
the  pleura  with  antiseptics  is  dangerous  and  unnecessary.  Even  when  the  pus  is 
foul  and  putrid  the  absorption  ceases  and  the  temperature  falls  as  soon  as  free 
drainage  through  two  openings  is  established.  Specially  made  rubber  tubes  (like 
tracheotomy-tubes,  only  with  the  closed  end  and  lateral  openings)  may  be  used,  or 
they  can  be  fashioned  as  required  out  of  drainage  tubing,  by  passing  it  through  a 
piece  of  stout  rubber  three  or  four  inches  square,  slitting  one  end  down  on  three 
sides,  and  securing  the  branches  to  the  face  of  the  shield  with  a  suture.  The 
length  of  time  they  are  necessary  varies,  of  course,  in  each  case.  Usually,  as  the 
openings  become  lined  by  granulations,  the  tubes  can  be  shortened  until  they  are 
only  just  long  enough  to  project  through  the  wall ;  then  the  question  is  determined 
by  the  amount  of  discharge.  It  is  better  to  leave  them  in  until  they  are  practically- 
forced  out  from  within  ;  if  they  are  left  off  too  soon,  the  opening  begins  to  con- 
tract immediately  ;  drainage  is  checked,  and  the  temperature  begins  to  rise.  Re- 
placing them,  even  after  three  days,  may  be  a  matter  of  considerable  difficulty, 
requiring  trephining  or  excision.  Occasionally  the  exposed  surface  of  the  rib 
necroses,  but,  although  this  may  check  the  healing  of  the  wound,  it  rarely  causes 
any  serious  trouble. 

Thoracoplasty. 

In  old  cases  of  empyema  the  lung  is  so  firmly  bound  down  that  in  spite  of 
the  aid  it  receives  from  the  collapse  of  the  walls  and  the  displacement  of  the  vis- 
cera, it  is  unable  to  expand  sufficiently  to  fill  the  cavity.  Nearly  always  this  is  due 
to  the  operation  having  been  delayed,  and  if  the  discharge  is  more  than  a  very 
minute  quantity  it  is  almost  sure  to  end  sooner  or  later  in  albuminoid  disease. 
Something  can  be  done  by  allowing  the  patient  to  sit  up  as  soon  as  he  can,  en- 
couraging him  to  move  about,  and  perhaps  by  systematic  exercises  and  the  inhala- 
tion of  compressed  air,  but  it  is  not  probable  that  this  can  do  much.  Practically 
the  only  course,  if  it  is  clear  the  cavity  cannot  contract  any  more,  is  to  divide 
the  external  wall  so  that  it  may  yield  sufficiently.  This  is  usually  known  as  Est- 
lander's  operation,  or  thoracoplasty ;  it  involves  the  removal  of  a  considerable 
length  (often  six  or  seven  inches)  of  every  rib  (it  may  be  seven  or  eight)  that 
enters  into  the  formation  of  the  wall  of  the  cavity,  and  naturally  should  never  be 
performed  unless  it  is  absolutely  certain  that  obliteration  in  any  other  way  is  im- 
possible. Moreover,  the  condition  of  the  heart,  the  other  lung,  and  the  kidneys 
must  be  taken  into  careful  consideration  first ;  adherent  pericardium  (which  is  not 
an  uncommon  complication  in  cases  of  empyema),  phthisis  or  albuminoid  degen- 
eration, if  it  is  distinctly  present  already,  are  practically  prohibitive. 

The  first  thing  is  to  ascertain  the  shape  and  size  of  the  cavity  as  accurately 


868     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

as  possible  with  the  finger  and  a  probe.  Usually  it  runs  upward  and  backward 
across  the  general  direction  of  the  ribs,  so  that  it  may  be  necessary  to  commence 
at  the  second  and  remove  portions  of  five  or  six  ;  the  first,  of  course,  should  never 
be  touched. 

.\  single  vertical  incision  is  usually  sufficient;  occasionally  two  mav  be 
necessary,  or  it  may  answer  better  to  raise  the  soft  tissues  in  a  flap  [Schede's  ope- 
ration]. As  a  rule,  the  ribs  lie  so  close  together  that  it  is  impossible  to  slip  the 
finger  nail  between  them,  and  the  preliminary  section  must  be  made  with  a  saw, 
commencing  over  the  cavity  at  its  anterior  margin.  As  soon  as  a  portion  of  one 
or  two  has  been  excised,  a  better  idea  can  be  formed  as  to  what  is  re(]uired.  Ac- 
cording to  Pearce  Gould,  the  whole  of  the  bone  that  forms  the  outer  wall  of  the 
empyemic  cavity  must  be  taken  away,  a  free  opening  being  first  made  in  front, 
and  then  the  rest  of  the  wall  divided  from  within  by  means  of  cutting  forceps. 
[Subperiosteal  resection  of  the  ribs  is  a  much  less  serious  operation,  and  it  may  be 
performed  with  comparatively  little  hemorrhage,  and  often  without  wounding  the 
intei-costal  vessels  or  pleura.  Not  only  does  the  chest  wall  collapse,  but  the  bony 
rib  is  reproduced.  This  ideal  result  I  had  the  pleasure  of  seeing  in  a  case  at  the 
United  States  Marine  Hospital,  Chicago,  1891.] 

Pneumoxotomv. 

Incision  of  the  lung  may  be  practiced,  according  to  Godlee,  in  cases  of  gan- 
grenous cavities,  abscesses  caused  by  the  extension  of  suppuration  from  other  parts 
into  the  lung,  abscesses  connected  with  foreign  bodies,  bronchiectatic  cavities, 
provided  they  are  single  (multiple  ones  can  hardly  receive  nmch  relief  this  way), 
and  tubercular  cavities,  if  there  is  only  one,  and  the  cough  is  very  hara.ssing.  In 
one  or  two  cases  a  similar  operation  has  been  practiced  for  hydatid  disease,  and  a 
few  instances  are  recorded  in  which  tumors  have  been  removed  from  the  lung. 
The  localization  of  the  disease  and  the  treatment  of  the  pleura  are  the  chief  diffi- 
culties. 

No  incision  may  be  made  until  the  existence  and  accessibility  of  the  cavity 
have  been  proved  by  puncture,  and  even  then  the  greatest  care  is  rerjuired,  for  the 
lung,  unless  it  is  consolidated  by  inflammation,  is  so  yielding  that  a  thick-walled 
sac  can  easily  be  pushed  to  one  side.  As  a  rule,  cavities  should  not  be  approached 
from  behind,  for  the  large  vessels  run  for  the  most  part  along  the  posterior  surface 
of  the  bronchi.  The  size  of  a  cavity  cannot  be  estimated  from  the  amount  of 
fluid  that  is  coughed  up  ;  according  to  Godlee,  upward  of  a  pint  may  come  within 
twenty-four  hours  from  a  space  that  would  not  hold  as  much  as  two  ounces.  If  a 
cavity  is  found,  the  lung  tissue  should  be  incised,  and  explored  as  far  as  possible 
with  the  finger,  part  of  a  rib  being  removed  if  necessary,  and  a  large  drainage 
tube  inserted.  The  shape  is  always  very  irregular,  and  it  must  be  a  long  time 
before  the  sloughs  have  separated,  and  cicatrization  can  jjrocure  its  obliteration. 

The  treatment  of  the  pleura  presents  unusual  difficulties.  There  can  be  no 
doubt  that  it  is  not  advisable  to  incise  a  i)utrid  cavity  in  the  lung  unless  the  pleural 
surfaces  are  adherent.  If  there  is  localized  gangrene,  and  if  it  has  already  lasted 
for  some  time,  the  danger  is  not  so  great ;  adhesions  are  usually  present  under 
these  conditions,  and  the  lung  is  so  consolidated  by  inflammation  that  it  is  in  but 
slight  danger  of  collapsing ;  but  in  acute  cases  and  in  bronchiectasis  it  is  impos- 
sible to  be  certain.  An  attempt  may  be  made  to  find  out  by  ascertaining  the 
mobility  of  the  lung;  if  a  needle  is  driven  through  an  intercostal  space  into  the 
pulmonary  tissue,  it  will  show  to  a  certain  extent  by  its  movement  whether  the 
lung  is  fixed  or  not,  but  it  is  very  easy  to  place  too  much  reliance  upon  this.  In 
some  instances  it  may  be  possible  to  suture  the  two  surfaces  together  and  wait  for 
a  week,  or  to  ]jrocure  adhesions  by  means  of  the  cautery  applied  to  the  intercostal 
muscles,  but  often  it  is  imjiossible  to  wait  so  long,  and  even  then  the  adhesions  are 
so  soft  and  delicate  that  the  greatest  care  must  be  taken  not  to  break  them  down. 

[Dr.  E.  Wyllis  Andrews,  of  Chicago,  showed  to  the  Chicago  Medical  Society, 


OPERATIONS  UPON  THE  THORAX.  869 

in  1892,  several  large  calcareous  concretions  taken  from  the  human  lung  by  in- 
cision. At  the  date  of  the  report,  the  patient  had  much  improved  subsec[uent  to 
the  operation.] 

Paracentesis  ok  the  Pericardium. 

This  may  be  required  for  serous  effusion,  when  the  quantity  is  increasing  to 
such  an  extent  that  the  action  of  the  heart  is  failing,  or  for  a  collection  of  pus, 
such  as  is  not  uncommon  in  the  pygemia  that  complicates  acute  necrosis.  It  may 
be  performed  in  any  interspace  from  the  third  to  the  eighth  (the  fourth  or  fifth  is 
usually  recommended),  preference  being  given  to  that  which  shows  the  clearest 
indication  of  fluid,  and  a  spot  should  be  selected  about  one  inch  from  the  edge  of 
the  sternum,  so  as  to  avoid  the  internal  mammary  artery  on  the  one  side  and  the 
pleura  on  the  other.  The  direction  of  the  puncture  must  depend  upon  the  locality  ; 
if  it  is  on  the  left  of  the  sternum,  the  needle  should  be  pushed  backward  and 
toward  the  right.  The  right  ventricle  of  the  heart  has  been  perforated  on  several 
occasions. 

A  preliminary  incision  should  be  made  through  the  skin  and  a  fine  aspirator 
needle  used.  If  the  fluid  is  clear  and  serous,  the  cavity  should  not  be  emptied  ; 
removal  of  part  will  probably  give  sufficient  relief;  if,  however,  it  is  purulent 
(this  is  often  indicated  by  cedema  of  the  skin),  the  incision  should  be  gradually 
deepened  until  the  pericardium  is  exposed  sufficiently  to  introduce  a  drainage  tube. 


870     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  XVIII. 

INJURIES  AND   DISEASES  OE   THE   ABDOMEN. 

SECTION   I.— INJURIES    OF  THE    ABDOMEN. 

Contusions. 

Blows  upon  the  abdomen  may  affect  the  walls,  or  the  viscera,  or  both  together. 
They  are  always  accompanied  by  a  very  severe  degree  of  shock,  and  it  is  said  that 
a  fatal  result  has  followed  without  any  structural  lesion  having  been  discovered  at 
the  autopsy.  Certainly  death  may  result  from  such  apparently  trivial  injuries  as 
rujjture  of  the  i)arietal  peritoneum  without  hemorrhage,  or  puncture  of  a  small 
hydatid  cyst  of  the  liver,  probably  owing  to  reflex  paralysis  of  the  heart. 

Owing  to  this  peculiarity  it  is  often  impossible  to  form  a  conception  as  to  the 
extent  of  the  injury  (the  viscera  may  be  reduced  to  pulp  without  the  skin  showing 
a  sign  of  bruising,  as  in  what  used  to  be  called  wind  contusions,  from  spent  round- 
shot),  and  the  prognosis  must  be  very  guarded.  The  shock  may  pass  off  within  a 
few  minutes  or  a  few  hours,  or  it  may  prove  fatal,  or  it  may  be  followed,  without 
any  break  or  interruption,  by  signs  of  hemorrhage  or  of  rupture  of  some  of  the 
hollow  vi.scera. 

{a)  Contusion  and  Subcutaneous  Laceration  of  the  Wall  of  the  Abdomen. — A 
hgematoma  may  form  in  the  subcutaneous  tissue,  or  in  the  sheath  of  the  muscles  ; 
in  some  cases  the  extravasation  is  very  extensive,  usually  it  is  absorbed  (leaving,  if 
the  muscle  has  been  much  injured,  a  weak  spot  in  the  wall  of  the  abdomen  through 
which  a  hernia  may  take  place  subsequently),  but  occasionally  suppuration  sets  in. 
Abscesses  of  the  abdominal  wall  caused  in  this  way  are  characterized  by  the  enor- 
mous amount  of  induration  that  surrounds  them,  and  not  unfrequently,  even 
when  they  have  no  communication  with  the  viscera,  by  the  ftetid  nature  of  their 
contents. 

Laceration  of  muscles,  especially  of  the  rectus  abdominis,  is  not  a  rare  occur- 
rence. It  may  be  caused  by  a  sudden  effort,  as,  for  examjjle,  in  parturition,  or 
by  a  blow  when  the  muscle  is  rigidly  contracted.  In  tetanus  it  is  not  uncommon, 
and  it  is  said  to  be  of  fre(][uent  occurrence  after  typhoid  fever,  owing  to  the  degene- 
ration of  the  contractile  substance.  The  signs  are  characteristic,  but,  unhappily, 
if  the  rupture  is  complete,  nothing  can  be  done  to  secure  union  of  the  ends,  and 
an  abdominal  support  must  be  worn  afterward.  Laceration  of  the  diaphragm  can 
only  be  recognized,  if  the  patient  lives,  by  the  subsequent  occurrence  of  traumatic 
phrenic  hernia. 

The  parietal  peritoneum  sometimes  gives  way  by  itself,  owing  to  its  want  of 
elasticity,  but  this  is  not  so  common  as  in  the  case  of  the  visceral  layer,  probably 
because  of  the  presence  of  the  subperitoneal  fatty  tissue.  It  may  be  followed  by 
peritonitis. 

(J})  Rupture  of  the  Viscera. — A  very  slight  degree  of  force  is  enough  some- 
times ;  an  enlarged  spleen,  for  example,  or  a  distended  bladder  with  atrophied 
walls,  tears  at  once,  and  the  latter,  at  least,  will  give  way  under  the  mere  pressure 
of  the  muscles.  Most  instances,  however,  are  due  to  extreme  degrees  of  violence, 
the  worst  being  what  are  known  as  buffer  accidents.  The  liver  suffers  the  most 
frequently,  on  account  of  its  size  and  position  ;  sometimes  the  gall-bladder  is  torn 
as  well.  The  stomach  may  give  way  (especially  if  it  is  distended),  usually  near 
the  pylorus.  The  small  intestine  may  be  torn  across  (generally  at  the  end  of  the 
duodenum,  for  here  the  most  movable  part  is  joined  to  the  most  fixed),  the  spleen 
may  be  ruptured,  the  kidney,  its  pelvis,  or  the  ureter  lacerated,  and  the  mesentery, 


INJURIES  OF  THE  ABDOMEN. 


S71 


with  its  blood-vessels,  rent  in  any  direction.  The  pancreas,  owing  to  its  position, 
usually  escapes,  unless,  as  sometimes  happens,  the  contents  are  completely  crushed. 
The  diagnosis  of  many  of  these  injuries  is  impossible  until  secondary  conse- 
ciuences  have^made  their  appearance.  The  patient  simply  lies  utterly  prostrate, 
and  it  is  not  possible  to  tell  whether  his  condition  is  due  to  shock  alone  or  to  shock 
combined  with  hemorrhage,  or  rupture  of  the  viscera.  The  bladder  may  be 
excluded  by  passing  a  soft  catheter ;  if  it  is  empty  at  the  time  of  the  accident  it 
is  almost  certain  to  have  escaped  (unless  the  pelvis  is  fractured  too)  ;  if  it  was  full, 
and  has  'dven  way,  nothing  but  a  little  blood-stained  fluid  follows  when  the 
catheter  is  passed.  Hemorrhage  into  the  peritoneal  cavity  may  be  diagnosed  by 
the  increasing  intensity  of  the  collapse,  the  yawning  and  jactitation  of  the  patient, 


IScdlBladder 


Z/miilicUs 
4<:^LuinhX 


Cac 


Po  u parts  Miy 


Fig.  367.— Diagram  Showing  the  Position  of  the  Abdominal  Viscera. 

and  by  the  dullness  in  the  flanks,  the  level  of  which  continues  to  rise,  and  varies 
with  the  position  ;  but  this  gives  no  information  as  to  whether  it  is  simple  rupture 
of  some  mesenteric  vessel,  or  a  hopeless  laceration  of  the  liver.  In  rupture  ot 
the  stomach  there  may  be  blood-stained  vomiting  ;  but,  again,  this  may  arise  Irom 
simple  bruising  of  the  mucous  membrane,  or,  particularly  when  the  rent  is  exten- 
sive, it  may  not  occur  at  all.  The  rapid  accumulation  of  gas  m  the  peritoneal 
cavity,  causing  obliteration  of  the  liver  dullness,  points  in  the  same  direction.  It 
the  intestine  is  lacerated  vomiting  may  occur,  but  the  passage  of  blood  per  anum 
is  more  decisive.  Prof.  Senn  proposed,  in  cases  of  this  kind,  to  inflate  the  rectum 
and  large  intestine  with  hydrogen  or  some  other  unirritating  gas,  and  undoubtedly 
in  the  case  of  bullet  wounds,  where  there  is  an  external  aperture,  and  the  gas  that 
escapes  can  be  collected  and   identified,  this   proceeding  is  of  some  benefit,     in 


872    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

other  cases  it  can  only  be  considered  an  indication  if,  after  it  is  injected,  resonance 
makes  its  appearance  in  some  locality  into  which  the  intestines  do  not  usually  pene- 
trate, as,  for  example,  between  the  liver  and  the  anterior  abdominal  wall. 

Treatment. — In  the  vast  majority  of  these  accidents  active  measures  are  out 
of  the  (luestion.  The  patient  must  be  kept  perfectly  (juiet  in  bed,  well  under  the 
influence  of  opium,  and  with  a  large  ice-bag  over  the  injured  part,  so  arranged 
that  it  does  not  rest  its  weight  too  much  upon  it.  Stimulants  should  be  avoided 
if  possible  ;  sometimes,  when  the  heart  is  distinctly  failing,  they  must  be  given, 
but  if  there  is  any  hemorrhage,  they  are  only  likely  to  precipitate  the  end.  Only 
a  little  ice  (in  small  fragments,  and  not  too  often)  may  be  allowed  by  the  mouth  ; 
any  food  that  is  considered  advisable  in  the  first  forty-eight  hours  should  be  given 
in  the  form  of  suppositories  or  small  enemata. 

In  exceptional  instances  it  may  be  possible  to  form  a  more  accurate  diagnosis. 
If,  for  example,  there  is  clearly  some  fracture  of  the  ribs  over  the  liver,  and  the 
hemorrhage  is  serious,  or  if  blood-stained  vomiting  and  rapid  distention  of  the 
peritoneal  cavity  with  gas  are  followed  within  a  few  hours  by  peritonitis,  indicat- 
ing rupture  of  the  stomach  or  intestine  ;  or  if  the  bladder  contains  but  a  small 
quantity  of  blood-stained  urine,  in  spite  of  the  fact  that  none  has  been  passed,  it 
is  undoubtedly  justifiable  to  open  the  abdomen,  try  to  find  the  seat  of  injury,  deal 
with  it  as  it  requires,  and  wash  out  the  cavity  thoroughly  with  hot  water.  The 
spleen  and  kidney  have  been  removed  for  hemorrhage  ;  rents  in  the  liver  have 
been  sewn  up  ;  the  bladder  has  been  sutured  many  times  successfully,  and  life  has 
been  preserved  even  after  f?ecal  matter  has  been  extravasated  into  the  peritoneal 
cavity.  Unfortunately,  the  proportion  of  cases  in  which  such  a  proceeding  can  be 
recommended  is  a  very  small  one ;  in  by  far  the  majority,  opium  is  the  only 
resource. 

Wounds. 

Wounds  of  the  abdomen  are  divided  into  those  that  penetrate  the  peritoneal 
cavity  and  those  that  do  not,  and  the  former  again  into  those  that  are  accompanied 
by  injury  to  the  viscera  and  those  which  only  implicate  the  wall. 

1.  Non-pcnctrating  wounds  may  be  incised,  punctured,  or  lacerated.  If  there 
is  any  doubt  as  to  the  peritoneum  being  involved,  and  the  wound  is  more  than  a 
puncture,  or  if  the  instrument  with  which  it  was  inflicted  is  dirty,  the  patient 
should  be  placed  under  an  anaesthetic  and  the  opening  carefiilly  enlarged,  each 
layer  of  tissue  being  divided  successively  upon  a  director  until,  if  necessary,  the 
subperitoneal  fat  is  exposed.  In  other  respects  the  wounds  must  be  treated  on 
ordinary  principles,  deep  sutures  being  used  to  bring  the  various  layers  together 
after  the  tissues  have  been  thoroughly  cleansed,  as,  owing  to  the  constant  movement 
of  the  part,  it  is  very  difficult  to  maintain  accurate  apiwsition  in  any  other  way. 
If  the  wound  is  of  any  size  ventral  hernia  is  very  likely  to  follow,  unless  an 
abdominal  support  is  worn. 

2.  Penetrating  Wounds. —  In  all  wounds  that  involve  the  parietal  peritoneum 
(except  needle  punctures)  the  injured  tissues  should  be  thoroughly  examined  (the 
skin  wound  being  enlarged,  if  necessary),  cleansed,  and  accurately  brought 
together  with  the  serous  surfaces  in  contact.  A  continuous  catgut  suture  should 
be  used  for  the  peritoneum  (so  as.  to  make  sure  of  immediate  union),  if  from  the 
amount  of  bruising  or  from  other  causes  it  is  doubtful  whether  the  other  tissues 
will  heal  at  once.  On  the  other  hand,  with  a  clean  incised  wound,  the  sutures 
may  be  passed  through  everything,  peritoneum,  muscles,  and  skin,  as  after  an 
operation.  Opium  is  usually  advisable,  and  the  dressings  must  be  abundant  and 
elastic  (a  sponge  wrung  out  of  carbohc  solution  may  be  placed  next  the  skin  with 
wood-wool  over  it  and  all  around  it),  so  as  to  ensure  the  parts  being  kept  at  rest 
and  in  accurate  apposition. 

{a)  When  it  is  certain  the  viscera  are  not  hurt  nothing  further  is  required. 
The  patient  must  be  kept  perfectly  quiet  in  bed,  on  liquid  food,  until  the  wound 
is  sound. 


INJURIES  OF  THE  ABDOMEN.  873 

(/')  When  they  are  injured  they  must  be  dealt  with  accortling  to  circum- 
stances. They  may  either  protrude  or  not  ;  in  the  former  case  there  is  the  addi- 
tional risk  of  strangulation  (owing  to  the  lessened  pressure  upon  the  extruded  part 
it  always  becomes  intensely  congested)  ;  in  the  latter,  of  some  of  the  contents  of 
the  hollow  viscera  (if  they  are  hurt)  entering  the  peritoneal  cavity.  Whichever 
it  is,  there  should  be  no  hesitation  in  enlarging  the  external  wound  if  there  is  not 
sufficient  space,  or  making  another  if  it  is  not  conveniently  situated. 

The  omentum  should  be  thoroughly  cleansed  with  a  dilute  antiseptic  and 
returned.  If  it  is  too  dirty  and  badly  torn,  or  if  it  is  very  much  congested,  it 
may  be  treated  as  in  an  ordinary  case  of  hernia — ligatured  in  successive  portions 
with  silk,  cut  off,  and  the  stump,  after  it  is  certain  there  is  no  bleeding,  reduced. 

The  hollow  viscera,  if  the  wound  involves  the  peritoneal  surface,  must  be 
made  secure  by  means  of  sutures.  If  there  is  only  a  small  puncture,  the  mucous 
coat  often  prolap.ses  and  plugs  the  opening,  so  that  there  is  no  escape  ;  but  it  is 
not  wise  to  trust  to  this ;  it  is  much  safer  to  replace  the  everted  edges  and  unite 
the  serous  surfaces  over  it  with  Lembert's  suture.  Clean  incised  wounds  should 
be  treated  in  the  same  way.  Even  contused  wounds,  such  as  are  caused  by  bullets, 
may  be  sutured  so  long  as  the  internal  diameter  of  the  intestine  is  not  reduced  to 
half  its  normal  size,  and  sometimes  it  may  be  possible  to  render  them  more  secure 
by  making  use  of  omental  grafts,  after  Senn's  fashion.  If,  however,  owing  to  the 
amount  of  bruising  or  the  situation  of  the  injury,  it  is  not  possible  to  effect  this 
without  causing  too  much  contraction,  or  if  there  are  numerous  wounds  close 
together,  it  is  safer  to  resect  the  injured  portion,  removing  it  altogether,  or,  in 
addition  to  sewing  up  the  wounds,  to  establish  what  is  known  as  an  intestinal 
anastomosis — graft  one  piece  into  the  side  of  another.  Finally,  if  this  is  imprac- 
ticable, or  if,  from  the  patient's  condition,  it  is  not  likely  that  he  would  stand  so 
prolonged  an  operation,  an  artificial  anus  must  be  made,  the  two  ends  being 
adjusted  side  by  side,  so  that  in  case  of  recovery  a  further  operation  can  be  per- 
formed at  a  later  period. 

In  those  rare  cases  in  which  the  extra-peritoneal  portion  of  the  bowel  is 
involved,  the  external  opening  should  be  enlarged  and  made  as  direct  as  possible, 
introducing  a  drainage  tube,  so  that  the  contents  of  the  bowel  may  escape  at  once. 
Gangrenous  intestine  must  be  treated  as  in  an  ordinary  case  of  hernia. 

If  the  solid  viscera,  such  as  the  liver  or  the  spleen,  are  wounded,  the  hemor- 
rhage is  usually  very  severe.  It  may  be  possible  sometimes  to  check  it  in  the  case 
of  the  former  by  means  of  deep  catgut  sutures,  and  the  spleen  and  portions  of  the 
liver  have  been  excised.  The  gall  bladder,  if  it  is  wounded,  should  be  sutured 
in  the  same  way  as  the  intestine. 

If  any  fjecal  matter,  bile,  foreign  substances,  or  even  any  large  quantity  of 
blood  has  entered  the  peritoneal  cavity  it  should  be  thoroughly  cleansed.  Hot 
water  (105°  F.)  and  boracic  lotion  are  the  least  injurious.  The  sides  of  the 
wound  are  raised,  and  the  fluid  directed  into  all  parts  of  the  cavity  by  means  of 
glass  tubes,  moving  the  bowels  gently  with  the  hand  so  that  the  whole  surface  may 
be  bathed  in  turn.  If  a  syphon  irrigator  is  used  the  force  of  the  stream  is  easily 
regulated  by  raising  or  lowering  it.  The  excess  can  be  removed  from  Douglas's 
pouch  with  a  sponge,  but  usually  in  these  cases  a  drainage  tube  is  advisable  for 
twenty-four  hours. 

In  many  cases  it  is  difficult  to  tell  whether  the  viscera  have  been  injured  or 
not,  and  if  they  have,  in  how  many  places.  Upward  of  a  dozen  perforations  may 
be  caused  by  a  single  bullet.  It  is  impossible  to  follow  the  track  of  a  ball  across 
the  peritoneal  cavity,  although,  of  course,  its  direction  may  help  a  little,  and  it  is 
equally  impossible  to  overhaul  and  examine  bit  by  bit  the  whole  of  the  intestine. 
It  is  in  these  circumstances,  according  to  Senn,  that  inflation  by  hydrogen  gas  is 
likely  to  prove  of  most  service,  the  tube  being  introduced  into  the  anus  and  the 
lowest  puncture  found  first  ;  then  into  this  one  for  the  next,  and  so  on  until  the 
whole  intestine  is  proved  sound. 

The  at'ter-treatment  of  these  cases  must  be  carried  out  on  general  principles. 
56 


S74    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Shock  is  always  very  severe  and  must  be  treated  by  warmth,  and,  if  the  heart 
shows  signs  of  failing,  stimulant  enemata.  Opium  is  absolutely  necessary,  as  it  is 
imperative  to  keep  the  bowels  confined  and  as  quiet  as  possible.  Nothing  should 
be  given  by  the  mouth  for  at  least  twenty-four  hours.  If  there  is  very  great  thirst 
it  can  be  relieved  by  a  warm  water  enema  with  much  less  disturbance.  As  a  rule, 
there  is  very  little  urine  secreted,  and  if  the  bladder  is  emptied  at  the  time  of  the 
operation  it  can  usually  be  left  for  twenty-four  hours.  If  at  the  end  of  that  time 
the  patient  cannot  pass  it  without  straining,  or  if  there  is  a  complaint  of  distention 
and  discomfort,  the  catheter  must  be  used  again.  Small  quantities  of  dilute  beef- 
tea  may  be  given  on  the  second  day,  or  a  little  weak  arrowroot.  Milk  is  better 
withheld,  as  it  is  apt  to  pass  into  the  small  intestine  in  curdled  masses. 
Injuries  of  the  kidneys,  bladder,  etc.,  are  dealt  with  elsewhere. 


SECTION    II.— SURGICAL  AFFECTIO.NS  OF  THE  STOMACH. 

Operations  on  the  Stomach. 

A  considerable  variety  of  operations  may  be  performed  upon  the  stomach. 
It  may  be  opened  and  stitched  to  the  wall  (gastrostomy),  or  to  the  adjacent  intes- 
tine (gastro-duodenostomy  or  gastro-jejunostomy)  ;  it  may  be  opened  (either  for 
the  removal  of  foreign  bodies  or  for  operations  upon  its  mucous  surface),  stitched 
up  again,  and  returned  into  the  peritoneal  cavity;  or  it  may  be  opened,  part  of 
its  wall  excised,  and  the  wound  secured  by  sutures. 

I.  Gastrostomy. — This  may  be  performed  for  cancerous,  traumatic,  or  syph- 
ilitic stricture  of  the  oesophagus,  when  dilatation  by  bougies  or  tubage  is  either 
impracticable  or  inadvisable.  Until  within  the  last  few  years,  the  mortality, 
especially  in  cases  of  carcinoma,  was  appalling,  the  patients  dying  either  from 
peritonitis  or  exhaustion.  Of  these  the  former  can  be  prevented  ;  the  latter  can 
only  be  avoided  by  operating  before  the  patient's  strength  is  too  much  reduced. 
It  must,  however,  always  be  recollected  that  this  operation  is  in  no  sense  a  cura- 
tive one;  it  merely  treats  a  symptom,  and  if  this  can  be  done  equally  well  with 
less  risk  to  life  in  some  other  way,  that  way  should  certainly  be  preferred 

The  line  of  the  incision  is  parallel  to  the  margin  of  the  ribs  upon  the  left 
side.  The  opening  must,  as  Greig  Smith  points  out,  be  as  high  as  possible,  so 
as  to  avoid  traction  upon  the  stomach  ;  but  it  must  be  at  least  an  inch  from  the 
edge  of  the  liver  and  from  the  ribs.  This  point  marks  the  middle  of  the  incision, 
which  is  about  two  inches  and  a  half  in  length.  The  skin  and  superficial  struc- 
tures are  divided,  the  sheath  of  the  rectus  exposed,  and,  as  recommended  by 
Howse,  opened  in  a  vertical  direction.  If  this  is  done,  and  the  fibres  of  the 
muscle  separated  from  each  other  in  the  same  line  with  the  handle  of  the  scalpel, 
the  orifice  is  surrounded  by  muscular  fibres,  and  the  risk  of  jirolapse  of  the  mu- 
cous membrane  and  escape  of  the  contents  of  the  stomach  diminished.  The 
subperitoneal  fat  is  then  exposed,  divided,  and  the  peritoneal  cavity  opened  in 
the  usual  way. 

If  the  stomach  is  distended  it  may  present  at  once  ;  nearly  always,  however, 
it  is  empty  and  collapsed,  hidden  between  the  liver  and  the  colon.  When  this  is 
the  case  the  fingers  must  be  introduced,  and  passed  along  the  under  surface  of  the 
left  lobe  ;  the  first  structure  they  touch  after  leaving  it  must  be  the  stomach.  The 
opening  in  the  stomach  should  preferably  be  near  the  cardiac  end  ;  but  if  this 
causes  the  least  traction,  it  must  be  made  in  the  most  convenient  situation. 

The  further  stages  depend  upon  whether  the  stomach  is  to  l)e  opened  at  once 
or  not.  If  the  time  can  be  afforded,  there  is  no  doubt  the  latter  is  advisable  ; 
even  twelve  hours  will  often  seal  the  surfaces  together  ;  in  two  days  the  lymph 
will  be  comparatively  firm  ;  but  when  the  patient  is  exhausted  from  the  combined 


OPERATIONS  ON  THE  STOMACH.  875 

effects  of  carcinoma,  starvation,  and  shock,  it  very  often  happens  that  this  is 
impracticable,  and  that  food  must  he  introduced  at  once.  Rectal  enemata  will 
maintain  existence  if  the  patient  is  already  well  nourished  and  is  kept  perfectly 
warm  in  bed,  without  beinj,^  exposed  to  injurious  influence  of  any  kind  ;  but 
under  conditions  such  as  these  they  are  exceedingly  unsatisfactory,  'rhe  tempera- 
ture is  the  best  guide  :   if  it  is  in  the  least  subnormal  there  is  no  time  to  waste. 

If  it  is  not  intended  to  open  the  stomach  for  some  days,  it  need  only  be  held 
up  against  the  edges  of  the  abdominal  wound  ;  the  serous  surfaces  grow  together, 
and  by  the  time  the  supporting  structure  is  removed,  the  lymph  is  sufficiently  firm. 
Two  hare-lip  pins  will  answer;  the  serous  and  muscular  coats  of  the  stomach  are 
pinched  up  together  and  transfixed,  and  the  ends  of  the  pins  (protected  with  a 
piece  of  drainage  tubing)  are  allowed  to  rest  upon  the  skin. 

Sutures  are  advisable  in  most  cases.  One  must  be  passed  through  the  serous 
and  muscular  coats  of  the  stomach  opposite  the  centre  of  the  opening.  It  gives 
something  to  hold  the  stomach  by,  so  that  it  does  not  fall  back,  and  later  it  marks 
the  spot  for  the  puncture.  The  others  must  traverse  the  whole  thickness  of  the 
abdominal  wall,  but  only  the  serous  and  muscular  coats  of  the  stomach.  I'hey 
may  be  interrupted,  two  long  ones  or  four  short  ones  being  used,  or  continuous, 
so  as  to  secure  adaptation  all  the  way  round,  the  skin  in  either  case  being  pro- 
tected by  passing  a  piece  of  rubber  tubing  under  the  projecting  loop.  In  addition 
a  second  set  of  sutures  may  be  inserted,  securing  the  serous  and  muscular  coats  of 
the  stomach  to  the  cut  edges  of  the  parietal  peritoneum  and  the  skin.  If  the 
stomach  is  to  be  opened  at  once,  or  within  twenty-four  hours,  this  is  essential. 

The  wound  should  be  protected  with  some  non-adhesive  dressing,  and  cov- 
ered with  abundance  of  wood-wool.  The  patient  must  be  kept  as  warm  as  possible 
and  fed  by  means  of  enemata  ;  a  certain  amount  of  stimulant  is  always  advisable 
(in  spite  of  its  tendency  to  make  the  patient  lose  heat),  as  not  unfrequently  the 
heart  suddenly  gives  out.  Traction  upon  the  stomach  alone  is  sufficient  to  make 
it  stop,  and  when  the  patient's  reserve  is  almost  used  up  the  greatest  care  is  re- 
quired. 

According  to  Howse,  five  days  is  the  usual  time  for  opening  the  stomach. 
The  extent  of  the  adhesions  depends  partly  upon  the  strength  of  the  patient,  partly 
upon  the  amount  of  disturbance  the  structures  have  been  subjected  to,  and  the 
accuracy  of  adaptation.  Occasionally  when  the  exhaustion  is  very  extreme,  as  in 
advanced  carcinoma,  they  hardly  form  at  all.  No  anaesthetic  is  required  ;  the 
suture  that  has  been  left  marks  the  spot  (otherwise  it  may  be  very  difficult  to 
make  it  out),  and  all  that  is  needed  is  a  puncture  with  a  very  sharp  double-edged 
tenotomy  knife.  A  blunt  one  may  fail  to  penetrate  the  mucous  coat.  A  small 
catheter  is  then  introduced  by  the  side  of  the  knife  :  this  is  withdrawn  and  some 
warmed  and  peptonized  milk  injected.  The  catheter  should  be  secured  in  the 
wound,  or  it  may  be  difficult  to  find  the  opening  again  ;  the  irritation  of  the  acid 
gastric  juice  can  be  prevented  to  some  extent  by  using  dressings  soaked  in  carbon- 
ate of  soda.  After  a  time  the  size  of  the  catheter  may  be  increased,  or  it  may  be 
replaced  by  a  soft  red  rubber  tube  provided  with  a  flange,  somewhat  similar  to 
those  used  for  tracheotomy. 

2.  Gastro-diiodenosfomy  or  gastro-jejunostomy  may  be  required  in  cases  of 
stenosis  of  the  pylorus,  whether  simple  or  malignant.  Of  the  two  the  latter  is  to 
be  preferred,  as  the  first  loop  of  the  jejunum  is  covered  over  with  peritoneum  and 
can  be  brought  without  any  undue  traction  into  contact  with  the  anterior  surface 
of  the  stomach.  A  communication  is  made  between  the  two  viscera,  and  their 
serous  and  muscular  coats  accurately  sewn  together  all  round.  In  order  to  effect 
this  they  must  be  brought  up  well  into  the  wound,  and,  as  Barker  recommends, 
the  suturing  on  the  posterior  surface  should  be  completed  as  far  as  possible  before 
any  opening  is  made.  It  is  probable,  however,  that  in  any  operation  of  this 
kind  in  the  future,  either  Senn's  decalcified  bone-plates  (as  described  in  opera- 
tions upon  the  intestine)  or  some  modification  of  them  will  be  employed,  as  the 
adaptation  is  much  more  perfect  and  secure,  without  requiring  one-fourth  of  the 


876    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

time  ;  and  it  does  not  seem   unlikely  that  this  operation  will  almost   supersede 
pylorectoniy  for  carcinoma. 

3.  Gastrotomy. — Hy  this  is  understood  a  simjjle  incision  in  the  wall  of  the 
stomach,  for  the  jjurpose  of  removing  a  foreign  body,  dilating  the  u;so])hagus  or 
pylorus,  or  curetting  a  carcinoma.  'I'he  wound  is  a  temporary  one,  and  after  the 
purpose  for  which  it  was  made  is  accomplished,  is  sewn  u])  again.  It  must  not  be 
confused  with  laparotomy,  which  is  confined  to  an  incision  into  the  abdominal 
cavity. 

The  stomach  (imless  there  is  some  contra-indication)  should  first  be  washed 
out  with  a  solution  of  boracic  acid.  Some  may  be  left  in  if  it  is  thought  desira- 
ble that  the  cavity  should  be  partially  distended,  but  it  is  not  in  any  way  neces- 
sary. The  parietal  incision  may  be  in  the  middle  line  or  i)arallel  to  the  costal 
margin  on  the  left  side,  having  its  centre  opposite  the  eighth  or  ninth  rib.  The 
stomach  is  found  in  the  same  way  as  before  ;  brought  to  the  surface  and  secured 
by  two  temporary  sutures  passed  through  the  serous  and  muscular  coats.  The 
incision  (which  should  not  be  made  until  every  precaution  has  been  taken  to  j)re- 
vent  any  of  the  contents  escaping)  should  be  parallel  to  the  vessels,  vertical,  that 
is  to  say.  Afterward  the  wound  is  secured  by  Lembert's  suture ;  the  stomach 
allowed  to  fall  back,  and  the  parietal  incision  closed  in  the  usual  way. 

This  may  be  required  for  the  removal  of  a  foreign  body  from  the  stomach  or 
the  lower  end  of  the  asophagus  ;  in  cases  of  (non-malignant)  stenosis  of  the  pylo- 
rus or  oesophagus  (Loreta's  operation,  or  dilatation  of  the  contracted  orifice  from 
within  by  means,  first  of  one  finger,  then  of  two,  until  it  feels  as  if  further  disten- 
tion would  result  in  tearing)  ;  or  for  the  scraping  away  of  a  malignant  growth 
from  the  interior  by  means  of  a  curette  [as  proposed  by  Bernays,  of  St.  Louis]. 
So  far  as  the  operation  is  concerned  it  has  proved  very  successful,  but,  of  course, 
in  the  last-mentioned  case,  it  can  only  be  palliative  in  its  action,  and  it  is  ques- 
tionable whether  some  form  of  anastomosis  with  the  intestine  would  not  be  pre- 
ferable. 

4.  Fylo7-ectomy. — In  this  the  pylorus,  with  the  adjacent  parts  of  the  stomach 
and  duodenum,  is  excised,  and  the  orifices  ap]:)roxi mated  and  fastened  together 
with  sutures.  It  is  only  required  in  cases  of  malignant  disease,  and  then  is  only 
advisable  when  there  are  no  adhesions  or  enlarged  glands.  If  either  of  these 
complications  is  present,  the  removal  of  the  growth  will  not  cure  the  patient ;  and 
gastro-jejunostomy  affords  as  fair  a  prospect  of  relief  with  infinitely  less  risk.  The 
pylorus  must  be  isolated  ;  the  great  omentum  detached  and  ligatured  in  successive 
portions  without  endangering  the  blood  supply  of  neighboring  structures  more 
than  can  be  helped  ;  the  stomach  opened  and  divided  on  the  proximal  side  of  the 
growth  ;  and  the  duodenum  on  the  distal.  As  soon  as  the  mass  is  removed  and 
all  bleeding  stop]:)ed,  the  wounds  must  l)e  .secured.  As  that  in  the  stomach  is  much 
the  larger  of  the  two,  it  must  be  sewn  up  independently,  until  the  orifice  is  con- 
tracted to  the  size  of  that  of  the  duodenum.  Many  of  the  sutures  may  be  passed 
from  the  inner  surface;  but,  if  possible,  a  second  set,  joining  the  muscular  and 
serous  coats  only,  should  be  used  as  well.  The  operation  has  on  many  occasions 
taken  several  hours  to  perform  ;  the  number  of  sutures,  if  leakage  is  to  be  pre- 
vented, is  enormous  ;  the  risk  of  gaping,  especially  where  the  peritoneal  coat  is 
not  firmly  adherent,  is  very  great,  and  in  by  far  the  majority  of  instances  the 
patient  has  either  never  rallied  from  the  shock  or  has  died  shortly  after  from  peri- 
tonitis. 

5.  In  addition  to  this,  gastrorraphy  has  been  performed  for  perforating  ulcer, 
the  stomach  being  drawn  forward  and  the  opening  secured  by  sutures. 


HERNIA.  877 


SECTION  111.— HERNIA. 

The  escape  of  any  of  the  viscera  from  its  natural  cavity  is  a  hernia,  provided 
it  passes  through  an  abnormal  or  accidental  opening  ;  but  when  untjualified,  it  is 
usually  applied"  to  the  abdomen  only.  Internal  hernia,  in  which  a  portion  of  the 
intestine  is  disj^laced  inside  the  peritoneal  cavity,  is  treated  of  with  internal  stran- 
gulation. 

Causes. — These  may  be  immediate  or  predisposing. 

1.  Immediate  or  Exciting  Causes. — Hernia  may  nearly  always  be  traced  to 
the  action  of  the  abdominal  muscles  upon  the  viscera.  It  is  more  common  among 
those  that  follow  laborious  occupations  with  constant  heavy  strains,  than  among 
those  who  lead  a  sedentary  life,  and  it  may  be  caused  either  by  a  single  sudden 
effort  or  by  continual  repetition  ;  even  the  straining  in  calculus  of  the  bladder,  or 
phimosis,  are  sufficient  in  those  who  are  predisposed  to  it. 

2.  Fredisposing  Causes. — Certain  parts  of  the  abdominal  wall  are  naturally 
weaker  than  the  rest  :  the  umbilicus,  for  example,  the  crural  ring,  especially  in  the 
adult  female,  and  the  inguinal  canal.  In  many  there  is  a  distinct  bulging  over  the 
internal  abdominal  ring  on  coughing  or  straining;  the  internal  oblique  is  poorly 
developed  ;  or  it  does  not  arise  from  Poupart's  ligament  in  front  of  this  spot ;  the 
openings  are  large,  or  the  conjoined  tendon  and  the  intercolumnar  fascia  are  thin 
and  weak. 

Congenital  malformations  are  not  infrequent  ;  late  descent  of  the  testes,  for 
example,  and  patency  of  the  tunica  vaginalis  ;  defective  development  of  the  dia- 
phragm ;  or  separation  of  the  recti  from  each  other  in  the  linea  alba. 

In  other  cases  there  are  acquired  defects  :  the  muscles  have  been  torn  or 
bruised  ;  the  fasciae  divided  in  operations  ;  inflammation  has  caused  softening  and 
yielding  of  the  wall ;  there  has  been  repeated  distention,  as  in  pregnancy  or  ascites  ; 
or  sudden  emaciation  has  led  to  absorption  of  the  fat  from  over  the  crural  ring. 

The  length  of  the  mesentery  is  of  some  assistance.  In  infancy  it  measures  one- 
fifth  of  the  body  (taking  it  from  the  root  to  the  convex  border  of  the  intestine), 
at  puberty  one-eighth,  and  in  adult  life  one-ninth  ;  and  its  root  lies  much  lower 
on  the  right  side  than  on  the  left,  which  accounts  in  part  for  the  greater  frequency 
of  the  congenital  variety  upon  that  side.  But  probably  it  is  never  too  short  to 
allow  a  hernia  to  descend.  Instances  are  recorded  in  which  a  piece  of  intestine, 
which  normally  could  not  touch  the  internal  ring,  has  been  forced  into  it  by  acci- 
dental pressure. 

The  general  laxity  of  the  pelvic  peritoneum  during  child-bearing  may  account 
in  some  measure  for  the  frequency  of  femoral  hernia  at  that  time  of  life  ;  and  there 
is  no  doubt  that  the  descent  of  a  hernia  for  the  first  time  is  greatly  favored  by 
diarrhoea  and  other  disorders  which  might  reasonably  be  imagined  to  cause  relaxa- 
tion of  the  mesentery. 

Prolapse  of  the  mesentery  is  very  important.  It  rarely  occurs  before  late 
adult  life  and  is  always  associated  with  a  peculiar  and  easily  recognized  bulging 
of  the  lower  part  of  the  abdomen.  The  epigastric  region  is  flat  and  hollow  :  be- 
low there  is  a  great  projection,  not  only  in  the  middle  line,  but  at  the  sides,  form- 
ing a  sort  of  triple  bulging,  due  to  the  yielding  of  the  muscles  at  their  weakest 
part.  This  always  means  that  the  root  of  the  mesentery  has  glided  down,  possibly 
owing  to  the  degeneration  of  the  suspensory  muscle  and  ligament  at  the  end  of 
the  duodenum,  and  that  any  measure  for  radical  cure  that  aims  at  merely  strength- 
ening the  abdominal  wall  must  fail.  Very  often  in  these  cases  prolapse  of  the 
kidneys  and  of  other  viscera  occurs  at  the  same  time. 

Hernia,  there  is  no  doubt,  is  hereditary,  or  rather  the  conditions  that  predis- 
pose to  it.     Men  are  more  liable  to  it,  especially  the  inguinal  forms,  than  women ; 


878    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

on  the  other  hand,  the  femoral  and  unibihcal  are  more  common  in  the  latter. 
Owing  to  the  freciuencyof  the  congenital  inguinal  variety,  hernia  is  met  with  very 
often  during  the  first  year  of  life  ;  and  at  this  time  it  is  more  common  on  the  right 
side  than  on  the  left.  Then  the  number  falls  off  rapidly  and  continues  to  diminish 
until  after  puberty.  From  that  time  it  grows  larger,  until  it  has  been  said  that 
one  in  four  of  those  over  sixty  years  of  age  suffer  from  it.  Prolapse  of  the  mesen- 
tery, as  years  advance,  tends  to  eciualize  the  frequency  on  the  two  sides,  so  that  at 
five  and  forty  left  hernia  is  as  common  as  right,  and  a  little  later  double  hernia 
more  common  than  either  alone. 

Anatomy. 

A  hernia  is  generally  enclosed  in  a  sac  continuous  with  the  peritoneum, 
and  surrounded  by  prolongations  of  the  various  layers  that  form  the  wall  of  the 
abdomen. 

I.  The  Sac. — Except  in  cases  of  rupture  of  the  wall  of  the  abdomen,  hernia 
of  the  bladder,  and  sometimes  of  the  colon,  a  peritoneal  sac  is  always  pre.sent.  In 
congenital  inguinal  hernia  it  exists  already  ;  the  hernia  descends  into  the  open 
vaginal  process  of  peritoneum  in  front  of  the  spermatic  cord.  In  all  others  it  is 
formed  gradually  by  the  pressure  of  the  viscera  upon  the  inner  surface.     At  first 


Fig.  368. — Oblique  Inguinal  Hernia.     Bubonocele  on  right 
side,  but  passing  through  external  ring  on  left. 


Fig.  369. — Direct  Inguinal  Hernia. 


there  is  a  simple  depression  with  a  wide  orifice;  then,  as  the  protrusion  extends 
further  and  reaches  more  yielding  structures,  the  peritoneum  becomes  stretched 
and  displaced  until  it  forms  a  globular  sac  communicating  with  the  normal  cavity 
by  a  narrow  neck.  In  this  stage  the  lining  is  still  unaltered,  merely  thrown  into 
folds  at  the  neck,  owing  to  the  shape  of  the  parts,  and  the  contents  can  only  be 
strangulated  by  the  contraction  of  the  structures  that  lie  around.  Later,  the  neck 
becomes  thickened,  hardened,  and  condensed  ;  the  folds  grow  together  and  fuse 
with  the  fibrous  structures  outside  until  they  form  a  ring  of  dense  cicatricial  tissue, 
and  this  keeps  on  contracting,  until  sometimes,  if  the  hernia  is  prevented  from 
descending,  it  closes  completely.  Not  unfrequently,  however,  before  this  stage  is 
reached,  while  there  is  still  a  small  aperture  in  the  centre  of  a  dense  fibrous  ring,  a 
knuckle  of  intestine  is  scjueezed  down  through  it,  and  is  so  tightly  held  that  the 
circulation  in  it  is  stopped  :   in  other  words,  it  is  strangulated. 

Sometimes  more  than  one  constriction  is  present.  The  original  neck  may 
have  been  pushed  down  by  a  fresh  protrusion,  and  a  second  neck  formed  above  it ; 
or  the  sac  may  have  been  constricted  at  the  same  time  in  two  places,  at  the 
internal  and  the  external  rings,  for  example ;  or,  in  the  congenital  variety,  a 
constriction  may  make  its  appearance  in  the  tunica  vaginalis  on  a  level  with  the 
upper  part  of  the  testicle,  so  that  the  cavity  assumes  the  shape  of  an  hour-glass ; 
and  any  one  of  these  may  be  the  seat  of  strangulation. 


HERNIA.  879 

Diverticula  also  are  sometimes  fouiul,  especially  in  the  congenital  form,  and 
not  untVeciucntly  they  are  very  large,  extending  upward  in  the  front  wall  of  the 
abdomen  between  the  muscles,  or  behind  them  in  front  of  the  fascia.  These 
intraparietal  sacs  are  of  great  importance,  for  if  a  hernia  descends  it  may  easily  be 
returned  into  the  diverticulum  instead  of  the  abdomen,  leaving  the  strangulation, 
if  one  is  present,  unrelieved. 

Hydrocele  of  the  sac  is  a  very  rare  condition.  Several  pints  of  fluid  may 
collect  in  it  when  the  orifice  is  temporarily  obstructed  by  a  hernia  ;  but  the  term 
hydrocele  should  be  reserved  for  those  cases  in  which  fluid  accumulates  after  the 
neck  of  the  sac  has  l)een  completely  and  permanently  closed.  It  has  been  met  with 
in  femoral  and  in  inguinal  hernicX,  and  it  may  render  the  diagnosis  very  difficult. 

2.  The  Contents. — With  the  exception  of  the  pancreas,  all  the  viscera  of  the 
abdomen  have  been  found  in  hernial  sacs  at  one  time  or  another ;  the  most 
common  is  the  ileum,  especially  the  last  few  feet,  and  then  the  omentum.  The 
caecum  and  colon,  which  come  next,  are  much  more  rare,  and  the  others  are  only 
met  with  in  congenital  malformations. 

When  the  i^rotrusion  consists  of  intestine  it  is  called  an  enterocele ;  when 
omentum,  epiploccle ;  if  both  are  together,  entero-epiplocele.  In  this  case  the 
intestine  nearly  always  lies  behind  the  omentum,  concealed  by  it;  in  some  rare 
instances,  however,  it  is  in  the  middle,  in  a  kind  of  inner  sac.  Cystocele, 
gastrocele,  and  other  similarterms,  are  occasionally  used. 

3.  The  structures  that  cover  a  small  hernia  are  but  little  changed  ;  they  merely 
stretch  and  yield,  and  the  sac  can  still  be  easily  reduced.  As  the  size  increases, 
however,  this  becomes  different.  The  subserous  fat  wastes  and  grows  fibrous  ;  the 
sac  becomes  adherent ;    it  is  thickened  in  some 

places  from  the  irritation  of  the  truss,  and  thinned  ^^ 

in  others  ;  the  coverings  become  matted  together,        •^"'  "* 

so  that  their  structure  can  no  longer  be  distin- 
guished ;  and  at  length  the  parts  around  are  hope- 
lessly distorted  from  the  continued  traction,  so 
that,  for  example,  the  internal  inguinal  ring  is 
dragged  opposite  the  external. 

Symptoms. — A  hernia  often  causes  griping 
and  colicky  pains  in  the  abdomen,  probably  from 
the  way  in  which  it  drags  on  the  mesentery  and 
impedes  peristalsis  ;  while  dyspepsia  and  a  feeling 
of  discomfort  on   exertion   and  after   meals   are  f.g.  37o.-Femorai  Her,„a. 

nearly  always  present ;   but  in  many  cases  either 

this  is  not  noticed  or  is  put  down  to  other  causes.  The  character  of  the  swelling 
depends  upon  its  contents.  When  the  main  bulk  consists  of  intestine  the  surface 
is  uniform  and  elastic  ;  a  distinct  impulse  can  be  felt  when  the  patient  coughs  or 
strains ;  and  if  it  is  of  any  size  and  the  walls  are  not  too  tense,  it  is  resonant  on 
percussion.  Omentum,  on  the  other  hand,  feels  hard  and  doughy  ;  the  surface  is 
uneven,  and  though  there  is  a  certain  degree  of  impulse  in  most  cases  communi- 
cated from  the  abdomen,  the  swelling  does  not  become  tense  and  expand  in  all 
directions  in  the  .same  way  as  intestine.  The  method  of  reduction,  too,  is  dif- 
ferent ;  the  intestine  slips  back  suddenly,  often  with  a  peculiar  gurgling,  and  the 
patient  experiences  at  once  a  feeling  of  relief;  omentum  disappears  more  gradually, 
and  if  both  are  down  together,  is  almost  always  the  last  to  go. 

The  sac  can  only  be  reduced  in  the  early  stage  of  a  hernia,  before  it  has 
acquired  a  definite  shape  and  contracted  adhesions  to  the  surrounding  structures. 

Treatment. — A  hernia  must  be  prevented  from  descending,  either  by  means 
of  a  suitable  contrivance  (a  truss  or  belt),  or  by  closing  the  aperture  through  which 
it  has  escaped.  The  former  is  only  palliative,  although,  if  it  is  adopted  suffi- 
ciently early  in  children  and  carried  out  with  proper  care,  a  permanent  cure  may 
generally  be  looked  forward  to;  the  latter  is  known  as  the  radical  cure,  and  aims 
at  allowing  the  patient  to  dispense  with  a  truss  altogether. 


88o     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

I.    Trusses. — A  truss  consists  of  a  pad  or  cushion  attached  to  a  metal  spring 

surrounding  the  body,  so  arranged  with  straps  that  its  position  remains  unaltered 
in  the  most  varied  movements.  Inelastic  trusses,  made  of  a  leather  band  (as  the 
Moc-Main  truss)  instead  of  a  spring,  are  of  use  in  large  irreducible  herniae,  but 
cannot  be  relied  upon  for  ordinary  work  ;  they  fail  to  exert  sufficient  pressure  when 
the  patient  is  stooping,  the  jjosition  of  all  others  in  which  the  hernia  most  easily 
descends. 

The  pad  is  generally  made  of  cork,  covered  with  flannel,  linen,  and  wash- 
leather  ;  but  rubber,  water,  and  air  cushions  may  be  used  where  pressure  is  painful 


Fig.  371. — Truss  for  Inguinal  Hernia. 

or  the  surface  irregular.  For  an  oblique  inguinal  hernia  it  should  be  pear-shaped, 
about  three  inches  long,  two  inches  at  its  broadest  part,  and  three-quarters  of  an 
inch  in  thickness;  the  outer  surface  is  flat,  and  has  two  studs  upon  it  for  the 
attachment  of  the  straps  ;  the  inner  is  slightly  convex,  looking  upward  as  well  as 
backward,  especially  when  the  abdomen  is  protuberant,  and  lies  upon  the  internal 
ring  and  the  inguinal  canal,  not  touching,  though  it  may  come  quite  close  to,  the 
pubic  spine.  If  the  hernia  is  congenital,  the  pad  should  be  prolonged  downward 
between  the  scrotum  and  the  thigh,  tapering  off  gradually  (rat-tail  truss; ;  and  if  it 
is  direct;  or  if  it  is  an  old  oblique  one  with  the  rings  dragged  nearly  opposite  each 


Fig.  372. — Single  Circular  Spring  Truss  for  Congenital  Scrotal  Hernia. 


Other,  a  cross-bar  may  be  added  over  the  upper  border  of  the  pubic  symphysis,  so 
that  the  pubic  spine  lies,  as  it  were,  in  a  recess.  In  these  ca.ses,  however,  it  is 
usually  advisable  for  the  patient  to  wear  a  double  truss  ;  very  often,  especially  in 
the  direct  form,  there  is  a  certain  amount  of  weakness  on  the  other  side  as 
well ;  the  inconvenience  of  a  double  truss  is  no  greater  than  that  of  a  single  one  ; 
and  if  the  two  pads  are  held  together  by  a  strap  or  cross-bar  over  the  pubes,  the 
security  is  very  much  greater. 

Wood's  pads  are  based  on  a  different  princijjle  ;    they  are  made  of  boxwood, 
ivory,  ebonite,  or  some  other  firm,  non-absorbent  material,  and  they  are  shajied  so 


HERNIA. 


88i 


that  the  pressure  falls,  not  upon  the  opening,  but  all  round  it.  The  pad  for  an 
oblicpie  inguinal  hernia,  for  example,  is  cut  like  a  horse-shoe  with  one  side  (that 
which  covers  the  inner  pillar)  longer  than  the  other  ;  the  spring  is  fixed  to  the 
geometric  centre ;  the  spermatic  cord  and  the  pubic  spine  fit  themselves  into  the 
interval  between  the  sides  of  the  shoe  ;  and  the  rupture  is  i)revented  from  descend- 
ing by  the  tension  across  the  opening  ;  that  for  a  direct  hernia  is  in  the  form  of  a 
ring,  the  centre  of  which  corresponds  to  the  axis  of  the  hernial  opening.  In 
either  case  the  tissues  j^roject  upward  in  the  centre,  where  there  is  no  pressure  ; 
and  this  and  the  double  bearing  greatly  diminish  the  chance  of  slipping. 

For  a  femoral  hernia  the  pad  is  smaller,  beveled  a  little  on  the  outer  side  to 
avoid  pressure  upon  the  femoral  vein,  and  above  so  that  it  may  fit  well  up  under 
Poupart's  ligament  and  bring  the  walls  of  the  canal  together.  If  an  operation 
has  been  performed,  and  Gimbernat's  ligament  freely  divided,  this  is  not  enough  ; 
in  such  cases  a  thigh-belt,  laced  up  around  the  upper  part  of  limb,  with  a  trian- 
gular pad  over  the  saphenous  opening  and  filling  up  the  greater  part  of  Scarpa's 
triangle,  is  required,  and  even  this  will  only  prevent  the  hernia  increasing  in  size. 

Umbilical  herni^e  are  best  kept  in  place  by  a  shallow  concave  plate,  which  at 
the  same  time  supports  the  lower  part  of  the  abdomen.  Nipple-shaped  projec- 
tions only  make  the  opening  larger.  Pads  with  spiral  springs  are  very  comfort- 
able, but  cannot  be  relied  qn  where  strength  is  required,  as  they  are  apt  to  yield 
if  the  strain  is  severe. 

The  pad  in  most  cases  is  rigidly  attached  to  the  spring ;  but  in  some,  as  in 
Salmon  and  Ody's,  there  is  a  ball-and-socket  joint,  and  in  others  it  can  be  shifted 


Fig.  373. — Double  Femoral  Truss  with  Circular  Spring. 


upward  or  downward  and  fastened  in  any  position.  The  spring  passes  round  the 
rim  of  the  pelvis,  fitting  closely  to  the  figure,  just  belo\v  the  iliac  spines,  and 
above  the  glutei.  If  the  truss  is  a  single  one  the  free  end  is  beaten  out  flat,  and 
shaped  so  as  to  cling  round  the  opposite  hip.  Its  strength  is  regulated  by  the 
muscular  condition  of  the  patient  and  the  size  of  the  rupture,  and  it  should  ahvays 
exert  slight  pressure,  even  when  the  body  is  at  rest.  Where  the  employment 
necessitates  great  exertion,  it  may  be  advisable  to  have  two  trusses  of  different 
strength.  The  under  strap,  which  prevents  riding  up,  should  always  be  fastened 
to  the  lower  stud,  and  in  the  erect  position  should  be  moderately  tight. 

Measurements. — In  young  adults  with  a  flat  abdoiiien  it  is  sufficient  to  give 
the  measurement  from  the  pubic  symphysis  to  the  anterior  superior  spine,  and 
from  this  round  the  back  to  the  opposite  one ;  but  in  all  other  cases  the  exact  line 
of  the  truss  should  be  followed,  from  the  ring  to  the  spine  of  the  ilium,  from  this 
to  the  opposite  one,  and  then  back  to  the  ring  again  ;  and  when  there  is  any 
peculiarity  of  structure,  such  as  an  oblique  pelvis  or  pendulous  abdomen,  this 
should  be  mentioned,  and  the  direction  in  which  the  pad  is  to  press  carefully 
noted.  The  vertical  distance  of  the  internal  ring,  from  a  line  joining  the  two 
anterior  superior  spines,  is  often  useful.  In  addition,  full  particulars  must  be 
given  as  to  the  size  and  nature  of  the  hernia,  the  side  on  which  it  is  situated,  the 
muscular  condition  and  the  employment  of  the  patient,  and  the  age  and  sex. 

To  test  the  truss,  the  patient  should  be  seated  on  the  edge  of  a  chair,  with 
the  knees  separated  so  that  the  structures  around  the  rings  are  relaxed,  and  di- 


882    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

reeled  to  strain  downward.  If  tlie  rupture  does  not  escape,  the  pad  fits  the  open- 
ing and  the  spring  is  sufficiently  strong.  Too  strong  a  one  is  injurious,  and  its 
pre.ssure  tends  to  cause  absorption  of  the  tissues  beneath.  For  the  first  week  the 
truss  is  generally  exceedingly  uncomfortable,  but  it  must  be  worn  all  day,  and,  in 
some  instances,  at  night  as  well,  though  a  lighter  one  is  sufficient  then.  In  any 
case  it  should  be  adjusted  in  the  morning  while  the  patient  is  still  lying  down, 
care  being  taken  that  the  hernia  is  completely  reduced.  U  the  skin  becomes 
tender,  it  may  be  bathed  with  eau  de  Cologne  and  dusted  with  violet  powder. 
Waterproof  trusses,  covered  with  india-rubber,  are  required  for  bathing. 

Innumeral)le  modifications  have  been  devised  for  special  hernice.  An  excel- 
lent one  consists  of  a  .semi-circular  spring  with  a  broad  flat  plate  on  the  sacrum, 
and  a  movable  pan  over  the  ])rotrusion  ;  and  it  should  be  adjusted  around  the 
opposite  side  of  the  trunk.  Pads  filled  with  sand,  or  moulded  on  the  spot  itself, 
are  often  of  use  if  the  skin  is  tender  and  a  water-pad  is  not  available.  Irreducible 
hernia  may  be  enclosed  in  a  hinge-cup,  made  of  a  rim-plate  covered  with  leather, 
or  supported  in  a  laced  bag  truss,  in  the  hope  that  the  size  may  be  diminished  by 
the  continued  pressure.  Belts  may  be  required  for  umbilical  or  ventral  protru- 
sions. A  skein  of  Berlin  wool  may  be  used  for  the  congenital  hernia  of  children, 
as  described  by  Coates,  of  Salisbury.  It  consists  of  about  twenty  threads  tied  to- 
gether at  intervals  to  prevent  their  separating,  with  the  loop-end  of  the  skein 
placed  over  the  abdominal  ring  ;  the  other  end  is  carried  across  the  pubes  round 
the  opposite  side  behind  the  body,  and  brought  down  in  the  fold  of  the  groin  to 
pass  through  the  loo[)  ;  it  is  then  taken  between  the  thigh  and  the  scrotum  under 
the  limb,  and  brought  up  behind  it  to  be  fastened  to  the  horizontal  portion.  The 
loop,  with  the  skein  passing  through  it,  forms  a  pad  resting  on  the  inguinal  canal ; 
the  wool  is  sufficiently  elastic  to  exert  reasonable  pressure,  and  cannot  gall  the 
skin  Moreover,  it  can  be  renewed  as  often  as  required,  and  when  it  is  thought 
that  the  truss  may  be  left  off  the  strength  can  be  gradually  reduced  by  diminish- 
ing the  number  of  strands. 

Irreducible    Hernia. 

A  hernia  is  irreducible  when,  without  the  circulation  or  the  passage  of  faeces 
being  impaired,  it  cannot  be  returned  into  the  abdomen. 

In  a  few  cases  this  is  due  to  changes  in  the  tissues  around  or  in  the  sac  ;  nearly 
always  it  is  the  result  of  the  condition  of  the  rupture  itself.  The  size  may  be  the 
obstacle,  as  in  large,  neglected  scrotal  or  umbilical  hernige.  The  shape  may  pre- 
vent it,  especially  if  it  consists  of  omentum  ;  this  assumes  the  form  of  an  inverted 
mushroom,  tough  and  fibrous  at  the  neck,  wide  and  expanded  in  the  body  of  the 
sac.  Much  fluid  renders  it  difficult,  owing  to  the  way  in  which  it  protects  the 
intestine  from  manipulation  ;  but  this  is  usually  only  temporary,  and  can  be  easily 
removed  by  tapping.  Adhesions  are  exceedingly  common  and  are  much  more 
serious.  They  may  form  between  the  sac  and  its  contents,  or  between  the  struc- 
tures inside,  so  that  they  cannot  change  their  relative  position.  Finally,  in  some 
cases  it  is  due  to  anatomical  peculiarities,  such  as  the  absence  of  a  peritoneal  cov- 
ering, as  in  hernia  of  the  bladder. 

Irreducible  hernic^,  if  left  to  themselves,  tend  to  increase  in  size  until  almost 
the  whole  of  the  intestines  may  find  their  way  into  the  sac.  Even  when  they  are 
small  they  cause  extreme  discomfort  ;  dyspepsia,  dragging  pains,  and  colic  are  of 
frequent  occurrence,  especially  after  food,  from  interference  with  the  movement  of 
the  stomach  ;  when  large,  they  l)ecome  a  serious  source  of  danger.  Constipation 
may  lead  to  the  accumulation  of  faeces,  and  this  to  obstruction  ;  strangulation  may 
occur,  either  gradually,  as  in  consequence  of  obstruction,  or  suddenly,  from  the 
descent  of  a  fresh  portion.  This  is  especially  frequent  in  the  femoral  ej^iplocele 
of  women  ;  irreducible  omentum  is  in  them  of  common  occurrence,  and,  from  its 
giving  rise  to  no  serious  symptoms,  often  receives  no  attention  ;  but  the  band 
running  down  from  the  stomach  to  the  crural  ring  acts  as  an  inclined  plane, 
which,  as  the  intestines  sweep  round  the  peritoneal  cavity,  guides  them  infallibly 


HERNIA.  8S3 

into  the  orifice.  Besides  this,  an  irreducible  hernia  is  constantly  liable  to  become 
inflamed,  as,  owing  to  its  size,  it  is  very  much  exposed  to  injury  ;  and  even  rupture 
of  the  intestines  or  of  the  sac  may  occur  from  accidental  violence. 

Treatment. — This  must  be  guided  by  the  age  and  condition  of  the  patient 
and  the  size  and  nature  of  the  rupture. 

Where  the  patient  is  old  and  feeble,  not  likely  to  undertake  vigorous  work, 
the  hernia  should  be  enclosed  in  a  bag-truss,  laced  up  on  one  or  both  sides,  or  in 
a  cup  made  of  soft  leather  supported  by  a  metal  rim.  Sometimes,  as  suggested 
by  Bryant  (Fig.  374),  the  pad  may  be  made  of  metal  moulded  on  a  cast  taken  from 
the  hernia  when  it  is  at  its  smallest.  In  this  way  the  rupture  can  always  be  pre- 
vented from  increasing,  and  sometimes  can  be  materially  reduced  in  size. 

In  younger  people,  if  the  rupture  consists  of  omentum  only,  an  attempt  may 
be  made  to  reduce  the  size  by  procuring  absorption  of  the  fat.  The  patient  should 
be  confined  to  bed,  on  diet  consisting  very  largely  of  lean  meat ;  an  ice-bag  should 
be  placed  upon  the  swelling,  and  small  doses  of 
iodide  of  potash  given.  Sometimes  under  these 
conditions  the  size  is  so  much  reduced  in  the 
course  of  ten  days  or  a  fortnight  that  taxis  suc- 
ceeds under  an  anaesthetic  ;  but  the  smallest  ad- 
hesions are  suiificient  to  prevent  it.  If  this  fails, 
a  truss  may  be  fitted  over  iti  but  if  there  is  much 
inconvenience,  either  from  this  or  from  gastric 
trouble  ;  or  if  the  patient  is,  as  most  of  them  are 
in  the  lower  classes  of  life,  too  careless  to  be 
trusted  ;  or  if  they  are  likely  to  be  placed  in  cir- 
cumstances in  which  they  could  not  at  once  ob- 
tain advice,  it  becomes  questionable  whether  an 
operation  should  not  be  undertaken. 

Great    difificultv    is    experienced   sometimes 

•■1  -i  u        u'  11  J  4.  1       ^       Fig.    ^74. —  Pad    and    Truss    for    Irreducible 

With  sailors,  who  have  allowed  an  enterocele  to  '  Hernia, 

attain  an  enormous  size,  and  perhaps  become  ex- 
tensively adherent,  before  applying  for  relief.    In  such  a  case,  however,  an  opera- 
tion should  never  be  lightly  undertaken  ;  it  usually  involves  prolonged  dissection, 
and  it  may  be  found,  after  all,  impossible  to  complete  it. 

Obstructed  Hernia. 

A  hernia  is  obstructed  or  incarcerated,  when,  without  the  circulation  being 
affected,  the  passage  of  the  faeces  is  arrested,  either  from  accumulation  in  the  in- 
terior or  from  the  impaction  of  scybala.  This  can  only  happen  with  large  hernise, 
and  probably  only  with  those  that  contain  some  portion  of  the  colon  ;  the  contents 
of  the  small  intestine  are  too  liquid. 

The  most  typical  example  occurs  in  the  neglected  umbilical  herniae  which  are 
so  common  after  middle  life  in  women  who  have  had  large  families.  A  large  pen- 
dulous mass  hangs  down  over  the  edge  of  the  umbilicus,  sometimes  tympanitic,  but 
more  often  hard  and  uneven  ;  generally  speaking,  it  is  not  very  tender,  though  it 
is  often  the  seat  of  a  griping  pain,  and  the  coils  of  intestine  can  be  felt  and  even 
seen  working  in  it.  Constipation  is  complete,  unless  the  sigmoid  flexure  and  the 
rectum  contain  faeces ;  the  tongue  is  thickly  furred  and  inclined  to  be  dry  ;  the 
appetite  is  lost ;  nausea  is  common,  though  the  patient  seldom  is  actually  sick  ; 
and,  although  there  is  great  discomfort,  and  perhaps  painful  colicky  spasm  in  the 
abdomen,  there  is  an  entire  absence  of  the  depression  characteristic  of  strangula- 
tion. The  danger  is  that  the  veins  may  become  compressed,  and  the  return  of 
blood  impeded,  until  the  congestion  passes  into  strangulation.  I  have  known  a 
patient  suffer  from  an  obstructed  umbilical  hernia  on  four  occasions,  at  intervals 
of  a  few  months  ;  the  last  time  the  movements  of  the  intestine  suddenly  ceased, 
and  the  patient  began  to  sink  \  strangulation  had  set  in. 


884    DISEASES  AND  INJURIES   OF  SPECIAL  STRUCTURES. 

Treatment. — Position  in  these  cases  is  most  important  ;  so  long  as  the 
hernia  liangs  down  it  is  hard,  tense,  and  often  (edematous  at  the  lowest  part  ;  when 
it  is  raised  over  the  orifice  from  which  it  has  escaped,  it  becomes  soft  and  flaccid. 
This  should  be  assisted  by  warmth  and  kneading  day  after  day,  so  as  to  empty 
part  of  the  bowel  ;  the  colon  should  be  thoroughly  evacuated  with  enemata ;  the 
diet  small  in  quantity  but  fairly  nutritious  ;  and  opium  only  given  if  there  is 
severe  pain  ;  afterward  the  bowels  must  be  kept  relaxed  until  the  size  of  the  hernia 
is  reduced  again. 

Inflamed  Hernia. 

Irreducible  herni?e,  especially  those  containing  omentum,  may  become  in- 
flamed from  the  pressure  of  an  ill-fitting  truss,  from  taxis,  or  other  forms  of  injury  ; 
much  more  rarely  from  the  impaction  of  faeces,  or  as  a  result  of  enteritis.  In 
most  cases  the  sac  is  empty,  but  the  walls  are  thickened  and  softened  ;  the  endo- 
thelium disappears  ;  in  its  place  there  is  a  roughened  surface  coated  with  lymph, 
and  all  the  contents  are  congested,  swollen,  and  cjedematous.  Sometimes  the  sac 
is  filled  with  a  turbid  fluid.  Sup]niration,  fortunately,  is  rare  (unless  the  bowel  is 
strangulated)  ;  nearly  always  the  inflammation  subsides,  and  the  lymph  becomes 
absorbed,  leaving  a  few  adhesions  between  the  structures  inside. 

The  skin  over  the  sac  is  reddened,  edematous,  and  adherent  to  the  fa.scia 
beneath  ;  the  pain  is  very  severe,  with  marked  tenderness  on  pressure  ;  and  the 
sac  feels  swollen  and  tense,  but  there  is  still  an  impulse  on  coughing,  and  some- 
times in  a  large  hernia  the  finger  can  be  passed  along  the  pedicle  for  some  distance. 
The  patient  is  ill  and  feverish,  with  nausea  and  abdominal  tenderness,  especially 
in  the  region  of  the  sac  ;  but  there  is  no  collapse  ;  the  face  is  not  anxious  or  the 
tongue  dry,  and  the  pulse  has  not  the  small,  wiry  character  characteristic  of 
strangulation. 

The  treatment  is  the  same  as  in  local  peritonitis  ;  the  patient  must  be  placed 
in  bed  and  kept  on  milk  diet;  small  doses  of  opium  may  be  given  every  few  hours 
at  first,  then  at  longer  intervals.  An  ice-bag  should  be  placed  over  the  swelling, 
until  the  temperature  is  reduced,  but  in  old  people  it  should  not  be  kept  on  longer 
than  this.  Afterward,  the  bowels  must  be  carefully  regulated,  and  the  hernia 
protected  from  further  injury. 

Strangulated  Hernia. 

A  hernia  is  strangulated  when  it  is  so  tightly  constricted  that  the  circulation  is 
stopped.  The  whole  circumference  of  the  gut  may  be  caught ;  or  only  one  side  of 
a  loop,  as  in  Littre's  hernia,  so  that  the  channel  is  not  completely  closed  :  or  the 
intestine  itself  may  be  free,  and  the  omentum  only  involved  ;  the  symptoms  are 
essentially  the  same,  though  they  differ  in  intensity. 

Causes. — Strangulation  may  occur  during  perfect  health,  suddenly  and  with- 
out warning  ;  in  many  instances,  however,  there  is  a  history  of  some  previous  in- 
testinal trouble,  dyspepsia,  diarrhoea,  or  colic  ;  and  it  is  possible  that  this  increases 
the  liability,  either  from  the  general  malaise  and  want  of  tone  in  the  abdominal 
muscles,  or  from  the  relaxed  state  of  the  mesentery. 

The  immediate  cause  is  usually  a  sudden  effort,  lifting  a  heavy  weight,  or 
straining  at  stool  with  the  thighs  in  such  a  i)osition  that  the  abdominal  rings  are 
relaxed  and  unprotected  ;  but  strangulation  may  be  gradual,  and  it  has  been  known 
to  occur  during  sleep.  Where  there  is  a  congenital  sac,  the  hernia  may  be  stran- 
gulated the  first  time  it  descends,  and  then,  especially  if  the  patient  is  a  young 
adult,  the  effect  is  very  characteristic  :  a  loop  of  intestine  is  suddenly  squeezed 
through  a  narrow  channel  into  a  wider  space  beyond,  and  the  circulation  is 
stopped  at  once.  The  same  thing  hai)|)ens  if  the  sac  is  an  old  one  and  the  hernia 
has  not  descended  for  some  considerable  time,  and  very  often  these  cases  are  the 
worst,  from  the  unyielding  nature  of  the  tissues  at  the  neck.  When  there  is 
already  an  irreducible  hernia,  especially  if  it  consists  of  omentum,  and  a  fresh  loop 


STRANGULATED  HERNIA. 


885 


is  squeezed  down  behind  it,  the  constriction  is  rarely  tight  enough  to  cut  off  the 
circulation  at  once  ;  the  veins  only  are  compressed,  and  blood  continues  to  enter, 
until  the  walls  of  the  intestine  become  black  and  almost  solid  from  the  amount 
they  contain.  The  same  occurs  when  a  hernia  that  is  already  obstructed  becomes 
strangulated,  only  the  onset  is  then  even  more  gradual. 

In  recent  hernia,  in  which  the  sac  has  as  yet  no  existence  of  its  own,  but  is 
merely  a  temporary  depression  of  the  ])eritoneum,  the  constriction  is  necessarily 
caused  by  the  tissues  outside  it.  In  older  cases  it  may  be  the  same,  but  more  often 
the  hernia  is  caught  by  the  neck  of  the  sac,  which  has  become  hard  and  unyield- 
ing. In  rare  instances  the  intestine  is  strangulated  by  bands  inside  the  sac  passing 
across  from  one  wall  to  the  other,  or  by  its  slipping  through  an  accidental  open- 
ing in  a  piece  of  unreduced  omentum. 

A\'hether  the  strangulation  is  rapid  or  slow,  the  effect  is  always  the  same  ;  the 
onlv  difference  is  in  the  length  of  time  and  the  amount  of  congestion. 

Pathological  Appearances. — The  intestine  may  be  free,  or  adherent  to  the 
body  or  the  neck  of  the  sac.  Its  color  may  be  but  slightly  changed  ;  generally  it 
is  redder  than  natural,  with  distended  veins,  and  sometimes  it  is  purple  and  almo-st 
black  with  blood  e.xtravasated  between  its  layers.  In  the  early  stages  its  walls  are 
firm  and  dense,  thicker  than  natural,  and  rigid  from  the  congestion.  Later,  as  its 
vitality  begins  to  fail,  the  surface  becomes  dull  and  loses  its  polish  ;  it  may  look 
granular  or  be  coated  over   with  lymph  ;  later  still  the  walls  become  soft  and 


Collapsed  and 
bloodless 
tal  end. 


Neck  of  sac. 


Fjg.  375. — An  Unstrangulated  Hernia. 


Fig.  376. — A  Strangulated  Hernia. 


flaccid,  yielding  to  the  least  pressure,  the  color  changes  to  an  ashy  gray  or  green, 
and  gangrene  sets  in.  Sometimes  the  sloughing  commences  in  the  loop  ;  more 
often,  especially  when  the  edge  of  the  constriction  is  sharp,  like  Gimbernat's  liga- 
ment, the  mucous  membrane  gives  way  first  in  a  line  corresponding  to  the  band, 
and  the  feeces  are  extravasated  into  the  sac. 

If  the  strangulation  is  relieved  before  this,  a  deep  groove  may  be  found  run- 
ning round  the  whole  or  part  of  the  bowel,  often  so  marked  that  traces  of  it  are 
present  for  weeks.  Above  the  strangulated  loop  the  intestine  is  distended  and 
deeply  congested  ;  below  it  is  empty,  pale,  and  flaccid.  At  the  ring  itself  the 
peritoneum  may  be  unaltered  if  the  hernia  is  recent,  or  thickened  and  opaque  if  it 
has  descended  many  times.  If  the  intestine  is  inflamed  it  is  usually  firmly  adher- 
ent at  the  neck  ;  unless  it  has  given  way  inside  the  abdomen  above  the  stricture, 
or  inflammation  has  been  caused  by  reducing  some  of  the  contents  of  the  sac, 
these  adhesions  protect  the  general  cavity  of  the  peritoneum  so  thoroughly  that 
anything  more  than  local  peritonitis  is  exceptional. 

When  omentum  is  present  it  undergoes  similar  changes,  whether  it  has 
recently  descended  and  is  soft  and  delicate  in  structure,  or  is  old,  tough,  and 
fibrous.  The  blood-vessels  become  distended  ;  it  swells  up  and  becomes  oedema- 
tous ;  and  unless  the  constriction  is  relieved  it  grows  darker  and  darker  until  it 
forms  a  slate-colored,  offensive,  and  putrid  mass. 

The  sac  nearly  always  contains  a  certain  amount  of  fluid,  which  varies  accord- 


S86    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

ing  to  the  condition  of  the  hernia  and  the  vigor  with  which  taxis  has  been  applied. 
When  quite  recent  it  is  bright  and  clear  ;  as  the  congestion  increases  it  becomes 
blood-stained  from  the  giving  way  of  small  vessels,  especially  if  any  force  is  used  ; 
and  occasionally  there  are  coagula.  Flakes  of  lymi)h  are  sometimes  present,  and 
in  the  worst  cases,  when  gangrene  has  set  in,  it  is  filled  with  jnis  of  the  most 
offensive  description  and  mixed  with  gas.  Occasionally,  even  when  there  is  no 
perforation,  there  is  a  distinctly  faecal  odor,  just  as  there  is  sometimes  in  abscesses 
of  the  abdominal  wall. 

A  peritoneal  sac  is  very  rarely  wanting,  but  in  the  case  of  the  colon  there  may 
be  only  a  partial  one.  Sometimes  it  is  so  thin  that  the  contents  can  be  seen 
through  it  without  difficulty :  in  old  cases,  especially  when  a  truss  has  been  worn, 
it  may  be  so  thick  that  layer  after  layer  of  fibrous  tissue  is  divided,  under  the  im- 
pression that  each  is  the  last.  In  a  itw  instances  portions  of  the  subserous  fat 
still  retain  their  connection  with  it,  so  that  it  has  a  deceptive  resemblance  to 
omentum.  In  recent  hernia  it  can  be  isolated  from  the  structures  around  ;  in  old 
ones,  however,  it  is  closely  incorporated  with  them,  especially  at  the  neck. 


J 


Fig.  377. — Extreme  Venous  Congestion  and  Iiiici^,i.t.,.l  il<.i 

of  the  Bowel. 


le  Effects  of  Severe  Strangulation 


The  tissues  outside  the  sac  may  be  unaltered  ;  but  not  unfrequently  they  are 
bruised  or  inflamed  from  the  severity  of  the  taxis.  When  the  contents  of  the  sac 
are  gangrenous  and  suppuration  has  set  in,  the  apj>earances  are  simj^ly  those  of  an 
abscess. 

Symptoms. — The  symptoms  of  strangulation  are  collapse,  vomiting,  and 
pain.  Where  the  patient  is  young  and  in  vigorous  health,  and  where  the  strangu- 
lation is  sudden  and  complete,  the  symptoms  begin  instantaneously  and  with  great 
severity  ;  where,  on  the  other  hand,  the  patient  is  feeble  and  anaemic,  or  where 
there  is  already  a  large  epiplocele  protecting  the  intestine  from  too  great  pressure, 
they  set  in  very  gradually,  and  some  hours  may  pass  before  they  reach  their  full 
intensity.  In  addition,  it  is  not  improbable  that  the  part  of  the  intestine  involved 
is  of  some  importance.  The  collapse  and  the  vomiting  are  due,  entirely  at  first, 
to  the  effect  of  the  strangulation  upon  the  nerves,  especially  upon  the  great 
plexuses  in  the  abdomen,  and,  though,  perhaps,  to  a  less  extent,  this  is  true  of  the 
pain  as  well.  It  is  not  improbable,  as  Treves  has  pointed  out,  that  the  jejunum  with 
its  muscular  walls,  copious  blood  supply,  well-developed  nerve  jilexuses,  and  vig- 
orous functional  activity,  would  resent  an  injury  more  energetically  than  the  lower 


STRANGULATED  HERNIA.  887 

ileum,  where  the  muscular  tissue  is  more  scanty,  the  blood  supjjly  less  free,  and 
the  functional  activity  less  pronounced. 

The  aspect  of  the  patient  changes  almost  at  once.  The  face  is  drawn  and 
pinched,  the  cheek  blanched,  the  lips  white,  the  eyes  sunken  and  surrounded  bv 
dark  rings,  and  the  forehead  covered  with  perspiration  ;  the  patient  looks  prema- 
turely old,  and  the  expression  is  that  of  intense  distress.  The  skin,  especially  on 
the  extremities,  is  cold,  the  temperature  is  sul)normal,  and  the  pulse  small,  feeble, 
and  com])ressible,  often  as  many  as  120  and  even  140  beats  in  the  minute.  The 
tongue  at  first  is  white,  but  it  soon  becomes  dry  and  brown  ;  there  is  intense  thirst, 
and  the  amount  of  urine  secreted  is  far  below  normal.  Like  the  other  signs  of 
collapse,  this  is  due  to  the  disturbance  of  the  abdominal  nerve-plexuses,  and  is 
acute  in  proportion  to  the  extent  to  which  they  are  involved. 

VomHiiti:;  may  come  on  at  the  moment  of  strangulation,  or  not  until  later. 
When  it  has  commenced  it  rarely  ceases,  its  character  gradually  changing  as  the 
contents  of  the  stomach,  duodenum,  and  small  intestine  are  successively  ejected. 
At  first  it  may  consist  of  undigested  food  ;  very  soon  it  becomes  bilious  in  char- 
acter, and,  after  three  or  four  days'  strangulation,  it  comes  up  in  great  gushes,  a 
dark-brown,  muddy  liquid,  intensely  offensive  in  odor,  sometimes  distinctly  faecal. 
It  is  probable  that  the  peristaltic  action  of  the  intestine  is  reversed,  although 
apparently  in  intestinal  obstruction,  when  the  proximal  part  of  the  intestine  is 
thrown  into  violent  colic,  the  contents,  even  of  the  ileum,  can  be  ejected  without. 

Pain  varies  considerably.  In  some  it  is  local,  and  comes  on  at  the  moment 
of  descent,  caused  by  the  stretching  of  the  ti.ssues  around  the  sac,  and  when  the 
strangulation  is  sudden  it  may  be  very  severe.  In  others  it  is  scarcely  noticed, 
and  the  patient  may  be  almost  unaware  of  the  existence  of  the  rupture.  A  fixed, 
dragging  pain,  referred  to  the  umbilicus,  is  nearly  always  present,  probably  due 
either  to  traction  on  the  mesentery  or  to  the  effect  upon  the  great  nerve-plexuses. 
Besides  these  there  are  usually  wandering  colicky  pains  all  over  the  abdomen, 
caused  by  the  violent  and  irregular  movements  of  the  bowels  above  the  strangula- 
tion, and  made  worse  by  any  attempt  at  taxis. 

Constipation  is  nearly  always  present,  caused  not  by  the  obstruction,  but  by 
the  effect  upon  the  nerves,  for  even  when  the  sigmoid  flexure  is  full  the  bowels  are 
rarely  opened  after  strangulation  has  set  in.  Exceptions  to  this,  however,  some- 
times occur,  and  there  may  be  one  or  two  motions  when  the  lower  bowel  is  full. 

In  Littre's  hernia  the  interior  of  the  intestine  is  sometimes  closed  by  the 
kinking  opposite  the  strangulation,  but  often  it  is  patent  all  the  way  through. 
Constipation,  however,  is  the  rule  in  this  as  well  as  in  other  forms,  although  in  a 
{t\\  cases  (three  out  of  fifty-three)  Treves  found  that  there  was  diarrhcea,  and  in 
several  of  the  others  the  bowels  responded  to  aperients. 

The  local  symptoms  are  generally  very  prominent,  but  occasionally  the  patient 
is  not  aware  of  the  existence  of  a  hernia,  although  it  may  have  been  in  a  state  of 
strangulation  for  forty-eight  hours.  Obturator  and  sciatic  hernise  especially  are  so 
small  and  so  deeply  placed  that  the  tumor  often  cannot  be  made  out,  even  after 
careful  examination.  If  the  hernia  is  an  old  one,  that  has  been  down  many  times, 
the  size  is  likely  increased,  but  it  may  be  impossible  to  obtain  exact  information. 

Small  hernise,  when  strangulaftd,  are  hard  and  tense,  or  doughy  if  they  con- 
tain omentum  ;  large  ones,  especially  those  that  are  irreducible,  are  often  fairly 
soft,  as  the  strangulated  part  may  be  simply  a  loop  at  the  back  covered  in  by  the 
rest.  In  many  cases  the  tumor  is  dull  on  percussion,  although  it  contains  intestine, 
partly  because  of  the  liquid  in  the  sac,  partly  because  the  amount  of  air  is  so  small 
and  the  walls  so  thick. 

Absence  of  impulse  on  coughing  or  straining  is  the  chief  local  feature;  the 
contents  of  the  sac  are  shut  off  from  the  abdomen,  and  nothing  more  can  enter. 
In  large  hernia  the  impulse  can  sometimes  be  felt  as  low  down  as  the  neck,  there 
it  ceases  abruptly.  The  skin  may  be  tender,  but,  as  a  rule,  this  is  not  marked 
unless  the  sac  is  inflamed  or  taxis  has  been  too  vigorous. 

As  the  case  progresses  and   gangrene  becomes  imminent,  the  constitutional 


888     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

symptoms  grow  more  distinct.  The  vomit  is  intensely  offensive,  or  dark,  like 
coffee-grounds,  and  it  comes  without  effort  in  great  gushes  ;  there  is  constant  and 
painful  hiccough,  the  pulse  becomes  intermittent,  the  abdomen  begins  to  swell 
and  become  tympanitic  ;  it  is  not  very  painful  as  yet,  but  the  whole  surface  is 
tender;  the  mind  begins  to  wander,  the  face  becomes  more  haggard,  the  patient 
tosses  restlessly  about,  growing  colder  and  colder,  and  at  length  sinks  exhausted. 
Occasionally,  before  the  end,  the  local  pain  ceases,  the  tenseness  of  the  tumor 
disappears,  and  it  slips  up  almost  of  itself,  making  the  abdominal  symjjtoms  tenfold 
worse.  More  fre^iuently  the  swelling  increases,  and  becomes  resonant  as  the  gases 
of  putrefaction  collect;  the  skin  becomes  livid  and  oedematous,  and  at  length 
gives  way,  allowing  the  intensely  foetid  contents  to  escape  externally,  and  leaving, 
if  the  patient  survives,  either  a  faecal  fistula  or  an  artificial  anus. 

It  very  commonly  happens,  especially  in  an  irreducible  femoral  epijjlocele, 
that  after  the  sac  is  laid  open,  nothing  but  omentum  is  found,  although  the  symp- 
toms of  strangulation  may  have  been  well  marked.  It  is  possible  that  in  some  of 
these  a  small  knuckle  of  intestine  has  been  strangulated  behind  the  rest,  and 
reduced  by  taxis  before  the  operation,  without  its  having  been  noticed  ;  the  size 
is  small,  and  it  may  be  quite  concealed,  but  there  is  no  doubt  that  strangulated 
omentum  can  give  rise  to  the  same  symptoms  as  intestine,  though  less  marked  and 
less  acute.  The  pain  is  not  so  severe  or  the  vomiting  so  constant ;  constipation 
is  less  complete  and  the  constitutional  symptoms  are  milder.  The  local  distress 
is  also  inconsiderable,  the  tumor  feeling  harder,  and  permitting  manipulation  more 
freely  than  when  it  contains  intestine.  As  time  progresses,  however,  the  symptoms 
become  as  severe  as  in  other  forms.  The  same  thing  has  been  known  when  only 
peritoneum  was  involved. 

The  time  that  elapses  before  gangrene  or  ulceration  of  the  mucous  membrane 
occurs  is  very  variable.  Erichsen  mentions  a  case  in  which  the  vitality  was 
destroyed  in  eight  hours  ;  in  other  instances  the  intestine  may  recover  even  after 
five  or  six  days.  It  depends,  to  some  extent,  upon  the  kind  and  size  of  the  hernia 
and  the  tightness  of  the  constriction,  but  there  is  no  doubt  that  a  great  deal  of 
the  injury  inflicted  on  the  bowel  is  due  to  ill-advised  and  violent  taxis. 

Symptoms  of  an  almost  identical  character  may  be  caused  by  other  condi- 
tions of  the  bowel.  Internal  hernia  and  strangulation  by  bands  or  through  aper- 
tures, are,  of  course,  really  the  same  ;  the  seat  of  strangulation  differs,  and  that 
is  all,  but  very  acute  symptoms  may  occur  in  volvulus,  acute  intussusception,  stric- 
ture and  impaction  of  feces  or  gall-stones,  sometimes  with,  sometimes  without 
previous  warning.  The  real  cause  of  the  symptoms  is  the  effect,  not  upon  the 
blood-vessels  (though  this  forms  a  convenient  standard  to  judge  of  the  vitality  of 
the  tissues),  but  upon  the  nerves  of  the  peritoneal  covering,  and  this  is  borne  out 
by  many  isolated  facts.  I  have  met  with  cases  of  external  hernia  in  which  all 
the  symptoms  of  strangulation  were  well  marked  without  the  bowel  being  either 
very  tightly  gripped  or  deeply  congested  ;  and  the  same  thing  has  occurred  from 
the  simple  retention  of  the  bowel  in  a  colotomy  wound  (Davies-Colley),  and  from 
hernia  of  the  subperitoneal  fat  dragging  upon  the  peritoneum. 

The  Diagnosis  of  Strangulation. — Inflamed  and  obstructed  irreducible 
herniae  are  occasionally  attended  by  symptoms*resembling  those  of  strangulation  ; 
there  is  constipation  with  pain,  and  perhaps  vomiting,  but  this  never  attains  the 
persistence  or  the  character  of  the  sickness  of  strangulation  ;  there  is  no  collapse, 
and  an  impulse  on  coughing  can  always  be  detected. 

Acute  peritonitis  is  more  difficult  ;  the  vomiting  may  be  persistent  and  very 
offensive,  the  patient  may  be  in  a  state  of  extreme  collapse  and  the  bowels  abso- 
lutely confined.  In  such  a  case  the  diagnosis  must  rest  chiefly  upon  the  absence  of 
relation  between  the  sac  and  peritonitis,  and  upon  the  physical  character  of  the 
hernia  itself. 

A  few  cases  are  recorded  in  which  the  vomiting  of  pregnancy  and  that  which 
sometimes  attends  the  late  descent  of  a  testis  have  been  mistaken  for  that  of  stran- 
gulation.    In  all  cases  of  doubt  an  operation  should  be  performed. 


STRANGULATED  HERNIA.  889 

Treatment. — The  strangulation  must  be  relieved  either  by  taxis  or  by  opera- 
tion with  the  least  possible  delay. 

I.  Taxis. — The  method  depends  upon  the  anatomy  of  the  part,  but  the  ])rin- 
ciple  is  the  same  in  all.  The  structures  around  the  hernia  must  be  relaxed  as  far 
as  possil)le,  the  neck  of  the  sac  must  be  steadied  with  one  hand,  sometimes,  as  in 
the  inguinal  variety,  pulling  it  slightly  down  so  as  to  straighten  it  out,  and  then 
the  gentlest  pressure  u.sed,  squeezing  it  a  little  from  side  to  side,  and  kneading  it 
carefully  with  a  view  of  emptying  the  hernia  of  some  of  its  contents,  or  of  return- 
ing the  piece  of  intestine  that  came  down  last.  Intestine  slips  up  with  a  sudden 
rush  and  the  patient  experiences  complete  relief  at  once  ;  omentum  does  not  dis- 
appear ([uite  in  the  .same  way,  but  as  it  yields  it  leaves  behind  it  a  distinct  sense 
of  something  gone. 

Of  all  the  aids  to  taxis  there  is  only  one,  an  anaesthetic,  that  can  always  be 
relied  upon,  and  that  one  may  only  be  used  when,  should  taxis  fail,  everything  is 
ready  for  immediate  operation.  It  is  manifestly  unfair  to  the  patient  to  expose 
him  a  second  time,  with  a  short  interval,  to  the  depressing  influence  of  an  anaes- 
thetic, and  to  run  the  risk  of  making  the  vomiting  and  the  other  symptoms  worse 
in  the  meantime.  Morphia  maybe  given  to  quiet  a  very  restless  patient  and  pre- 
vent exhaustion,  but  it  is  of  no  help  in  other  ways,  and  great  care  must  be  taken 
that  the  symptoms  of  strangulation  are  not  obscured  by  it  without  the  constriction 
being  relieved. 

An  ice-bag,  or  Leiter's  coil  with  ice-cold  water,  is  of  some  use  if  applied 
within  a  short  time  of  the  descent ;  the  bulk  of  the  mass  is  reduced,  and  occasion- 
ally, if  taxis  is  tried  then,  it  succeeds  almost  at  once,  but  cold  is  not  advisable  for 
old  people  with  feeble  nutrition,  or  where  the  hernia  has  already  been  cutoff  from 
the  circulation  for  some  time,  for  fear  of  accelerating  gangrene.  Over  omentum 
it  has  much  less  power.  A  hot  bath  maybe  used  in  large  inguinal  herniae  if  there 
is  much  spasm  and  the  patient  cannot  leave  off  straining ;  but  it  must  not  be  for- 
gotten that  a  bath  of  the  temperature  of  100°  F.  or  102°  F.  kept  up  for  half  an 
hour  may  cause  very  great  depression. 

From  time  to  time  other  aids  are  recommended  for  special  cases.  Inversion 
of  the  patient,  for  example,  raising  the  pelvis  well  above  the  shoulders,  so  that  the 
intestines  gravitate  toward  the  diaphragm,  is  highly  spoken  of  in  some  cases  of 
large  inguinal  hernia.  Care  must  be  taken  to  keep  the  hips  well  flexed  if  it  is  tried. 
Aspiration  of  the  intestine  is  exceedingly  risky,  but  the  fluid  in  the  sac  may  some- 
times be  drawn  off  with  a  trocar  and  cannula  with  advantage.  Enemata  should 
never  be  used,  and  purgatives  are  the  worst  things  possible. 

Taxis  is  more  liable  to  succeed  with  an  inguinal  than  with  a  femoral  hernia; 
the  constriction  in  the  one  is  muscular,  in  the  other  mainly  ligamentous ;  but  the 
tension  of  the  obliquus  externus  has  an  immense  influence  upon  the  size  of  the 
crural  ring ;  if  the  finger  is  placed  in  the  canal  while  a  patient  is  straining  or 
vomiting,  Poupart's  ligament  descends  upon  it  with  immense  force.  In  the  same 
way  taxis  is  more  successful  in  acquired  inguinal  hernia  than  in  the  congenital 
form,  but  here  the  length  and  obliquity  of  the  neck  are  additional  reasons.  Very 
small  and  very  large  hernire  and  those  which  are  tense  and  hard  are  more  difficult 
of  reduction,  other  things  being  equal,  than  those  which  are  lax  and  moderate  in 
size. 

Accidents  from  Taxis. — Taxis  is  responsible  for  a  very  large  proportion  of  the 
fatal  results  of  hernia.  The  bowel  is  intensely  congested  ;  its  walls  are  rigid  and 
almost  solid  with  blood  ;  it  is  prevented  from  returning  by  a  constricting  ring  with 
an  edge  sometimes  almost  as  sharp  as  a  knife,  and  over  which  it  bulges  in  all 
directions  ;  the  vitality  of  the  tissues  is  seriously  impaired  ;  no  fresh  blood  has 
passed  through  it  for  hours  or  even  days  ;  and  while  it  is  caught  like  this  an 
attempt  is  made  to  force  it  through.  Sometimes  by  careful  attention  to  position, 
and  by  using  every  endeavor  to  relax  the  tissues,  the  ring  may  be  so  widened  that 
some  of  the  blood  in  the  walls  or  of  the  gas  in  the  interior  is  squeezed  out,  and 
then  the  rest  may  follow  ;  but  if  the  congestion  is  severe  and  the  walls  rigid  and 
57 


890     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


solid,  it  is  impossible  for  tlieni  to  yield  sufficiently,  while,  on  the  oilier  hand,  they 
bruise  with  the  greatest  ease,  l^ven  when  the  constricting  band  is  divided  and 
manii)ulation  applied  directly  to  the  intestine,  and  to  the  proper  end  of  the  loop, 
not  indiscriminately  to  the  outside  of  the  tumor,  reduction  is  often  very  difficult ; 
and  I  have  heard  of  a  case  in  which  it  was  necessary,  although  the  neck  of  the  sac 
had  been  freely  incised,  to  open  the  abdomen  and  make  use  of  traction  from  the 
interior. 

Bruising  of  the  skin  and  cellular  tissue,  ecchymoses  in  the  walls  of  the  intes- 
tines or  in  the  omentum,  and  hemorrhages  into  the  bowel  or  the  sac,  are  common 
results  of  taxis,  and  often  cau.se  inflammation.  Other  consequences,  not  so  fre- 
quently met  with,  are  more  dangerous  ;  rents  in  the  serous  coat,  for  example, 
rupture  of  the  bowel,  bruising  to  such  an  extent  that  sloughing  ensues,  and  injuries 
of  the  sac,  which  may  lead  to  the  serious  mistake  that  the  hernia  has  been 
reduced  while  the  strangulation  still  persists.  Of  these  last  the  two  most  common 
are  reduction  en  masse  and  rupture  of  the  sac.  It  is,  however,  only  fair  to  say 
that  in  the  majority  of  instances  they  have  been  the  result  of  the  patient's  own 
violence. 

In  the  true  reduction  en  masse  (Fig.  378)  the  sac  is  separated  from  its  sur- 
roundings, and  with  its  contents  still  unreduced,  is  pushed  bodily  into  the  sub- 
peritoneal space.  It  can  only  occur  in  tolerably  recent  hernia,  in  which  the  sac 
is  not  adherent,  and  is  most  common  in  the  direct  inguinal  form.  lUit  it  may  be 
imitated  easily  in  femoral  hernia  if  the  sac  is  freely  separated  from  the  tissues 
around  and  an  attempt  made  to  reduce  the  contents  without  opening  it ;  suddenly 
the  whole  may  slip  through  the  crural  ring  into  the  abdomen. 

The  extent  of  the  displacement  is  not  so  great  in  the  other  forms.  In  one 
(Fig.  379),  which  appears  to  be  more  common  in  congenital  inguinal  hernia,  the 

neck  of  the  sac  only  is  detached  and  forced 
in  (carrying  with  it  the  strangulated  portion 
of  intestine),  while  the  rest  still  j)rotnides  in 
the  inguinal  canal  ;  in  another  the  sac  is 
hardly  detached  at  all ;  but  the  unreduced 
intestine  is  so  pushed  up  the  canal,  sometimes 
into  a  kind  of  diverticulum  lying  between 
the  peritoneum  and  the  fascia  transversalis, 
that  reduction  is  complete,  so  far  as  external 
appearance  is  concerned  (Fig.  380).  These 
diverticula  may  either  be  formed  at  the  time 
by  partial  displacement  of  the  sac,  or  they 
may  be  congenital,  and  then  they  frequently 
attain  a  very  large  size. 

Rupture  of    the  sac  may  l)e  associated 
Fig  378.— Reduction  en  v,asse,\\iv.  Sac  entirely  ^yjth  this,  or  it  may  occur  independently  (Fig. 

detached  from  its  former  site  (as  shown  by  the  '  n      t  i 

dotted  hne),  and  pushed  into  the   Subperitoneal    381).         1  he  rent  USUally  lieS    UpOU    the    pOStC- 

^'^'"^-  rior  aspect,  near  the  neck,  and  the  intestine 

is  gradually  squeezed  out  through  it  into  the  subserous  tissue. 

The  symptoms  in  all  of  these  are  very  nearly  the  same.  The  contents  of  the 
sac  do  not  slip  back,  they  are  gradually  pushed  to  one  side,  leaving  a  certain  degree 
of  fullness  over  the  neck  ;  sometimes  even  a  distinct  tumor  can  be  felt,  dull  on 
l^ercussion,  and  very  painful.  In  a  few  ca.ses  the  mass  has  been  felt  repeatedly, 
returning  into  the  abdomen  with  the  least  pressure  and  descending  again  as  soon 
as  the  patient  coughed  or  strained,  but  not  disappearing  altogether.  The  consti- 
tutional symptoms,  so  far  from  being  relieved,  are  generally  made  a  great  deal 
worse  by  the  injury  inflicted  upon  the  contents. 

If  any  of  the  conditions  is  suspected,  the  sac  must  be  exposed  and  oi)ened  at 
once.  The  incision  may  be  made  in  the  ordinary  situation,  or,  if  the  tumor  can- 
not be  distinctly  felt,  in  the  middle  line  ;  all  the  ordinary  apertures  can  be  easily 
explored  from  this.     The  neck  must  then  be  divided  freely,  the  bowel  drawn  out 


STRANGULATED  HERNIA.  891 

and  examined,  and  the  finger  passed  well  up  into  the  abdomen  and  down  to  the 
bottom  of  the  sac,  so  as  to  make  sure  the  condition  is  relieved. 

In  a  few  instances  an  omental  sac,  with  the  bowel  strangulated  in  it,  lies  inside 
the  peritoneal  one,  and  it  is  possible  that  this  may  be  reduced  bodily,  intestine 
and  all,  into  the  abdomen.  If  this  occurs  the  symptoms  persist  in  the  same  way, 
and  the  abdomen  must  be  opened  to  ascertain  the  cause,  as  in  other  cases  of  inter- 
nal hernia. 

Taxis,  even  when  successful,  is  sometimes  followed  by  serious  consequences. 
Of  these  the  most  common  is  peritonitis  ;  the  intestine  is  either  inflamed  at  the 
time  of  reduction  or  becomes  inflamed  after  being  so  long  anaemic,  and  allows 
infective  irritants  to  work  their  way  into  its  walls.  Suppuration  and  sloughing 
may  set  in,  or  adhesions  form,  binding  down  the  bowel,  or  stricture  may  develop 
from  the  injury  the  coats  have  sustained.  Sometimes  a  patient  progresses  favor- 
ably for  three  or  four  days  and  then  sinks  suddenly  into  a  state  of  collapse,  from 
the  separation  of  a  small  gangrenous  patch,  and  death  may  occur  from  shock, 
especially  in  the  case  of  stout,  middle-aged  women,  whose  circulation  is  already 
embarrassed.  I  have  known  this  happen  on  several  occasions  in  which,  as  an 
anaesthetic  was  not  administered,  nothing  else  could  have  been  held  responsible. 

The  length  of  time  taxis  may  be  applied  before  further  measures  are  resorted 


Fig.  379. — Reduction  into  the  Can.il.  Fig.  380. — Intraparietal  Hernia.  FiG,  381. — Rupture  of  the  Sac. 

Three  different  varieties  of  Imperfect  Reduction. 


to  cannot  be  laid  down  in  an  absolute  manner ;  it  depends  upon  the  size  and  kind 
of  hernia ;  whether  it  is  tense  or  lax  ;  how  long  it  has  been  down  ;  whether  any 
previous  attempts  have  been  made,  and  whether  there  are  any  signs  of  inflamma- 
tion. If  there  is  a  small  tense  knuckle  of  intestine  lying  in  the  crural  canal,  with- 
out any  impulse  on  coughing,  and  if  it  has  just  descended,  a  single  trial  may  be 
made,  and  then  an  ice-bag  laid  on  the  swelling  for  four  or  five  hours.  If  at  the 
end  of  that  time  it  appears  unchanged,  and  does  not  yield  at  once,  the  patient 
should  be  placed  under  an  anaesthetic  and  herniotomy  performed.  If  the  symp- 
toms are  very  acute,  indicating  a  severe  degree  of  strangulation,  as,  for  example, 
in  congenital  inguinal  hernia  in  young  adults,  even  this  is  not  advisable ;  it  is 
better,  for  the  sake  of  the  intestine,  to  give  an  anaesthetic,  and  if,  when  the  mus- 
cles are  relaxed,  a  very  brief  attempt  does  not  succeed,  operate  at  once.  On  the 
other  hand,  a  large  scrotal  or  umbilical  hernia,  the  contents  of  which  are  soft  and 
lax,  consisting  largely  of  omentum  and  without  acute  symptoms,  may  be  manipu- 
lated wnth  considerable  freedom.  If  the  skin  over  the  hernia  is  red  or  tender  ;  if 
the  strangulation  has  lasted  for  two  days  acutely,  or  three  under  any  circumstances  ; 
if  the  constitutional  symptoms  are  severe  ;  or  if  there  is  the  least  suspicion  as  to 
the  condition  of  the  intestine,  taxis  should  not  be  employed  at  all. 

The  subsequent  treatment,  if  the  intestine  has  been  strangulated,  requires  as 


S92    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

much  care  as  after  an  operation.  A  spica  or  a  truss  must  be  applied  at  once  to 
prevent  the  descent  of  the  rupture  again  ;  the  patient  must  be  placed  in  bed  ;  no 
food  allowed  for  twenty-four  hours,  and  nothing  but  a  little  ice  until  the  vomiting 
from  the  anaesthetic  has  ceased  ;  and  a  hypodermic  injection  of  morphia  or  some 
tincture  of  opium  should  be  given  to  keep  the  intestine  at  rest  for  at  least  forty- 
eight  hours. 

Herniotomy  or  Kelotomy. — If  taxis  fails,  or  it  is  not  thought  advisable  to  try 
it,  the  constriction  must  be  divided. 

The  patient  is  placed  under  an  anresthetic,  with  the  shoulders  slightly  raised 
and  the  knees  flexed  ;  and  the  skin  shaved  and  thoroughly  cleansed.  The  incision 
is  over  the  neck  of  the  sac  ;  in  inguinal  hernia,  over  the  external  ring  in  the  direc- 
tion of  the  canal  ;  in  femoral,  over  the  upper  part  of  the  tumor  immediately  below 
Poupart's  ligament ;  and  the  tissues  between  the  skin  and  the  sac  are  divided  layer 
by  layer  until  the  outer  wall  of  the  latter  is  reached. 

In  recent  hernia  the  sac  is  readily  recognized.  It  has  a  bluish  appearance, 
like  a  thin-walled  cyst,  and  is  covered  with  a  layer  of  loose  cellular  tissue,  devoid 
of  fat ;  and,  unless  adherent,  it  can  usually  be  thrown  into  folds  and  made  to  move 
over  the  subjacent  structures  by  pinching  it  up  with  the  forceps.  In  other  cases 
the  intestine,  or  the  yellow  fat  of  the  omentum,  can  be  seen  through  it,  so  that 
there  is  no  doubt  when  it  is  reached.  In  old  herniae,  however,  over  which  a  truss 
has  been  worn  for  years,  the  difficulty  may  be  very  great ;  the  sac  may  be  thick, 
dense,  and  fibrous,  so  that  layer  after  layer  is  divided,  each  one  apparently  the 
last;  or  it  may  be  so  closely  adherent  to  the  structures  around  that  its  definition 
is  impossible.  Sometimes  there  is  a  cyst  lying  over  it  (generally  a  bursa)  which 
may  be  opened  by  mistake;  or,  as  in  encysted  or  infantile  hernia,  there  may  be 
a  definite  peritoneal  sac  in  front.  The  difficulty  is  especially  serious  when  the 
sac  is  flaccid  or  empty,  or  surrounded  by  subserous  fat ;  under  these  conditions, 
especially  if  it  has  been  bruised  by  taxis,  it  may  resemble  congested  omentum  very 
closely.  In  other  instances  it  does  not  contain  any  fluid,  or  the  intestine  is  adher- 
ent to  its  inner  surface  over  the  front,  so  that  it  is  in  danger  of  being  wounded  ; 
and,  what  is  perhaps  most  serious  of  all,  the  sac  may  be  partially  or  entirely  want- 
ing. In  this  case  (which  rarely  happens  except  with  the  bladder  and  some  por- 
tions of  the  colon),  the  hernia  rapidly  forms  adhesions  to  the  cellular  tissue  around, 
and,  unless  the  muscular  wall  is  recognized  as  it  is  aj^proached,  there  is  great  dan- 
ger of  its  being  incised  by  mistake. 

In  certain  cases — large  scrotal  or  umbilical  hernise  with  subacute  symptoms — 
the  attempt  to  reduce  the  hernial  mass  en  bloc  should  be  made,  though  in  the  lat- 
ter it  is  not  likely  to  succeed,  owing  to  the  extraordinary  thinness  of  the  walls; 
there  is  considerable  danger  in  exposing  a  large  quantity  of  intestine  to  cold  or  to 
the  irritation  of  sponging;  but  it  should  never  be  thought  of  in  small  herniae  with 
acute  symptoms  ;  in  those  of  a  mixed  character — entero-epiploceles,  for  example 
— as  there  might  be  an  omental  sac  inside ;  or  in  any  case  in  which,  either  from 
the  condition  of  the  skin,  the  history,  or  the  constitutional  signs,  there  is  the 
slightest  suspicion  as  to  the  state  of  the  contents.  If  the  operator  has  decided 
upon  opening  the  sac,  it  should  be  done  before  dividing  the  constriction  outside, 
for  fear  of  a  yjiece  of  intestine  slipping  back  unawares. 

Great  care  is  needed  while  opening  the  sac  to  avoid  injury  to  the  structures 
beneath.  Part  of  the  wall  should  be  pinched  up  with  the  dissecting  forceps,  and 
opened  with  the  knife  on  the  flap,  not  cutting  toward  the  interior.  Fluid  usually 
escapes  at  once.  A  director  should  then  be  introduced  into  the  opening,  and  the 
sac  freely  divided  up  to  the  neck. 

The  subsequent  proceedings  depend  upon  the  condition  of  the  contents.  If 
there  is  intestine  and  it  is  not  seriously  injured,  the  stricture  is  divided  and  the 
hernia  returned  at  once.  The  incision  is  made  in  the  same  way,  whether  the  seat 
of  strangulation  is  outside  the  sac  and  is  divided  without  opening  the  latter,  or 
whether  it  lies  in  the  neck  :  either  the  finger  nail,  or  a  flat  director,  is  insinuated 
under  the  margin  of  the  band  (and  often  it  is  so  tight  that  this  is  a  matter  of  con- 


STRANGULATED  HERNIA. 


893 


Fig.  382. — Method  of  Dividing  the  Constriction. 


siderable  difficulty)  and  then  a  licrnia  knife  or  a  blunt-pointed  bistoury,  with  the 
greater  portion  of  the  edge  protected  with  wrapping,  i.s  gently  slipped  under,  and 
a  very  small  incision  made,  without  any  cutting,  simply  by  the  pressure  of  the 
blade.  As  soon  as  this  is  done  the  difficulty  disajjpears  :  the  nail  can  be  intro- 
duced more  easily,  and  either  the  original  wound  enlarged,  or,  what  is  far  to  be 
preferred,  two  or  three  small  ones  made.  Large  incisions  are  not  only  more  likely 
to  injure  adjacent  structures,  such  as  an  abnormal  artery,  but  weaken  the  abdom- 
inal wall  and  lead  to  a  very  intract- 
able form  of  hernia.  Care  must  be 
taken,  when  the  sac  is  opened,  that 
the  intestines  do  not  bulge  upward  by 
the  side  of  the  director  and  get  in  the 
way  of  the  knife  ;  it  is  to  prevent  this 
that  the  hernia  director  is  especially 
broad. 

Occasionally,  as  already  men- 
tioned, there  is  some  difficulty  in  re- 
ducing the  intestine  after  the  stricture 
has  been  divided,  owing  to  the  thick- 
ness and  rigidity  of  the  walls  ;  but  this  may  generally  be  overcome  by  applying 
ta.xis  first  to  that  end  of  the  loop  which  was  the  last  to  descend.  If  this  fails  the 
intestine  may  be  drawn  slightly  downward  ;  so  long  as  reasonable  care  is  used  this 
may  be  done  without  fear,  as  the  difficulty  only  occurs  when  the  walls  are  unusu- 
ally firm  and  solid.     Aspiration  of  the  bowel  should  not  be  attempted. 

The  condition  of  the  intestine,  whether  it  is  fit  to  be  returned  into  the  abdo- 
men or  not,  is  determined  by  its  consistence  and  color.  If  it  is  soft  and  flabby, 
instead  of  firm  and  resilient,  if  there  are  ashy-gray  or  green  spots  upon  it,  or  if  the 
fluid  is  turbid  and  very  offensive,  it  certainly  is  not.  The  difficulty  is  greatest 
where  the  intestine  is  almost  black,  and  has  lost  its  lustre,  or  is  coated  over  here 
and  there  with  flakes  of  lymph,  or  where,  without  any  evidence  of  gangrene,  it 
shows  that  it  has  been  very  tightly  constricted  ;  undoubtedly  it  stands  a  better 
chance  of  recovery  inside  the  abdomen  than  if  it  is  left  in  the  sac  ;  on  the  other 
hand,  it  is  almost  sure  to  set  up  a  certain  degree  of  peritonitis.  Probably  in  this 
case  it  is  best  to  return  it,  having  first  passed  a  catgut  loop  through  the  mesentery, 
so  that  it  may  be  retained  near  the  orifice.  Possibly  then,  if  sloughing  does  set 
in,  adhesions  may  form  around  and  faecal  extravasation  be  prevented. 

[When  there  are  evidences  of  inflammatory  action  in  the  loop  of  intestine, 
it  is  well  to  irrigate  it  with  a  warm  antiseptic  solution  before  returning  it.] 

Where  the  condition  of  the  bowel  is  hopeless,  it  may  either  be  left  ///  situ,  so 
that  if  the  patient  survives  an  artificial  anus  is  formed,  or  it  may  be  drawn  down 
at  each  end  until  the  whole  of  the  gangrenous  part  is  exposed,  resected,  sutured 
and  returned.  Which  of  these  methods  should  be  adopted  depends  upon  the  cir- 
cumstances of  each  case  ;  as  a  rule  the  patient  is  too  feeble  and  exhausted  to  stand 
so  prolonged  an  operation  as  enterectomy,  and  in  femoral  hernia,  in  which  gan- 
grene is  most  common,  there  is  the  serious  objection  that  it  practically  entails 
division  of  Poupart's  ligament.  If  the  intestine  is  kept  in  situ  the  stricture  should 
be  interfered  with  as  little  as  possible  and  the  adhesions  around  the  neck  of  the 
sac  should  not  be  touched  ;  they  are  the  only  safeguard  against  a  certainly  fatal 
peritonitis.  The  wound  should  simply  be  left  wide  open  ;  as  the  congestion  and 
swelling  subside  the  faeces  find  their  way  out  through  the  upper  orifice,  and  either 
a  faecal  fistula  or  artificial  anus  is  formed.  Peritoneal  rents  in  the  coat  of  the 
bowel  should  be  sewn  up  with  catgut.  A  pin-hole  perforation,  if  the  surrounding 
part  is  healthy,  may  be  treated  in  the  same  way. 

Recent  adhesions,  unless  the  intestine  is  gangrenous,  can  be  broken  down 
with  the  fingers  ;  older  ones,  if  not  too  extensive,  may  be  dissected  off.  In  large 
irreducible  herniae,  however,  this  is  often  impossible  without  endangering  the 
bowel ;  and  the  rupture  must  be  left  in  situ  after  the  strangulation  has  been  re- 


894    n  IS  EASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

lieved.     Later,  when  the  wound  has  healed,  the  hernia  may  be  fitted  with  a  suit- 
able truss. 

Omentum  must  be  thoroughly  unraveled  before  anything  is  done  with  it ;  a 
small  knuckle  of  intestine  is  often  concealed  behind  it  or  in  its  substance,  and 
may  be  easily  overlooked.  If  it  has  only  recently  descended  and  is  not  congested, 
it  maybe  returned  ;  but  if  it  is  old  and  fibrous,  or  if  it  is  already  much  injured,  it 
should  be  secured  with  a  clamp  or  forceps,  cut  off  and  ligatured  bit  by  bit.  As 
soon  as  it  is  certain  that  there  is  no  risk  of  hemorrhage,  the  end  should  be  returned 
well  within  the  peritoneal  cavity  ;  if  it  is  left  at  the  neck  of  the  sac  it  does  not  act 
as  a  safeguard  and  plug  the  opening,  but  encourages  the  descent  of  a  fresh  jjortion 
by  guiding  it  to  the  weakest  spot,  and,  by  leaving  a  band  extending  from  the 
stomach  to  the  groin,  exposes  the  patient  to  the  danger  of  internal  strangulation. 
[Some  operators  stitch  the  omentum  to  the  peritoneum  on  the  inside  of  the  inter- 
nal ring,  in  order  to  have  an  additional  safeguard  against  recurrence.] 

The  wound  in  the  sac,  after  the  contents  are  reduced,  must  be  treated  in  the 
same  way  as  other  wounds  of  the  peritoneum  ;  but  in  addition  to  closing  the  ori- 
fice into  the  peritoneal  cavity,  an  attempt  should  be  made  to  strengthen  that  part 
of  the  wall  so  that  the  descent  of  another  hernia  at  the  same  spot  may  be  pre- 
vented. [In  all  cases  where  a  strangulated  hernia  has  been  operated  upon,  it  is 
well  to  close  the  ring,  and  conclude  the  operation  as  would  be  done  in  an  opera- 
tion for  radical  cure.] 

When  the  intestine  is  gangrenous  no  attempt  should  be  made  to  close  the 
wound.  In  other  cases  it  should  be  thoroughly  cleansed,  dried,  and  sutured  with 
catgut,  leaving  a  drain  at  the  most  dependent  orifice.  An  alxsorbent  dressing 
should  then  be  carefully  packed  over  it,  so  that  the  sides  are  pressed  together,  and 
a  bandage  applied  over  this.  The  tube  should  be  removed  the  next  day  to  clear 
it  of  any  coagula,  and,  if  need  be,  introduced  again  through  the  superficial  part 
of  the  Avound.  Afterward  the  dressing  need  not  be  disturbed  until  the  wound  is 
sound. 

No  food  should  be  allowed  for  twenty-four  hours,  only  a  itw  fragments  of  ice 
to  allay  thirst ;  but  if  the  patient  is  collapsed  and  the  pulse  failing,  small  quanti- 
ties of  brandy  with  soda  water,  a  teaspoonful  at  a  time,  may  be  given  at  frequent 
intervals,  until  the  skin  is  beginning  to  grow  warm  again.  Meanwhile  hot  flan- 
nels and  hot-water  bottles  should  be  placed  all  round,  and  every  effort  made  to 
maintain  the  temperature.  As  soon  as  consciousness  returns,  one-third  of  a  grain, 
.02  gramme,  of  morphia  should  be  given  hypodermically  to  check  peristalsis,  and 
if  the  bowel  was  much  injured,  or  if  from  the  purgatives  the  patient  has  taken 
there  is  any  fear  of  diarrhoea,  small  quantities  of  opium  must  be  given  two  or  three 
times  a  day  until  the  danger  is  past.  Milk,  beef-tea,  and  arrowroot  may  be  al- 
lowed after  twenty-four  hours,  provided  there  is  no  sickness,  and  at  the  end  of  four 
or  five  days,  if  all  goes  well,  a  little  custard  or  fish.  If  the  bowels  are  left  to 
themselves  they  are  usually  opened  as  soon  as  the  patient  begins  to  take  solid  food, 
at  the  end  of  five  or  six  days  ;  or,  if  not,  an  enema  may  be  given.  In  many  cases 
they  remain  confined  for  much  longer  periods  without  causing  any  distress. 
[Opiates  must  be  given  with  caution  and  only  in  case  of  necessity.  Their  fre- 
quent administration  leads  to  ballooning  of  the  intestines  from  tympanites,  which 
not  only  adds  to  the  patient's  distress,  but  greatly  disturbs  the  vital  processes  by 
mechanical  pressure]. 

Death  may  be  due  to  shock  or  to  exhaustion,  especially  if,  owing  to  the  pur- 
gatives that  are  .so  often  taken  before  advice  is  sought,  diarrhaa  begins  as  soon  as 
the  hernia  is  reduced.  In  most  cases,  however,  the  immediate  cause  \?,  peritonitis  ; 
the  symptoms  that  were  present  before  the  operation  persisting,  and  growing 
worse,  until  collapse  sets  in.  The  intestine  may  have  given  way.  causing  faecal 
extravasation  ;  or  the  coats  of  the  bowel,  after  being  so  long  deprived  of  blood, 
may  have  become  inflamed,  as  soon  as  the  circulation  was  restored  ;  or  their 
vitality  may  have  been  so  impaired  that,  without  actual  rujjture,  infective 
material  can   pass  through  them  into  the  peritoneal   cavity ;    or  the  contents 


STRANGULATED  HERNIA.  895 

of  the   sac    may   have    been    septic    at   the   time.      In   any   case   the  symptoms 
are  characteristic. 

The  i)atient  lies  with  the  knees  and  hii)s  flexed;  the  peculiar  haggard  and 
anxious  aspect  on  the  face  continues  and  grows  more  distinct ;  there  is  not,  when 
the  effects  of  the  anaesthetic  wear  off,  that  e.xpression  of  relief  significant  of  suc- 
cessful reduction  ;  the  tongue  remains  dry  and  brown  ;  the  pulse  becomes  more 
rapid  and  thready  ;  the  vomiting  and  constipation  persist;  the  temperature  may 
rise  a  few  degrees,  but  very  commonly,  es])ecially  when  there  is  gangrene,  it  either 
remains  stationary  or  becomes  subnormal  ;  and  the  patient,  overcome  by  septic 
poisoning,  falls  into  a  semi-unconscious  state,  resembling  typhoid.  Sometimes  the 
abdomen  is  distended,  firm,  hard,  and  intensely  painful  when  touched,  while  the 
respiration  is  confined  to  the  upper  part  of  the  thorax ;  more  frequently,  although 
the  surface  is  always  tender,  the  collapse  is  so  profound  that  there  is  no  complaint 
of  pain  ;  and  the  abdomen,  although  its  walls  are  tense  from  the  contraction  of 
the  muscles,  is  empty  rather  than  distended,  and  moves  a  little  when  the  patient 
draws  a  deep  breath.  In  such  a  ca.se  it  is  usually  iouxxd  post-mortem  that  there  are 
flakes  of  lym[)h  upon  the  serous  membrane,  and  no  adhesions ;  nothing  but  an 
intensely  irritating,  semi-purulent,  and  turbid  fluid. 

In  other  cases  the  symptoms  of  strangulation,  the  vomiting,  collapse,  and  con- 
stipation persist,  it  may  be,  for  one  or  two  days,  before  peritonitis  sets  in  or  the 
last  stage  is  reached  ;  and  then  it  becomes  a  question  whether  the  strangulation 
has  reafly  been  relieved,  or  whether  there  may  not  be  some  further  cause  which 
has  not  yet  been  ascertained.  Reduction  en  masse  may  have  occurred,  or  the 
intestine  may  have  been  incompletely  reduced  ;  slight  volvulus,  owing  to  the 
elongation  of  the  me.sentery,  may  have  followed  ;  or  there  may  be  a  second  hernia, 
either  external,  at  some  other  of  the  abdominal  openings,  or  internal,  through 
the  omentum,  perhaps;  or,  finally,  the  strangulated  portion  of  intestine,  without 
becoming  gangrenous  or  setting  up  peritonitis,  may  have  been  so  injured  that  it 
is  no  longer  capable  of  doing  its  work  {ileus paralyticus^).  In  such  circumstances 
there  should  be  no  hesitation  in  exploring  the  abdomen  ;  it  is  the  only  course  left ; 
if  any  tumor  or  hardness  can  be  detected,  as  in  reduction  en  masse,  the  incision 
should  be  made  over  it ;  if  there  is  no  guide,  the  abdomen  should  be  opened  in 
the  middle  line,  the  seat  of  the  original  operation  examined  first,  then  the  other 
situations  in  which  hernia  commonly  occurs,  and  if  this  does  not  reveal  anything, 
the  collapsed  intestine,  below  the  injured  part,  must  be  found  and  traced  upward 
until  the  cause  is  ascertained. 

Care  must  be  taken  not  to  mistake  the  vomiting  that  arises  from  the  anaes- 
thetic for  that  which  is  due  to  the  persistence  of  strangulation.  As  a  rule,  there 
is  little  difficulty,  for  even  when  it  continues  for  more  than  a  few  hours,  and  is 
not  checked  by  giving  small  fragments  of  ice  to  suck,  or  by  warm  applications  to- 
the  abdomen,  it  is  never  offensive  or  faecal  in  character,  it  does  not  come  up  in 
great  gushes,  and  the  retching  is  much  more  severe. 

Sequelae, — Strangulation  of  intestine  may  be  followed  by  after  consequences 
of  a  more  or  less  serious  description. 

Local  peritonitis  is  very  common  and  is  often  preservative.  The  intestine, 
after  reduction,  has  become  inflamed,  or  may  have  sloughed  and  adhesions  formed 
around  it  to  prevent  the  extravasation  of  faeces  ;  but  this  may  lead  to  serious 
results  at  a  later  period.  The  intestine  may  be  tied  down  in  a  loop  ;  or  it  may  be 
dragged  upon  at  one  spot  until  it  forms  an  angle  in  the  interior,  obstructing  the 
passage  of  the  contents  ;  or  the  peritoneum  may  be  so  thickened  that  peristalsis 
is  rendered  difficult ;  and  even  stricture  may  result. 

In  other  cases  stricture  is  due  to  the  injury  sustained  by  the  mucous  mem- 
brane. It  ulcerates  opposite  the  sharp  edge  of  the  constricting  band,  especially 
in  femoral  hernia,  and  after  reduction,  when  it  cicatrizes,  it  sometimes  narrows 
the  canal  to  a  very  serious  extent. 

Volvulus,  or  twisting  of  the  intestine,  causing  very  acute  symptoms,  sometimes 


896    DISEASES  AND  INJUR  J ES  OF  SPECIAL  STRUCTURES. 

happens,  the  regularity  of  the  movements  being  broken  and  thrown  out  of  order 
by  the  elongation  of  the  mesentery  and  the  formation  of  adhesions. 

When  gangrene  sets  in  and  the  contents  of  the  bowel  are  discharged  exter- 
nally, either  an  artificial  anus  or  0.  /(real  fistula  is  formed,  according  to  the  extent 
of  the  slough.     If  it  is  the  whole  circumference  of  a  loop,  so  that  the  two  ends 

DiatfiitJrd  jTiwfl 
ebote  Sirfr/i/rr  ^ 


Fig.  383.— Stricture  of  the  Sm.-iU  Intestine  after  Strangulated  Hernia. 

open  on  the  surface  side  by  side,  it  is  an  artificial  anus ;  if,  on  the  other  hand, 
only  one  side  gives  way,  so  that  the  f?eces  in  part  find  their  way  externally,  in 
part  follow  the  natural  route,  it  is  d, /cecal fistula.  In  a  few  instances  a  communi- 
cation has  formed  between  two  loops  of  the  bowel,  inside  the  abdomen — 2l  fistula 
bimucosa. 


SPECIAL  HERNL^. 


Inguinal  Hernia. 

Inguinal  hernia  protrudes  through  one  or  both  abdominal  rings.  There  are 
two  classes  :  the  external,  oblique,  or  indirect,  the  neck  of  which  lies  outside  the 
deep  epigastric  artery  ;  and  the  internal,  or  direct,  the  neck  of  which  lies  to  the 
inner  side. 

I.   Oblique  Inguinal  Hernia. 

In  this  the  intestine  enters  the  internal  ring,  passing  in  front  of  the  deep 
epigastric  artery,  and  lies  in  the  inguinal  canal,  in  front  of  the  spermatic  cord. 
If  it  does  not  emerge  through  the  external  ring,  it  is  called  a  bobonocele ;  if  it 
project  it  is  complete,  and  if  it  descend  sufficiently  far  it  is  scrotal  or  labial,  ac- 
cording to  the  sex. 

The  sac  may  be  congenital  or  acquired  ;  in  the  former  case  the  bowel  lies 
in  the  tunica  vaginalis,  which  has  either  not  been  closed  or  has  been  forced  open 
again  ;  in  the  latter  a  new  sac  is  formed  out  of  the  peritoneum  covering  the 
internal  ring. 

a.  Congenital  Inguinal  Hernia. — The  peritoneum  which  lines  the  lower  part 
of  the  abdomen  in  the  fcetus,  and  that  which  is  attached  to  the  gubernaculum 
testis,  descend  with  the  testis  between  the  eighth  and  ninth  months,  the  testis  and 
peritoneum  coming  down  together,  or  the  pouch  preceding  the  testis.  This  pro- 
cess of  peritoneum  is  the  tunica  vaginalis ;  at  birth  it  very  commonly  communi- 
cates with  the  general  cavity,  and  it  may  continue  to  do  so  for  a  few  months  or  even 
for  the  whole  of  life,  though  the  opening  may  be  so  small  as  only  to  admit  serum 
(congenital  hydrocele).  As  a  rule  it  becomes  obliterated,  first  at  the  internal 
ring,  then  immediately  above  the  testis,  leaving  an  isolated  sac  in  between,  and 
finally  this  disappears.  The  right  testis  descends  later  than  the  left  ;  often  it  does 
not  reach  the  scrotum  until  the  ninth  month  ;  and  consequently  the  changes  that 


INGUINAL   HERNIA. 


897 


take  place  about  the  inguinal  canal,  are  later  on  the  right  side.  For  this  reason, 
and  because  of  the  lower  attachment  of  the  mesentery  on  the  right,  congenital 
inguinal  hernia  on  the  left  side,  by  itself,  is  very  rare  ;  it  may,  and  very  com- 
monly does,  occur  on  both  ;  but  if  it  is  met  with  on  one  only  it  is  almost  sure  to 
be  the  right. 

Hernia  into  the  tunica  vaginalis  is  called  congenital,  because  of  the  condition 
of  its  sac.  Naturally  it  is  frequently  met  with  at,  and  shortly  after,  birth  ;  but  it 
may  not  occur  until  adult  years;  and  the  pouch  may  remain  open  for  the  whole 
of  life  without  the  intestine  ever  entering  it. 

There  are  two  varieties  of  congenital  hernia,  depending  upon  the  mode  of 
closure  of  the  canal :  — 

1.  When  the  tunica  vaginalis  is  open  the  whole  way  down,  so  that  the  intestine 
can  descend  as  low  as  the  testis  and  come  into  contact  with  it  (Fig.  384). 

2.  When  the  sac  is  closed  above  the  testicle.  In  this  case  the  hernia  descends 
into  the  funicular  portion  of  the  tunica  vaginalis  only,  and  rests  upon  the  top  of 
the  testicle  without  touching  it  (Fig.  385).      Occasionally  the  closure  at  this  point 


IISI1  /  / 


vW,  ^^^^ 


■'^  -v^^^ 


Fig.  384. — Congenital  Hernia  into  the  Tunica  Vagi- 
nalis testis.    The  intestine  and  testis  in  contact. 


"SSivics.^rcSS!' 


Fig.  385. — Congenital  Hernia  into  the  Funicular 
portion  of  the  tunica  vaginalis.  The  same 
diagram  would  answer  equally  well  for  an 
acquired  hernia. 


is  incomplete  ;  there  is  a  constriction,  but  nothing  more,  so  that  if  a  hernia  de- 
scends and  passes  down  to  the  bottom  it  assumes  the  shape  of  an  hour-glass. 

Congenital  inguinal  hernia  is  also  common  in  female  children,  the  protrusion 
passing  down  in  the  canal  of  Nuck  ;  and  is  sometimes  met  with  in  adults,  consti- 
tuting the  ordinary  form  of  labial  hernia. 

{F)  Acquired  Oblique  Inguinal  Hernia. — This  is  rare  before  adult  life  and  is 
much  more  common  among  men  than  women.  It  enters  the  internal  ring, 
gradually  pushing  the  peritoneum  in  front  of  it,  forming  a  bubonocele  first,  and 
then  becoming  complete.  Its  progress,  therefore,  is  gradual,  while  that  of  the 
congenital  variety  is  rapid  and  sudden  ;  in  course  of  time  it  may  attain  a  very 
large  size,  and  by  its  weight  drag  one  ring  so  near  the  other  that  the  inguinal 
canal,  as  such,  is  destroyed,  and  the  rupture  appears  to  come  directly  out  of  the 
abdomen. 

There  are  two  varieties,  one  exceedingly  rare  ;  the  other,  the  most  common 
of  all,  depending  upon  the  size  and  relation  of  the  tunica  vaginalis. 

I.  It  occasionally  happens  that  the  tunica  vaginalis  is  closed  at  the  internal 
ring  and  nowhere  else,  so  that  there  is  a  great  pouch  of  peritoneum  investing  the 


898    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 


testicle  below,  extending  up  the  inguinal  canal,  and  only  shut  off  from  the  abdo- 
men by  a  thin  septum.  If  an  obli(]ue  hernia 
develops  under  these  conditions,  a  fresh  sac 
is  pushed  down  either  l^ehind  this  or  into  it 
(invaginating  it),  so  that  when  the  intestine 
is  exposed  by  an  incision  from  the  front 
three  layers  of  serous  mem])rane  are  divided 
— the  anterior  and  i)Osterior  walls  of  the 
tunica  vaginalis  and  the  anterior  wall  of  the 
hernial  sac.  This  is  the  infantile  hernia  of 
Hey  (Fig.  386).  The  encysted  hernia  of 
Astley  Cooper  is  probably  the  same ;  the 
cicatricial  septum  which  was  supposed  to 
stretch  across  the  orifice  of  the  canal  having 
been  shown  by  Lockwood  to  have  no  exist- 
ence. 

2.  In  the  other,  the  common  form  of 
acquired  oblicjue  hernia,  the  tunica  vagina- 
lis is  in  no  relation  with  the  peritoneal  sac. 
A  fresh  one  is  formed,  which  generally  de- 
scends in  front  of  the  spermatic  cord,  but 
occasionally  in  its  substance,  and  the  testicle  is  at  first  below,  then  below  and 
behind  the  hernia,  becoming  more  prominent  as  the  sac  grows  tense. 


Fig.  386. — Infantile  Hernia. 


2.    Direct  Inguinal  Herfiia. 

In  this  the  protrusion  usually  takes  place  through  the  structures  that  lie 
immediately  behind  the  external  ring,  the  conjoined  tendon  and  the  triangular 
ligament  being  stretched  or  split ;  occasionally,  however,  the  neck  of  the  sac  is 
higher  up,  on  the  outer  side  of  the  obliterated  hypogastric  artery,  between  it  and 
the  epigastric,  and  the  hernia  lies,  for  a  very  short  part  of  its  course,  in  the  canal. 
The  coverings  are  the  same  as  in  the  oblique  form,  except  that  the  conjoined 
tendon  (when  it  is  not  split)  takes  the  place  of  the  cremasteric  fascia.  The  cord, 
however,  lies  more  to  the  outer  side  of  the  sac  ;  the  hernia  is  usually  smaller  and 
more  globular,  and,  after  it  is  reduced,  the  finger  seems  to  pass  straight  into  the 
abdominal  cavity. 

Diagnosis. — Inguinal  hernia  must  be  distinguished  from  : — 

1.  Swellings  in  front  of  the  inguinal  canal,  such  as  enlarged  glands.  These 
may  be  recognized  by  their  relation  to  the  external  ring.  If  the  tip  of  the  fore- 
finger is  placed  at  the  bottom  of  the  scrotum  and  pushed  upward,  invaginating 
the  skin,  behind  the  spermatic  cord,  it  rests  first  upon  the  front  of  the  pubes,  then 
on  the  ring  itself;  and  the  swelling,  if  it  is  a  gland,  can  be  lifted  away  from  the 
front  of  the  canal. 

2.  Tumors  below  the  inguinal  canal.  Of  these  the  most  important  \s  femoral 
hernia,  which  often  curls  up  over  Poupart's  ligament ;  the  neck  of  an  inguinal 
hernia,  however,  if  the  finger  is  placed  on  the  spine  of  the  pubes,  always  lies  in- 
ternal to  it ;  that  of  a  femoral  one  always  external. 

3.  Hydrocele,  hcematocele  and  tumors  of  the  testicle  are  distinguished  by  the 
line  of  separation  between  the  scrotal  swelling  and  the  external  ring.  The  only 
exception  is  that  form  of  hydrocele  which  occurs  in  infants  and  young  adults,  in 
which  the  tunica  vaginalis  is  closed  only  at  the  internal  ring,  and  the  swelling 
extends  through  the  external  one  into  the  canal.  The  swelling,  however,  begins 
in  the  scrotum  and  the  tumor  is  translucent. 

4.  Enlargements  in  the  canal  are  the  most  difficult,  and  if  there  is  the  least 
doubt,  and  symptoms  of  strangulation  are  present,  an  operation  should  be  per- 
formed at  once.  Eatty  tumor  or  sarcoma  of  the  cord,  encysted  hydrocele,  and  the 
testis  descending  late,  are  the  most  common,  but  though  their  position  in  the  in- 


INGUINAL  HERNIA.  899 

guinal  canal  can  l)e  altered  to  some  slight  extent,  none  of  them  can  be  reduced  in 
the  same  way  as  a  hernia.  It  is  said  that  varicocele  may  be  mistaken  for  hernia, 
although  the  difference  in  the  consistence  and  feeling,  and  the  way  in  which  a 
varicocele  disappears  when  the  patient  lies  down  and  rea])pears  when  he  stands 
up,  no  matter  what  pressure  is  made  upon  the  ring,  must  make  such  a  thing  almost 
impossible. 

Direct  hernia  is  distinguished  from  indirect  or  oblicpie  by  its  globular  shape 
and  the  absence  of  fullness  along  the  canal.  In  old  oblicpie  hernia  the  internal 
ring  may  be  dragged  so  far  to  the  inner  side  that  the  rupture  appears  to  come 
straight  out  from  the  abdomen  ;  but  this  never  happens  unless  the  size  is  very  con- 
siderable. It  is  sometimes  possible,  when  the  opening  has  been  stretched  by  long- 
continued  traction,  to  feel  the  deep  epigastric  artery. 

An  oblique  inguinal  hernia  is  probably  congenital  if  it  occurs  before  puberty 
(though  it  is  not  confined  to  this  period  of  life),  or  if  it  made  its  appearance  sud- 
denly ;  in  the  acquired  form  it  takes  some  time,  often  months,  to  stretch  the  tissues 
sufficiently.  The  relation  to  the  testis  is  not  a  certain  guide  ;  if  the  intestine  is 
plainly  in  contact  with  it,  and  envelops  it,  the  hernia  is  probably  congenital ;  but 
the  converse  is  not  true. 

The  neck  of  a  congenital  inguinal  hernia  is  never  shortened  in  the  same  way 
as  that  of  an  acquired  one  ;  and  partly  from  this,  partly  from  the  suddenness  of 
its  occurrence,  it  is  very  mijch  more  likely  to  be  strangulated. 

Treatment. — i.  Taxis. — The  shoulders  and  the  pelvis  should  be  slightly 
raised  to  relax  the  abdominal  muscles,  the  thigh  flexed  and  adducted,  and  the 
patient  directed  to  breathe  as  cpiietly  as  possible,  and  avoid  straining.  The 
fingers  of  one  hand  grasp  the  neck  of  the  sac  and  pull  it  slightly  downward  ;  the 
other  manipulates  the  hernia.  In  direct  and  old  acquired  ones  the  pressure  is 
applied  from  before  backward  ;  in  those  that  are  recent  or  congenital  it  follows 
the  course  of  the  canal. 

If  the  hernia  is  reduced,  it  must  be  kept  from  descending  again,  either  by 
means  of  a  pad  and  a  spica  bandage  (put  on  while  the  limb  is  flexed)  as  a  tempo- 
rary measure,  or  a  truss,  the  pad  of  which  lies  upon  the  internal  or  external  ring, 
according  to  the  variety,  and  presses  either  directly  backward  or  backward  and 
upward,  according  to  the  shape  of  the  abdomen.  It  must  not  touch  the  pubic 
spine  or  rest  upon  the  cord,  and  the  spring  must  be  so  adjusted  that  while  it  does 
not  press  injuriously  when  the  patient  is  at  rest,  it  is  sufficiently  strong  to  retain 
the  hernia  even  when  he  strains  downward  with  the  hips  partially  flexed.  In  the 
congenital  variety,  if  the  hernia  is  prevented  from  descending,  the  neck  of  the 
sac  usually  closes  of  its  own  accord,  and,  with  sufficient  care,  a  permanent  cure 
may  be  looked  forward  to  in  most  cases  under  ten  years  of  age.  Owing  to  the 
fact  that  the  mesentery  does  not  grow  in  proportion  to  the  body,  the  tendency  for 
the  rupture  to  descend  diminishes  rapidly  ;  but  if  it  comes  down  once  all  the  good 
is  undone.  When  the  hernia  is  irreducible  but  not  strangulated,  either  the  rup- 
ture must  be  supported  and  prevented  from  increasing  by  means  of  a  bag-truss,  or, 
if  the  patient's  age  and  constitution  allow  it,  and  the  hernia  is  not  too  large  or 
too  extensively  adherent,  an  attempt  may  be  made  to  return  it  and  effect  a  radical 
cure. 

When  there  is  an  undescended  testicle  the  treatment  depends  upon  the  situa- 
tion and  condition  of  the  organ  and  the  age  of  the  patient.  As  a  rule,  if  the  testis 
does  not  descend  within  a  i^w  months  of  birth,  it  remains  quiescent  until  puberty. 
Then  it  may  come  down,  but  whether  it  does,  or  whether  it  remains  in  the  inguinal 
canal,  hernia  is  an  exceedingly  common  complication  and  strangulation  not  unfre- 
quent.  If  the  testis  can  be  pushed  either  back  into  the  abdomen  or  out  through 
the  ring,  a  truss  can  usually  be  worn,  and  ultimately  a  cure  may  result ;  but  if  it 
remains  in  the  inguinal  canal  it  rarely  happens,  even  with  water  or  air  pads,  that 
it  is  able  to  accommodate  itself  sufficiently  well.  Under  these  circumstances  it  is 
usually  advisable  to  perform  some  radical  operation,  and  either  transplant  the 
testicle,  or  if  it  is  small  and  shrunken,  or  extensively  adherent,  remove  it  altogether 


900     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

and  stitch  up  the  pillars  of  the  ring.  The  same  treatment  should  be  adopted  when 
a  retained  testis  is  met  with  in  an  operation  for  strangulated  hernia. 

If  strangulation  is  acute,  particularly  if  the  hernia  is  congenital,  the  patient 
should  be  placed  under  an  anaesthetic,  and  unless  taxis  succeeds  at  once  an  opera- 
tion be  performed.  If,  on  the  other  hand,  the  rupture  has  been  down  many  times 
before,  and  the  symptoms  are  not  severe,  an  ice-bag  or  a  hot  bath  may  be  tried 
and  a  delay  of  a  few  hours  sanctioned. 

2.  Herniotomy. — An  incision  two  inches  in  length  is  made  over  the  long  axis 
of  the  tumor,  opposite  the  external  ring,  and  the  skin,  sujjerficial  fascia,  and  super- 
ficial external  pudic  vessels  divided  (Fig.  387).  The  margins  of  the  ring  are  then 
defined.  In  some  cases  the  sac  is  deeply  grooved  by  the  fibres  of  the  external 
oblique,  and  if  these  are  divided  the  constriction  is  relieved  without  anything 
further.  More  frequently  there  is  only  a  shallow  mark,  no  real  constriction,  and 
layer  after  layer  of  tissue  is  divided  on  a  director  until  the  sac  is  exposed.  This 
is  opened  with  proper  precautions,  the  forefinger  passed  along  the  anterior  surface 
of  the  protrusion  as  f^ir  as  the  internal  ring,  and  the  seat  of  stricture  felt.  The 
finger  nail  is  slipped  beneath  it  and  a  curved  blunt-pointed  hernia  knife  passed 
along  the  finger  with  the  blade  laid  flat,  until  it  can  be  guided  beneath  the  con- 
stricting band.  The  edge  is  then  turned  upward  and  a  very  small  incision  made 
parallel  to  the  linea  alba,  so  that,  whether  the  hernia  is  internal  or  external,  the 
deep  epigastric  artery  may  not  be  wounded. 

The  contents  of  the  hernia  must  then  be  dealt  with,  the  sac  removed,  ligatured 
or  sewn  into  a  pad  according  to  circumstances,  and  the  pillars  of  the  ring  sutured 
as  in  the  operation  for  the  radical  cure. 


Radical  Cure. 

By  the  radical  cure  of  hernia  is  meant  an  operation  that  will  not  only  perma- 
nently prevent  the  hernia  descending,  but  will  relieve  the  patient  of  the  incon- 
venience of  a  truss. 

In  certain  cases  it  is  admitted  that  some  measure  of  this  kind  is  either  neces- 
sary or  very  desirable.  After  herniotomy,  for  example,  if  the  bowel  is  not  gan- 
grenous or  the  patient  exhausted,  an  attempt  should  always  be  made  to  close  the 
opening.     In  other  instances  there  are  special  reasons  why  a  truss  is  not  desirable  ; 

there  may  be,  for  example,  an 
undescended  tetsis  fixed  in  the 
inguinal  canal  ;  or  a  large  mass 
of  unreduced  omentum  over 
which  a  pad  will  not  fit  com- 
fortably ;  or  the  hernia  may  be 
of  such  a  nature  that  no  truss 
is  able  to  retain  it ;  or  the  patient 
may  be  too  unintelligent  or  too 
careless,  or  he  may  be  placed  in 
such  circumstances  that  were 
anything  to  happen  to  his  in- 
strument it  could  not  be  re- 
newed. In  such  as  these  there 
is  no  doubt — the  question  is, 
how  far  an  operation  is  advis- 
able as  an  alternative  to  a  truss, 
and  whether  it  can  be  relied  upon  to  effect  a  permanent  cure  without  too  much  risk. 
If  the  cases  are  properly  selected  it  is  certainly  effectual.  In  children,  for 
example,  in  whom,  from  carelessness  or  other  reasons,  a  truss  has  failed  to  procure 
the  closure  of  the  canal,  in  young  adults  with  a  recent  hernia,  and  in  older  men 
of  sound  constitution  and  wiry  frame,  in  whom  the  inguinal  canal  has  not  yet  been 
distorted,  a  cure  is  practically  certain,  and  the  risk  is  so  small  that  it  is  a  matter 


Fig.  387. —  Incision  in  Inguinal  Hernia. 


INGUINAL   HERNIA.  901 

of  question  whether  it  is  really  greater  than  that  attendant  on  the  wearing  of  a 
truss.  On  the  other  side,  the  presence  of  a  hernia  disqualifies  from  entering  the 
Services,  renders  a  man  at  the  most  active  period  of  his  life  unfit  for  many  kinds 
of  employment,  and  exercises  a  definite  restraint  in  everything  he  does. 

If,  however,  the  patient  has  already  reached  middle  life,  is  comfortable  with  a 
truss,  and  has  lost  the  impulsive  activity  of  youth  ;  or  if  he  is  old  for  his  years  ; 
or  if  the  abdominal  walls  are  thickened  and  fat,  or  shaped  so  as  to  suggest  pro- 
lapse of  the  mesentery;  or  if  there  is  the  least  suspicion  as  regards  his  general 
health — the  cure  might  be  effectual ;  but  the  risk  is  too  great,  provided,  that  is  to 
sav,  the  rupture  can  be  kept  up  with  a  truss.  When  this  cannot  be  done  the  ques- 
tion rests  on  entirely  different  grounds. 

{a)  Subcutaneous  Operations. — These,  which  met  with  very  fair  success  in 
the  hands  of  those  who  devised  them,  have  given  way  almost  entirely  to  the  open 
ones. 

Injection. — The  idea  of  plugging  the  canal  with  lymph  by  means  of  injec- 
tion has  recently  been  revived,  but  not  with  great  success.  It  may  be  done  either 
through  an  incision  or  subcutaneously  with  an  instrument  devised  by  Keetley 
[or  the  Warren  syringe].  The  scrotum  is  invaginated  with  the  forefinger,  the  sac 
pushed  well  up,  and  the  needle  of  the  syringe  passed  through  the  skin  from  above 
and  outside  the  internal  ring  down  toward  the  pubes,  until  it  meets  the  finger  in  the 
canal ;  when  its  position  is  assured,  the  finger  is  withdrawn  and  the  fluid  injected. 
Absolute  alcohol  (five  minims)  has  been  tried  without  confining  the  patient  to 
bed,  but  the  injection  had  to  be  repeated  many  times.  Glycerine  and  tannic  acid 
produce  more  reaction  ;  the  tissues  around  swell  up,  the  groin  becomes  full  and 
tender,  and  a  good  deal  of  lymph  is  effused.  [Heaton,  of  Boston,  used  extract 
of  white  oak  bark.]  But,  although  the  method  may  be  safe,  it  is  not  certain.  It 
may  be  impossible  to  injure  the  hernia  with  the  needle  pointing  toward  the  pubes, 
but  the  injection  maybe  thrown  into  the  spermatic  cord,  or  some  of  it  may  escape 
into  the  tissues  outside  the  canal,  and  the  sac  is  not  dealt  with  in  any  way.  Some 
of  these  objections  are  overcome  by  sutures  as  well,  but  in  this  the  open  method 
throughout  is  to  be  preferred. 

ib)  The  Open  Method. — In  this  the  sac  and  the  external  ring  are  thoroughly 
exposed.  As  compared  with  the  former,  it  is  more  precise  and  certain  in  its  re- 
sults, quite  as  safe  so  far  as  the  danger  to  life  is  concerned,  and  does  not  expose 
the  cord  to  so  much  risk.  It  is,  of  course,  the  only  plan  admissible  when  the 
hernia  is  irreducible. 

The  operation  consists  of  two  distinct  steps,  one  dealing  with  the  sac,  the 
other  with  the  canal.  The  patient  must  be  carefully  prepared,  and  the  parts 
shaved  and  thoroughly  cleansed  ;  the  incision  through  the  skin  lies  over  the  ex- 
ternal ring,  or  may,  with  advantage,  be  placed  a  little  higher. 

The  Sac. — The  first  step  is  to  isolate  this  thoroughly.  In  congenital  hernia, 
if  the  cord  causes  any  difficulty,  the  plan  suggested  by  ^IcEwen  may  be  followed. 
The  sac  is  opened  and  two  longitudinal  incisions  are  made  in  it,  one  on  either  side 
of  the  cord,  parallel  to  it,  so  that  this,  with  the  strip  that  adheres,  is  left  undis- 
turbed. If  the  pouch  is  open  right  down  to  the  testicle,  the  lower  end  must  be 
separated  from  the  rest  to  form  a  tunica  vaginalis  ;  but  it  is  not  necessary  to  sew 
this  up  ;  the  walls  collapse  and  adhere  to  each  other,  or  to  the  testis,  almost  at  once. 

When  the  sac  is  separated  it  may  be  either  cut  off,  the  neck  being  tied  and 
fixed  by  sutures  at  the  internal  ring,  invaginated,  twisted,  or  sewn  up  into  a  pad 
and  pushed  into  the  subserous  space,  so  that  it  no  longer  lies  in  the  canal  at  all. 
Of  these,  the  two  last  are  to  be  preferred  ;  in  both  the  separation  of  the  sac  must 
be  complete  and  the  peritoneum  continuous  with  it  must  be  detached  for  at  least 
half  an  inch  inside  the  margin  of  the  internal  ring. 

{a)  Torsion  (Ball). — The  sac  is  first  examined  to  make  sure  that  it  is  empty. 
The  neck  is  grasped  with  a  pair  of  broad  catch-forceps,  and,  while  the  finger  de- 
taches the  tissues  around,  is  twisted  until  it  is  felt  to  be  quite  tight  and  that  any 
further  torsion  would  tear  it.     A  stout  catgut  ligature  is  then  placed  round  the 


902    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

twisted  sac  as  high  as  possible,  tied  tightly,  and  the  ends  cut  off  short.  The  effect 
of  this  is  to  throw  the  peritoneum  around  the  opening  into  a  number  of  spiral 
folds,  extending  over  such  a  distance  that,  in  two  cases,  the  opposite  ring  was 
narrowed  sufficiently  to  prevent  the  descent  of  a  hernia.  Sutures  are  i)assed  after- 
wards through  the  pillars  of  the  ring  and  the  twisted  neck,  so  as  to  press  the 
latter  toward  the  abdominal  cavity,  and  prevent  anything  like  a  funnel-shaped 
depression  on  the  jx'ritoneal  surface.  No  ill  result  has  ever  been  recorded  after 
this,  but  it  must  not  l)e  forgotten  that,  in  some  cases,  strangulation  of  the  jjarietal 
peritoneum  (as  in  subperitoneal  fatty  hernire)  has  given  rise  to  symptoms  of 
the  same  character,  although  of  less  intensity,  as  strangulated  intestine. 

{b)  Folding  (McEwen). — In  this  the  sac  is  thoroughly  freed,  not  only  at  the 
fundus  and  neck,  but  for  half  an  inch  further  inside  the  constricting  ring;  it  is 
then  drawn  down,  examined  to  see  that  it  is  free,  and  a  stout  catgut  suture 
fastened  to  its  base.  This  is  threaded  on  a  needle  and  passed  through  the 
serous  layers  from  side  to  side  at  very  short  intervals,  working  toward  the 
neck,    so   that   when   it    is    drawn    upward   the  sac    is    thrown    into   a   series  of 


l\W' 


M. . 


>*?: 


XT-  >C' 


Fig.  388. — McEwen's  Pad,  as  seen  from  the  Inside.  Fig. 


■The  Canal  seen  from  inside,  showing  its  valvular 
shape.     {A/ier  Astley  Cooper.) 


short  folds  closely  pressed  together.  The  pad  thus  formed  is  jnished  inside 
the  ring,  and  fixed  there  by  passing  the  suture  through  the  muscles  on  the 
front  wall  of  the  abdomen  from  within  outward.  In  this  way,  a  solid  block 
of  invaginated  sac  is  placed  over  the  ring — not  in  the  canal — projecting  into 
the  peritoneal  cavity  (Fig.  388),  so  that  when  the  coils  of  the  intestine  are 
forced  downward,  they  are  thrown  off  on  to  either  side.  Owing  to  the  way  in 
which  the  margins  of  the  ring  are  refreshed  by  detaching  the  peritoneum,  the  pad 
very  soon  becomes  adherent  at  its  new  site. 

The  Canal. — The  second  step  is  to  suture  this,  and  restore  its  valvular  shape 

(Fig.  389)-  .      , 

Where  it  has  not  been  shortened  by  the  traction  of  the  hernia,  the  simplest 
method  is  to  pass  aListon's  needle,  threaded  with  silk  or  well-seasoned  catgut,  up 
the  canal  along  the  finger  until  it  perforates  the  inner  boundary  of  the  ring.  It  is 
then  unthreaded,  withdrawn  (leaving  the  suture),  threaded  again  with  the  other 
end,  and  pas.sed  through  the  outer  boundary  at  the  opposite  point.  Four  to  seven 
sutures,  according  to  the  length  of  the  canal,  may  be  passed  in  this  way,  each  per- 
forating all  the  structures  that  form  its  outer  and  inner  walls,  and  leaving  beneath 


INGUINAL  HERNIA. 


903 


them  a  small  space  along  the  floor  for  the  spermatic  cord.  If  the  neck  of  the  sac 
has  been  tied  or  twisted,  the  first  suture  may  be  passed  through  it  to  hold  it  well 
up  in  the  abdomen  ;  but,  in  any  case,  it  must  perforate  the  l)oundaries  of  the  inner 
ring  as  high  as  possible.  This  one  should  be  secured  a.s  soon  as  it  is  passed  ;  the 
others  should  all  be  inserted  before  one  is  tied,  in  order  that  the  effect  on  the 
spermatic  cord  may  be  noted  when  they  are  all  lifted  up  together. 

When  the  canal  is  shortened  McEwen's  plan  is  preferable;  merely  stitching 
the  opposite  walls  together  scarcely  forms  any  protection.  The  finger  is  introduced 
into  the  canal,  after  the  pad  formed  out  of  the  sac  has  been  placed  in  position, 
and  the  deep  epigastric  artery  and  the  inner  border  of  the  ring  carefully 
defined.  A  hernia  needle  with  a  sharp  lateral  curve  at  the  end  (right  or  left 
according  to  the  side)  is  passed  up  the  canal  through  the  conjoined  tendon  (in 
and  out)  into  the  canal  again,  and  threaded  there,  so  that  when  it  is  withdrawn 


P'iG.  390. — McEwen's  Sutures  to  draw  the  Conjoined  Tendon  down  to  Poupart's  Ligament. 


a  loop  of  catgut  is  left  on  the  deep  surface  of  the  tendon  with  the  two  ends  free 
in  the  canal  (Fig.  390).  These  are  dealt  with  separately.  The  upper  is 
threaded  on  a  needle  and  passed  through  the  internal  oblique  muscle,  and  the 
aponeurosis  of  the  external  oblique  from  within  the  canal  toward  the  surface,  on 
a  level  corresponding  to  the  upper  end  of  the  loop.  The  lower  is  treated  in  the 
same  way,  but  is  only  passed  through  Poupart's  ligament. 

By  this  a  double  suture  is  formed  across  the  internal  ring,  drawing  its  inner 
margin  outward  toward  the  under  surface  of  Poupart's  ligament.  The  two  free 
ends  emerge  on  the  surface  of  the  external  oblique,  the  loop  lies  on  the  abdominal 
side  of  the  conjoined  tendon  ;  when  the  ends  are  tied  together  this  is  drawn 
directly  outward  and  downward  until  it  lies  beneath  the  margin  of  the  outer 
pillar  and  closes  the  ring  like  a  valve. 


904     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

A  second  double  suture  may  be  passed  in  the  same  way  lower  down  in  the 
canal,  or,  now  that  the  valve  is  restored,  the  walls  may  be  sewn  together  as  in  the 
former  plan. 

In  some  cases,  oi)erating  upon  this  plan,  I  have  found  very  little  difficulty 
in  securing  anything  like  a  conjoined  tendon.  In  one,  at  least,  there  was  nothing 
of  the  kind  attached  to  the  ileo-pectineal  line,  and  probably  this  was  the  cause  of 
the  hernia. 

The  sutures  should  either  be  of  chromicized  catgut,  tendon  or  silk  ;  their 
object  is  to  secure  the  position  of  the  sac  and  the  walls  of  the  canal  until  a  sufficient 
amount  of  lymph  has  been  thrown  out  to  consolidate  them  and  glue  them  all 
together,  ^^'ire  js  unnecessary;  it  cannot  hold  fibrous  tissues  together  if  there  is 
any  strain,  antl  although,  if  the  wound  heals  by  the  first  intention,  it  becomes 
buried  and  disappears,  it  is  always  liable,  years  afterward,  like  any  other  foreign 
body  embedded  in  soft  parts,  to  set  up  a  certain  amount  of  irritation,  and  grad- 
ually ulcerate  its  way  out.  In  a  successful  case  the  tissues  become  hard  and  dense 
after  the  operation,  and  not  unfrequently  after  the  stitches  have  been  absorbed,  or, 
at  least,  have  lost  all  hold  on  the  parts,  the  walls  of  the  canal  become  more  and 
more  closely  approximated  by  the  gradual  contraction  of  the  lymph  that  has  been 
poured  out.  The  sutures  should  never  be  drawn  too  tight  for  fear  of  their  cutting 
out  too  soon,  and  care  should  always  be  taken  that  a  sufficient  amount  of  space  is 
left  for  the  spermatic  cord. 


Fig.  3QI. — The  Pillars  Open, 
the  Cord  Held  Up. 


Fig.  392. — The  Pillars  Fig.  393. — The  Deep 
Sutured,  the  Cord  Fascia  Closed  over 
Held  Up.  the  Cord. 

Radical  Operation  for  Inguinal  Hernia.     {After  Bassini.) 


The  treatment  of  the  wound  is  very  simple.  It  is  well  sponged  out  with  an 
antiseptic  and  dried  ;  the  edges  of  the  skin  are  brought  together  with  a  continuous 
catgut  suture,  and  sprinkled  over  with  iodoform  ;  and  the  groin  is  carefully  and 
evenly  packed  with  an  absorbent  dressing,  so  as  to  ensure  eipiable  pressure  and 
perfect  rest.  If  there  has  been  much  handling  of  the  parts  a  drainage  tube  is 
inserted,  and  the  dressing  is  removed  the  next  day  to  make  sure  that  it  is  not 
clogged ;  afterward  it  is  enough  if  it  is  placed  just  between  the  edges  of  the 
wound.  At  the  end  of  a  week  or  ten  days  healing  is  generally  perfect,  and  the 
tube,  with  the  portion  of  the  sutures  that  has  not  been  absorbed,  is  found  lying 
upon  the  skin. 

A  spring  tru.ss  should  not  be  worn  after  the  operation,  as  its  pressure  tends 
to  cause  premature  absorption  of  the  lymph  ;  but  the  abdominal  wall  requires  a 
certain  amount  of  support  for  some  months.  In  infants  this  may  be  managed 
wTth  a  skein  of  Berlin  wool  as  already  described  ;  but  for  children  and  adults  the 
form  of  appliance  known  as  Harrison's  truss  answers  best.  It  consists  of  a  well- 
fitting  pelvic  band,  and  two  short  thigh  pieces  made  of  linen,  like  a  pair  of  very 
short  drawers,  fitting  tightly  and  fastened  with  lacers.  A  perineal  band  prevents 
its  ascending,  and  it  may  in  addition  be  furnished  with  a  scrotal  bag,  and  with 
braces  passing  over  the  shoulders. 

[The  method  introduced  by  Bassini,  in  1888,  modified  according  to  the  neces- 


FEMORAL   HERNIA. 


905 


sities  of  the  particular  case,  is  at  jiresent  most  in  favor  in  the  United  States.  'I'his 
operation  consists  essentially  in  a  reformation  of  the  inguinal  canal  and  transplanta- 
tion of  the  cord.  Bassini  asserted  that  his  methotl  was  without  danger,  that  the  cure 
was  speedy,  and  that  no  truss  was  required  after  the  operation.  Marcy  thus  describes 
Rassini's  ojieration  :  "  He  lays  open  the  canal  to  the  internal  ring.  The  sac  is 
separated,  drawn  down,  ligated,  and  resected.  The  closed  peritoneum  is  returned, 
the  si)ermatic  cord  pushed  aside,  and  the  posterior  margin  of  Poupart's  ligament 
exposed.  The  deeper  layer  is  dissected  in  such  a  manner  that  it  can  be  brought 
in  close  apposition  to  Poupart's  ligament.  From  the  ileo-pubic  tubercle  the  canal 
is  united  jjosteriorly,  from  five  to  seven  centimetres,  to  the  entrance  of  the  cord 
into  the  abdominal  cavity.  The  cord  is  then  replaced,  and  the  aponeurosis  of 
the  external  oblique  sutured,  only  opening  sufficient  for  the  cord  without  com- 
pression being  left.     The  wound  is  closed  with  drainage." 

In  my  hands  this  operation  has  been  modified  by  freshening  the  edges  of  the 
pillars,  and  suturing  with  stout  chromicised  catgut,  or  whale  tendon,  or  kangaroo 
tendon,  the  "purse-string"  method  most  frequently  used;  the  cord  is  then 
brought  down,  as  in  Bassini's  operation,  and  the  wound  closed  without  drainage. 
I  have  seen  no  death  follow  the  operation,  and  I  haliitually  employ  it  after  release 
of  the  intestine  in  strangulated  hernia.  My  youngest  patient  with  strangulation 
was  five  months  old  (Presbyterian  Hospital,  Chicago,  1892),  and  my  oldest 
seventy-four  years.] 


Femoral  Hernia. 

Hernia  into  the  crural 
canal,  the  small  conical 
space  with  base  upward 
which  is  bounded  in  front 
by  Poupart's  ligament,  the 
deep  crural  arch,  and  the 
falciform  edge  of  the  fascia 
lata  ;  on  the  inner  side  by 
Gimbernat's  ligament ;  on 
the  outer  by  the  femoral 
vein  ;  and  behind  by  the 
bone  (Fig.  394).  In  very 
rare  instances  the  rupture 
protrudes  externally  to  the 
vessels. 

Femoral  hernia  rarely 
occurs  under  puberty,  and 
is  more  common  among 
women  than  among  men. 
The  sac  is  always  acquired, 
and  the  tissues  that  lie  in 
the  canal  are  pushed  down 
by  it  and  compressed  so  as 
to  form  a  fascia  propria. 
At  the  saphenous  opening 
it  comes  into  contact  with 
the  cribriform  fascia,  and 
as  soon  as  this  gives  way 

the  hernia  curls  upward  upon   itself  until  it   projects  over  Poupart's 
and  lies  upon  the  abdomen.     The  size  is  rarely  very  large,  although 
ones  are  not  uncommon.     The  contents  may  be  intestine  only,  but  i 
proportion    of  instances  there  is    as  well  a  mass   of  irreducible  and 
omentum.     In  one  or  two  cases  the  caecum  has  been  found  inside. 
5ii 


Fig.  394 


ligament, 

moderate 

n   a  large 

adherent 


9o6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Femoral  hernia  fither  forms  a  small,  tense,  rounded  tumor  immediately  below 
Poupart's  ligament,  or  a  larger,  softer  swelling,  of  irregular  shape,  traceable  to 
a  neck  in  the  crural  canal.  So  long  as  it  is  not  strangulated  there  is  an  impulse 
on  coughing  ;  and  if  the  portion  of  intestine  is  not  too  small  (Littre's  hernia 
usually  takes  jjlace  here)  or  too  much  covered  in  with  omentum,  it  may  be 
resonant  on  percussion. 

Diagnosis. — Itii^uitial  Ilcniia. — Sometimes,  especially  in  women,  a  fold 
which  may  be  mistaken  for  the  fold  of  the  groin  e.xtends  across  the  thigh  lower 
down  ;  but  the  spine  of  the  pubes  can  always  be  felt,  and  the  neck  of  a  femoral 
hernia  always  lies  below  it  and  to  the  outer  side. 

Psoas  Abscess. — The  swelling  in  this  case  lies  beneath  the  vessels  as  well  as  to 
their  inner  side  ;  there  is  a  fullness  in  the  iliac  fossa  above  ;  fluctuation  oin  usually 
be  detected,  and  gradual  reduction  takes  place  when  pre.ssure  is  made  upon  the 
swelling. 

Varix  of  the fctnoral  vein  occ?i%\ox\a.\\y  resembles  femoral  hernia  ;  there  may  be 
an  impulse  on  coughing  ;  but  if  the  finger  is  placed  on  Poupart's  ligament  after  the 
swelling  has  been  reduced  the  vein  is  filled  from  below. 

Enlarged  lymphatic  glands  often  present  great  difficulty,  especially  when  there 
is  only  one  and  it  is  not  elongated  transversely ;  but  it  never  possesses  a  neck  like 
that  in  hernia. 

Fattx  growtlis  in  the  canal,  cysts,  hydrocele  of  the  sac,  and  a  thickened  empty 
sac  often  cannot  be  diagnosed.  In  such  circumstances,  if  symptoms  of  strangula- 
tion are  present,  an  exploratory  operation  should  be  performed. 

Treatment. — i.  Reducible  Hernia. — This  should  be  .supported  by  a  truss 
the  pad  of  which  presses  a  little  upward  as  well  as  backward,  hooking  under 
Poupart's  ligament,  and  is  beveled  off  on  the  outer  side  so  as  not  to  compress  the 
femoral  vein. 

2.  Irreducible  but  not  Strangulated.— \{  there  is  only  a  small  amount  of 
omentum  (the  common  form)  a  pad  may  be  moulded  over  the  protrusion  to  prevent 
its  increasing  ;  or  an  attempt  may  be  made  to  effect  reduction  by  taxis  after  the 
prolonged  application  of  ice  combined  with  scanty  diet  and  iodide  of  ])otash  ;  but, 
especially  in  young  women,  it  is  advisable  to  have  the  sac  opened,  the  omentum 
removed,  and  a  radical  cure  performed.  On  the  one  hand  there  is  the  exceed- 
ingly slight  risk  of  the  operation  ;  on  the  other  there  is  the  existence  of  an  omental 
band  passing  down  from  the  stomach  to  the  groin,  exposing  the  patient  to  the 
danger  of  internal  strangulation,  and  forming  a  kind  of  inclined  plane  which 
guides  the  intestine  infallibly  to  the  weakest  spot  in  the  wall.  In  most  of  the  cases 
in  which  operation  is  required  a  small  knuckle  of  intestine  is  caught  and  concealed 
behind  irreducil)le  omentum. 

If  Gimbernat's  ligament  is  too  freely  incised,  the  hernia  that  follows  is  either 
irreducible,  or,  if  it  can  be  reduced,  cannot  be  retained  in  position.  In  such  cases 
a  firmly-made  thigh  belt,  laced  up,  with  a  triangular  pad  to  fit  in  Scarpa's  triangle, 
affords  more  relief  than  anything  else.  It  should  either  be  attached  to  a  truss  or 
provided  with  a  pelvic  band  of  its  own. 

3.  Strangulated. — In  femoral  hernia  the  symptoms  are  generally  acute,  and 
taxis  has  little  chance  of  succeeding,  owing  to  the  unyielding  character  of  the  edges 
of  the  ring.  If  a  portion  of  intestine  has  only  just  descended,  an  ice-bag  may  be 
tried  for  a  short  time  in  the  hoi)e  of  reducing  its  bulk  ;  but  if  it  is  small  and  tense, 
and  is  down  for  the  first  time,  or  if  there  is  an  old  epiplocele,  it  is  better  to  give 
the  i)atientan  anesthetic,  and  if  taxis  does  not  succeed  at  once,  operate.  In  the 
one  case,  if  the  least  pressure  is  used,  the  edge  of  Gimbernat's  ligament  cuts  into 
the  congested  bowel  ;  in  the  other,  owing  to  the  mass  of  omentum  in  front,  the 
pressure  is  too  diffused  to  act  with  any  certainty.  If  the  symptoms  of  strangulation 
have  lasted  acutely  for  more  than  two  days,  or  if  there  is  a  history  of  many  attempts 
at  taxis,  especially  by  the  patient  himself,  the  operation  should  be  performed  at 
once. 

In  applying  taxis  the  position  of  the  patient  is  the  same  as  for  inguinal  hernia. 


UMBILICAL   HERNIA.  907 

the  thigh  flexed,  adducted,  and  rotated  inward.  The  direction  of  the  pressure  is 
upward  and  backward,  the  tumor,  if  it  has  spread  over  Poupart's  ligament,  being 
drawn  downward.  The  neck  of  the  sac  is  steadied  with  one  hand,  the  utmost 
gentleness  being  used,  and  softly  squeezed  from  side  to  side,  while  the  other  draws 
the  rupture  down  and  then  quietly  presses  it  up  again. 

The  incision  is  vertical  immediately  over  the  neck,  with  its  upper  end  on 
Poupart's  ligament.  The  layers  divided  vary  in  each  case,  and  often  it  is  thought 
that  the  sac  is  exposed  when  the  fascia  propria  is  reached.  The  difference  is  plain 
at  once  if  they  are  traced  up  to  the  neck  ;  the  one  comes  from  the  abdomen,  the 
other  does  not.  Hey's  ligament,  the  curled-in  edge  of  the  falciform  process 
attached  to  the  ilio-pectineal  line,  is  the  first  tense  band  divided,  and  sometimes  then 
the  hernia  can  be  reduced.  More  often  the  deep  crural  arch  and  the  lower  fibres 
of  Gimbernat's  ligament,  where  it  is  separating  from  Poupart's,  must  be  cut  as 
well.  If  there  is  no  reason  for  opening  the  sac,  the  finger  nail  is  slipped  beneath 
them,  and  the  end  of  a  probe-pointed  hernia  knife  gently  insinuated  and  slowly 
turned  round,  so  as  to  make  a  small  incision  upward  and  slightly  inward.  If  this 
fail,  or  if  it  is  not  thought  advisable  to  try  it,  the  sac  is  opened  with  the  usual  pre- 
cautions and  an  incision  made  from  the  inside  in  the  same  direction. 

The  incision  should  be  made  very  slowly  by  the  pressure  of  the  knife,  and 
should  be  as  short  as  possible  ;  if  more  space  is  recjuired  it  is  better  to  make  a 
second  than  to  divide  Gimbernat's  ligament  more  freely,  as  this  is  usually  followed 
by  a  most  intractable  form  of  hernia.  Moreover,  in  a  small  proportion  of  cases 
(about  one  per  cent.),  the  obturator  artery  pursues  an  abnormal  course,  coming  off 
from  the  deep  epigastric  and  winding  round  the  upper  border  and  inner  side  of  the 
crural  ring.  If,  as  it  usually  does,  it  runs  down  between  the  hernia  and  the  vessels 
it  is  not  likely  to  be  hurt ;  but  if  it  loops  round  it  may  easily  be  divided,  as  it  lies 
actually  on  the  sac.  For  this  reason  the  finger  should  be  used  in  preference  to  a 
director,  as  the  pulsation  can  sometimes  be  felt.  Injury  to  the  vessel  may  be 
avoided  by  using  a  blunt  hernia  knife  ;  the  fibrous  tissue  is  so  tense  that  anything 
will  divide  it,  while  the  artery  is  simply  pushed  away.  If  it  should  be  hurt  an 
attempt  must  be  made  to  find  the  ends  and  ligature  them  or  secure  them  with  clamp 
forceps,  but  without  dividing  Poupart's  ligament;  an  incision  should  be  made 
above  it,  as  for  ligature  of  the  external  iliac,  and  a  careful  dissection  carried  down 
until  the  bleeding  points  are  exposed.  In  one  case  the  lower  end  of  the  artery  was 
drawn  right  into  the  obturator  foramen.  Free  hemorrhage  may  occur  from  the 
division  of  a  small  vein,  but  this  stops  of  itself. 

The  contents  of  the  sac  must  be  dealt  with  according  to  the  ordinary  rules, 
but  especial  care  is  required  in  femoral  hernia,  as  the  constriction  may  cause  ulcer- 
ation, and  even  sloughing,  of  the  mucous  membrane  without  evidence  of  much 
congestion.  Moreover,  a  small  knuckle  of  intestine  is  sometimes  concealed  behind, 
and  even  in  the  interior  of  a  mass  of  irreducible  omentum. 

The  sac,  when  it  has  been  emptied,  should  be  detached  thoroughly  from  the 
tissues  around,  and  sewn  up  into  a  pad  after  McEwen's  plan.  Afterwards  a  suture 
may  be  passed  through  the  boundaries  of  the  ring  in  a  way  devised  by  Wood  for 
the  radical  cure  ;  a  Liston  needle  is  passed  through  the  pubic  portion  of  the  fascia 
lata,  entering  about  an  inch  below  and  emerging  close  to  the  pectineal  line,  and 
then  through  Poupart's  ligament.  Catgut,  silk,  or  wire  may  be  used,  as  in  the 
inguinal  operation,  and  two,  or  at  the  most  three,  sutures  inserted  between  Gimber- 
nat's ligament  and  the  femoral  vein. 

Umbilical  Herxia. 

Thismav  be  congenital,  or  it  may  occur  during  infancy,  or  later,  during  adult 
life. 

(a)  The  congenital  form  of  umbilical  hernia  is  due  to  the  visceral  plates  fail- 
ing to  meet  in  the  middle  line,  and  allowing  some  portion  of  the  intestine,  and,  in 


9o8    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

rare  cases,  the  greater  part  of  the  al)(h)niinal  contents,  to  protrude.  Owing  to  the 
method  of  its  development  tlie  c;\icum  is  often  found  in  it. 

A  sac  is  j)resent  in  most  instances,  formed  from  the  |)eritoneum,  and  extend- 
ing among  the  tissues  of  the  cord.  It  may  be  so  thin  that  the  nature  of  the  con- 
tents can  be  seen  at  once,  or  it  may  l)e  thick.  Occasionally  it  is  wanting,  even 
when  the  protrusion  is  small  ;  in  cases  of  great  deformity  it  is  never  developed. 
Strangulation  may  occur  at  the  neck. 

Reduction  and  ligature  of  the  sac  at  its  neck  should  be  performed  imme- 
diately after  V)irth  ;  if  the  protrusion  is  left  the  delicate  tissues  dry  uj)  and  l:)ecome 
adherent  to  the  bowel.  In  cases  of  strangulation,  or  where  the  contents  have 
formed  adhesions  to  the  wall,  or  are  irreducible  for  other  reasons,  the  sac  must  be 
opened.  If  reduction  is  successful  the  edges  of  the  ring  .should  be  brought 
together  with  a  catgut  suture. 

{F)  The  umbilical  hernia  which  is  so  common  in  infants  is  due  to  the  stretch- 
ing of  the  cicatrix  shortly  after  birth.  It  never  appears  to  lead  to  strangulation, 
and  it  is  usually  cured  rapidly  by  the  contraction  of  the  orifice,  if  the  rupture  is 
prevented  from  escaping.  Tight  abdominal  belts  with  button-shaped  projections 
to  fit  into  the  opening  are  most  injurious  ;  the  pad  should  either  be  flat  (a  penny 
sewn  up  in  wash  leather  forms  a  very  convenient  one)  or  dispensed  with  altogether, 
the  skin  being  merely  rolled  up  into  two  folds,  one  on  either  side,  and  held 
together  with  strapping.  In  the  case  of  a  boy,  four  years  of  age,  in  whom  the 
Intrusion  still  i)ersisted,  I  laid  oi)en  the  sac  (wiiich  was  very  much  thickened  from 
the  constant  irritation  of  trusses),  ligatured  the  neck  and  sewed  up  the  opening 
with  catgut.     Wood  has  recommended  lacing  the  orifice  round  with  a  suture. 

(f)  The  form  that  occurs  in  adult  life  protrudes  through  the  linea  alba  close 
to  the  umbilicus,  occasionally  in  more  places  than  one,  so  that  two  herniae  lie  in 
the  same  tumor,  separated  at  their  necks  by  a  tense  band  of  fibrous  tissue.  It  is 
usually  met  with  in  women  who  have  had  large  families,  and  it  may  attain  an 
enormous  size,  hanging  down  like  a  pendulous  tumor  filled  with  omentum,  small 
intestine,  or  colon. 

This  hernia  is  frequently  irreducible,  and  when  it  attains  any  size  is  especially 
liable  to  become  obstructed  and  inflamed.  Strangulation,  when  it  occurs,  is 
usually  a  sequel  of  obstruction  ;  the  tumor  is  allowed  to  hang  down  over  the 
sharp  edge  of  the  ring,  the  veins  are  compressed,  congestion  sets  in,  the  orifice 
becomes  blocked  with  the  swollen  mass,  and  at  length  the  circulation  is  stopped. 

When  the  hernia  is  reducible  it  must  be  retained  in  position  by  a  suitable 
belt  ;  if  this  is  impassible,  it  should  be  well  supported,  especially  from  beneath, 
and,  as  far  as  can  be,  prevented  from  increasing.  Strangulation  is  often  very 
insidious.  The  hemia  has  been  irreducible  for  some  time  and  is  perhaps  obstructed. 
At  first  there  is  only  discomfort  or  uneasiness  ;  then  vomiting  begins,  and  soon  the 
constitutional  signs  of  strangulation  set  in  definitely.  Taxis  may  succeed,  but, 
owing  to  the  way  in  which  the  strangulated  loop  is  shielded  by  the  rest,  it  often 
fails.  In  this  case  an  incision  must  be  made  over  the  upper  i)art  of  the  tumor 
(Wood  prefers  the  lower),  and  the  neighboring  abdominal  wall,  in  the  middle  line, 
and  the  skin  carefully  divided  over  the  margin  of  the  orifice.  The  sac  is  exces- 
sively thin,  and  the  tissues  are  generally  matted  together  from  constant  irritation  ; 
but  an  attempt  should  always  be  made  to  relieve  the  constriction  without  opening 
the  peritoneum.  If  it  cannot  be  done,  either  a  small  incision  must  be  made 
through  the  fibrous  ring,  from  the  inside  of  the  sac  at  one  or  two  points,  and  the 
strangulated  loop  reduced,  the  rest  being  left  as  it  was  before,  or  the  sac  may  be 
laid  freely  open,  the  contents  unraveled  and  released  from  the  omentum,  which  is 
spread  over  and  among  them,  and  the  operation  completed  as  in  abdominal  sec- 
tion, excising  the  redundant  ])ortion.  Which  of  the  two  should  be  i)erformed  must 
be  determined  by  the  circumstances  of  each  case  ;  the  latter  requires  the  greatest 
care  and  may  be  exceedingly  tedious  and  prolonged,  but  the  results  do  not  seem 
to  be  more  unfavorable. 


VENTRAL   AND  OBTURATOR   HERNIA.  909 

In  one  case  in  which  the  walls  of  the  abdomen  were  enormously  thickened 
from  the  dei)Osit  of  fat,  I  made  an  incision  in  the  linea  alba  below  the  umbilicus, 
where,  owing  to  the  pressure  of  the  tumor,  the  tissues  were  not  Cjuite  so  thick  as  in 
other  parts,  dilated  the  stricture  from  the  inside,  and  withdrew  the  strangulated 
loop.  The  immediate  result  was  successful,  but  the  patient  died  some  weeks  later 
from  bronchitis  and  prolonged  sup|)uration  in  the  abdominal  wall. 

Ventral  Hernia. 

Hernia  through  the  linea  alba  (except  at  the  umbilicus)  the  linea  semilunaris, 
or  some  other  part  of  the  abdominal  wall  that  is  not  usually  weak.  It  may  be  the 
result  of  defective  development,  or  it  may  be  due  to  operations,  injuries,  extreme 
distention,  rupture  of  muscles,  abscesses  leaving  a  yielding  cicatrix,  or,  in  short, 
anything  that  impairs  the  strength  of  the  part.  It  must  be  treated  in  all  respects 
like  umbilical  hernia.  Strangulation  is  rare,  although  I  have  met  with  instances  of 
it.  Hernise  of  the  subperitoneal  fat  may  occur  in  the  middle  line,  and  have  been 
known  to  cause  symptoms  of  strangulation  from  dragging  upon  the  peritoneum 
beneath. 

Obturator  Hernia. 

Hernia  through  the  obturator  canal  in  the  upper  and  outer  part  of  the  thyroid 
foramen  is  always  acquired,  is  much  more  common  in  women  than  in  men,  and 
rarely  occurs  until  middle  age  ;  apparently  it  is  connected  with  the  emaciation  and 
loss  of  fat  which  often  follow  the  climacteric.  It  protrudes  either  between  the 
obturator  externus  and  pectineus,  or  through  one  or  other,  stretching  the  fibres 
over  it,  and  causes  an  indefinite  fullness  in  the  groin,  behind  and  to  the  inner  side 
of  the  femoral  vessels,  between  them  and  the  adductor  longus.  The  obturator 
artery  and  vein  may  lie  either  to  the  inner  or  outer  side,  the  relation  they  bear  to 
the  neck  of  the  sac  being  very  inconstant. 

This  form  of  hernia  is  rarely  recognized  unless  it  is  strangulated.  It  is  always 
small  and  deeply  buried  ;  and,  unless  there  is  pain  along  the  obturator  nerve,  there 
is  little  or  nothing  to  direct  attention  to  it.  If  strangulation  sets  in  the  symptoms 
are  generally  acute  ;  the  inner  side  of  the  thigh  is  tender  and  painful  ;  sometimes, 
if  the  patient  is  thin,  a  certain  amount  of  fullness  may  be  made  out,  especially 
when  the  hips  are  slightly  flexed  and  abducted  ;  the  muscles  of  the  abdominal  wall 
are  rigid,  and  the  movements  of  the  thigh  are  attended  with  pain.  Vomiting  and 
collapse  usually  come  on  at  once  and  are  very  severe.  In  about  half  the  cases 
there  is  a  complaint  of  pain  running  down  the  inner  side  of  the  thigh  to  the  knee- 
joint,  or  even  into  the  leg,  evidently  due  to  the  pre.ssure  upon  the  nerve ;  but  in 
many  instances  this  symptom  has  not  been  noted.  Examination  per  vaginam  is 
stated  to  have  been  of  assistance  in  the  diagnosis. 

Taxis  has  been  successful  in  a  fair  number  of  cases.  The  thigh  should  be 
flexed,  adducted,  and  rotated  a  little  inward  to  relax  the  muscles  around  the  hernia 
as  much  as  possible ;  and  the  pressure  must  be  applied  from  below  upward.  If 
this  fails  to  give  relief,  and  the  symptoms  point  to  strangulation,  an  incision  should 
be  made  to  the  inner  side  of  the  femoral  vessels,  parallel  to  them,  commencing 
immediately  below  Poupart's  ligament,  and  the  pectineus  muscle  exposed.  The 
fascia  covering  it  is  divided,  the  muscular  fibres  separated  and  held  apart,  and  the 
finger  passed  down  to  explore  the  upper  and  outer  part  of  the  obturator  canal.  If 
the  sac  can  be  made  out  it  must  be  separated  from  the  tissues  around  and  opened 
so  that  the  condition  of  the  intestine  may  be  assured.  The  stricture  is  divided  by 
cutting  either  directly  downward,  or  a  little  downward  and  outward.  In  several 
instances  the  local  symptoms  have  been  so  obscure  that  abdominal  section  has 
been  performed  for  the  relief  of  strangulation. 

Other  varieties  of  hernia  are  very  rare,  and  possess  but  slight  surgical  interest. 
Diaphrag7natic  hernia  may  be  either  congenital  or  acquired.      In  the  former 


9IO    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

case  the  protrusion  takes  place  by  the  side  of  the  ensiform  cartihij^e,  between  the 
costal  and  xiphoid  ])ortions  of  the  diaphragm,  or  through  some  accidentally  weak 
part,  and  it  is  usually  covered  with  a  sac.  In  the  latter,  which  is  much  the  more 
common,  any  part  of  the  diaphragm  may  give  way  and  allow  the  intestines  to  be 
forced  through  the  rent  into  the  pleura. 

The  congenital  form  scarcely  admits  of  diagnosis  :  in  the  actpn'red  one,  if  the 
amount  of  the  protrusion  is  very  great  (and,  occasionally,  the  stomach,  spleen, 
part  of  the  liver,  and  a  considerable  i)roportion  of  the  intestine  are  forced  into 
the  pleural  cayity),  death,  generally  speaking,  occurs  at  once  from  the  interference 
with  the  thoracic  viscera;  in  other  cases,  if  the  patient  survives,  there  is  great 
distress,  arising  from  the  dispUicement  of  the  organs  and  the  adhesions  that  form 
between  them  :  and  strangulation  may  occur. 

Perineal  Hernia. — In  this  the  protrusion  takes  place  either  between  the 
bladder  and  rectum,  or  the  bladder  and  vagina,  according  to  the  sex.  Usually  it 
passes  through  the  fibres  of  the  levator  ani  and  forms  a  soft,  easily  reducible  swell- 
ing to  one  side  of  the  middle  line. 

Pudendal  hernia  may  occur  in  women  past  middle  life,  the  sac  descending 
between  the  ramus  of  the  ischium  and  the  vagina  into  the  posterior  part  of  the 
labium.      It  might  be  mistaken  for  a  labial  cyst. 

Sciatie  hernia  has  been  described  by  Astley  Cooper,  the  rupture  lying  between 
the  pyriformis  and  the  s[)ine  of  the  ischium. 

Lumbar  hernia  occurs  in  Pott's  triangle,  the  small  space  l)ounded  by  the  ex- 
ternal oblique,  the  latissimus  dorsi,  and  the  crest  of  the  ilium.  It  must  either  pass 
through  the  aponeurosis  of  the  transversalis  and  the  internal  oblique,  or  stretch 
them  gradually  before  it  as  coverings  of  the  sac. 

[See  plate  opposite,  illustrating  case  of  lumbar  hernia,  back  and  front  view, 
from  photograph  sent  the  editor  by  Dr.  C.  H.  Mastin.] 


SECTION  IV.— INTESTINAL  OBSTRUCTION. 

Intestinal  obstruction  includes  all  cases  of  internal  hernia,  strangulation  by 
bands,  twisting,  intussusception,  stricture  and  impaction.  For  clinical  purposes 
these  are  divided  into  two  great  classes. 

In  the  one  the  onset  is  instantaneous,  and  the  chief  symptoms  are  due  to  the 
effect  upon  the  nervous  system.  The  patient  is  in  perfect  health  :  suddenly  and 
without  warning,  some  part  of  the  bowel  is  caught  or  twisted  ;  the  circulation  is 
stopi)ecl ;  the  great  nerve-plexuses  are  thrown  into  a  state  of  violent  disorder  ; 
vomiting,  collapse,  and  pain  come  on  at  once;  the  vomit  rapidly  becomes  faecal ; 
the  prostration  is  complete  ;  and,  if  the  patient  does  not  sink  from  exhaustion,  the 
intestine  becomes  gangrenous  in  the  course  of  a  few  days. 

In  the  other  the  onset  is  gradual,  and  the  symptoms  for  a  time  ill-defined  ; 
the  health  often  has  been  failing ;  there  have  been  previous  slight  attacks  of  a 
similar  character,  at  first  relieved  easily,  then  with  greater  difficulty,  until  at  length 
absolute  obstruction  and  distention  of  the  abdomen  set  in.  Pain  is  present,  but  it 
comes  on  spasmodically  and  grows  more  and  more  intense.  \'omiting,  when  it 
does  occur,  is  due  to  the  accumulation  of  food,  not  to  the  effect  upon  the  nervous 
system  ;  but  the  case  may  run  a  course  of  weeks  without  its  happening  once. 
Collapse  does  not  come  on  until  the  end  is  approaching. 

It  must  not  be  imagined,  however,  that  every  case  can  be  included  at  once 
under  one  of  these  headings  ;  the  diagnosis  of  the  cause  and  of  the  seat  of  intestinal 
obstruction  is  one  of  the  most  difficult  in  surgery,  and  often  an  operation  has  to 
be  performed  with  the  double  object  of  exploration  and  relief. 

Occasionally  the  aspect  of  a  case  changes  suddenly  :   chronic  obstruction  be- 


O 

UJ 
CO 

< 

o 

CO 

z 


I- 

co 

$   < 


ACUTE   INTESTINAL   OBSTRUCTION. 


911 


conies  acute,  the  symptoms  become  infinitely  more  severe,  and  the  patient  sinks 
from  prostration,  the  more  rapidly  because  of  the  exhaustion  caused  by  the  previous 
illness. 

Acute  Intestinal  Obstruction,  or  Internal  Strangulation. 

The  svmptoms  acute  and  the  strangulation  sudden,  as  in  external  hernia. 
Causes. —  The  most  useful  classification  is  that  adopted  by  Treves  :  — 

1.  Internal  hernia  and  strangulation  by  bands  of  all  kinds. 

2.  Volvulus. 

3.  Acute  intussusception. 

4.  Sudden  obstruction  due  to  gall-stones,  or  impaction  of  fseces,  with  or  with- 
out previous  narrowing  of  the  bowel.  Stricture,  in  most  instances,  is  gradual ;  but, 
occasionally,  the  closure  suddenly  becomes  complete,  and  the  symptoms  as.sume  an 
intensely  acute  character. 

I.  Internal  Hernia  and  Strangulation  by  Batids. — Pouches,  which  may 
become  hernial  sacs,  are  occasionally  developed  from  depressions  on  the  posterior 
wall  of  the  abdomen.  One  of  these  is  the  duodeno-jejunal  fossa,  caused  by  the 
fold  of  peritoneum  covering  the  inferior  mesenteric  vein  ;  another  is  the  subcecal, 
to  the  inner  side  of  the  caecum,  bounded  above  by  a  fold  passing  from  the  pro- 
montory to  the  caecum  ;  and  there  may  be  a  third,  the  i?itersigmoid,  between  the 
left  ureter,  the  superior  hemorrhoidal  vein  and  the  spermatic  vessels.  In  other 
cases  a  pouch  is  formed  by  the  yielding  of  the  wall  at  one  spot,  the  fascia  covering 
the  iliacus,  for  example,  so  that  the  peritoneum  protrudes  into  the  tissues  beneath. 

Rings  and  loops  are  sometimes  present  in  the  peritoneal  cavity.  A  hernia 
has  been  known  in  the  foramen  of  Winslovv  ;  but,  more  frecjuently,  the  opening  is 
abnormal,  in  the  mesentery  or  the  omentum,  or  in  a  sheet  of  lymph  thrown  out 
during  an  attack  of  inflammation. 

Bands  and  adhesions  are  more  common.  Pelvic  peritonitis  in  women,  and 
typhlitis  in  men,  are  the  causes  in  most  of  the  cases.  In  some  the  omentum  is  fixed 
to  the  pelvis,  and  rolled  up  into  the  shape  of  a  fan  ;  this  occurs  more  often  in  men, 
partly  owing  to  the  typhlitis,  partly  owing  to  the  frequency  of  hernia.  In  others 
there  is  a  tough  fibrous  band  thrown  across  from  one  part  to  another  at  the  back  of 
the  abdomen  ;  or  two  distant  loops  of  intestine  become  connected  together  by  an 
adhesion  which,  as  they 
separate,  is  stretched  out 
into  a  narrow  cord ;  or, 
again,  a  portion  of  intes- 
tine, the  appendix  vermi- 
formis  for  example,  or 
the  pedicle  of  an  ovarian 
tumor,  or  even  a  Fallopian 
tube,  is  tied  down  in  such 
a  way  that  a- small  space  is 
left  behind.  No  matter 
how  it  is  produced,  when 
a  band  of  any  kind  is  pres- 
ent, there  is  always  the 
danger  of  strangulation. 
The  intestine  slips  under 
it,  sometimes  in  a  great 
coil,  and  either  becomes, 
congested  or  else  twisted 
upon  itself  so  that  it  can- 
not return  ;  in  a  very  (ew 
hours  it  becomes  loaded  ; 
the  veins  are  constricted, 
and    the  circulation  stopped. 


IV  r^ 


/ 


A 


Fig.  395. — Strangulation  of  Small  Intestine  by  Band. 


In  rare  instances  the  traction  of  a  band  upon  one 


912    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

side  of  the  intestine  has  caused  it  to  bend  so  acutely  as  to  close  the  lumen  ;  and 
the  same  thing  has  occurred  from  the  bowel  being  coni])ressed  or  held  in  a  bent 
position,  or  even  from  its  being  tied  down  by  adhesions,  especially  when  it  is 
doubled  into  a  loop. 

Bands  that  are  long  and  loose,  or  that  are  attached  only  at  one  end,  are 
scarcely  less  dangerous  ;  in  the  former  case  they  are  sometimes  thrown  into  a  kind 
of  spiral  coil,  through  the  centre  of  which  a  loop  of  intestine  may  descend. 
Probably,  as  Treves  has  pointed  out,  this  is  of  little  consecjuence  so  long  as  the 
intestine  is  healthy  ;  but  if  the  sides  of  the  loop  are  adherent  to  each  other,  or  if 
the  bowel  is  held  by  adhesions  doubled  upon  itself,  the  neck  is  very  likely  to  be 
narrower  than  the  rest,  and  strangulation  is  highly  j^robable.  When  one  end  is 
unattached,  a  knot,  sometimes  of  a  very  complicated  character,  may  be  formed 
around  the  bowel,  and  lead  to  the  same  result.  One  end  is  free  and  slightly  en- 
larged ;  this  slips  inside  a  loop  formed  by  the  rest,  the  intestine  pushing  it  on 
until  at  length  the  knot  is  drawn  tight  and  the  bowel  strangulates  itself. 

Meckel's  diverticulum,  the  remains  of  the  vitelline  duct,  is  an  especial  source 
of  danger.  Springing  from  the  ileum  a  short  distance  above  the  c?ecum,  it  is 
directed  forward  toward  the  umbilicus.  Sometimes  it  is  a  tul)e  resembling  the 
small  intestine,  and  opening  on  the  exterior ;  more  often  it  jirojects  two  or  three 
inches,  and  ends  in  a  fibrous  cord  ;  or  the  end  is  free  and  enlarged  or  club-shaped  ; 


Fig.  3^6. —  Prolapse  of  Intestine  through  Meckel's  Diverticulum. 

or  it  may  have  secondary  attachments  elsewhere.  It  acts  like  a  peritoneal  band  : 
if  it  is  fixed  at  both  ends  a  loop  of  intestine  may  slip  beneath  and  be  twisted  on 
itself  and  strangulated  ;  it  may  coil  itself  into  a  loop,  or  if  the  end  is  enlarged 
and  free  it  may  knot  itself  into  a  snare  ;  in  a  few  cases  a  loop  of  intestine  has 
fallen  over  it  and  become  acutely  bent ;  in  one  or  two  instances  it  has  exerted 
such  traction  upon  the  intestine  as  to  close  the  lumen  completely  ;  and  finally  it 
may  allow  the  intestine  to  become  extruded  through  it  ;  the  mucous  membrane  is 
prolapsed  first,  and  this  is  followed  by  more  and  more  of  the  bowel,  until  there 
is  a  huge,  intensely  congested  protrusion,  turned  inside  out,  projecting  through  the 
umbilicus.  In  one  case  of  this  kind  I  was  obliged  to  open  the  abdomen  before 
the  mass  could  be  reduced  (Fig.  396). 

Strangulation  by  bands  or  through  apertures  form,  according  to  Treves,  one- 
fourth  of  the  total  number  of  cases  of  intestinal  obstruction  from  all  causes.  Of 
these  more  than  one-third  are  due  to  false  ligaments,  about  one-fifth  to  the  omen- 
tum, and  rather  more  than  one-fifth  to  the  presence  of^  Meckel's  diverticulum. 

2.  Volvulus. — Of  this  there  are  two  forms.  In  the  more  common  a  loop  of 
intestine,  the  ends  of  which  lie  close  together,  is  tw-isted  around  its  long  axis  ;  in 
the  other,  two  distinct  loops  are  twisted  around  each  other.  A  third,  very  rare 
form,  twisting  on  its  own  axis,  has  been  described  in  the  colon. 

Owing  to  its  anatomical  relations  the  sigmoid  flexure  is  the  common  seat  of 
volvulus  ;  but  it  cannot  occur  even  here  unless  the  mesentery  is  elongated,  and  the 


ACUTE   INTESTINAL  OBSTRUCTION. 


913 


ends  of  the  loop  dragged  close  together  by  long-continued  distention.  For  this 
reason  it  rarely  occurs  under  middle  life,  is  almost  unknown  in  children,  and  is 
usually  jjreceded  by  chronic  constipation.  It  may  hai)pen  to  the  caecum,  when, 
owing  to  the  i)crsistence  of  a  fcjetal  condition,  there  is  a  long  meso-ca;cum  and 
mesocolon  ;  and  to  the  small  intestine,  if  a  loop  becomes  tied  together  and  fixed 
by  atlhesions  ;  but  these  are  very  rare. 

The  second  form  of  volvulus  may  affect  the  same  regions  ;  but  it  is  very 
uncommon. 

The  immediate  cause  is  probably  some  sudden  movement  of  the  body  ;  the 
effect  is  a  tight  twisting  of  both  ends,  leaving  the  long  and  heavy  loop  hanging 
down  without  any  power  of  recovering  itself.  In  some  instances  the  pressure  of 
the  anterior  abdominal  wall  seems  to  retain  it.  Venous  congestion  sets  in  at 
once  ;  the  loop  becomes  enormously  distended  with  gases  that  are  set  free  in  it  ; 
it  may  even  reach  the  diaphragm,  and  by  its  pre.s.sure  prevent  the  swelling  of  other 
portions  of  the  intestine  ;  peritonitis  is  almost  invariable,  and  .sets  in  exceedingly 
early  ;  and  ulceration  of  the  mucous  membrane  in  the  bowel  above  the  seat  of 
constriction,  or  gangrene  of  the  loop,  follows  rapidly.  At  first  the  coil  can  be 
untwisted  without  much  difficulty,  but  after  a  little  while  the  walls  become  so 
dense  that  it  rolls  back  as  soon  as  the  pressure  is  taken  from  it.  Volvulus  may 
prove  fatal  within  forty-eight  hours. 

Volvulus  may  occur  after  the  reduction  of  a  strangulated  hernia,  causing  per- 
sistence of  the  symptoms  ;  and  in  the  case  of  bands  strangulation  is  often  the  re- 
sult of  the  combination,  the  band  and  the  twist. 

3.  Intussusception  is  the  prolapse  of  one  part  of  the  intestine  into  the  interior 
of  another  immediately  adjoining.  It  is  a  very  common  form  of  obstruction, 
making  up  very  nearly  one-third  of  the  whole  ;  and,  owing  to  the  mobility  of  the 
intestines  in  children,  is  especially  frequent  among  them.  More  than  half  the 
cases  occur  under  ten  years  of  age. 

If  a  section  is  made  through  an  intussusception,  three  layers  of  intestine  are 
divided,  the  innermost  or  entering  layer  ;  the  outermost,  or  sheath  ;  and  the  mid- 
dle or  returning  one,  in  which  the  mucous  surface  is  outside,  facing  the  mucous 
surface  of  the  sheath,  and  the  peritoneal  inside,  facing  that  of  the  entering  layer. 
The  two  inner  layers  are  known  as  the  intussusceptum.  In  exceptional  cases  five 
and  even  seven  layers  are  met  with. 

The  mesentery  is  carried  in  with  the  bowel,  lying  between  the  peritoneal 
surfaces  of  the  inner  layers,  and  dragging  the  intussusception  into  a  cone,  the 
apex  of  which  lies  at  the  point,  the  base  at  the  neck.  A  certain  amount  of  elonga- 
tion is  necessary  to  allow  this,  but,  owing  to  the 
direction  taken  by  the  bowel,  not  so  much  as  might 
be  expected  :  and  as  an  ileo-csecal  intus.susception 
can  reach  the  rectum  within  a  few  hours,  the  increased 
length  is  not  due  merely  to  stretching.  The  effect 
of  this  traction  is,  in  general,  to  throw  the  intestine 
into  a  curve,  and  to  tilt  up  the  orifice  of  the  intus- 
susceptum, so  that  it  has  the  aspect  of  a  slit  and  looks 
toward  the  side  of  the  bowel  rather  than  the  axis. 

Intussusception  exists  in  two  different  forms.  In 
the  common  one,  the  apex  of  the  invagination  never 
changes  ;  the  part  that  entered  first  continues  in  front 
throughout,  and  the  increase  is  entirely  at  the  expense 
of  the  sheathing  layer  ;  in  the  other  (ileo-colic),  Avhich 
only  occurs  at  one  part  of  the  intestine  and  is  rare 
there,  the  ileum  slips  further  and  further  down  the 
colon  through  the  valve,  without  the  caecum  following 
it ;  the  increase  is  entirely  at  the  expense  of  the  small  intestine,  and  the  apex 
is  constandy  shifting.  Not  unfrequently  after  a  time  this  variety  changes  into 
the  other. 


.^ii- 


Fig.  397. — Double  Intussusception. 


914    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

The  ordinary  form  may  be  enteric,  ileo-caical  or  colic.  Of  these  the  first 
and  last  are  seldom  met  with,  and  are  rarely  of  any  length  ;  the  second  is  the 
usual  one,  the  ileo-caical  valve  forming  the  apex,  and  gradually  passing  through 
the  colon  and  rectum  until  i)erhaps  it  protrudes  at  the  anus.  The  frecjuency  with 
which  intussusception  takes  place  at  this  spot,  is  due,  to  some  extent,  to  the 
difference  in  size  between  the  two  parts,  and  to  the  fixed  position  of  the  caecum, 
but,  as  Leichtenstern  and  others  have  pointed  out,  there  is  a  very  close  analogy 
between  the  sphincter-like  ileo-ceecal  valve  and  the  sphincter  of  the  rectum, 
and  between  the  invagination  that  takes  place  at  the  one  and  the  prolapse  that 
occurs  with  equal  frequency,  especially  in  children,  at  the  other.  Ileo-caecal 
tenesmus  probably  sets  in  whenever  there  is  any  violent  catarrh  or  abnormal  irri- 
tability of  the  intestine,  just  as  anal  tenesmus  occurs  in  similar  conditions  of  the 
rectum  ;  and  the  repeated  and  forcible  peristalsis,  driving  down  on  to  the  firmly 
closed  ileo-ca2cal  valve,  causes  intussusception  in  the  one  case,  just  as  it  causes  pro- 
lapse of  the  rectum  in  the  other.  If  the  ccecum  is  freely  movable,  as  it  usually 
is  in  children,  ileo-csecal  intussusception  occurs  ;  if,  on  the  other  hand,  it  is  fixed, 
as  in  adults,  ileo-colic.  When  once  the  invagination  has  commenced,  the  contact 
of  the  swollen  and  congested  apex,  stimulating  the  walls  of  the  intestine  below, 
tends  to  make  it  increase  indefinitely. 

In  upward  of  one-half  the  recorded  cases  of  intussusce])tion  no  exciting  cause 
can  be  found.  It  is  undoubtedly  more  common  in  delicate  patients  than  in  those 
who  are  strong  and  robust ;  and  in  most  instances  where  there  is  a  definite  reason 
for  its  occurrence,  it  has  followed  diarrhoea,  free  purgation,  or  colic  due  to  the 
presence  of  undigested  food.  Possibly  slight  degrees  of  it,  undergoing  sponta- 
neous reduction,  occur  more  commonly  than  is  usually  imagined  in  severe  colic 
attended  with  great  prostration.  In  a  few  instances  it  has  followed  injury,  blows 
upon  the  abdomen,  or  jumping  a  child  up  and  down,  and  there  is  no  doubt  that 
the  presence  of  fibrous  polypi  in  the  intestine  predisposes  to  it.  The  relation  that 
exists  between  intussusception  and  epithelioma  is  more  doubtful.  In  several  cases 
the  apex  has  been  found  to  be  the  seat  of  malignant  disease,  and  in  one  the  con- 
vexity of  the  curve  was  involved,  but  it  is  difficult  to  say  whether  this  was  the  cause 
or  the  consequence,  due  to  the  prolonged  irritation. 

The  method  of  production,  according  to  Nothnagel,  is  much  the  same 
whether  the  intussusception  is  due  to  paralysis  or  to  spasmodic  contraction  (which 
is  the  more  usual  of  the  two),  affecting  one  segment  of  the  bowel.  The  intestines 
above  scarcely  take  any  share  in  the  proceeding  ;  the  longitudinal  muscular  fibres 
simply  keep  drawing  the  bowel  from  below,  over  the  narrowed  part,  until  an 
invagination  is  produced  and  the  apex  has  become  swollen  and  congested.  True 
intussusception  must  be  distinguished  from  the  invagination  which  is  not  uncom- 
monly found  in  the  bodies  of  children  who  have  died  from  cerebral  disease. 
Several  of  these  may  occur  together,  they  are  never  of  any  size,  and  can  always  be 
reduced  without  difficulty.  Probably  they  are  due  to  the  disorderly  character  of 
the  peristalsis  when  the  circulation  is  beginning  to  fail. 

Effect. — This  chiefly  concerns  the  invaginated  part  and  its  mesentery  ;  the 
sheath  may  escape  altogether,  although  sometimes  it  becomes  gangrenous,  and  the 
part  above  at  first  shows  scarcely  any  change  ;  later  it  may  be  dilated  and  the  walls 
hypertrophied,  or  ulceration  may  occur  and  end  in  perforation.  It  all  depends 
upon  the  character  of  the  constriction  ;  where  this  is  very  tight  the  bowel  inside 
becomes  intensely  congested,  blood  pours  out  from  the  mucous  membranes,  the 
walls  become  thickened  and  almost  solid,  especially  along  the  convexity  and  at  the 
apex,  and  the  intussuscepted  part  soon  becomes  gangrenous.  The  middle  layer 
usually  suffers  the  most  severely  ;  in  some  instances  the  whole  invagination  is 
destroyed  and  comes  away  in  a  mass,  the  separation  taking  place  at  the  neck  ;  more 
frequently  it  is  detached  in  shreds,  and  occasionally  the  inner  coat  is  gradually 
cut  off  from  the  rest,  unfolded,  and  pas.sed  with  the  middle  layer,  turned  inside 
out. 

Where  the  constriction  is  less  severe  a  low  form  of  inflammation  sets  in,  the 


ACUTE   INTESTINAL   OBSTRUCTION.  915 

walls  become  thickened,  adhesions  form  between  the  peritoneal  surfaces,  some- 
times at  the  neck  only,  but  more  frei[uently  wherever  they  are  in  contact,  and  if 
the  patient  lives  the  whole  of  the  intussuscepted  part  may  at  length  slough  off. 
Obstruction  is  not  common,  in  spite  of  the  thickening  of  the  walls  and  the  way  in 
which  the  orifice  at  the  apex  is  dragged  to  one  side  by  the  mesentery.  Very  often 
the  intussuscei)tion  is  irreducible,  even  when  there  are  no  adhesions — the  walls  are 
so  thickened,  especially  along  the  convexity,  and  the  apex  is  swollen  out  to  such 
an  extent,  that  the  tissues  cannot  be  unfolded  without  being  torn.  The  same  result 
may  follow  from  twisting  of  the  bowel  inside  the  sheath,  from  rigid  contraction  of 
the  ileo-ca^cal  valve,  or  from  the  presence  of  a  fibrous  polypus  springing  from  the 
mucous  membrane. 

Where  the  constriction  is  very  lax  there  may  be  little  alteration  even  after 
months,  but  not  unfretpiently  after  some  little  time  the  symptoms  suddenly  change 
and  become  acute.  Peritoneal  adhesions  are  more  common  in  chronic  than  in 
acute  cases,  and  often  render  reduction  impossible  ;  according  to  Treves  they  are 
present  in  no  less  than  eighty  per  cent.  Sometimes  they  are  only  at  the  neck,  or 
they  may  be  general,  or  limited  to  the  part  first  invaginated,  so  that  the  whole 
can  be  reduced  with  the  exception  of  the  last  i^w  inches.  The  walls  of  the  bowel 
above  are  hypertrophied  ;  sometimes  there  is  considerable  distention,  owing  to  the 
narrowing  of  the  passage  by  the  swelling  and  bending  of  the  intussuscepted  part. 
Ulceration  may  occur,  but  when  the  bowel  becomes  gangrenous  the  process  is 
usually  more  gradual  than  in  acute  cases  ;  it  may  involve  the  mucous  membrane 
only,  or  it  may  begin  at  the  apex  of  the  invagination  and  extend  slowly  upward 
until  in  some  extreme  instances  the  greater  part  or  even  the  whole  of  the  large 
intestine  has  sloughed,  leaving  the  ileum  continuous  with  the  rectum. 

4.  In  stricture  of  the  intestine  the  symptoms  sometimes  undergo  a  sudden 
change,  become  intensely  acute  and  resemble  those  of  strangulation.  This  may 
depend  upon  a  variety  of  conditions  :  the  narrowed  part  may  have  become  blocked  ; 
a  fold  of  mucous  membrane  may  have  fallen  over  the  orifice  ;  the  bowel,  especially 
in  the  case  of  the  small  intestine,  may  have  suddenly  become  bent  upon  itself, 
and  closed  the  passage  ;  or,  if  the  obstruction  is  below  the  sigmoid  flexure,  and 
this  becomes  greatly  distended,  volvulus  may  suddenly  set  in  and  cause  a  fatal 
termination  within  a  few  hours.  As  a  rule,  the  symptoms  are  hardly  so  abrupt  or 
so  violent  as  those  of  strangulation,  and  nearly  always  there  is  a  history  of  previous 
trouble  and  of  similar  slighter  attacks.  If  the  onset  is  sudden  and  the  symptoms 
acute,  as  occasionally  happens,  especially  in  stricture  of  the  small  intestine,  there 
is  no  means  of  diagnosing  one  from  the  other. 

Gall-stones  which  have  ulcerated  through  into  the  duodenum,  faecal  accumu- 
lations, and  very  rarely  foreign  bodies,  may  cause  symptoms  of  strangulation,  even 
when  there  is  no  stricture  ;  but,  in  this  case  again,  it  seldoms  happens  that  they 
are  so  acute,  or  the  collapse  so  extreme.  A  fatal  result,  however,  has  been  known 
to  occur  from  this  cause  within  four  days,  and  the  average  duration  of  acute  ob- 
struction by  impacted  gall-stone  is  only  seven. 

Symptoms. — These  conditions  are  grouped  together,  because  they  are  sud- 
den in  their  onset,  and  because,  with  certain  exceptions,  they  present  the  charac- 
teristic features  of  intestinal  strangulation,  collapse,  pain,  vomiting,  and  constipa- 
tion. Of  these  the  two  first  are  always  present,  the  others  are  not  so  constant  ; 
vomiting,  for  example,  does  not  always  occur  in  volvulus,  or  only  makes  its  appear- 
ance toward  the  end,  while  diarrhoea,  with  a  discharge  of  blood  and  mucus  from 
the  anus,  is  the  rule  in  acute  intussusception. 

{a)  The  collapse  is  most  striking  in  internal  hernia,  strangulation  by  bands, 
and  acute  intussusception.  The  patient  is  utterly  prostrate  ;  the  temperature  falls  ; 
the  pulse  is  feeble  and  rapid  ;  the  face  is  pinched,  the  eyes  sunken,  the  extremities 
cold,  and  the  secretion  of  urine  diminished.  The  severity  depends,  to  some  ex- 
tent, upon  the  part  involved  ;  it  is  more  marked,  for  example,  in  the  small  than  in 
the  large  intestine,  and  nearer  the  pylorus  than  at  the  lower  end,  but  the  amount 
caught  and  the  tightness  of  the  constriction  are  even  more  important.    In  volvulus 


9i6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  prostration  may  prove  fatal  in  two  or  three  days,  but,  as  a  rule,  it  comes  on 
more  slowly,  and  reaches  its  maximum  gradually. 

{If)  Pain  is  never  altogether  absent,  although  it  varies  in  character  and 
severity.  When  strangulation  is  the  prominent  feature,  and  the  ])critf)neum  and 
the  walls  of  the  bowel  are  crushed  together,  it  comes  on  at  once  and  lasts  through- 
out, varied  only  by  attacks  of  colic,  which,  as  in  strangulated  hernia,  are  espe- 
cially severe  when  the  abdomen  is  examined.  If,  on  the  other  hand,  the  symptoms 
are  due  to  gradual  narrowing  of  the  bowel,  as  in  chronic  obstruction,  the  pain  from 
the  first  is  of  a  peculiar  griping  character,  coming  on  at  intervals,  with  jjeriods  of 
repose  and  comjiarative  comfort  between.  Later,  as  the  obstruction  becomes  com- 
l)lete,  the  attacks  grow  more  and  more  frequent,  and  the  intervals  shorter,  until  at 
length  it  is  continuous,  with,  every  few  minutes,  violent  storms  of  colic,  often 
visible  on  the  abdomen  as  the  coils  of  intestine  move  over  and  over.  Tenderness 
is  seldom  present,  unle.ss  peritonitis  has  set  in,  or  there  has  been  severe  cramp 
affecting  the  abdominal  muscles. 

{c)  Vomiting. — As  in  external  hernia,  this  is  reflex,  caused  by  injury  to  the 
intestinal  nerves.  In  acute  strangulation  it  begins  at  once,  and  persists  without 
ceasing  ;  first  the  contents  of  the  stomach,  then  those  of  the  duodenum,  and, 
after  a  time,  of  the  lower  part  of  the  intestine.  Toward  the  end  it  ])ecomes  faical, 
if  the  obstruction  is  low  down  in  the  ileum,  or,  if  the  contents  of  the  bowel  are 
retained  sufficiently  long  for  decomposition  to  set  in.  In  volvulus,  on  the  other 
hand,  vomiting  may  not  be  present  at  all,  or  it  may  be  very  scanty,  and  even  give 
a  certain  amount  of  relief. 

(^/)  Constipation,  in  most  cases,  is  absolute.  Even  when  the  sigmoid  flexure 
is  full  of  faeces,  there  is  usually  no  evacuation,  owing  to  the  profound  effect  upon 
the  nervous  system.  Acute  intussusception,  however,  must  be  excepted  ;  in  this 
absolute  constipation  is  very  rare  ;  diarrhcxa  is  the  rule,  and  nearly  always  there 
is  a  discharge  of  blood  and  mucus,  with  violent  tenesmus. 

These  symptoms  are  common,  more  or  less,  to  all  forms  of  acute  intestinal 
obstruction  ;  others  are  less  general,  and  serve  to  distinguish  one  variety  from 
the  other. 

Ititernal  strangulation,  however  produced,  presents  the  closest  resemblance 
to  strangulated  hernia.  It  usually  occurs  in  young  adults ;  the  onset  is  sudden, 
the  collapse,  pain,  and  vomiting  (which  soon  become  fjecal)  are  characteristic; 
constipation  is  absolute  from  the  first ;  there  is  no  tenesmus  or  tenderness  on 
pressure  until  i)eritonitis  sets  in)  ;  meteorism  is  absent ;  the  coils  of  intestine  can- 
not be  seen  through  the  wall,  and  no  tumor  can  be  felt.  As  bands  are  the  most 
common  cause,  there  is  a  history  of  previous  peritonitis  or  i)erityphlitis,  or  of  the 
reduction  of  a  strangulated  (external)  hernia,  in  a  very  large  proportion  of  cases. 

Volvulus,  as  compared  with  this,  very  rarely  occurs  before  forty,  is  far  more 
common  in  the  sigmoid  flexure  than  elsewhere,  and  is  usually  preceded  by  chronic 
constipation.  The  on.set  is  sudden,  and  the  pain  .severe;  but  vomiting  does  not 
commence  at  once,  and,  unlike  that  of  strangulation,  it  may  give  a  certain  amount 
of  relief.  Tenesmus  is  occasionally  present.  The  immense  distention  of  the  affected 
bowel,  the  extreme  prostration,  and  the  rapid  occurrence  of  peritonitis  are  the 
most  important  features.  The  abdomen  becomes  distended,  until  the  diaphragm 
can  scarcely  act  ;  the  muscles  are  tense  and  rigid,  and  the  walls  excpiisitely  tender  ; 
sometimes  there  is  dullness  on  percussion  at  the  back,  but,  as  a  rule,  it  is  resonant 
all  over;  no  coils  of  intestine  can  be  seen,  and  no  sign  of  any  tumor.  It  is  pos- 
sible that  manual  examination  of  the  rectum  and  enemata  may  be  of  some  use  in 
the  diagnosis  of  the  ordinary  form. 

Acute  intussusception  stands  in  great  contrast  to  these  ;  more  than  half  the 
cases  occur  under  ten  years  of  age,  and  a  very  large  proportion  in  infants.  Like 
the  others,  the  onset  is  sudden,  attended  with  pain,  usually  distinctly  paroxysmal, 
and  great  prostration  ;  but  the  vomiting  is  not  so  constant,  and  does  not  occur  so 
early  as  in  internal  strangulation,  and  absolute  constipation  is  hardly  ever  present. 
Diarrhcea  is   the  rule,  and  in  more  than  eighty  per  cent,  there  is  a  discharge  of 


ACUTE   INTESTINAL  OBSTRUCTION.  917 

blood  and  nuicus  from  the  anus,  with  well-marked  tenesmus.  A  sausage-shaped 
tumor  can  be  felt  in  a  large  proi)ortion,  sometimes  through  the  rectimi  (in  which 
case  it  bears  a  close  resemblance  to  the  os  uteri),  more  often  through  the  abdomi- 
nal wall,  in  the  line  of  the  colon  ;  it  varies  much  in  distinctness  and  becomes 
especially  plain  during  an  attack  of  colic.  'I'he  region  of  the  swelling  is  nearly 
always  tender  from  the  first ;  no  coils  of  intestine  are  visible,  and  meteorism  and 
abdominal  distention  are  not  marked,  until  the  peritonitis  has  spread  from  the 
region  of  the  intussusception  and  becomes  general.  Intussusception  in  infants,  if 
the  parts  are  very  tightly  constricted,  may  prove  fatal  from  collapse  in  forty-eight 
hours. 

Diagnosis. — Acute  intestinal  strangulation  must  be  distinguished  from  peri- 
typhlitis and  peritonitis  (especially  that  form  which  is  due  to  ulceration  of  the 
appendi.x),  and  from  certain  other  conditions  which,  owing  to  the  effect  they  pro- 
duce upon  the  great  nerve  ple.xuses,  give  rise  to  symptoms  of  a  closely  similar 
character  (pseudo-strangulation.) 

Sudden  obstruction,  due  to  impacted  gall-stones  or  the  closure  of  a  stricture, 
can  only  be  distinguished  from  internal  strangulation  by  the  previous  history. 

Perityphlitis  seldom  begins  without  some  previous  indication  ;  there  may  have 
been  irregularity  of  the  bowels,  or  an  attack  of  indigestion  ;  local  tenderness  in  the 
iliac  fossa  is  an  early  symptom  ;  sometimes  there  is  a  distinct  feeling  of  resistance 
in  the  same  place,  or  even  a  certain  amount  of  swelling  ;  very  often  there  is  a  his- 
tory of  previous  attacks  of  a  similar  nature,  and  usually  there  is  a  slight  but  dis- 
tinct rise  of  temperature  from  the  first.  Peritonitis,  again,  of  such  a  nature  as  to 
be  mistaken  for  acute  intestinal  strangulation,  is  always  severe,  and  attended  from 
the  first  with  fever,  distention  of  the  abdomen,  and  intense  continued  pain.  Ascites 
very  soon  makes  its  appearance,  the  vomiting  is  of  a  different  character,  the  skin 
over  the  whole  surface  is  exceedingly  tender,  and,  if  it  is  due  to  perforation,  gas 
very  soon  collects  in  the  abdominal  cavity,  and  causes  a  diminution  in  the  hepatic 
dullness.  If,  however,  the  patient  is  not  seen  until  the  peritonitis  is  already  gen- 
eral, or  if,  as  frequently  happens  in  such  cases,  the  patient  is  too  exhausted  to 
give  any  account  of  his  symptoms,  the  diagnosis  of  the  cause  is  impossible. 

\\\  pseiido-straiigiilatio7i,  on  the  other  hand,  or  where  a  part  of  the  bowel  is 
paralyzed,  and  the  symptoms  are  due,  not  to  inflammation,  but  to  the  effect  upon 
the  nervous  system,  the  diagnosis  is  often  very  difficult,  and  cases  are  not  unknown 
in  which  all  the  characteristic  signs  of  internal  strangulation  have  been  present, 
and  have  terminated  fatally,  without  any  evidence  of  mechanical  obstruction  being 
found  after  death. 

Paralysis  of  one  segment  of  intestine  may  be  the  direct  result  of  injury,  or 
may  be  reflex.  Instances  of  the  former  {ileus  paralyticus^  are  not  uncommon  after 
the  reduction  of  strangulated  hernia,  and  probably  the  cases  in  which  fjecal  vomit- 
ing and  other  signs  of  acute  strangulation  have  occurred  in  the  course  of  typhoid 
and  other  diseases  that  involve  the  coats  of  the  bowel,  or  even  after  injury  to  the 
abdomen,  are  to  be  explained  in  the  same  way  ;  the  bovvel  is  so  much  injured  in 
one  spot  that  it  practically  acts  as  a  stricture  which  has  suddenly  become 
impassable. 

In  other  cases  the  paralysis  is  reflex,  excited  by  some  distant  affection,  inflam- 
mation of  a  retained  testicle  or  of  a  hydrocele,  or  phlegmon  of  the  anterior  wall  of 
the  abdomen,  and  the  symptoms  subside  as  soon  as  the  pain  and  irritation  are 
relieved.  In  neither  case  does  the  paralysis  of  the  intestine,  however  produced, 
account  for  more  than  vomiting  and  constipation  ;  the  violence  of  the  pain,  the 
severity  of  the  vomiting  and  the  collapse,  are  the  result  of  reflex  disturbance, 
starting  from  the  damaged  nerves  in  the  bowel,  involving  the  great  abdominal 
plexuses. 

Symptoms  of  a  similar  character  occasionally  arise  from  disease  of  the  nervous 
system,  hysteria,  for  example,  although  chronic  obstruction  is  more  common. 
Tubercular  peritonitis,  meningitis,  hepatic  and  renal  colic,  dysentery  and  various 
other  affections,  have  at  times  caused  a  certain  amount  of  difficulty  in  diagnosis. 


9iS    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Treatment. — In  acute  intestinal  obstruction  the  first  object  is  to  release  the 
bowel,  whether  it  is  strangulated  by  a  l)and  twisted  on  itself,  invaginated  into 
another  segment,  or  blocked  in  such  a  way  as  to  cause  the  same  symptoms.  Except 
possibly  in  this  last  mentioned  case,  it  is  of  little  avail  merely  to  secure  the  dis- 
charge of  the  contents  by  opening  the  intestines  above  (in  volvulus  it  is  done  with 
the  hope  of  uncoiling  and  releasing  the  twist)  ;  the  benefit  obtained  is  only  tran- 
sient, the  cause  is  not  removed,  the  nervous  symptoms  are  not  relieved,  and  gan- 
grene with  fatal  peritonitis  is  practically  inevitable.  It  is  true  that  a  few  cases  of 
wonderful  recovery  without  active  treatment  are  recorded  ;  but  the  numl;er  is 
exceedingly  small,  and  if  the  j^atient  is  left  the  chances  of  spontaneous  reduction 
or  of  recovery  with  an  artificial  anus  are  infinitely  less  than  in  external  strangulated 
hernia. 

The  more  sudden  the  onset  and  the  more  marked  the  nervous  symptoms,  the 
more  urgent  is  the  need  for  active  treatment.  When  the  commencement  is 
gradual,  preceded,  perhaps  with  other  symptoms,  the  difficulty  is  greater  ;  but  the 
possibility  of  an  acute  termination  to  a  chronic  affection  must  always  be  borne  in 
mind,  and  if  no  diagnosis  can  be  made,  and  the  patient's  condition  admit  of  it,  an 
operation  should  be  performed  for  exploration  before  it  is  too  late. 

I.  Where  all  the  characteristic  signs  of  acute  intestinal  strangulation  are  pre- 
sent, with  sudden  onset  and  symjjtoms  urgent  from  the  first,  as  in  strangulated 
external  hernia.  Such  a  condition  may  arise  from  internal  hernia,  strangulation 
by  bands,  omentum,  or  Meckel's  diverticulum,  sudden  obstruction  from  kinking, 
looping,  traction,  or  twisting  (volvulus)  of  the  small  intestine,  from  ileus  paralyti- 
cus or  other  affections  attendant  on  taxis  ;  or  exceptionally  from  stricture,  impac- 
tion of  foreign  bodies  or  compression  by  some  external  tumor.  There  is  no 
method  at  present  by  which  it  is  possible  to  distinguish  one  of  these  from  the  others  ; 
the  symptoms  are  practically  the  same  ;  and  if  unrelieved  they  all  end  in  the  same 
way — gangrene  and  peritonitis,  which  prove  fatal,  as  a  rule,  in  the  course  of  five 
or  six  days. 

The  patient  should  be  kept  absolutely  at  rest  and  as  warm  as  possible ; 
exposure  to  cold,  especially  during  the  operation,  is  exceptionally  serious,  owing 
to  the  collap.se  ;  no  food  may  be  allowed,  only  a  fragment  of  ice  to  allay  thirst,  but 
an  enema  of  brandy  may  be  given  with  advantage,  and  if  the  patient  has  had  no 
opium  a  small  injection  of  morphia  hypodermically.  The  effect  of  this  is  wonder- 
ful;  the  pain  is  relieved,  the  severity  of  the  vomiting  diminishes,  the  skin  becomes 
warmer,  the  collapse  passes  off  to  a  certain  extent,  and  the  secretion  of  urine 
begins  to  increase.  Care,  however,  must  be  taken  not  to  mistake  the  nature  of  the 
improvement ;  the  opium  relieves  the  collapse  so  that  the  patient  ajjpears  to  rally  ; 
it  does  not  remove  the  cause.  This,  as  in  external  hernia,  can  only  be  done  by 
operation  ;  enemata,  massage,  and  the  other  methods  of  treatment  that  have  been 
advocated  from  time  to  time,  are  worse  than  useless  ;  they  cause  delay  and  inflict 
further  injury. 

If  the  diagnosis  is  definite,  the  sooner  the  operation  is  performed  the  better  ; 
if  it  is  postponed  until  the  condition  of  the  patient  is  hopeless  it  is  not  to  be 
blamed  for  the  result. 

If  the  vomiting  is  severe  or  the  stomach  much  distended,  an  oesophageal  tube 
should  be  passed  and  the  cavity  washed  out  with  hot  water.  An  anaesthetic  is  only 
really  necessary  for  the  preliminary  incision,  and  the  patient  should  never  be  anaes- 
thetized to  complete  insensibility. 

The  incision  should  always  be  made  in  the  middle  line  l>elow  the  umbilicus,  a 
catheter  having  first  been  passed  to  make  sure  that  the  bladder  is  empty.  The 
whole  of  the  abdomen  may  be  explored  from  this  point,  there  is  very  little  bleed- 
ing, no  important  structures  are  divided,  any  part  of  the  small  intestine  may  be 
brought  out  through  it  (except  the  fixed  part  of  the  duodenum),  a  portion  of  the 
colon  even  has  been  excised  (Treves),  and  it  is  practically  impossible  in  the  vast 
majority  of  cases  to  localize  the  seat  of  the  strangulation. 

An  incision  two  inches  in  length  is  sufficient ;  the  superficial   structures  are 


ACUTE   INTESTINAL  OBSTRUCTION.  919 

divided,  the  i)eritoncuni  and  the  wound  extended  sufficiently  with  scissors  or  with 
a  scalpel,  using  the  fingers  as  a  director  ;  and  the  gap  is  filled  at  once  with  a  loop 
of  bowel  more  or  less  congested. 

In  the  easiest  cases,  where,  for  example,  the  strangulation  is  dependent  upon 
an  umbilical  band  or  Meckel's  diverticulum,  the  diagnosis  can  be  made  at  once 
with  the  finger.  More  frequently  nothing  can  be  felt.  In  this  difficulty  the  coils 
of  small  intestine  lying  near  should  be  carefully  inspected  and  the  one  that  is  most 
congested  allowed  to  protrude  into  the  wound,  hot  sponges  renewed  as  soon  as  they 
become  cool,  being  used  to  protect  and  control  it.  It  is  true  that  exjjosure  of  the 
intestine  is,  as  a  rule,  to  be  most  carefully  avoided  ;  if  the  bowel  is  allowed  to 
become  cool,  or  even  if  it  is  exposed  to  the  air  for  any  length  of  time,  the  gravity  of 
the  operation  is  immensely  increased,  but  it  is  a  choice  between  evils,  and  probably 
the  ])rotrusion  is  the  least. 

It  need  not  be  a  great  coil  ;  nearly  always  by  gently  moving  it  about  it  can 
be  seen  which  of  the  ends  is  the  more  congested  and  dilated,  and  this  guides  infallibly 
to  the  seat  of  strangulation.  Usually  it  is  not  far  off,  for  as  Greig  Smith  has 
pointed  out,  the  greater  amount  of  bowel  is  within  three  inches  of  the  umbilicus, 
and  the  most  dilated  coils  rise  to  the  surface.  Sometimes,  as  was  first  pointed  out  by 
Rand,  of  Liverpool,  it  is  possible  to  make  out  which  is  the  upper  end  of  the  loop, 
and  even  whether  it  belongs  to  the  nearer  or  more  distant  part  of  the  small 
intestine,  by  passing  the  finger  down  to  the  root  of  the  mesentery  against  the  spinal 
column. 

If  the  distention  is  too  great  to  allow  exploration,  either  the  intestine  must  be 
punctured  with  a  capillary  trocar  in  many  places,  to  let  out  the  air,  or  an  incision 
made  in  the  protruding  loop  in  order  to  empty  the  neighboring  segments.  Of 
these  methods  the  former  is  scarcely  safe ;  leakage  is  very  likely  to  occur  from 
paralysis  of  the  walls  of  the  intestine.  It  has  been  done  through  the  wound,  and 
guided  by  the  hand,  through  the  abdominal  wall  at  some  distant  spot ;  but  to  afford 
effectual  relief  it  must  be  practiced  at  many  points.  The  other  method  is  strongly 
advocated  by  Greig  Smith,  not  only  to  allow  of  exploration,  but  as  a  means  of 
relief;  he  points  out  that  in  such  cases  as  these  the  mere  distention  of  the  intestine 
is  sufficient  to  perpetuate  the  obstruction  ;  the  bowel  no  longer  lies  in  gentle 
curves,  but  forms  acute  flexures  which  act  as  valves  and  prevent  its  being  emptied 
even  after  death,  and  he  compares  this  with  the  benefit  which  often  follows  the  use 
of  Kussmaul's  esophageal  tube.  In  short,  he  regards  evacuation  of  the  intestinal 
contents  as  an  essential  part  of  the  operation.  The  loop  of  the  bowel  is  secured  to 
some  strapping  fixed  on  the  front  wall  of  the  abdomen  by  means  of  four  quill 
sutures  passing  through  the  serous  and  muscular  coats,  and  an  aspirator  trocar  and 
cannula  introduced  into  the  centre  of  the  square  marked  out.  Evacuation  may 
take  an  hour  or  more,  the  abdomen  being  gently  kneaded  the  whole  time,  but  as 
soon  as  the  skin  incision  is  made  and  the  sutures  passed  the  auc-esthetic  should  be 
discontinued. 

As  a  last  resource,  when  nothing  can  be  found,  even  after  the  distention  is 
relieved,  the  opening  may  be  enlarged  (if  the  patient's  condition  will  admit  of 
further  exploration),  the  hand  introduced,  and  the  hernial  openings,  the  csecum, 
and  then,  according  to  its  condition,  the  colon  or  the  small  intestine  carefully 
traced  back,  beginning  with  a  part  that  is  empty  and  collapsed,  until  the  seat  of 
strangulation  is  found. 

The  actual  constriction  rarely  presents  any  difficulty  ;  small  bands  can  usually 
be  broken  down  with  the  finger;  longer  ones  may  require  division,  and  in  such 
cases  it  is  as  well  to  ligature  them  near  their  attachments  and  remove  them  ; 
omentum  may  be  treated  in  the  same  way.  Meckel's  diverticulum,  if  it  has  to  be 
divided,  should  be  treated  like  a  portion  of  intestine,  the  end  invaginated,  and  the 
serous  and  muscular  coats  sewn  together  over  it.  When  stricture,  or  the  impaction 
of  a  gall-stone  or  other  foreign  body,  is  sufficiently  acute  to  cause  symptoms  of 
strangulation,  the  bowel  may  be  opened  and  the  obstruction  removed,  or  the 
stricture  resected,  as  the  case  may  be.      In  one  or  two  instances  an  impacted  gall- 


920    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

stone  has  been  <:;ently  passed  on  throutih  the  ileo-ca^cal  valve,  and  Tait  has  sul(- 
gested  that,  as  they  are  very  brittle,  it  might  be  possible  to  crush  them  or  split 
them  with  a  needle.  It  seldom  happens,  however,  that  the  condition  of  the  walls 
is  sufificiently  good  to  allow  this  to  be  done.  In  many  cases  it  is  wiser  to  be 
content  with  the  formation  of  an  artificial  anus,  which  may  be  dealt  with  later, 
when  the  patient  has  recovered.  The  same  thing  should  be  done  when  the  state 
of  the  bowel  is  such  that  its  recovery  is  a  matter  of  question. 

Treves  has  pointed  out  that,  even  when  one  constricting  band  has  been  divided 
and  a  definite  strangulation  relieved,  it  is  always  as  well  to  make  sure  that  there 
is  no  second.  Instances  of  twofold  strangulation  by  bands  have  occurred  on  more 
than  one  occasion. 

The  subsequent  steps  in  the  operation  present  no  special  feature.  If  the 
constriction  has  been  found,  and  there  has  been  no  hemorrhage  or  escape  into  the 
peritoneal  cavity,  the  less  the  parts  are  disturbed  the  better  ;  the  wound  must  be 
closed  as  in  other  operations.  If,  on  the  other  hand,  there  has  been  much  bleed- 
ing, the  cavity  may  require  to  be  sponged  out,  and  if  any  of  the  intestinal  contents 
have  escaped,  it  must  be  thoroughly  irrigated  with  hot  water.  Drainage  must  be 
provided  for  if  peritonitis  is  present  at  the  time  or  is  expected  to  follow. 

In  many  cases  the  condition  of  the  patient  is  much  too  critical  to  stand  any 
prolonged  or  systematic  exploration  ;  the  face  is  drawn  and  jiinched  ;  the  pulse 
very  rapid  and  scarcely  perceptible  ;  there  is  dullness  in  the  flanks,  the  coils  of 
intestine  being  filled  with  fluid  ;  the  stomach  is  distended  with  fluid  and  gas  with- 
out the  patient  having  strength  to  vomit  it  up ;  and  there  is  complete  apathy  and 
almost  insensibility  to  pain.  In  such  as  these  (ireig  Smith  recommends  an  injec- 
tion of  cocaine,  a  small  incision,  and  if  the  seat  of  strangulation  is  not  api)arent 
at  once,  suturing  the  intestine  as  already  described,  so  that  it  may  be  emptied  of 
its  contents.  It  may  give  relief  for  a  time  until  the  patient  rallies,  and  it  is  not 
possible  to  do  more. 

The  after  treatment  must  be  conducted  on  the  same  principles  as  in  external 
herniotomy.  The  blankets  must  be  warmed,  and  hot  bottles  kept  round  the 
patient ;  the  temperature,  which  is  not  unfrequently  subnormal  before  the  opera- 
tion, is  often  still  further  reduced  by  shock  and  exposure,  and  by  the  anaesthetic  ; 
moreover,  life  has  to  be  sustained  on  a  mininum  of  food.  Nothing  may  be  given 
by  the  mouth  for  at  least  forty-eight  hours ;  only  small  fragments  of  ice  at  long 
intervals  to  allay  the  thirst ;  and  even  at  the  end  of  that  time  food  should  only  be 
given  by  the  spoonful.  The  strength  must  be  maintained  by  small  enemata  of 
peptonized  food  with  brandy  every  three  or  four  hours,  so  as  to  allow  the  intestine 
ample  time  for  recovery,  and  the  patient  must  be  kept  under  opium.  Hypodermic 
injections  of  morphia  are  the  most  useful,  as  there  is  never  any  question  how  much 
has  been  lost  if  the  patient  should  be  sick  ;  but  the  tincture,  with  an  ecpial  quantity 
of  water,  is  sometimes  preferred;  and  this  must  be  continued  until  there  is  no 
longer  any  fear  of  the  intestine  giving  way,  or  of  peritonitis. 

The  prognosis  depends,  as  in  strangulated  hernia,  upon  the  condition  of  the 
bowel  ;  but  there  is  not  as  yet  a  sufficient  series  of  cases  to  form  any  estimate  as 
to  the  probable  mortality.  It  is  manifestly  unfair  to  include  those  (and  they  form 
by  far  the  majority)  in  which  the  o])eration  has  been  done  as  a  last  resource,  when 
everything  else  has  been  tried,  when  the  patient  is  in  a  state  of  collapse,  and 
general  peritonitis  has  set  in  ;  sometimes  even  under  these  circumstances  it  has 
proved  successful,  and  there  is  no  reason  why,  if  it  were  done  before  the  bowel  is 
too  much  injured  and  the  patient's  strength  exhausted,  the  mortality  should  be 
much  higher  than  after  external  herniotomy. 

2.  Volvulus,  when  it  affects  the  small  intestine  or  the  caecum,  cannot  be 
diagnosed  from  the  preceding ;  if  such  a  condition  is  found  after  laparotomy,  an 
attempt  must  be  made  to  uncoil  the  bowel,  or,  failing  this,  the  loop  must  be 
emptied  through  an  incision  and  an  artificial  anus  formed. 

Volvulus  of  the  sigmoid  flexure  has  never  been  known  to  recover  without 
operation,  though  in  one  case  (quoted  by  Treves),  which  terminated  fatally  at  last, 


ACUTE  INTESTINAL  OBSTRUCTION.  921 

.the  patient  had  suffered  from  many  previous  attacks  of  colic,  but  iiad  always  been 
able  to  obtain  relief  by  lying  in  one  si>ecial  position.  If  the  case  is  left  to  itself 
peritonitis  is  invariable ;  the  distention  becomes  immense;  the  serous  coat  gives 
way  ;  and  gangrene  ensues,  unless  the  patient  dies  first  from  asphyxia  or  collapse. 
In  the  very  early  stages  it  is  possible  that,  if  the  coil  is  exposed  through  an 
abdominal  wound,  it  may  be  untwisted  and  gradually  emptied  ;  but  if  there  is 
much  distention,  and  the  walls  are  thickened  and  congested,  either  this  cannot  be 
done,  or,  if  it  is  accomplished,  the  bowel  at  once  resumes  its  former  position.  In 
such  a  case  the  coil  of  intestine  must  be  laid  open  and  secured  to  the  wall  of  the 
abdomen,  so  that  it  may  empty  itself  thoroughly.  Possibly  after  this  has  been 
done  the  circulation  will  recover,  and  the  passage  from  above  be  restored  ;  if  not, 
an  artificial  anus  must  be  formed.  If  the  patient  recovers,  the  greatest  care  must 
be  taken  not  to  allow  the  bowels  to  become  confined  or  the  colon  loaded. 

3.  Acute  intussusception  differs  from  the  other  forms  of  intestinal  strangulation 
in  the  fact  that  a  certain  proportion  of  cases  recover  spontaneously,  the  bowel 
either  releasing  itself  or  becoming  gangrenous  and  sloughing  off.  How  often  the 
former  of  these  occurs  it  is  impossible  to  say  ;  probably  it  takes  place  in  many  of 
the  cases  of  severe  intestinal  colic,  in  which  opium  gives  such  complete  relief,  but 
there  is  no  means  of  proving  it.  The  latter,  as  Treves  has  pointed  out,  is  too 
exceptional  an  occurrence,  especially  in  the  young,  to  deserve  any  reliance  ;  and 
it  is  probable  that  it  is  much  more  rare  than  statistics  show.  Besides,  even  when 
it  does  happen,  over  forty  per  cent,  of  the  patients  die  from  effects  directly  con- 
nected with  the  process  ;  the  separation  is  premature  ;  or  the  ulceration  continues 
and  leads  to  perforation  ;  or  hemorrhage  occurs  ;  or  the  patient  dies  from  prolonged 
exhaustion  ;  stricture,  sufficient  to  cause  symptoms  of  obstruction,  apparently  is 
not  proved. 

In  these  cases  opium  is  invaluable.  In  other  forms  of  acute  intestinal  stran- 
gulation it  relieves  the  collapse  and  places  the  patient  in  a  more  favorable  condition 
for  further  treatment ;  but  in  acute  intussusception  it  does  much  more  :  it  stops  the 
violent  peristalsis  ;  prevents  the  invagination  increasing;  diminishes  the  risk  of 
congestion  and  strangulation  ;  and  occasionally  relieves  the  spasm  so  completely 
that  the  symptoms  subside  of  themselves  and  the  bowel  quietly  regains  its  place. 
Unfortunately  this  result  is  only  occasional,  and  great  care  must  be  taken  that  the 
symptoms  are  not  merely  concealed  without  the  cause  being  removed.  Unless 
every  sign  disappears  and  relief  is  complete,  no  reliance  can  be  placed  upon  it. 

Enemata  are  often  successful  in  the  early  stages,  especially  when  the  large 
intestine  only  is  concerned,  and  when  the  symptoms  point  rather  to  incarceration 
than  strangulation.  When  the  tumor  is  to  be  felt  on  the  right  side,  or  even  in  the 
middle  line,  the  chances  are  much  less;  and  if  inflammation  has  set  in  and  caused 
the  formation  of  adhesions,  or  if  the  intussuscepted  part  has  become  thickened 
from  long-standing  congestion,  success  is  out  of  the  question  :  the  bowel  will  give 
way  sooner  than  unfold.  They  should  not  be  tried  ii"  collapse  and  prostration  are 
prominent  features. 

Insufflation  with  air  has  been  recommended  on  the  ground  that  the  bowel  is 
not  so  likely  to  be  ruptured  ;  on  the  other  hand,  water  has  succeeded  (Waren  Tay) 
after  air  has  been  tried  and  failed.  Moreover,  the  quantity  used  can  be  measured 
more  easily.  The  position  of  the  patient  is  not  material  so  long  as  the  knees  are 
well  flexed;  there  is  no  advantage,  that  is  to  say,  in  inversion.  An  anaesthetic  is 
generally  advisable  ;  in  one  case  under  my  care  reduction  was  effected  easily  when 
the  muscles  became  relaxed,  although  the  same  injection  had  failed  before.  Siphon 
action  is  preferable  to  a  syringe,  the  flow  is  uniform  and  the  pressure  can  be 
gradually  increased  to  any  required  extent.  It  is  essential  that  the  fluid  should 
enter  very  slowly  and  quietly,  so  that  the  bowel  may  have  time  to  unfold  itself,  and 
it  should  not  be  allowed  to  escape  again  too  soon.  Regurgitation  may  be  entirely 
prevented  by  means  of  Lund's  insufflator,  the  ring  of  which  stretches  the  margins 
of  the  anus  and  effectually  blocks  it.  Gently  kneading  the  abdomen  at  the  same 
time,  drawing  the  bowel  down  toward  the  anus  from  below  the  intussusception,  is 
59 


92  2    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

sometimes  of  assistance  when  the  walls  of  the  abdomen  are  thin  and  flaccid,  as  in. 
a  child,  and  when  the  swelling  can  be  distinctly  felt.  By  itself  it  is  probably  of 
little  value.  How  much  fluid  should  be  used  varies  necessarily  with  every  case,  and 
no  guide  can  be  laid  down. 

When  reduction  is  successful  the  tumor  can  be  felt  to  slipaway  suddenly  from 
under  the  hand,  sometimes,  but  not  often,  with  a  gurgling  noise  ;  the  abdomen 
becomes  evenly  and  slowly  distended,  and  the  severity  of  the  symptoms  disappears 
at  once  ;  but  of  these  signs  the  last  is  the  only  one  upon  which  any  reliance  can  be 
placed.  The  intussusception  ma\-  apparently  be  reduced,  but  in  reality  be  only 
concealed  by  the  distention  of  the  rest ;  or  the  apex  may  remain  caught,  owing  to 
the  way  in  which  it  is  swollen  ;  or  the  bowel  itself  may  give  way,  and  the  contents 
suddenly  discharge  themselves  into  the  peritoneal  cavity. 

If  enemata  fail,  or  if  the  intussusception  persistently  returns,  the  choice  lies 
between  leaving  the  bowel  to  itself  while  the  patient  is  kept  under  the  influence  of 
opium,  or  performing  laparotomy  at  once. 

The  duration  of  these  cases  varies  very  much  :  acute  ones,  esjjecially  in  young 
infants  and  in  the  small  intestine,  may  prove  fatal  within  forty-eight  hours;  the 
majority  last  from  four  to  seven  days  ;  some  survive  for  longer  periods  still.  The 
chances  of  spontaneous  recovery,  however,  are  exceedingly  slight  :  in  infants, 
according  to  Treves,  elimination  occurs  in  only  2  percent.  ;  and,  between  the  ages 
of  two  and  five,  in  no  more  than  six  ;  and  even  when  this  does  take  place  the  result 
is  fatal  in  the  majority  Between  eleven  and  twenty  years  of  age,  on  the  other 
hand,  the  results  of  the  expectant  method  are  more  successful ;  the  deaths  after 
spontaneous  separation  are  only  twenty-eight  per  cent.  ;  but  after  that  time,  again, 
the  chance  of  recovery  becomes  more  remote.  Clearly,  therefore,  so  far  as  infants 
are  concerned,  spontaneous  recovery  is  very  doubtful ;  and  though  the  prospect 
may  be  better  in  youth  and  young  adult  life,  it  must  be  remembered  that  elimina- 
tion, to  commence  with,  does  not  occur  in  more  than  half. 

There  are  no  statistics  showing  the  results  of  early  laparotomy  ;  in  acute  intus- 
susception, if  enemata  fail,  it  should  be  done  at  once,  within  twenty-four  hours, 
in  the  same  way  that  herniotomy  is  done  at  once  if  taxis  fails  ;  it  is  of  no  use  wait- 
ing until  collapse  or  peritonitis  has  set  in,  or  the  patient's  strength  is  exhausted  ; 
and  the  chances  of  an  acute  case  becoming  chronic,  or,  if  it  does  become  chronic, 
of  the  patient's  surviving,  are  much  too  remote  to  deserve  the  least  reliance. 

The  operation  must  be  performed  in  the  same  way  and  with  the  same  precau- 
tions as  laparotomy  for  intestinal  strangulation,  the  incision  being  in  the  middle 
line.  When  the  intussusception  is  exposed  an  attempt  must  be  made  to  draw  down 
the  sheathing  layer  from  off  it,  using  the  utmost  gentleness  for  fear  of  tearing  the 
bowel,  which  is  often  much  softened  already  ;  it  is  of  no  use,  in  most  instances, 
trying  to  draw  the  intussusception  out.  Sometimes  this  succeeds  at  once  ;  but, 
even  after  three  days,  it  may  be  impossible,  either  from  adhesions,  from  swelling  and 
congestion  of  the  invaginated  part,  from  the  way  in  which  it  is  twisted  and  curved 
inside  the  other,  or  from  the  presence  of  a  polypus.  In  such  a  case,  or  if  the  bowel 
is  torn  or  gangrenous,  the  only  choice  left  is  primary  resection,  suturing  the  ends 
together;  short-circuiting  the  intestine  by  means  of  Senn's  approximation  plates  ; 
or  forming  an  artificial  anus,  leaving  the  intussuscepted  part  to  take  care  of  itself. 
The  first,  no  doubt,  is  the  ideal  one,  but  in  most  cases  that  proceeding  is  advisable 
which  can  be  accomplished  most  quickly  and  with  the  least  disturbance. 

Chronic  Intestinal  Obstruction. 

The  onset  gradual  and  the  symptoms  due  not  so  much  to  the  reflex  action  of 
the  nervous  system  as  to  the  i)rogre.ssive  narrowing  of  one  portion  of  the  bowel. 

In  many  instances  the  final  attack  has  been  ])receded  by  slighter  ones.  At 
first  they  attract  but  little  attention  :  the  narrowed  part  is  blocked  by  some  undi- 
gested food  or  faecal  mass  which  soon  gives  way  ;  constipation  and  colic  last  for  a 
time,  and  then  there  is  a  certain  amount  of  diarrh(jea.     Later,  as  the  constriction 


CHRONIC  INTESTINAL   OBSTRUCTION.  923 

grows  tighter,  these  attacks  become  more  frecjiient  and  last  longer  ;  and,  at  length, 
in  one  of  them  the  closure  is  final,  and  the  oI)striiction  complete. 

The  pain  is  intermittent  at  the  first,  with  long  pauses  between.  As  the  passage 
becomes  narrower  the  paroxysms  grow  more  severe  and  the  intervals  shorter,  until 
at  last  there  is  a  continuous  griping  all  over  the  abdomen,  with  every  now  and  then 
violent  storms  of  colic.  There  is  no  collapse  until  near  the  end.  It  is  due  to  peri- 
tonitis or  exhaustion,  not  to  the  injury  inflicted  upon  the  bowel.  Vomiting,  in  the 
same  way,  is  caused  by  the  accumulation  of  food,  or  the  action  of  purgatives,  and 
may  not  appear  for  weeks  ;  the  time  when  it  does  occur  depends  chiefly  upon  the 
distance  of  the  obstruction  from  the  pylorus.  Constipation  is  absolute,  although 
the  rectum  may  be  emptied.  Meteorism  is  very  marked,  especially  if  the  obstruc- 
tion is  low  down  ;  the  walls  of  the  abdomen  gradually  become  thin  and  stretch 
before  the  increasing  pressure,  and  the  coils  of  intestine,  enlarged  and  hypertrophied 
from  the  increased  amount  of  work,  are  visible  in  many  cases,  on  the  surface  of  the 
abdomen,  especially  (.luring  the  attacks  of  colic. 

In  spite  of  this  difference  it  is  impossible,  in  many  cases,  to  draw  a  definite 
line  between  obstruction  and  strangulation.  Sometimes,  as  in  impacted  gall-stones, 
the  first  closure  is  final  and  the  symptoms  intensely  acute  ;  or  in  true  intestinal 
strangulation,  slight  attacks  of  a  similar  character  have  occurred  previously  and 
been  mistaken  for  colic  ;  or,  again,  intestinal  strangulation  suddenly  happens  to  a 
patient  who  is  already  suffering  from  chronic  constipation.  The  distinction  that 
is  wanted  is  a  clinical  one  ;  the  pathological  data  are  fairly  clear,  but  as  yet  it  does 
not  seem  possible  to  place  them  in  definite  association  with  the  symptoms. 

Causes. — (i)  Narrowing  of  the  lumen  of  the  bowel,  whether  due  to  stricture, 
compression  from  the  outside,  or  to  looping,  bending  or  twisting  of  the  bowel 
itself.  (2)  Loss  of  muscular  power  and  accumulation  of  faeces.  (3)  Chronic 
intussusception. 

I.  Of  these  by  far  the  most  common  \^  stricture,  originating  in  the  mucous  or 
submucous  layers  of  the  bowel,  and  caused  usually  by  cicatricial  tissue  or  by 
carcinoma. 

Simple  stricture  is  occasionally  met  with  in  the  small  intestine,  and  then  it 
may  be  multiple;  in  the  large,  in  which  it  is  nearly  always  single,  it  is  infinitely 
more  common.  Upward  of  one-half  occur  in  the  region  of  the  sigmoid  flexure  ; 
from  this  they  graclually  become  more  rare  as  the  caecum  is  reached,  although 
stricture  of  the  hepatic  flexure  is  slightly  more  common  than  that  of  the  transverse 
colon.  In  the  small  intestine  it  is  most  frequent  toward  the  lower  end  ;  occasion- 
ally it  involves  the  ileo-csecal  valve. 

In  most  cases  the  cause  of  the  ulceration  has  disappeared  ;  there  is  nothing 
either  in  the  shape  or  character  of  the  cicatrix  to  lead  to  any  conclusion.  Of  the 
rest  a  large  proportion  is  due  either  to  dysentery  or  tubercle.  The  former  leaves 
behind  it  exceedingly  irregular  cicatrices,  very  often  involving  a  large  extent  of 
bowel,  and  so  hard  and  dense,  and  associated  Avith  so  much  contraction  that,  accord- 
ing to  Treves,  not  improbably  some  of  the  cases  of  reputed  scirrhus  are  really  due 
to  this.  The  latter  is  more  common  in  the  ileum,  where  it  may  either  spread  in  a 
longitudinal  direction  producing  little  effect,  or  around  the  bowel  transversely,  in 
which  case,  if  it  cicatrizes,  it  leaves  an  annular  stricture,  rarely  very  tight. 
Ulceration  following  catarrh,  or  due  to  the  irritation  of  long-retained  faeces  (ster- 
coral), is  not  uncommon  in  the  large  intestine,  especially  in  the  c;^cum.  Syphilis, 
in  all  probability,  accounts  for  a  few  ;  and  stricture  is  said  to  have  been  caused  by 
the  peptic  ulcers  that  are  occasionally  found  in  the  first  part  of  the  duodenum,  and 
even  by  those  that  occur  in  typhoid  fever. 

Stricture  of  the  small  intestine  sometimes  follows  blows  and  severe  contusions 
of  the  wall  of  the  abdomen,  and  may  occur  after  the  reduction  of  strangulated 
hernia,  owing  to  the  injury  sustained  by  the  mucous  membrane. 

Malignant  stricture  may  be  either  primary  or  secondary  ;  the  former  is  prob- 
ably always  due  to  columnar  epithelioma;  the  latter  naturally  depends  upon  the 
character  of  the  original  growth. 


924    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Columnar  ei)ithelioma  generally  occurs  as  an  annular  constriction,  the  growth 
following  the  course  of  the  vessels  ;  much  more  rarely  in  the  form  of  nodules  or 
flattened  plaques.  The  stricture  is  always  short  and  narrow  ;  from  the  outside  it 
seems  almost  as  if  a  piece  of  string  had  been  tied  around  the  gut.  The  peritoneum 
is  usually  thickened  and  sometimes  is  adherent ;  the  rest  of  the  structures  disap- 
l)ear  ;  there  is  merely  an  irregular  ulcer  extending  transversely  around  the  interior 
of  the  l)Owel.  with  its  base  and  sides  hardened  and  infiltrated  by  the  new  deposit. 
Very  often  the  diameter  is  so  small  that  it  scarcely  admits  a  goose-quill. 

Non-malignant  tumors  oi\k\t^  bowels,  adenomata,  fibromata,  and  fibro-myomata, 
have  a  tendency  to  assume  a  polypoid  shape,  and  may  lead  to  intu.ssusception,  but 
they  rarely  of  themselves  obstruct  the  interior.  Lympho-sarcoma  sometimes  causes 
immense  thickening  of  the  wall,  but  seldom  gives  rise  to  any  symptoms. 

Compression. — The  rectum,  the  sigmoid  flexure,  and  the  lower  part  of  the 
ileum  (especially  those  coils  which  hang  down  into  the  cavity  of  the  pelvis)  may 
be  compressed   by  tumors  growing  from   the  walls  of  the  abdomen  or  connected 


X, 


Fig.  398. — MaUgnant  Disease  of  Large  Intestine. 


Fig.  399.— Annular  Stricture  due  to  Epithelioma. 


with  the  other  viscera.  In  some  cases  the  symptoms  are  acute  ;  in  twelve  out  of 
twentv-two  collected  by  Treves  the  patient  died  before  the  ninth  day  (in  one  on 
the  second)  :  the  bowel  was  suddenly  caught  in  some  way,  or  bent  upon  itself, 
and  though  the  pain  and  collapse  were  scarcely  so  marked  or  .so  severe  as  in 
strangulation  by  bands,  the  points  of  difference  were  not  sufficient  to  make  the 
diagnosis  certain.  In  the  others  the  course  was  chronic,  sometimes  resembling 
that  of  stricture  with  intermittent  colic,  sometimes  presenting  nothing  but  increas- 
ing constipation. 

In  most  cases  this  compression  is  affected  by  a  tumor  growing  from  the  pelvis, 
or  connected  with  the  ])elvic  organs,  the  retroverted  uterus,  for  example,  and  uter- 
rine  or  ovarian  tumors  :  but  it  has  been  caused  by  vesical  calculus,  al^scesses  con- 
nected with  the  bones  or  the  viscera,  extra-uterine  foitation,  tumors  of  the  kidney 
or  pancreas,  floating  kidney,  hydatid  cysts,  and  even  by  an  enlarged  and  displaced 
spleen. 

Compression  may  also  be  caused  by  peritoneal  adhesions,  especially  at  the 
hepatic  and  splenic  flexures  of  the  colon.     In  some  cases  the  peritonitis  may  be 


CHRONIC  INTESTINAL   OBSTRUCTION.  925 

due  to  fcecal  accimiulatioii ;  in  others  it  s])reads  from  the  liver,  gall-bladder,  or 
other  neighboring  structures;  in  others,  again,  it  follows  ulceration  of  the  mucous 
membrane,  and  the  cicatricial  stricture  inside  the  bowel  is  made  worse  by  the 
peritoneal  thickening  around  it.  Whatever  may  be  the  cause,  the  l)owel  becomes 
narrowed  ;  the  walls  become  hard  and  dense,  and  a  stricture  is  formed  which  can- 
not be  distinguished  by  any  of  its  symj)toms  from  that  which  is  due  to  dysentery 
or  malignant  disease. 

Matting  together  of  the  intestine  after  operations  for  strangulated  hernia,  or 
ovarian  tumors,  pelvic  or  tubercular  peritonitis,  bending  of  the  bowel,  forming  a 
valve  in  the  interior,  or  limited  adhesions  imj^eding  the  peristaltic  action  of  one 
segment,  may  all,  according  to  Treves,  give  rise  to  the  symptoms  of  chronic  ob- 
struction. Volvulus  is  nearly  always  acute  ;  in  one  or  two  of  the  cases,  however, 
in  which  the  caecum  has  been  concerned,  it  has  lasted  some  length  of  time,  and 
the  symptoms  have  resembled  those  of  obstruction  rather  than  strangulation. 

Obstruction  by  gall-stones  and  foreign  bodies  resembles  compression  of  the 
bowel  in  this,  that  while  many  of  the  cases  are  exceedingly  acute  others  are 
chronic,  the  masses  lying  latent  for  years,  and  then,  perhaps,  causing  symptoms 
of  slow  obstruction.  Gall-stones  find  their  way  in  by  gradual  ulceration,  so  that 
sometimes  there  is  a  history  of  previous  peritonitis.  Foreign  bodies  for  the  most 
part  consist  of  materials  swallowed  in  small  quantities  from  time  to  time  and 
worked  up  into  solid  masses- with  mucous  or  vegetable  fibre.  Pins,  cherry-stones, 
cocanut-fibre,  yarn,  and  many  other  substances  have  been  met  with  on  various  oc- 
casions, rolled  up  into  enormous  masses.  Concretions,  composed  of  carbonate 
of  magnesia  (taken  as  medicine),  phosphate  of  lime  and  magnesia,  and  other 
indigestible  substances  mixed  together  are  more  rare,  but  occasionally  attain  an 
enormous  size. 

2.  Loss  of  Power  in  the  Muscular  Fibre  of  the  Intestine  and  Accumulation  of 
Fceces. — This  rarely  happens  in  the  small  intestine,  but  is  not  uncommon  in  the 
large,  especially  in  the  caecum,  transverse  colon,  and  sigmoid  flexure.  The  causes 
are  very  various — want  of  exercise,  hysteria,  chronic  catarrh  of  the  mucous  mem- 
brane, hereditary  influence,  in  short,  anything  that  tends  to  impair  the  activity  of 
the  peristalsis.  As  a  result  the  faeces  collect  and  become  hard  and  solid,  the  bowel 
below  contracts,  that  above  becomes  distended  ;  at  length,  the  muscular  fibres,  al- 
ready too  weak  for  their  work,  are  stretched  until  they  are  not  able  to  contract  at 
all,  and  the  passage  is  completely  obstructed  {ileus paralyticus).  In  many  of  the 
cases,  as  mentioned  already,  chronic  peritonitis  sets  in  and  increases  the  difiiculty 
by  the  thickening  of  the  serous  coat  that  it  causes;  in  others  ulceration  of  the 
mucous  membrane  occurs  in  the  bowel  above,  and  even  if  the  obstruction  is  re- 
moved in  time  to  prevent  perforation,  the  subsequent  cicatrization  may  lead  to  the 
formation  of  a  true  stricture. 

3.  Chronic  intussusception  is  a  term  applied  somewhat  arbitrarily  to  cases  that 
have  lasted  longer  than  a  month.  It  is  classed  with  chronic  obstruction  more  as 
a  matter  of  convenience  than  because  of  the  symptoms,  for  these  are  of  the  most 
indefinite  and  irregular  character. 

Pathological  Effects. — The  consequences  of  obstruction  are,  speaking  gen- 
erally, the  same  as  those  that  occur  elsewhere  in  the  body  under  similar  conditions 
— dilatation  and  hypertrophy  ;  but,  from  anatomical  reasons,  and  because  of  the 
nature  of  the  contents,  they  differ  considerably  in  their  importance. 

Where  the  difificulty  has  arisen  slowly,  the  coils  of  bowel,  especially  in  the 
case  of  the  small  intestine,  sometimes  become  of  immense  thickness,  so  that  during 
the  attacks  of  colic,  when  they  are  seen  through  the  abdominal  wall,  they  may  be 
mistaken  for  the  transverse  colon.  The  distention  is  greatest  immediately  above 
the  obstruction  ;  the  splenic  flexure,  for  example,  may  be  as  large  as  the  stomach, 
and  the  sigmoid  one  may  stretch  right  over  the  other  side  of  the  abdomen  ;  the 
mucous  membrane  becomes  exceedingly  thin  ;  stercoral  ulcers  make  their  appear- 
ance, and  sometimes,  partly  from  the  compression  of  the  blood-vessels,  partly  from 
the  irritation  of  the  retained  faeces,  extensive  tracts  become  gangrenous.     In  the 


926     DISEASES  AND  INJURIES   OF  SPECIAL  STRUCTURES. 

case  of  the  large  intestine  the  ulceration  is  most  marked  immediately  above  the 
obstruction,  and  in  the  c?ecum,  where,  if  the  ileo-caecal  valve  is  competent,  the 
])ressure  is  greatest,  the  intermediate  portions  may  be  quite  intact,  or  the  whole 
surface  may  be  more  or  less  involved.  Perforation  is  not  uncommon,  leading  to 
i'ajcal  extravasation  and  general  peritonitis  ;  in  some  exceptional  cases  the  extra- 
l)eritoneal  portion  of  the  bowel  gives  way,  or  adhesions  form  between  two  neigh- 
l)oring  coils,  so  that  a  fistula  is  established  and  this  result  avoided. 

Causes  of  Death. — Death  may  ensue  in  various  ways  in  the  course  of 
chronic  intestinal  obstruction.  Perforation,  for  examjjle,  may  take  jjlace  suddenly, 
and  lead  to  faecal  extravasation  ;  the  stricture  may  become  blocked  by  a  mass  ot 
faeces,  or  some  foreign  body,  or  it  may  be  covered  in  by  a  fold  of  mucous  mem- 
brane ;  volvulus  or  acute  bending  may  occur  \  or  the  bowel  above  may  gradually 
become  so  dilated  that  the  pressure  alone  is  sufficient  to  close  the  opening,  and 
the  symptoms  suddenly,  from  one  hour  to  another,  become  acute,  resembling,  but 
rarely  quite  so  severe  as.  those  of  strangulation.  In  other  cases,  especially  where 
there  is  malignant  disease,  the  stricture  gradually  grows  so  narrow  that  at  last  the 
patient  dies,  worn  out  and  emaciated  by  the  long-continued  trouble.  Very  narrow 
strictures  may  exist  for  a  long  time  in  the  small  intestines  without  causing  any 
symptoms,  owing  to  the  liquid  character  of  the  contents,  and  occasionally,  but 
much  more  rarely,  when  there  is  persistent  diarrhcea,  this  happens  in  the  large. 

Symptoms. — i.  In  stricture,  peritoneal  adhesions,  and  compression,  the 
symptoms,  so  far  as  the  obstruction  is  concerned,  are  essentially  the  same  ;  the 
differential  diagnosis  is  often  impossible,  except  from  the  history  and  age  of  the 
patient,  from  the  ])resence  of  a  tumor  or  some  other  additional  evidence,  and  the 
locality  is  in  many  cases  equally  uncertain. 

Co/ic,  constipation,  and  distention  of  the  abdomen  are  generally  present.  In 
a  typical  case  the  attacks  at  first  are  intermittent,  with  intervals  of  comparative 
comfort ;  but  as  the  constriction  becomes  narrower,  they  grow  more  and  more 
frequent  until  at  length,  when  the  obstruction  is  complete,  they  never  really  cease, 
although  they  are  worse  every  now  and  then.  Sometimes  they  occur  suddenly  in 
patients  who  are  perfectly  well  to  all  appearance  ;  more  often  they  are  preceded  by 
dyspepsia,  diarrh(jea  or  constipation.  In  a  few  rare  cases  there  is  only  one,  the 
bowel  becomes  kinked,  or  the  narrowed  portion  is  blocked  for  the  first  and  last 
time,  and  the  symptoms  are  those  of  strangulation.  In  most  cases  the  onset  is 
insidious,  and  the  first  attacks  slight,  merely  regarded  as  indigestion  ;  only  as  the 
case  progresses  do  they  become  definitely  associated  with  vomiting  and  consti- 
pation. 

Pain. — As  a  rule  nothing  can  be  gathered  from  the  locality  of  the  pain  ;  as 
often  as  not  it  is  referred  at  first  to  the  umbilicus,  but  it  soon  becomes  general,  and 
it  rarely  happens  that  the  patient  is  able  to  describe  it  as  beginning  and  ending  at 
any  definite  spot.  It  is  due  to  violent  peristalsis,  and  is  always  griping,  even  when 
it  is  continuous  ;  the  coils,  which  are  nearly  always  visible  through  the  wall  of  the 
abdomen,  working  over  and  over  each  other.  Food,  enemata,  and  even  digital 
examination  of  the  rectum,  may  bring  on  an  attack.  Sometimes  toward  the  end 
it  becomes  less  severe,  probably  from  the  muscular  and  nervous  mechanism  of  the 
bowel  becoming  exhausted. 

The  pain  is  generally  more  acute  when  the  seat  of  obstruction  is  in  the  small 
intestine  ;  in  this  case  it  is  often  traceable  to  the  food,  coming  on  at  regular  inter- 
vals after  meals,  and  it  may  be  relieved  by  aperients,  which  when  the  colon  is  con- 
cerned merely  aggravate  it. 

Constipation  is  the  rule.  During  the  attacks  of  colic  it  is  always  present,  and 
as  they  pass  off  is  often  followed  by  diarrhoea.  In  the  small  intestine,  where  the 
contents  are  liquid,  it  may  not  ai^pear  until  comparatively  late  ;  and  until  the  con- 
striction is  very  tight,  it  may  generally  be  relieved  by  aperients.  .  When  the  colon 
or  the  sigmoid  flexure,  on  the  other  hand,  is  involved,  there  may  be  a  certain 
amount  of  spurious  diarrhoea  for  a  time,  similar  to  that  which  is  often  present  in 
faecal  accumulation,  kept  up  by  the  irritation  of  the  mucous  membrane  ;  but  always 


CHRONIC  INTESTINAL   OBSTRUCTION.  927 

at  length  the  ol)struction  becomes  complete,  and  sometimes  no  motion  is  passed 
for  weeks  before  death.  A  single  copious  motion  after  prolonged  obstruction  is, 
according  to  Treves,  often  significant  of  perforation. 

Metcorism. — The  distention  of  the  abdomen  dejicnds  upon  tiie  seat  of  obstruc- 
tion and  the  amount  of  diarrhuia ;  when  the  constriction  is  high  up  it  may  be 
altogether  wanting,  except,  perhaps,  during  the  attacks  of  colic,  and  in  some  cases 
there  is  retraction  instead,  owing  to  the  emaciation.  On  the  other  hand,  in 
stricture  of  the  sigmoid  flexure,  the  enlargement  may  be  immense,  the  diaphragm 
being  pushed  up  into  the  thorax,  displacing  the  heart,  and  seriously  impeding 
respiration.  During  the  attacks  of  colic,  and  if  peritonitis  sets  in,  the  walls 
become  tense  and  tender  ;  at  other  times  they  are  soft,  so'  that  when  the  coils 
of  bowel  are  distended  with  fasces  and  flatus  they  may  be  felt  as  well  as  seen 
through  them. 

Vomiting,  unless  the  obstruction  suddenly  becomes  acute,  is  not  a  prominent 
symptom.  Its  occurrence  and  severity  depend  upon  the  seat  of  obstruction  and 
the  amount  of  food  ;  when  the  stricture  is  near  the  pylorus  it  rarely  fails  to  make 
its  appearance  early  in  the  attacks  of  colic,  and  may  be  very  profuse;  when  it  is 
in  the  large  intestine  and  the  food  is  carefully  selected,  it  may  not  occur  for  weeks, 
and  it  rarely  becomes  faical  until  complete  obstruction  has  lasted  for  some  time. 
Other  symi)toms,  which  may  be  of  help  in  diagnosis,  are  occasionally  present. 
Tenesmus  only  occurs  in  stricture  of  the  large  intestine,  and  is  rare  even  then.  In 
carcinoma  of  the  sigmoid  flexure  there  is  not  unfrequently  a  thin  blood-stained 
discharge  from  the  anus,  especially  in  the  intervals  between  the  attacks  of  obstruc- 
tion. Sometimes  a  tumor  can  be  felt,  Qxther  per  rectum  or  through  the  abdominal 
wall,  but  rarely  when  the  small  intestine  is  concerned.  Masses  of  faeces  can  occa- 
sionally be  felt  in  the  caecum  or  the  transverse  colon,  and  this  may  be  stretched 
and  displaced  so  far  as  to  reach  the  symphysis.  The  outline  of  the  colon  may  be 
seen,  or  there  maybe  dullne.ss  or  percu.ssion  along  some  part  of  its  course — in  one 
flank,  for  example,  and  not  in  the  other — and  in  some  few  cases  valuable  infor- 
mation may  be  obtained  by  means  of  eneraata,  or  by  the  introduction  of  the  hand 
into  the  rectum. 

2.  Obstruction  due  to  /cecal  accumulation  rarely  occurs  until  comparatively  late 
in  adult  life,  and  is  more  common  in  women  than  in  men.  Not  unfrequently  it 
is  associated  with  hysteria  or  hypochondriasis,  and  nearly  always  there  is  a  history 
of  chronic  constipation  for  years  past ;  the  bowels  have  only  acted  at  long  inter- 
vals and  after  aperients  or  enemata,  and  the  motions  have  become  copious  and 
exceedingly  hard.  In  other  cases  the  patient  complains  of  persistent  diarrhoea 
with  thin  watery  stools ;  the  mucous  membrane  of  the  bowel  is  irritated  by  hard 
scybalous  masses,  and  the  secretion  mixed  with  the  liquid  portion  of  the  faeces  is 
constantly  flowing  down  into  the  rectum. 

The  symptoms  are  essentially  the  same  as  those  of  stricture  of  the  large  intes- 
tine, only  they  are  as  a  rule  more  chronic  ;  in  rare  instances  there  is  a  sudden 
acute  attack  with  prostration  and  vomiting,  probably  due  to  the  bowel  becoming 
bent  or  twisted  upon  itself  in  some  way,  or  to  atony  of  the  muscular  wall.  The 
patient  is  a  martyr  to  dyspepsia  ;  the  tongue  is  foul  ;  the  appetite  poor  ;  the 
breath  exceedingly  offensive,  and  there  are  constant  attacks  of  flatulence  with  dis- 
tention and  severe  griping  pain  and  nausea.  The  abdomen  is  large  and  resistant; 
faecal  masses  may  often  be  felt  through  its  walls,  sometimes  in  the  c^cum,  lying 
in  the  right  iliac  fossa,  more  often  in  the  transverse  colon  or  the  sigmoid  flexure. 
Tumors  of  considerable  size  are  occasionally  formed  in  this  way,  but  their  nature 
may  almost  always  be  made  out  from  their  mobility,  variable  shape,  and  doughy 
consistence.  The  diaphragm  is  pushed  up,  causing  palpitation  and  interfering 
with  respiration  ;  the  portal  circulation  is  obstructed  so  that  hemorrhoids  result ; 
sometimes  the  uterine,  spermatic,  or  iliac  veins  are  affected  as  well ;  and  the  patient 
loses  flesh  and  strength  and  not  unfrequently  becomes  hypochondriacal.  In  many 
instances  this  condition  persists  for  years,  relieved  from  time  to  time  with  aperi- 
ents and  enemata,  but  there  is  always  the  danger  that  sooner  or  later  the  muscular 


928     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

power  of  the  bowel  may  fail,  or  the  distention  above  increase,  until  at  length 
ulceration  and  perforation  occur. 

3.  Chronic  intussusception  is  exceedingly  variable  in  its  course.  It  is  rare  in 
children,  and  is  nearly  confined  to  the  large  intestine.  The  onset  is  usually  sud- 
den ;  in  most  instances  a  tumor  can  be  felt  through  the  abdominal  wall,  ox  per 
rectum,  and  the  coils  of  small  intestine  can  often  be  seen,  especially  during  the 
attacks  of  colic.  Vomiting  may  occur,  but  it  is  not  urgent  like  that  of  strangula- 
tion ;  tenesmus  and  a  discharge  of  l)lood-stained  mucus  are  rarely  absent ;  some- 
times there  is  constipation,  but  more  freciuentlya  kind  of  spurious  diarrh(ca.  The 
pain  is  seldom  severe^  except  during  the  attacks  of  colic,  when  all  the  symptoms 
become  intensified.  This  condition  has  been  known  to  continue  with  fluctuations 
for  months;  as  a  rule,  after  it  has  lasted  some  length  of  time,  either  the  bowel 
becomes  strangulated  or  the  patient  becomes  exhausted  from  the  prolonged  suf- 
fering and  want  of  food,  grows  thinner  and  thinner,  and  succumbs  at  last  rather 
suddenly. 

Diagnosis. — The  diagnosis  of  intestinal  obstruction  is  always  a  matter  of 
the  greatest  difficulty,  and  in  most  instances  the  examination  of  the  abdomen  has 
to  be  repeated  time  after  time,  during  the  attacks  of  colic  as  well  as  during  the 
intervals,  with  an  anaesthetic  as  well  as  without,  before  a  definite  opinion  can  be 
given. 

1.  The  Previous  History  of  the  Patient. — In  stricture  and  faecal  obstruction 
there  is  generally  a  record  of  previous  slight  attacks  of  a  similar  character,  yield- 
ing at  first  easily  to  remedies  and  gradually  becoming  more  severe  ;  constipation 
has  often  continued  for  a  time,  and  then  given  way  to  diarrhoea  ;  and  the  patient 
has  been  distressed,  and  the  action  of  the  bowels  and  the  digestion  disordered, 
for  some  considerable  period.  Scybalous  masses  passed  from  time  to  time,  and 
habitual  constipation  for  years  before,  point  rather  to  the  latter,  though  it  must  not 
be  forgotten  that  this  may  be  merely  a  complication  ;  a  blood-stained  discharge 
from  the  anus  is  suggestive  either  of  malignant  stricture  low  down  or  of  chronic 
intussusception. 

Antecedent  attacks  of  local  peritonitis  or  typhlitis ;  strangulation  of  a  hernia 
some  months  before  ;  injuries  to  or  operations  on  the  abdomen  ;  hepatic  colic, 
dysentery,  gastric  ulcer,  or  any  other  intestinal  trouble  ;  or  the  history  of  an 
abdominal  tumor,  may  be  of  very  great  significance.  Rapid  wasting,  without  suffi- 
cient apparent  cau.se,  is  suggestive  either  of  tuberculosis  or  of  malignant  disease  ; 
but  a  certain  degree  of  emaciation  is  always  present  in  chronic  obstructions,  and 
if  the  case  lasted  any  time  it  may  be  very  distinct. 

2 .  The  Mode  of  Onset  of  the  Present  Attack  and  the  Order  of  Appearance  and 
Severity  of  each  of  the  Symptoms. — If  it  commences  suddenly  and  the  vomiting  and 
prostration  are  serious  from  the  first,  it  must  be  regarded  as  a  case  of  intestinal 
strangulation.  Pathologically  the  actual  cause  may  be  a  gall-stone  or  some  other 
obstructing  agent;  the  symptoms  are  those  of  strangulation  and  must  be  met  in 
the  same  way  before  it  is  too  late. 

If  it  is  gradual,  each  symptom  mu.st  be  taken  in  order.  First  the  pain, 
whether  it  is  gri[)ing,  as  in  colic,  and  whether  the  i)aroxysms  are  becoming  more 
frequent,  showing  that  the  obstruction  is  growing  tighter.  If  it  occurs  a  short 
time  after  taking  food  and  is  relieved  by  aperients  it  is  probably  due  to  stricture 
of  the  small  intestine ;  if  it  is  continuous,  the  obstruction  is  com])lete ;  if  it  is 
made  worse  by  digital  examination  of  the  rectum  or  by  enemata,  it  is  most  likely 
in  the  large  intestine  ;  and  if  it  is  distinctly  localized,  or  if  it  always  ends  at  one 
spot,  it  may  point  to  the  seat  of  obstruction,  but  this  is  exceptional.  The  state 
of  the  bowels  is  of  equal  importance  ;  constipation  may  be  complete,  both  as 
regards  faeces  and  flatus  ;  or  there  may  be  a  certain  amount  of  diarrhcea,  as  in  faecal 
accumulation  ;  and  blood  and  mucus  may  be  passed  at  fre(]uent  intervals  with 
tenesmus,  as  in  chronic  intussusception.  Vomiting  is  rarely  of  much  help;  unle.ss 
the  attack  is  acute,  so  that  it  is  excited  by  the  injuries  to  the  nerves  of  the  bowel, 
it  does  not  come  on  until  late,  and  it  depends  chiefly  upon  the  amount  and  kind 


CHRONIC  INTESTINAL   OBSTRUCTION. 


929 


^{  food.  Stricture  of  the  small  intestine  high  up  is  an  exception,  as  in  this  vomit- 
ing is  one  of  the  earliest  symi)toms.'  It  seldom  becomes  stercoraceous  until  the 
obstruction  is  of  some  standing.  The  amount  of  urine  may  be  diminished,  but 
this  as  a  rule  depends  ui)on  the  small  (piantity  of  fluid  taken,  not,  as  in  strangula- 
tion, upon  the  presence  of  collapse. 

3.  Physical  Examination. — Inspection. — 'I'he  attitude  of  the  patient  is  generally 
such  as  to  relieve  the  abdominal  muscles  as  much  as  possible.  The  abdomen  may 
be  immensely  and  unevenly  distended  or  retracted,  according  to  the  seat  of 
obstruction  and  the  degree  of  emaciation.  The  walls  are  always  thin,  sometimes 
tense  and  stretched,  and  in  nearly  every  case  the  coils  of  intestine  can  be  seen 
working  through  them,  es|)ecially  during  the  paroxysms  of  colic.  Respiration  is 
usually  shallow  and  thoracic.  There  may  be  hiccough,  especially  in  advanced 
cases,  and  under  the  same  circumstances,  when  collapse  is  approaching,  there  may 
be  vomiting  without  effort,  coming  up  in  gushes,  as  in  strangulation.  Everything 
that  is  brought  up  or  that  is  passed/^/-  anuni  must  be  carefully  examined. 

Palpation. — The  first  thing  is  to  exclude  all  forms  of  hernia:  every  aperture 
through  which  one  could  take  place  must  be  carefully  examined.  Then  the  state 
of  the  walls  and  the  presence  of  any  tenderness  must  be  noted.  During  the  attacks 
of  colic  the  muscles  become  rigid  and  the  skin  is  very  tender  to  the  touch  ;  in  the 
intervals  this  disappears  to  a  great  extent  unless  there  is  some  inflammation,  such 
as  perityphlitis  or  peritonitis,  or  a  tumor  of  rapid  formation,  as  in  intussusception. 
Finally,  if  the  condition  of  the  abdomen  and  of  the  patient  allows  it,  the  surface 
must  be  gently  kneaded  to  ascertain  if  there  is  any  sense  of  resistance  in  one  part 
more  than  in  another,  or  if  any  sign  of  a  tumor  can  be  found.  Faecal  masses  are 
usually  nodular  in  shape,  moderately  hard  and  uneven  ;  generally  speaking  they 
are  movable,  but  this  depends,  of  course,  upon  the  portion  of  intestine  in  which 
they  are  contained  ;  sometimes  the  transverse  colon  reaches  down  as  low  as  the 
pubic  symphysis,  and  the  masses  can  be  pushed  up  nearly  to  the  ensiform  cartilage. 
Examination  of  the  patient  in  various  positions — the  knee  and  elbow,  for  example, 
— is  often  of  service  in  diagnosis. 

Percussion,  although  digital  examination  of  the  rectum  should  be  regarded  as 
part  of  palpation,  follows  next.  It  is  rarely  of  much  service,  although  one  flank 
or  one  iliac  fossa  is  occasionally  much  less  resonant  than  the  other. 

Examination  of  the  rectum  should  never  be  omitted  ;  in  young  subjects  in 
whom  the  perineum  is  soft  and  yielding  the  anus  should  be  pushed  so  far  in, 
especially  under  an  anaesthetic,  that  the  finger  can  touch  the  promontory  of  the 
sacrum,  and  faecal  masses,  stricture  of  the  rectum,  intussuscei)tion,  and  other 
conditions  diagnosed.  In  the  case  of  adults  a  moderately  small  hand  can  be 
introduced.  I  have  on  several  occasions  diagnosed  new  growths  al)ove  the  reach 
of  the  finger,  and  in  one  instance  a  mass  of  scybala  in  a  loop  of  intestine ;  but 
probably  the  chief  use  of  this  method  is  as  an  aid  to  the  long  enema  tube.  By 
itself  this  is  almost  worthless  for  diagnosis ;  but  if  it  is  guided  in  over  the  hand, 
so  that  it  can  be  freed  from  the  folds  of  the  bowel,  and  its  entrance  into  the  sig- 
moid flexure  assured,  it  can  be  passed  without  difficulty  into  the  descending  colon, 
beyond  the  point  at  which  the  bowel  can  be  exposed  in  the  loin. 

The  rectum  and  the  lower  part  of  the  large  intestine  vary  to  such  an  extent  in 
size  that  the  amount  of  fluid  which  can  be  introduced  gives  no  idea.  If,  however, 
the  long  tube  is  passed,  the  position  of  the  end  of  it  in  the  bowel  can  be  made  out 
with  tolerable  accuracy  by  means  of  auscultation. 

There  is  no  means  of  diagnosing  cancerous  stricture  of  the  small  or  large 
intestine  from  chronic  obstruction  due  to  cicatrices,  peritoneal  adhesions,  or  com- 
pression. Carcinoma  may  occur  in  the  intestine  at  twenty  years  of  age,  though 
it  is  much  more  common  later  in  life,  and  the  symptoms  are  practically  the  same  ; 
the  emaciation  is  a  little  more  rapid,  diarrhoea  is  rather  more  common,  especially 
at  the  beginning  of  the  case,  and  in  epithelioma  of  the  large  intestine  a  discharge 
of  blood  and  mucus  may  occur;   but  there  is  nothing  more  definite  on  which  a 


930     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

cliai,niosis  can  be  based.  The  prognosis  in  cancerous  stricture  is  rather  longer  than 
in  the  cicatricial  form,  so  far  as  life  is  concerned,  probably  because,  as  Treves  has 
pointed  out,  obstruction  does  not  make  its  appearance  so  early. 

Treatment. — i.  Chronic  Obstmction  due  to  Stricture,  Peritoneal  Adhesions, 
Volvulus  of  the  Cctcuin,  Compression,  etc.  —  So  long  as  the  closure  is  incomplete, 
relief  may  be  obtained  for  a  time  by  dieting  and  by  laxatives  and  enemata. 
Vigorous  purgatives  do  more  harm  than  good  by  disturbing  the  orderly  action  of 
the  intestine  and  hurrying  down  a  mass  of  semi-digested  material  on  to  the  face 
of  the  stricture.  The  object  is  to  nourish  the  patient  as  well  as  possible  without 
increasing  the  amount  of  indigestible  material  or  rendering  the  fceces  hard.  In  the 
small  intestine  this  is  tolerably  easy  for  a  time,  and  partly  by  restricting  the  diet 
to  small  quantities  of  liquid  food  given  at  long  intervals,  partly  by  nutrient  ene- 
mata, the  strength  may  be  maintained  for  a  considerable  period,  especially  if  it  is 
economized  by  warmth  and  avoidance  of  exertion.  When  the  large  intestine  is 
involved,  this  is  not  so  easy,  but  a  great  deal  may  be  done  at  first  by  means  of 
enemata  of  hot  water  with  some  alkali  to  soften  the  fceces  and  stimulate  the  walls 
of  the  bowel.  Not  unfrecpiently  a  stricture  that  has  been  impermeable  by  the 
impaction  of  a  mass  of  foeces  in  its  orifice,  may  be  entered  without  difficulty  from 
below,  and  the  intruding  substance  displaced,  and  perhaps  softened  sufficiently  to 
relieve  the  obstruction  for  the  time. 

Opium  is  invaluable  for  the  relief  of  pain,  as  in  acute  cases,  and  prevents  to 
a  certain  extent  the  severity  of  collapse,  but  it  has  little  or  no  influence  on  any  of 
the  causes  of  obstruction  mentioned  above,  and  obscures  the  symptoms  to  such  an 
extent  that,  when  it  has  been  given,  full  allowance  must  be  made  for  it. 

If  the  obstruction  is  complete,  or  if,  in  spite  of  all  precautions,  the  abdomen 
is  becoming  more  distended,  and  the  attacks  of  colic  more  frequent  and  more 
severe,  it  is  of  no  use  delaying  further;  if  any  operation  is  required,  it  should  be 
done  before  the  patient  is  exhausted. 

{a)  Where  the  Seat  of  Obstruction  can  be  Diagnosed. — If  it  is  in  the  small 
intestine,  the  abdomen  must  be  opened  in  the  middle  line,  and  the  cause  dealt 
with,  according  to  its  nature  and  the  condition  of  the  patient.  In  some  cases, 
relief  may  be  obtained  by  dividing  adhesions  and  so  releasing  the  bowel,  but  in 
the  majority  the  choice  lies  between  enterostomy,  short-circuiting  with  Senn's 
plates,  and  resection.  Of  these,  the  former  is  more  simple,  and,  if  a  large  extent 
of  bowel  is  involved,  is  the  only  one  admissible:  but  it  can,  of  course,  only  be 
regarded  as  a  palliative,  and  is  useless,  unless  the  seat  of  obstruction  is  low  down 
in  the  ileum.  Resection  alone  can  give  permanent  relief,  and  the  condition  of 
the  bowel  and  the  strength  of  the  patient  must  decide  whether  it  should  be  per- 
formed at  once  or  postponed  until  an  artificial  anus  has  been  formed. 

The  rule  is  the  same  in  the  case  of  the  large  intestine  ;  if  the  seat  of  obstruc- 
tion is  known,  the  bowel  should  be  opened  at  the  most  convenient  spot  above  ;  or, 
if  it  is  a  malignant  stricture,  an  attempt  may  be  made  to  excise  it,  and  either  form 
an  artificial  anus,  or  suture  the  two  ends  together,  according  to  circumstances. 
Compression  by  external  tumors  is  an  exception  ;  in  these  cases,  special  treatment 
is  required. 

(J))  Where  an  Exact  Diagnosis  Cannot  be  Made. — If  the  situation  is  entirely 
unknown,  median  lajjarotomy  must  be  performed  as  an  exploratory  measure,  and 
the  obstruction  dealt  with  according  to  what  is  found.  The  colon  or  ctecum  may 
be  opened  and  stitched  to  the  skin,  or  the  wound  closed  and  colotomy  performed 
later  on.  When,  however,  the  balance  of  evidence  points  distinctly  to  the  large 
intestine,  without  the  exact  site  being  indicated,  the  colon  should  be  opened  in  the 
right  loin  or  in  the  right  iliac  region.  If  the  bowel  is  found  not  to  be  distended, 
temporary  relief  may  be  obtained  by  opening  the  nearest  and  most  prominent  loop 
of  small  intestine. 

2.  Fcecal  Accumulation,  7iiith  Loss  of  Power  of  the  Wall  of  the  Intestine— 
Unless  acute  symptoms,  such  as  vomiting  and  prostration,  indicative  of  ileus,  set 


PERITYPHLITIS.  931 

in,  this  should  be  treated  with  laxatives  and  eneniata.  Lumbar  colotomy  must 
be  regarded,  according  to  Treves,  rather  as  a  surgical  misfortune  than  as  a  recog- 
nized method  of  treatment. 

A  siphon  apparatus  is  better  than  a  syringe,  as  the  pressure  is  more  uniform. 
The  patient  should  be  placed  so  that  the  abdominal  muscles  are  relaxed  as  far  as 
possible,  and  warm  water,  with  soap  or  oil,  allowed  to  flow  in  gently  until  by 
degrees  the  whole  of  the  colon  has  been  washed  out.  It  may  be  cleared  thoroughly 
aslilir  as  the  coicum  ;  there  is  no  fear  during  life  of  any  quantity  of  fluid  passing 
beyond.  A  little  turpentine  may  be  used,  if  a  more  stimulating  injection  is  re- 
quired.* Massage,  kneading  the  abdomen  in  the  course  of  the  colon,  and  elec- 
tricity are  sometimes  of  benefit  in  these  cases.  The  faradic  current  is  used,  and 
one  pole  is  placed  on  the  abdomen  or  the  dorsal  spine  ;  the  other,  properly  insu- 
lated, in  the  rectum. 

3.  Chronic  Intussusception. — Here,  as  in  the  acute  form,  opium  should  be 
given  at  once  to  check  the  increase  of  the  invagination,  and  to  delay  the  onset  of 
strangulation  and  inflammation.  Then  an  attempt  must  be  made  to  reduce  the 
bowel  by  means  of  enemata  given  with  great  care,  and  combined  with  massage 
under  an  anesthetic.  Reduction  has  taken  place  even  at  the  end  of  a  month,  but, 
as  Treves  has  shown,  adhesions,  as  a  rule,  very  soon  make  their  appearance  in 
cases  that  are  left  to  themselves.  If  enemata  fail,  the  only  course  left  is  laparotomy, 
and,  if  reduction  cannot  be  eff'ected  then,  either  resection,  short-circuiting,  or  the 
formation  of  an  artificial  anus. 


SECTION  v.— PERITYPHLITIS;  PERITONITIS. 

Perityphlitis. 

Inflammation  of  the  ceecum  and  appendix  is  common  in  young  adults,  espe- 
cially males.  It  may  be  simple  or  suppurative.  The  former  merely  leads  to 
thickening  and  condensation  of  the  tissues  around  ;  the  latter  ends  either  in  a 
perityphlitic  abscess,  or  in  general  peritonitis.  Suppuration  may  begin  outside 
the  bowel,  in  the  inflammatory  exudation  (forming  sometimes  a  secondary  com- 
munication with  the  intestine)  ;  but,  probably,  in  most  cases,  it  is  the  result  of 
perforation  (nearly  always  of  the  appendix),  especially  when  its  onset  is  instanta- 
neous, without  any  warning. 

Causes. — The  simple  form,  like  colitis,  usually  arises  from  the  accumulation 
of  scybala,  and  remains  limited  to  the  mucous  surface.  Occasionally,  the  inflam- 
mation is  more  severe,  involving  the  whole  thickness  of  the  wall,  and  then  the 
serous  covering  becomes  affected. 

The  perforative  form  may  be  due  to  ulceration  (the  stercoral  ulcers  of  old 
intestinal  obstruction,  or  those  resulting  from  tubercle,  syphilis,  or  dysentery,  for 
example)  ;  to  the  presence  of  foreign  bodies,  such  as  fish  bones  ;  or  to  the  appen- 
dix becoming  blocked.  When  this  occurs,  whether  it  is  due  to  cherry  stones, 
dried  feeces,  the  presence  of  adhesions,  or  any  other  cause,  the  secretion  accumu- 
lates, the  tension  grows  higher  and  higher,  inflammation  sets  in,  and,  unless  the 
obstruction  gives  way,  ulceration  follows,  and  ends  in  perforation. 

*  Hutchinson's  description  of  massage  of  the  abdomen,  in  cases  of  intestinal  obstruction,  is  as 
follows :  "  The  first  point  in  abdominal  taxis  is  the  full  use  of  an  ansesthetic,  so  as  to  obliterate  all 
muscular  resistance.  Next  (the  rectum  and  bladder  being  supposed  to  be  empty),  the  surgeon  wdl 
forcibly  and  repeatedly  knead  the  abdomen,  pressing  its  contents  vigorously  upward,  downward,  and 
from  side  to  side.  The  patient  is  now  to  be  turned  on  to  his  abdomen,  and  in  this  position  held  up  by 
four  strong  men,  and  shaken  backward  and  forward.  This  done,  the  trunk  is  to  be  held,  feet  upper- 
most, and  shaking  again  pmcticed  directly  upward  and  downward.  WhiKt  in  this  position,  copious 
enemata  are  to  "be  given.  The  whole  proceedings  are  to  be  carried  out  in  a  bond  fide  manner. 
Half  an  hour  or  more  is  to  be  spent  in  the  process." 


932     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

Cases  in  which  the  appendix  is  blocked  and  the  obstruction  yields  from  time 
to  time  without  actual  perforation  taking  place,  are  sometimes  distinguished  as 
relapsing  typhlitis. 

{a)  Simple  Perityphlitis. — This  usually  occurs  in  young  adults  who  are  sub- 
ject to  chronic  constipation.  They  may  even  have  pas.sed  scybalous  masses  or  have 
suffered  from  attacks  of  diarrhtea  (colitis)  e.xcited  by  them.  It  commences  quietly 
wMthout  a  rigor,  and  generally  with  little  fever.  Almost  from  the  first  there  is  a 
hard,  doughy  tumor  in  the  groin.  The  abdominal  muscles  are  rigid  and  tense,  and 
jjressure  causes  such  ])ain  that  it  is  rarely  possible  to  make  out  the  outline  without 
an  anoesthetic.  Vomiting  is  not  severe  or  continuous,  and  examination /<v-  rectum 
does  not  reveal  any  marked  thickening.  Very  often  there  is  a  history  of  number- 
less minor  attacks  (whenever,  indeed,  the  patient's  bowels  are  confined),  none  of 
which  has  been  sufficiently  severe  to  lead  him  to  seek  advice.  As  a  rule,  cases  of 
this  kind  are  not  seen  by  the  surgeon  at  all ;  they  may  last  a  week  or  ten  days  and 
cause  justifiable  alarm,  but  nearly  always  the  symptoms  disappear  under  low  diet, 
opium  and  enemata.  Probably  in  the  more  severe  cases,  the  peritoneum  is  always 
involved,  as  it  is  not  unfrequent  to  ^{nd  post-mortem  the  aj^pendix  firmly  tied  down 
by  adhesions. 

{li)  Perforative  Perityphlitis. — This  may  commence  in  the  same  way,  slowly 
and  insidiously,  but  as  a  rule,  the  symptoms  are  much  more  acute.  Often  there 
is  no  warning  of  any  kind,  and  no  history  of  constipation  or  digestive  trouble. 
Quite  suddenly  the  patient  is  seized  with  intense  pain  in  the  groin,  shooting 
down  the  thigh,  or  into  the  testis  and  the  perineum.  Vomiting  comes  on  almost 
at  once  ;  the  abdomen  begins  to  swell  and  become  tympanitic,  and  all  the  symp- 
toms of  acute  localized  peritonitis  are  developed  within  a  few  hours.  The  face 
and  the  pulse  change,  the  urine  is  scanty,  the  tem[)erature  rises,  and  the  respira- 
tion becomes  shallow  and  hurried.  Very  often  no  abdominal  tumor  can  be 
detected  ;  the  general  tympanites  obscures  everything,  but  usually  an  ill-defined 
fullness  can  be  made  out  through  the  rectum. 

In  other  cases  the  illness  is  of  longer  duration.  There  is  a  history  of  repeated 
trouble,  without,  however,  the  attacks  bearing  any  relation  to  the  condition  of  the 
bowels.  Rigors  are  not  uncommon  ;  the  temperature  is  high  and  very  irregular  ; 
a  certain  amount  of  fullness,  sometimes  definitely  limited,  can  be  felt  in  the  groin  ; 
occasionally  there  is  some  cedema  of  the  skin,  and  circumscribed  inflammatory 
induration  can  nearly  always  be  felt  through  the  rectum.  In  most  of  these  there 
is  a  localized  abscess  communicating  with  the  appendix  through  the  floor  of  an 
ulcer.  Its  walls  are  usually  fairly  thick  and  formed  of  the  surrounding  structures 
welded  together  by  adhesions  ;  but  each  attack  means  an  extension  in  some  direc- 
tion. The  pus  may  at  length  work  its  way  out  through  the  anterior  abdominal 
wall  and  point  in  the  groin  or  the  thigh,  or  it  may  burst  into  one  of  the  neigh- 
boring viscera,  or  discharge  itself  over  the  crest  of  the  ilium,  into  the  hip  joint, 
and  even  through  the  diaphragm  ;  but  each  time  there  is  always  the  danger  of  the 
l)eritoneum  suddenly  giving  way  (it  has  happened  as  a  result  of  manipulation)  and 
of  diffuse  peritonitis  following. 

Finally  a  certain  number  of  cases  have  been  described  as  relapsini:;  typhlitis. 
They  are  characterized  by  a  succession  of  attacks  scarcely  less  severe  than  those 
that  are  present  in  the  perforative  form  ;  but  though  sometimes  a  tumor  can  be 
detected  through  the  rectum,  there  is  nothing  but  indefinite  induration  to  be  felt 
in  the  iliac  fossa.  In  one  of  these  (a  patient  who  had  suffered  from  fourteen  severe 
recurrences  in  eighteen  months,  and  was  reduced  to  the  condition  of  a  hopeless 
invalid),  Treves  found  the  appendix  bent  upon  itself  and  immensely  dilated  ;  and 
in  another  it  was  of  enormous  size,  tied  down  by  adhesions,  and  on  the  point  of 
giving  way.  Probably  a  similar  condition  furnishes  the  starting  point  of  some  of 
those  cases  of  perforative  perityphlitis  in  which  suj^puration  is  localized.  So  long 
as  the  appendix  is  able  to  discharge  its  contents  from  time  to  time,  the  pain  and 
inflammation  are  only  of  moderate  intensity,  and  the  surrounding  tissues  become 
thickened  and  adherent ;    if  it  becomes   completely  blocked  ulceration  sets  in, 


PERITONITIS.  933 

perforation  follows,  the  appendix  becomes  gangrenous,  and  an  abscess  with  very 
irregular  walls  is  left. 

Treatment.— Perforative  perityphlitis,  if  left  to  itself,  may  end  in  the  ab- 
scess gradually  working  its  way  toward  the  surface,  causing  more  or  less  serious 
destruction,  or  it  may  lead  to  sudden  and  diffuse  i)eritonitis.  This  danger  is 
always  present,  l)ut  when  the  symptoms  are  acute  and  the  attacks  fretpient,  it  is 
imminent.  Immediate  operation  is  advisable  if  signs  of  perforation  have  suddenly 
appeared  in  a  person  previously  healthy  ;  if  there  is  evidence  of  acute  suppuration 
(rigors,  and  an  evening  rise  of  temperature,  with  great  tenderness  and  perhaps 
oedema),  particularly  if  it  is  spreading;  or  if  there  is  any  indication  of  a  chronic 
abscess  working  its  way  onward.  Further,  it  is  certainly  to  be  recommended  in 
cases  of  relapsing  typhlitis,  in  which,  from  the  severity  and  constant  repetition  of 
the  attacks,  it  is  clear  that  the  appendix  is  seriously  involved. 

Aspiration  through  the  wall  of  the  abdomen  has  been  strongly  recommended, 
but  the  chances  of  hitting  off  a  small  collection  of  inis  are  very  slight,  and  the  risk 
is  certainly  not  trivial. 

The  incision,  unless  there  is  some  distinct  indication  elsewhere,  should  be 
parallel  to  and  slightly  above  Poupart's  ligament,  almost  that  for  ligature  of  the 
external  iliac.  The  median  is  too  far,  and  the  advantages  of  the  linea  semilunaris 
are  very  doubtful.  Great  care  is  needed  when  the  peritoneum  is  reached.  It 
must  be  divided  freely,  the  intestine  exposed,  and  the  matted  coils  carefully  sepa- 
rated from  each  other  with  the  fingers  working  down  in  the  direction  of  the  caecum 
and  preventing  any  of  the  healthy  bowel  coming  near  the  disease.  If  pus  is  found 
it  must  be  dealt  with  according  to  circumstances  ;  it  may  be  possible  in  a  chronic 
case  to  sponge  out  the  cavity  and  expose  the  appendix,  and  sometimes  this  may  be 
removed  and  the  cut  edges  inverted  and  secured  with  sutures,  but  frequently  the 
adhesions  are  too  delicate  to  stand  such  manipulation,  and  all  that  can  be  done 
is  to  provide  free  exit  for  the  pus  by  means  of  a  drainage  tube,  in  the  hope  that 
the  surrounding  tissues  will  adhere  and  protect  themselves.  If  the  operation  is 
performed  for  relapsing  typhlitis,  a  quiet  interval,  when  there  is  no  acute  inflam- 
mation, should  be  selected,  and  the  margins  of  the  opening  made  when  the 
appendix  is  removed  may  be  inverted  and  stitched  together.  In  these  cases,  as 
pointed  out  by  Treves,  the  external  incision  should  commence  over  healthy  tissues, 
so  that  the  condition  of  the  diseased  part  may  be  made  out  from  the  serous  cavity  ; 
otherwise  it  may  be  impossible,  owing  to  the  presence  of  adhesions,  to  ascertain 
the  relative  position  of  the  various  structures  ;  the  appendix  or  the  caecum  may 
even  be  adherent  to  the  anterior  wall.  Care  must  be  taken  not  to  mistake  the 
ureter  for  the  appendix. 

Peritonitis. 

Inflammation  of  the  peritoneum  is  peculiar  in  many  respects.  The  surface 
of  the  cavity  is  of  enormous  size,  scarcely  less  than  that  of  the  skin  ;  it  possesses 
the  most  remarkable  power  of  absorption  (so  that  fluids  of  all  kinds,  poisonous  or 
not,  disappear  with  very  great  rapidity),  and  if  one  part  is  infected,  owing  to  the 
constant  movement  of  its  contents  and  the  freedom  of  communication  between 
all  its  cavities,  the  inflammation  is  very  likely  to  involve  the  whole. 

Causes. — Peritonitis  may  be  caused  by  unorganized  irritants,  chemical  or 
mechanical  ;  or  by  living  organisms,  specific  or  non-specific.  Further  it  may 
arise  by  direct  extension  from  the  structures  that  lie  adjacent  to  it,  the  walls  of  the 
intestine  or  of  the  abdomen. 

{a)  Simple  mechanical  irritation  produces  but  a  very  limited  eff"ect.  In  an 
old  hernia,  for  examijle,  the  neck  of  the  sac  and  the  serous  coat  of  the  intestine 
that  slips  into  it  (if  it  is  always  the  same  piece),  gradually  become  thickened, 
hard  and  dense,  from  organization  of  the  inflammatory  exudation. 

Chemical  irritants  vary  more  in  their  eff"ect ;  some  are  absorbed  at  once,  and 
merely  give  rise  to  constitutional  symptoms,  depending  upon  their  nature  and 
amount   (such,  for  example,   is  one    form  of  septicsemia   following   abdominal 


934     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

operations,  in  which  the  patient  becomes  cold  and  collapsed,  and  dies  within 
forty-eight  hours,  from  acute  blood  poisoning,  without  any  visible  sign  of  peri- 
tonitis). Others  irritate  the  surface,  so  that  exudation  takes  i)lace  instead  of 
absorption.  In  this  case  the  future  course  depends  upon  the  surrounding  condi- 
tions ;  if  the  injury  is  very  extensive,  death  may  occur  from  shock  ;  if  less  severe, 
the  lymph  that  is  poured  out  around  the  affected  area  either  becomes  organized, 
or,  if  pyogenic  irritants  gain  access  to  it,  breaks  down  into  pus. 

(/>)  Organic  irritants  may  be  either  specific  or  non-specific.  The  tubercle 
bacillus  is  by  far  the  best  known  example  of  the  former,  and  tubercular  peritonitis 
will  be  dealt  with  separately.  Syphilitic  peritonitis  rarely  occurs,  except  as  a 
result  of  extension  from  neighboring  organs,  such  as  the  liver,  and  presents  no 
special  features. 

The  non-specific  organisms  may  be  pyogenic  or  not.  Of  these  the  latter  are 
not  capable  of  causing  peritonitis  so  long  as  the  surface  of  the  membrane  is  unin- 
jured ;  if,  for  example,  putrid  fluid,  containing  only  the  organisms  of  putrefaction, 
is  injected  into  the  uninjured  peritoneal  cavity,  death  will  ensue  from  septicaemia  if 
the  quantity  is  large  enough,  but  if  it  is  small  the  whole  may  disappear  without 
exciting  any  local  irritation.  The  constitutional  effect  dei^ends  entirely  upon  the 
dose,  and  it  is  practically  the  same  whether  the  fluid  is  injected  into  the  blood- 
stream at  once,  or  allowed  to  find  its  way  in  through  the  peritoneal  cavity,  and  it 
follows  nearly  as  quickly  in  the  one  case  as  in  the  other. 

Even  the  pyogenic  organisms,  according  to  Grawitz,  can  only  cause  peritonitis 
under  special  conditions:  when,  that  is  to  say,  the  amount  of  fluid  injected  with 
them  or  poured  out  by  the  injured  surface  is  so  great  that  the  germs  are  produced 
more  rapidly  than  the  tissues  can  deal  with  them  ;  or  when  the  surface  of  the  peri- 
toneum is  injured  and  the  subepithelioid  layer  exposed.  In  many  instances  the 
inflammation  was  found  to  have  spread  from  the  i)rick  of  the  needle  that  had  been 
used  for  the  injection. 

Unhappily,  these  conditions  are  of  common  occurrence.  Infected  wounds, 
rupture  of  the  viscera,  perforation  of  the  intestine,  bursting  of  a  hydatid  cyst  or 
of  an  abscess,  and  communication  with  a  neighboring  cavity,  such  as  the  Fallopian 
tube  in  a  case  of  metritis,  present  in  abundance  everything  that  is  required  for  the 
development  of  acute  suppurative  peritonitis.  There  is  a  sufficient  amount  of 
nutrient  fluid  for  the  growth  of  the  germs,  or  if  there  is  not  it  is  poured  out  at  once 
by  the  irritated  peritoneum  ;  the  epithelioid  surface  is  injured  over  a  wider  or 
smaller  area  by  the  fluid  that  bathes  it ;  absorption  is  checked,  and  myriads  of 
pyogenic  organisms  can  make  their  way  in  from  the  intestine,  through  the  wound, 
or  even  through  the  blood  stream. 

(<:)  Peritonitis  due  to  extension  from  the  parts  around  varies  naturally  with 
the  primary  cause  ;  as  a  rule  it  is  protective  in  character,  and  leads  to  the  formation 
of  adhesions. 

Whether  cold  can  be  regarded  as  a  cause  is  uncertain  ;  there  can  be  no  doubt, 
however,  that  it  predisposes  to  it  by  lowering  the  vitality  of  the  tissues  and  render- 
ing them  more  susceptible. 

Symptoms. — Clinically,  peritonitis  may  be  sthenic  or  asthenic  in  character. 
The  latter  occurs  when  the  strength  of  the  patient  is  overcome  by  septicaemia, 
typhoid  fever,  or  Rright's  disease. 

In  the  sthenic  form  the  symptoms  are  very  striking.  They  may  be  a  succes- 
sion of  chills  or  a  rigor  ;  the  temperature  rises  at  once  ;  the  pulse  becomes  peculi- 
arly hard  and  rapid,  and  the  respiration  hurried  and  very  shallow.  The  abdomen 
may  be  retracted  at  first,  but  very  soon  it  begins  to  swell  over  the  affected  spot, 
and,  in  a  short  time,  the  whole  becomes  tense  and  hard,  the  muscles  are  abso- 
lutely rigid,  the  diaphragm  is  pushed  up  as  far  as  it  can  go,  and  the  least  touch 
causes  the  most  fearful  pain.  The  patient  lies  on  the  back  with  the  knees  drawn 
up  ;  the  face  becomes  pinched  and  anxious,  the  eyes  sunken,  and  the  tongue  dry 
and  brown  ;  vomiting  with  hiccough  is  very  common,  and  usually  the  fluid  is 
poured  up  in  gushes  almost  without  effort.     Constipation  is  almost  invariable, 


PERITONITIS. 


935 


and  the  amount  of  urine  secreted  is  very  small.  Toward  the  end  the  temperature 
may  fall,  and  the  i)atient  sink  into  a  state  of  collapse  ;  sometimes  this  occurs  almost 
w  ith  the  fust  onset  of  the  disease. 

In  the  asthenic  form  the  constitutional  symptoms  are  more  i)rominent.  The 
abdomen  may  or  may  not  be  distended,  sometimes  it  moves  with  respiration  ;  pain 
is  felt  on  j)ressure  ;  but  there  is  not  the  intense  tenderness  characteristic  of  the 
sthenic  variety.  The  pulse  is  very  small  and  weak,  the  temperature  subnormal, 
and  the  collapse  profound  from  the  first.  Fost-mortetn  there  are  no  adhesions 
between  the  coils  of  intestine  and  no  lymi)h  on  the  serous  surface,  merely  a  small 
(luantity  of  a  turbid,  intensely  poisonous  li(juid. 

Treatment. — It  used  to  be  the  rule  in  every  abdominal  operation  to  give 
opium  in  order  to  keep  the  intestines  quiet  and  prevent  peritonitis.  Now  it  is  rec- 
ognized that  while  ojjium  is  es.sential  when  the  walls  of  the  intestine  have  been  in- 
jured, and  is  of  great  value  in  localizing  inflammation,  it  can  do  nothing  to  pre- 
vent it;  indeed,  by  assisting  the  distention  of  the  intestine,  and  still  further 
impairing  the  muscular  tone  of  its  wall,  it  may  actually  intensify  the  evil  it  is  in- 
tended to  check.  For  this  reason,  Wylie,  Tait,  Greig  Smith,  and  others  recommend 
a  saline  purge  after  abdominal  operations  if  fluid  is  collecting  in  the  pelvis,  or  if 
there  is  a  rapidly  increasing  distention  of  the  abdomen,  with  restlessness  and  vomit- 
ing. The  tympanites  is  an  additional  cause  of  obstruction  and  vomiting;  opium 
only  encourages  it  ;  a  purge,  on  the  other  hand,  followed  by  a  turpentine  or  hot- 
water  enema,  will  carry  off  immense  quantities  of  gas  and  fluid,  and  relieve  the 
congestion  of  the  abdominal  vessels.  Afterward  the  beneficial  effect  may  be  con- 
tinued by  the  frequent  use  of  the  rectum  tube.  The  vomiting  that  is  consequent 
upon  an  anaesthetic  may  be  checked  by  allowing  the  patient  to  suck  one  or  two 
small  fragments  of  ice  (not  more)  ;  if  it  continues,  particularly  if  there  are  other 
signs  of  peritonitis  and  the  straining  is  very  severe,  a  cupful  of  hot  water  is  much 
more  serviceable,  and  occasionally  the  stomach  may  be  washed  out  with  advantage. 

If  in  spite  of  this  the  symptoms  grow  worse,  or  if  it  is  clear  from  the  first  that 
it  is  a  case  of  perforated  peritonitis,  the  only  hope  lies  in  giving  free  exit  to  the 
l)oisonous  fluid.  It  is  true  that  the  condition  of  the  patient  is  almost  desperate, 
and  that  shock  is  much  more  severe  when  the  peritoneum  is  inflamed  ;  but  if  the 
serous  cavity  is  unable  to  deal  with  the  poison  that  bathes  its  surfaces,  steps  must 
be  taken  first  to  prevent  any  more  entering,  and  then  to  get  rid  of  that  which  is 
already  there. 

Greig  Smith  recommends  the  injection  among  the  intestines  of  boroglyceride 
solution,  an  ounce  to  the  pint,  at  a  temperature  of  102°  F.  It  should  be  slowly 
forced  into  the  cavity  among  the  intestines  through  a  drainage  tube,  and  compelled 
to  remain  there  for  a  time  by  temporarily  plugging  the  orifice  ;  and  this  may  be 
repeated  several  times  a  day. 

Mikulicz  distinguishes  between  diffuse  peritonitis,  due  to  a  large  amount  of 
the  contents  of  the  intestine  being  poured  suddenly  into  the  cavity,  and  a  progres- 
sive form  which  is  localized  at  first.  The  former  can  only  be  treated  by  a  free 
opening  and  washing  out  the  cavity  with  hot  salt  and  water,  or  hot  boracic  solu- 
tion, until  it  is  thoroughly  cleansed.  The  latter,  on  the  other  hand,  may  remain 
localized  for  a  time,  and  if  the  situation  of  the  successive  foci  can  be  made  out, 
they  may  be  opened  and  drained  separately,  taking  great  care  not  to  disturb  any  of 
the  adhesions.  Thorough  drainage  of  the  peritoneal  cavity  is  almost  impossible, 
but  the  attempt  has  been  tried  by  making  numerous  openings  in  the  middle  line 
and  in  the  flanks,  and  by  passing  across  as  many  as  eight  large  perforated  tubes 
through  which  a  current  of  hot  salt  solution  could  be  sent. 

When  the  suppuration  is  localized  already,  the  prospect  is  much  more  hope- 
ful ;  there  are  already  many  instances  on  record  in  which  purulent  collections, 
consequent  on  intestinal  perforation,  gonorrhceal  inflammation,  and  other  causes 
have  been  successfully  drained. 


936    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Tubercular  Peritonitis. 

A  large  number  of  cases  of  encysted  tubercular  peritonitis  have  been  relieved 
and  not  a  few  cured  by  free  incision.  PLven  when  the  disease  is  part  of  a  general 
tuberculosis  a  certain  amount  of  benefit  may  be  obtained  without  in  any  way  has- 
tening its  progress.  In  the  earlier  cases  the  diagnosis  was  not  made  until  the 
cavity  had  been  incised,  and  from  the  extreme  difficulty  of  distinguishing  between 
some  of  these  forms  of  encysted  ascites  and  ovarian  and  other  cysts,  the  same 
mistake  is  not  unlikely  to  occur  again.  In  a  fair  projjortion  of  cases  the  diag- 
nosis has  l)een  verified  by  the  microscopic  examination  of  the  miliary  growths  and 
the  discovery  of  bacilli. 

Primary  peritoneal  tuberculosis  (the  class  of  disease  for  which  oj^eration  is 
most  suitable),  is  probably  not  common  ;  nearly  always  it  is  secondary,  but  as 
there  is  evidence  to  show  that  the  partial  removal  of  tubercular  foci  in  other  parts 
of  the  body  is  sometimes  beneficial,  the  patient  appearing  to  make  better  headway 
against  the  rest,  and  as  considerable  relief  may  not  unreasonably  be  expected  to 
follow  the  removal  of  a  mass  of  this  character  from  the  abdominal  cavity,  opera- 
tion is  not  negatived  by  this,  provided  the  disease  is  not  too  far  advanced. 
Whether  anything  more  than  simple  drainage  is  advisable  is  uncertain  ;  probably 
it  would  depend  to  a  large  extent  upon  the  size  of  the  cavity  and  the  character  of 
its  walls. 


SECTION  VI.— OPERATIONS  UPON  THE  INTESTINES. 

Enterostomy. 

This  is  sometimes  known  as  Nelaton's  operation.  A  small  incision  is  made 
in  the  abdominal  wall,  an  inch  and  a  half  or  two  inches  in  length  according  to 
the  thickness;  the  peritoneum  is  incised,  and  the  most  distended  loop  of  small 


Fn;.  400. — Inguinal  Wound  Made  in  Nelaton's  "  Operation  of  Enterostomy." 

intestine  that  lies  near  is  drawn  into  the  wound  and  fixed  with  sutures.  If  the 
case  is  urgent  and  the  bowel  must  be  opened  at  once,  very  accurate  and  very  firm 
adaptation  is  necessary,  as  in  such  cases  there  may  be  a  considerable  amount  of 
movement  as  soon  as  the  pressure  is  relieved.  The  parietal  peritoneum  may  be 
drawn  outward  and  fixed  to  the  skin  by  two  or  three  sutures  ;  and  then  four,  or 
better  six,  silk  threads  must  be  passed  through  the  united  layers,  the  visceral  peri- 
toneum, and  the  outer  coats  of  the  bowel.  One  or  two  catgut  sutures  may  be 
used  between  the  others  for  greater  accuracy.   The  opening  in  the  intestine  should 


LUMBAR  COLO  TO  MY.  937 

be  merely  a  puncture.  Escape  of  the  contents  may  be  best  prevented  by  covering 
the  edges  of  the  wound  with  an  antiseptic  ointment  and  using  the  aspirator. 

Where  it  is  possible,  it  is  advisable  to  divide  the  oi)eration  into  two  stages, 
stitching  the  l)owel  into  position  first  ;  and  two  or  three  days  later,  when  adhesions 
have  formed  between  the  i)eritoneal  surfaces,  making  the  opening  into  it,  and  if 
necessary  securing  it  by  further  sutures. 

As  originally  performed  by  Nelaton,  the  operation  was  in  the  right  iliac  fo.ssa, 
between  the  deep  epigastric  artery  and  the  anterior  superior  spine  of  the  ilium  ; 
and  the  portion  of  bowel  opened  was  the  small  intestine  immediately  above  the 
caecum.  It  may  be  done,  however,  in  the  middle  line  or  in  the  right  lumbar 
region,  if  it  is  found  when  the  colon  is  exposed  that  the  seat  of  obstruction  is 
higher  up. 

As  a  primary  operation  enterostomy  meets  with  but  little  favor.  The  cases  of 
obstruction  in  which  distention  of  the  bowel  is  the  only  cause  are  very  few  in 
number  ;  these  may  be  cured  by  such  an  operation,  and  the  opening  closed.  It  is, 
however,  as  yet  impossible  to  diagnose  them  from  other  forms  of  intestinal  stran- 
gulation in  which  the  operation,  if  it  were  performed,  would  merely  give  momen- 
tary relief,  leaving  the  real  source  of  the  mischief  untouched.  On  the  other  hand, 
when  the  colon  has  been  exposed  and  found  empty,  or  when  laparotomy  has  been 
performed  and  some  hopeless  condition  discovered — an  irreducible  and  extensive 
intussusception,  for  example — or  widely  spread  carcinoma  in  a  patient  who  is  com- 
pletely exhausted,  enterostomy  may  prove  of  the  greatest  service  by  relieving  dis- 
tention and  pain  and  prolonging  life. 

Greig  Smith  recommends  that  in  cases  of  intestinal  obstruction  in  which  the 
patient  is  much  collapsed,  this  operation  should  be  performed  under  local  anaes- 
thesia by  the  subcutaneous  injection  of  cocaine,  merely  to  give  time  to  rally.  P2ven 
if  nothing  is  given  the  pain  of  the  incision  is  scarcely  felt,  and  any  other  anaes- 
thetic, increasing  the  depression  or  causing  vomiting,  would  almost  certainly  ex- 
tinguish the  little  chance  that  is  left. 

COLOTOMY. 

The  colon  may  be  opened  either  in  the  lumbar  region  on  the  right  or  left 
side,  or  in  the  left  inguinal.  In  the  former  operation,  which  was  first  performed 
by  Amussat  on  the  right  side,  the  posterior  surface  of  the  bowel  where  it  is  un- 
covered by  peritoneum  is,  generally  speaking,  exposed  ;  in  the  latter  (Littre's) 
the  peritoneal  cavity  is  always  opened. 

Lumbar  Colotomy. 

The  colon  is  placed  half  an  inch  behind  the  middle  of  the  crest  of  the  ilium, 
as  measured  between  the  anterior  and  posterior  superior  spines,  lying  upon  the 
quadratus  lumborum,  immediately  below  the  kidney.  If  it  is  distended  there  is 
usually  a  considerable  surface  uncovered  by  peritoneum ;  when  it  is  collapsed  this 
contracts  ;  but  the  sides  may  generally  be  separated  from  each  other,  and  the 
bowel  reached  without  interfering  with  the  serous  surface.  In  a  certain  propor- 
tion of  cases,  however,  a  meso-colon  is  present,  especially  on  the  left  side  (Treves), 
and  then  it  is  impossible. 

The  patient  is  placed  on  the  opposite  side,  almost  semi-prone,  with  a  hard, 
round  pillow  under  the  loin  to  separate  the  last  rib  from  the  ilium.  The  margin 
of  the  erector  spinae  is  defined,  and  an  incision,  two  and  a  half  to  three  inches  in 
length,  is  made  obliquely  upward  and  backward  toward  the  angle  enclosed  by  the 
last  rib  and  the  spine.  The  middle  of  it  should  correspond  to  the  spot  at  which 
it  is  expected  the  bowel  will  be  found.  Practically,  unless  the  last  rib  is  much 
depressed,  the  incision  is  parallel  to  it  and  the  arteries,  and  lies  in  one  of  the 
natural  folds  ;  but  care  must  be  taken  not  to  bring  it  too  near  the  crest,  or  one 
margin  will  sink  below  the  other. 
60 


938     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

The  latissimus  dorsi,  with  a  few  fibres  of  the  external  obliciue,  and  the  internal 
oblique  are  divided  first  and  all  hemorrhage  stopped.  The  fascia  lumbonnii  is  slit 
uj)  on  a  director  for  the  whole  length  of  the  wound  and  the  outer  border  of  the 
quadratus  ex})Osed.  A  quantity  of  loose  fat,  in  which  the  kidney  is  embedded, 
and  the  transversalis  fascia  at  once  come  into  view,  the  latter  in  some  cases  closely 
resembling  the  peritoneum  in  appearance.  This  must  be  teased  through  gently 
with  forceps,  the  bleeding  stopped,  and  the  finger  introduced  to  ascertain  the 
position  of  the  kidney.  If  the  bowel  is  distended,  the  non-peritoneal  surface 
generally  rises  into  the  wound  at  once,  so  that  there  is  no  difficulty.  If  it  does 
not,  the  bowel  may  be  filled  with  air  from  the  anus  by  means  of  Lund's  insufflator, 
but  this  is  rarely  required.  As  a  rule,  it  is  sufficient  to  pass  the  finger  down  into 
the  angle  between  the  quadratus  and  psoas,  dividing  the  edge  of  the  former  a  little 
if  it  is  necessary,  and  by  rolling  the  patient  over  to  the  left  side  allow  the  bowel 
to  fall  against  the  digit.  The  intestine  should  now  be  hooked  well  forward  into 
the  wound,  the  sides  of  which  are  held  ai)art  by  retractors,  in  order  to  make  cer- 
tain that  the  portion  exposed  is  really  the  colon.  This  is  especially  necessary  on 
the  right  side ;  it  has  happened  to  several  of  the  best  operators  to  open  the  loop 
of  the  duodenum  by  mistake.  If  it  is  full  of  hard  scybalous  faeces,  or  if  one  of 
the  appendices  epiploicae  can  be  recognized,  it  is  usually  sufficient ;  but  the  only 
absolutely  sure  test  is  the  presence  of  a  band  of  longitudinal  fibres,  and  when  the 
non-peritoneal  surface  is  exposed  these  are  remarkably  inconsjjicuous.  Allingham, 
junior,  who  found  an  ascending  and  a  descending  meso-colon  in  five-sixths  of  the 
cases  he  examined,  considers  it  advisable,  unless  the  intestine  presents  itself  in  the 
wound,  or  can  be  recognized  beyond  all  doubt  at  once,  to  open  the  peritoneal 
cavity,  and  by  introducing  the  finger,  or  if  the  colon  is  much  displaced,  the  hand, 
to  find  the  portion  of  bowel  required  and  bring  it  up  to  the  surface.  The  cut 
edge  of  the  peritoneum  is  then  to  be  stitched  to  the  skin  so  as  to  shut  out  the 
abdominal  muscles  from  the  wound,  and  the  bowel  secured  in  position. 

When  the  intestine  must  be  opened  at  once,  a  large  curved  needle  is  passed 
through  the  skin  on  one  side  of  the  wound,  across  the  bowel,  and  then  through  the 

skin  from  within  outward  upon  the  opposite  side 
again.  The  same  thing  is  done  with  another 
needle  about  an  inch  lower  down.  The  ends  of 
these  sutures  are  to  be  held  by  an  assistant.  A 
small  puncture  is  then  made  with  a  tenotomy 
knife  in  the  centre  of  the  square  so  marked  out, 
and  the  two  threads,  as  they  traverse  the  interior 
of  the  bowel,  are  caught  up  and  pulled  out  in 
loops  by  means  of  an  aneurysm  needle.  As  soon 
as  the  loojjs  are  cut,  the  bowel  is  held  up  against 
the  skin,  slightly  overlapping  it,  by  four  silk  su- 
tures passing  through  its  whole  thickness.  Ad- 
ditional security  may  be  obtained  by  passing 
other  sutures  where  required,  either  to  hold  the 
bowel  to  the  skin,  or  to  bring  the  angles  of  the 
skin  wound  together  ;  and  often  it  is  advisable 
Fig.  4oi.-Method  of  Securing  Boweiin  Lum-  to  place  a  serics  of  buricd  catgut  sutures  in  the 
bar  Incision.  wouud  to  close,  as  far  as  possible,  the  planes  of 

cellular  tissue  between  the  muscular  strata. 
Whenever  it  is  possible  the  opening  of  the  bowel  itself  should  be  postponed  ; 
union  by  the  first  intention  may  make  everything  secure  within  three  days,  and 
prevent  all  fear  of  faecal  extravasation  and  suppuration,  and  an  interval  of  only  a 
few  hours  can  appreciably  diminish  the  risk.  The  intestine  may  be  secured  in 
position  by  sutures  passing  through  its  muscular  wall  only,  the  mucous  membrane 
being  carefully  avoided,  or  by  means  of  Howse's  forceps,  which  are  made  to  grasp 
small  folds  of  the  muscular  coat  at  intervals  of  about  half  an  inch,  and  are  then 
laid  flat  upon  the  skin  and  kept  in  position  by  broad  strips  of  plaster. 


INGUINAL  COLOTOMY  OR  LAPARO-COLOTOMY. 


939 


In  any  case,  it  is  absolutely  essential  to  draw  the  bowel  well  up  into  the  wound, 
so  as  to  form  a  spur  on  its  deep  surface  and  prevent  the  fasces  passing  beyond  ; 
unless  this  is  done  the  relief  is  exceedingly  imj)erfect,  and  faeces  may  collect  in  the 
part  below,  and  give  rise  to  serious  inconvenience  Madelung,  to  obviate  this,  and 
to  prevent  the  irritation  of  faeces  passing  over  a  cancerous  surface,  has  divided  the 
bowel  comi)letely,  sutured  the  upper  end  to  the  lumbar  wall,  and  completely  closed 
the  other  ;  but.  as  (ireig  Smith  points  out,  this  is  open  to  the  objection  that,  if  the 
stricture  becomes  closed,  there  can  be  no  escape  for  the  foul  and  decomposing  dis- 
charges in  the  lower  segment.  When  the  opening  is  a  considerable  distance  above 
the  seat  of  stricture,  and  the  bowel  is  much  distended,  it  is  of  advantage,  as  soon 
as  the  parts  are  fairly  firm,  to  introduce  the  tube  and  gently  wash  out  the  accumu- 
lation from  below.  Afterwards  the  spur  ought  to  be  sufficient  to  prevent  anything 
more  passing  on. 


Fig.  402. — Artificial  Anus  after  Colotomy  with  the  Oblique  Incision. 

The  discharge  of  faeces  is  generally  easy  ;  exceptionally,  when  there  are 
scybala,  it  may  be  necessary  to  wash  them  out,  or  even  to  extract  them  with 
forceps.  The  only  dressings  required  are  wood-wool,  or  some  other  absorbent  an- 
tiseptic material  in  large  pads,  changed  as  frequently  as  necessary,  and  some  zinc 
or  boracic  ointment  around  the  margins  of  the  wound.  Afterwards  an  apparatus 
must  be  worn  to  support  the  opening  and  collect  any  faeces  that  may  escape.  Ivory 
or  india-rubber  rings  may  be  used,  fixed  to  an  abdominal  belt  so  that  there  is  a 
certain  amount  of  pressure,  as  well  as  tension,  around  the  opening  ;  but  in  many 
cases  patients  find  the  greatest  amount  of  convenience  from  absorbent  pads  covered 
on  the  outer  surface  with  oiled  silk,  and  secured  by  a  linen  binder. 


Inguinal  Colotomy  or  Laparo-Colotomy. 

This  is  performed  in  the  left  inguinal  region,  but  when  it  is  desired  to  open 
the  caecum  or  ascending  colon,  a  similar  operation  may  be  carried  out  on  the  right 
side. 

Various  incisions  are  recommended,  but  in  the  majority  of  instances  one  two 
inches  in  length,  parallel  to  Poupart's  ligament,  and  about  one  inch  inside  the 
anterior  superior  spine,  fulfills  all  requirements.  Ball  prefers  the  linea  semilunaris, 
as  there  is  no  muscular  substance  divided.  All  bleeding  must  be  stopped  before 
the  peritoneum  is  opened.  As  soon  as  this  is  done  the  finger  is  introduced  and 
passed  along  the  lower  margin  of  the  iliac  crest  until  the  mesentery  guides  it  to 
the  sigmoid  flexure,  and  its  condition,  with  regard  to  distention  and  the  situation 
of  the  stricture,  is  ascertained.  The  parietal  peritoneum  is  then  sutured  to  the 
skin,  so  as  to  exclude  the  muscles  of  the  abdominal  wall,  and  a  loop  of  intestine, 
with  a  sufficient  length  of  mesentery,  is  pulled  out  and  secured.  The  simplest 
way  of  forming  a  spur  is  that  devi.sed  by  Allingham,  junior.  A  needle,  threaded 
with  carbolized  silk,  is  passed   through  the  meso-colon  behind    the  bowel,  and 


940    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

through  the  whole  thickness  of  the  abdominal  wall  on  either  side  of  the  opening, 
so  as  to  sling  the  intestine  up  and  bring  its  posterior  wall  forward.  The  sides  of 
the  intestine  are  then  fixed  all  round  to  the  margins  of  the  skin  by  silk  sutures 
jnssing  through  the  muscular  and  serous  coats  only,  and  leaving  at  least  two-thirds 
of  the  circumference  of  the  bowel  protruding  between  the  rows.  A  few  hours' 
delay  in  opening  the  intestine  is  even  more  essential  here  than  in  the  lumbar 
operation. 

Ball  recommends  that  a  loop  of  intestine  should  be  pulled  out  through  the 
wound,  emptied  as  far  as  possible,  by  gentle  pressure,  and  secured  for  the  time  by 
clamps  placed  above  and  below,  so  that  no  fceces  can  escape  when  it  is  opened. 
A  series  of  sutures  is  then  passed  through  the  whole  thickness  of  the  abdominal 
wall  on  either  side,  and  across  the  bowel  between  the  clamps.  One  should  pass 
through  the  meso-colon  in  the  angle  of  the  loop,  and  three  or  four  through  the 
bowel  above  and  below.  When  these  are  placed  in  position  the  convexity  of  the 
bowel  is  opened,  the  mucous  surface  carefully  cleansed,  and  the  threads  fished  out, 
divided,  and  secured,  with  the  exception  of  the  outermost  one  at  either  end.  The 
mucous  membrane  is  adjusted  all  round,  the  angles  of  the  wound  brought  together, 

leaving  the  handles  of  the  clamps  still  pro- 
truding, and  then  at  last,  when  everything 
is  secured,  the  clamps  are  withdrawn,  one  at 
a  time,  and  the  opening  closed  instantly  by 
tightening  up  the  sutures  that  have  been 
left.  In  this  way  the  upper  and  the  lower 
ends  of  the  loop  are  fixed  securely  side  by 
side,  and  no  escape  of  faces  is  allowed  until 
the  clamps  are  unscrewed,    ^^'hen  the  bowel 

Fig.   407. — Method  of   Securing  Bowel   in   Inguinal  ^   •,  ,       .  4.\.-  ^  ^ 

^  ^  Incision.  iiiust  be  Opened  at  once  this  plan  presents 

considerable  advantages  over  the  other  ;  but 
great  care  is  necessary  to  secure  it  sufficiently  firmly  without  bruising  it,  especially 
as  the  walls  are  not  unfrequently  much  softened  and  congested.  Redundant  por- 
tions of  the  bowel  can  be  removed  with  scissors  afterward,  as  far  as  maybe  neces- 
sary, without  its  being  felt. 

[In  Maydl's  operation,  incision  is  made  parallel  with  the  fibres  of  the 
external  oblique  muscle.  The  colon  is  drawn  into  the  wound,  and  a  glass  rod 
wrapped  with  iodoform  gauze,  thrust  through  the  mesentery  underneath  the  loop ; 
the  gut  is  then  stitched  under  the  rod  on  each  side.  If  considered  necessary  to 
open  the  colon  immediately,  the  peritoneum  of  the  abdominal  incision  is  stitched 
to  it,  and  the  incision  covered  with  iodoform  collodion.  If  it  is  intended  to  open 
the  colon  in  four  or  five  days  the  wound  is  well  packed  with  iodoform  gauze. 
When  ready  the  colon  is  opened  by  the  Pac(iuelin  cautery  and  drainage  tubes 
inserted  into  each  bowel  opening.  Through  these  tubes  irrigation  can  be  effectively 
carried  on,  and  the  action  of  the  external  oblicjue  muscle  takes  the  place  of  a 
sphincter.  The  accompanying  figures  from  Esmarch  ("  Chirurgische  Technik  ") 
will  render  further  de.scription  unnecessary.] 

Inguinal  v.  LuMn.\R  Colotomv. 

Little  reliance  can  be  placed  upon  the  older  statistics,  which  give  the  former 
of  these  operations  a  much  higher  rate  of  mortality  than  the  latter.  More  recent 
experience  tends  to  show  that,  so  far  as  this  is  concerned,  if  there  is  any  material 
difference,  the  balance  is  rather  on  the  other  side. 

In  a  certain  number  of  cases  lumbar  colotomy  is  almost  im])ossible:  a  faecal 
fistula  may  be  formed  in  the  loin,  sufficient  so  long  as  the  bowel  is  immensely  dis- 
tended ;  but  when  there  is  no  meso-colon,  and  the  walls  are  perhaps  four  or  even 
five  inches  in  thickness,  it  is  not  possible  to  draw  out  the  bowel  sufficiently.  The 
peritoneal  cavity,  it  is  true,  is  always  opened  in  the  one,  but  it  very. often  is  in  the 
other,  and  sometimes  without  its  being  known.     The  inguinal  operation  is  shorter. 


ENTERECTOMY. 


94' 


and  the  wound  much  smaller ;  the  large  intestine  can  be  found  more  easily,  and  can 
rarely  be  mistaken  ;  the  seat  of  stricture  can  often  be  ascertained,  and  it  is  always 
possible  to  make  sure  that  it  lies  below  the  wound.  So  far  as  the  after  treatment  of 
the  case  is  concerned,  there  is  no  (juestion  as  to  the  side  upon  which  the  advantage 
lies  :  the  tendency  to  prolapse  may  t)e  slightly  greater  in  the  inguinal  region,  but  it 
is  easily  controlled,  and  the  i)atient  can  attend  to  himself  much  better.  The  only 
exception  is  where  the  bowel  is  very  greatly  distended  and  the  walls  much  thinned  ; 
then  it  is  probable  that  the  immediate  risk  is  less  in  the  case  of  the  lumbar  than 
the  inguinal.  The  actual  distance  between  the  two  openings  is  not  more  than  four 
inches,  so  that  very  little  is  gained  in  this  respect  by  the  lumbar  incision. 


^k 


Fig.  404. — First  Stage  of  Maydl's  Operation  for  Artificial 
Anus.     (AJier  Esmarck) 


Fig.   405  -I.  The  Intestinal  Loop  drawn  forward. 
2.  Completely  severed. 
(a)  Conveying;  (<5)  Discharging  End. 


Prolapse  of  the  mucous  membrane  of  the  bowel  is  more  frequent  after  the  in- 
guinal than  the  lumbar  operation,  but  this  may  be  prevented  to  some  extent  by 
drawing  down  the  sigmoid  flexure  as  far  as  possible  and  fastening  in  the  wound  the 
highest  part  that  can  be  reached. 

It  must  not  be  forgotten  that  patients  who  are  suffering  from  abdominal  dis- 
tention and  are  worn  out  from  intestinal  obstruction,  frequently  take  anaesthetics 
badly,  and  that  the  position  necessary  for  the  lumbar  operation  still  further 
impedes  their  respiration. 

Enterectomy. 

Resection  of  the  small  intestine  may  be  performed  when  the  condition  of  the 
bowel  is  hopeless  from  gangrene,  irreducible  intussusception,  or  matting  together 
and  bending;  for  stricture,  simple  and  malignant;  for  perforating  wounds,  or  as 
a  plastic  operation  for  the  cure  of  artificial  anus.  If  the  condition  of  the  patient 
and  of  the  wall  of  the  intestine  is  such  as  to  admit  of  it,  the  two  ends  may  be 
sutured  together  and  returned  into  the  abdominal  cavity  at  once.  In  other  cir- 
cumstances an  artificial  anus  must  be  formed,  and  left  to  be  dealt  with  later  on. 

The  operation,  following  Greig  Smith,  is  conveniently  divided  into  three 
steps  :  (i)  the  isolation  of  the  bowel,  so  that  it  can  be  drawn  out  of  the  abdominal 
wound  and  emptied  ;  (2)  the  resection  ;  and  (3)  the  suturing  of  the  ends,  either 
to  each  other  (enterorrhaphy)  or  to  the  wall  of  the  abdomen. 

I.  Isolation. — In  most  instances  there  is  but  little  difficulty:  a  part  that  is 
gangrenous  or  has  been  wounded  can  generally  be  drawn  outside  and  thoroughly 


942     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

examined.  More  preparation,  however,  is  required  when  there  is  an  artificial 
anus:  the  abdomen  must  be  opened  above  and  below,  the  orifice  of  the  bowel 
closed,  and  the  adhesions  carefully  dissected  off;  and  in  the  case  of  malignant 
stricture  very  strict  examination  is  necessary  to  make  sure  that  the  whole  of  the 
growth  can  be  taken  away.  One  or  two  glands  may  be  removed,  but  if  there  is 
any  extensive  infiltration,  or  if  the  intestine  is  adherent,  the  attempt  is  not  likely 
to  succeed.  As  soon  as  the  bowel  is  drawn  out,  it  is  laid  upon  a  flat  carbolized 
sponge,  and  the  opening  into  the  abdomen  packed  with  more  sponges  to  prevent 
the  intrusion  of  faecal  matter  and  the  escape  of  more  of  the  intestine. 

2.  Resection. — As  soon  as  the  bowel  is  safely  held  away  from  the  margin  of 
the  wound,  it  should  be  opened  and  encouraged  to  empty  itself  as  far  as  possible. 
Whether  it  should  be  secured  above  and  below  with  clamps,  or  merely  held  with 
the  fingers,  depends,  to  a  large  extent,  upon  the  condition  of  the  bowel  itself  and 
upon  the  character  of  the  assistance  at  hand.  The  more  instrumental  compression 
can  be  dispensed  with  the  better,  but  it  must  be  allowed  that  nothing  can  prevent 
the  escape  of  the  contents  more  effectually  or  maintain  the  cut  edges  in  better 
apposition  for  the  application  of  the  sutures.  Many  forms  have  been  devised,  and 
something  may  be  said  in  favor  of  nearly  all,  but  perhaps  the  simplest  is  that 
adopted  by  INIakins.  It  merely  consists  of  a  pair  of  spring-catch  forceps  with 
longer  blades  than  usual,  and  a  screw  so  that  they  can  be  tightened  to  any  required 
extent.  The  blades  are  covered  with  rubber  tubing  to  avoid  injury  to  the  coats 
of  the  bowel. 

If  the  portion  of  the  bowel  to  be  removed  is  of  any  length  (in  Koeberle's  case 
the  amount  was  over  two  yards)  a  triangular  segment  of  mesentery  to  correspond 
must  be  taken  away  to  prevent  kinking  afterward.  The  base  of  the  triangle  should 
be  rather  smaller  than  the  interval  between  the  ends  of  the  intestine,  so  as  not  to 
interfere  with  their  blood-supply,  and  the  raw  edges  must  be  adjusted  to  each  other 
by  means  of  a  continuous  catgut  suture  carried  over  and  over  the  margins.  In 
most  cases,  however,  this  is  scarcely  necessary  ;  the  folds  may  be  drawn  together 
and  the  base  so  formed  stitched  to  the  intestinal  walls.  The  line  of  section  through 
the  mesentery  should  always  be  carried  as  close  to  the  attached  margin  as  possible, 
to  preserve  intact  the  row  of  anastomotic  loops   from  which  spring  the  vessels 

supplying  the  wall  itself.  Any  part  of  the  intes- 
tine separated  from  this  is  sure  to  slough.  Mac- 
Cormac  recommends  that  the  section  through  the 
bowel  should  not  be  exactly  transverse,  but  that 
rather  more  should  be  removed  on  the  convex 
side,  as  by  this,  after  the  suturing  is  complete,  the 
tube  remains  somewhat  straighter. 

3.  The  Sufurhig. — A  great  variety  of  intestinal 
sutures  have  been  described,  but  the  essential 
features  are  :  (i)  that  the  peritoneum  should  be  in 
contact  over  a  sufficiently  broad  surface  ;  (2)  that 
no  suture  traversing  the  mucous  membrane  should 
pass  at  once  through  the  serous  coat  as  well,  or  it 
will  inevitably  act  as  a  seton,  carrying  the  contents 
into  the  peritoneal  cavity  ;  if  sutures  are  used  to 
bring  the  mucous  edges  together,  they  should  be 
independent,  and  tied  on  the  mucous  surface,  so 
that  if  there  is  any  ulceration  they  may  fall  into 
the  cavity  of  the  bowel ;  (3)  that  the  sutures  should 
be  sufficiently  close  (eight  to  the  inch  at  least)  and 
pass  sufficiently  deep  to  secure  a  firm  hold.  Each 
F.c  4o6.-Lemberfs  Suture.  should  take  up  the  serous  layer,  the  whole  thickness 

of  the  muscular  wall  (which  is  much  thmner  in  the 
ileum  than  the  jejunum"),  and  a  few  fibres  of  the  submucous  coat.  Especial  care 
is   necessary  when  working  near  the  attachment  of  the  mesentery,  as  the  serous 


ENTERFCTOMY.  943 

layer  at  this  spot  is  separated  by  a  cellular  interval  from  the  structures  beneath, 
and  it  is  nearly  always  here  that  extravasation  occurs.  'Hie  last  requisite  is  that 
the  method  should  be  one  capable  of  rapid  ajjplication. 

Fine  China  twist  is  the  best  material,  and  one  row  of  sutures  at  least  should 
be  interrupted,  taking  care  that  they  are  not  sufficiently  tight  to  cause  sloughing. 
Continuous  sutures  are  admirably  adapted  for  securing  contact  and  for  strength- 
ening weak  places  ;  moreover  they  prevent  over-distention  of  the  bowel,  but  if 
it  contracts  they  become  loose  at  once. 

Treves  advises  that  there  should  be  two  rows  :  one  through  the  mucous  mem- 
brane, which,  as  soon  as  the  bowel  is  divided,  becomes  everted  ;  and  a  second,  further 
back,  turning  this  in  again,  through  the  serous  and  muscular  layers.  Yox  the  latter, 
I,embert's  is  the  most  useful  ;  the" needle  is  entered  about  three  to  three-and-a-half 
lines  from  the  margin,  passed  down  through  the  serous  and  muscular  coats  until 
the  resistance  of  the  submucous  layer  is  felt ;  and  then,  after  picking  up  a  few  fibres  of 
this,  brought  up  again  about  one  line  from  the  cut  edge,  and  introduced  into  the 
opposite  end  of  the  bowel  in  the  reverse  direction.  Czerny  combines  Lembert's 
with  another  row  inside,  passing,  not  through  the 
mucous  membrane  only,  but  through  the  whole  thickness 
of  the  bowel. 

One  or  two  sutures  should  always  be  passed  across 
the  cut  edges  of  the  mesentery  immediately  above  its 
attachment,  in  order  to  obliterate  as  far  as  possible  the 
triangular  space  that  normally  exists  there,  and  allow  all  t     ,     •  c 

o  1  .'  ./^-o'l-u  Fig.  407. — Lembert  s  Suture 

the  sutures  to  pass  through  the  serous  coat.     Greig  bmith  Tied, 

speaks  very  highly  of  Halsted's  plain  quilt  suture,  and 
makes  a  most  ingenious  use  of  it. 

"The  intestine  has  been  cut  away,  the  mesentery  divided  as  close  to  the 
bowel  as  deemed  desirable,  and  no  wedge-shaped  portion  removed.  Two  Makins 
clamps,  covered  with  rubber  tubing,  have  been  applied,  at  a  distance  of  about 
half  an  inch  from  the  divided  ends  of  the  bow^el.  A  purse-string  stitch  has  been 
so  arranged  along  the  divided  margin  of  the  mesentery  that  it  draws  together  the 
gap  of  cellular  tissue  and  the  attached  margins  of  gut,  while  it  leaves  free  small 
flaps  of  peritoneum,  which  may  be  grafted  on  to  the  base  of  the  line  of  union. 
Four  quilt  sutures  have  been  inserted  on  the  opposite  sides  of  the  divided  gut,  in 
the  exact  line  in  which  the  Lembert  sutures  are  to  be  placed  ;  the  two  on  each  side 
are  to  be  gathered  together  in  the  blades  of  catch -forceps,  and  gentle  and  steady 
traction  made  on  them  by  an  assistant.  This  raises  a  well-defined  fold  along  the 
edge  of  the  bowel  :  into  this  fold  the  sutures  are  inserted.  The  traction  on  the 
quilt-stitches  makes  certain  that  equal  distances  of  the  bowel  are  arranged  for 
suturing,  and  also,  by  raising  a  fold,  makes  the  insertion  of  Lembert's  stitches  more 
easy  and  ensures  their  being  placed  in  a  straight  line."  The  quilt-sutures  are  tied 
the  last  of  all,  and,  finally,  any  redundant  mesentery  is  fixed  along  the  line  of 
union  of  the  bowel.  Any  spot  that  appears  weak  may  be  strengthened  by  Dupuy- 
tren's  or  Apuolito's  continuous  suture  applied  outside. 

Senn  ('"'Annals  of  Surgery,"  1888),  who  has  performed  on  animals  an  in- 
valuable series  of  experiments,  prefers  a  modification  of  Joubert's  suture  where 
direct  union  of  tw^o  cut  ends  is  required.  The  time  is  very  much  shorter  ;  there 
is  less  danger  at  the  mesenteric  edge  ;  the  number  of  sutures  is  smaller,  the  risk 
of  their  giving  way  prematurely  and  of  their  perforating  the  mucous  membrane  is 
not  so  great,  and  there  is  not  so  much  fear  of  gangrene. 

The  direction  of  the  bowel  is  first  ascertained  by  Nothnagel's  test  (a  crystal 
of  a  sodium  salt  placed  upon  the  serous  surface,  causing  ascending  peristalsis),  the 
upper  end,  which  is  to  become  the  intussusceptum,  is  lined  with  a  soft  pliable 
rubber  ring  (made  from  a  flat  rubber  band,  one-third  to  one-half  of  an  inch  in 
width,  by  securing  the  two  ends  together  with  catgut  sutures),  which  is  stitched  to 
the  wall  at  its  lower  edge  with  a  continuous  catgut  suture.  The  two  ends  of  the 
bowel  are  then  fastened  together  with  four  catgut  sutures,  placed  at  equal  distances, 


944    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

and  the  upper  one,  supported  by  the  ring  inside,  is  pushed  into  the  other  so  as  to 
invaginate  it.  The  intussusceptum  must  be  a  little  longer  than  the  ring,  so  that 
there  may  be  a  distinct  neck  which  can  be  grasped  by  the  intussuscipiens.  A  few 
superfici;il  sutures  are  recpiired  to  prevent  disinvagination. 

The  ring  acts  as  a  splint,  keei)ing  the  part  at  rest,  and  its  pressure  (which  must 
not  be  too  great)  is  useful  in  securing  the  apposition  of  the  serous  surfaces.  When 
the  catgut  softens  it  comes  away  of  itself. 

There  is  no  doubt  that  by  this  process  the  operation  may  be  jjerformed  in  less 
than  one-fourth  the  time,  and  that  in  animals  it  succeeds  perfectly.  It  must  be 
remembered,  however,  that  the  human  intestine  is  of  larger  calibre,  and  its  walls 
for  the  most  part  thinner.  Probably  it  would  not  succeed  in  cases  of  obstruction 
where  the  ui)per  part  of  the  intestine  is  filled  with  fajces,  or  its  walls  much  softened 
and  congested.  For  such  the  formation  of  an  artificial  anus  is  to  be  preferred. 
In  perforating  wounds,  however,  where  perhaps  several  resections  have  to  be  per- 
formed, the  gain  in  point  of  time  alone  would  be  of  immense  advantage. 


Fig.  408. — Drawing  to  Show  Method  of  Intestinal  Sntiire.      (Greig  Smith.) 


Senn  has  also  practiced  a  most  ingenious  system  of  omental  grafting,  both  in 
ordinary  cases  of  circular  suturing  and  in  his  modification  of  Joubert's  method. 
A  flap  about  an  inch  in  width  (or  a  little  more),  and  sufficiently  long  to  reach 
round  the  bowel,  is  taken  from  the  margin  or  the  middle  of  the  omentum,  and  laid 
upon  the  line  of  junction  ;  two  catgut  sutures  are  used  to  fasten  it,  each  i)a.ssing 
twice  through  the  flap  (once  at  its  base  and  once  at  its  free  end),  and  through  the 
mesentery  of  the  bowel  in  between,  care  being  taken  that  when  the  sutures  are 
tied  they  correspond  in  direction  to  the  course  of  the  mesenteric  vessels.  At  first 
the  attachment  of  the  base  of  the  flap  to  the  omentum  was  preserved  intact ;  but 
in  his  later  experiments,  owing  to  the  possible  objection  that  kinking  might  be 
prdduced  by  this,  perfectly  isolated  strips  were  used  and  succeeded  equally  well. 
Slight  scarification  of  the  serous  surface,  not  sufficient  to  cause  bleeding,  is,  ac- 
cording to  the  same  authority,  of  additional  advantage  in  securing  early  and  firm 
adhesion  of  the  coats. 

Where  it  is  not  advisable  to  return  the  bowel  into  the  peritoneal  cavity,  the 


COLECTOMY.  945 

two  ends  are  sutured  rarefully  to  the  skin  around  tlie  abdominal  wound.  A  few 
stitches  should  be  put  in  first  to  connect  the  parietal  i)eritoneum  to  the  skin  and 
exclude  the  muscles,  and  the  external  openinj;  closed  as  far  as  possible  ;  then  the 
muscular  and  serous  coats  of  the  intestine  are  fastened  with  silk  at  as  many  points 
as  may  be  necessary  all  round  to  the  conjoined  peritoneum  and  skin.  If  the 
bowel  has  not  been  em])tied,  but  merely  the  contents  prevented  from  descending 
by  means  of  a  clamp,  this  should  not  be  removed  until  everything  is  secure,  for 
fear  of  the  faeces  in  their  first  rush  finding  their  way  into  the  peritoneum. 

The  peritoneal  cavity  itself  should  i)e  interfered  with  as  little  as  possible,  if 
blood  has  escaped  into  it  in  any  quantity  it  must  be  sjjonged  out ;  but  all  bleeding 
]joints  should  be  secured  before  it  is  opened,  and  the  section  through  the  bowel 
(which,  owing  to  the  congested  condition  of  the  walls,  often  bleeds  freely;  should 
not  be  made  until  it  can  be  well  isolated.  Fsecal  extravasation  is  very  much  more 
serious,  but  even  then  recovery  has  followed  after  the  peritoneum  has  been  thor- 
oughly washed  out  with  a  hot  solution  of  boracic  acid  ;  whether  a  drainage  tube 
should  be  used  or  not  must  depend  upon  the  amount  of  peritonitis. 

Whether  the  bowel  should  be  returned  into  the  peritoneal  cavity  at  once  and 
the  abdominal  wound  closed,  or  an  artificial  anus  formed,  must  be  decided  for 
each  case  by  the  condition  of  the  patient  and  of  the  intestines.  There  is  no  doul)t 
that,  for  obstruction  at  least,  the  former  of  the  two  is  the  less  successful,  but  it 
must  not  be  forgotten  that. an  artificial  anus  high  up  in  the  small  intestine  prac- 
tically means  starvation,  and  that  if  the  patient  is  to  be  cured  there  is  all  the  risk 
attendant  upon  the  second  operation.  In  case  of  wounds,  where  the  bowel  is 
healthy  and  the  patient  not  too  much  depressed,  there  is  no  doubt  the  operation 
should  be  completed  at  once. 

In  a  few  instances  an  intermediate  course  has  been  followed  ;  the  bowel  has 
been  returned  just  within  the  wound  and  secured  in  that  position  by  one  or  two 
sutures.  This  may  be  done  if  there  is  any  doubt  as  to  the  security  of  the  stitches 
in  the  bowel,  and  several  cases  in  which  it  has  been  adopted  have  recovered  after 
a  slight  discharge  of  fceces  through  the  abdominal  wound. 

Colectomy. 

Resection  of  the  colon  has  been  practiced  in  cases  of  gangrene  (upward  of 
fifteen  inches  of  the  transverse  portion  have  been  excised  successfully  in  umbilical 
hernia),  irreducible  intussusception,  gunshot  injury  and  stricture  ;  but  so  far,  at 
least,  as  malignant  disease  is  concerned,  and  this  is  the  chief  of  the  causes  for 
which  colotomy  is  performed,  the  advisability  of  such  a  proceeding  is  very  doubt- 
ful. It  rarely  ha|)pens  that  the  case  is  diagnosed,  or  that  such  a  serious  operation 
is  agreed  to  by  the  patient  in  time  for  complete  removal ;  adhesions  are  nearly 
always  present,  either  to  the  neighboring  viscera  or  to  the  parietes  of  the  abdo- 
men, and  recurrence  within  a  short  time  is  only  too  probable.  As  Kendal  Franks 
has  shown,  the  primary  mortality  is  exceedingly  high  (though  the  percentage  with 
improved  methods  is  certainly  growing  smaller),  and  of  those  who  recover  more 
than  half  are  known  to  have  suffered  from  a  recurrence  within  a  few  months. 
Colotomy  can  give  such  com])lete  relief  with  such  small  risk,  that  before  colec- 
tomy is  preferred  it  must  be  shown  that  there  is  a  reasonable  prospect  of  cure. 

The  operation  for  the  transverse  colon  is  performed  through  the  middle  line, 
and  portions  of  the  ascending  and  descending  colon  have  been  removed  in  the 
same  way,  but  this  must  be  considered  exceptional.  As  a  rule,  so  far  as  these  are 
concerned,  colectomy  is  only  possible  when  the  seat  of  disease  is  opposite  the 
lumbar  incision  and  the  bowel  is  sufficiently  free  for  it  to  be  well  pulled  out.  The 
method  is  the  same  as  in  enterectomy ;  peritoneal  surfaces  must  be  brought 
together  as  far  as  possible  ;  and  where  this  cannot  be  done  the  muscular  coats 
must  be  accurately  sutured,  but  this  greatly  increases  the  risk  of  suppuration  and 
retro-peritoneal  abscess. 


946     DISEASES  AND  INJURIES   OF  SPECIAL   STRUCTURES. 

CitCECTOMY. 

This  operation,  which  is  essentially  of  the  same  description,  has  been  per- 
formed on  several  occasions,  the  whole  of  the  ccecum  being  removed  and  the 
ileum  joined  to  the  ascending  colon. 

Intestinal  Anastomosis. 

By  this  is  meant  the  formation  of  a  fistulous  opening  between  two  i)ortions 
of  intestine,  or  between  the  intestine  and  the  stomach,  so  as  to  secure  the  direct 
transit  of  the  contents  from  one  to  the  other.  As  an  alternative  to  resection  and 
circular  suture  or  implantation  it  should  certainly  be  preferred  in  all  cases  in 
which  it  is  impossible  to  remove  the  cause  of  obstruction  :  in  which,  after  re.sec- 
tion,  continuity  cannot  be  restored  without  undue  traction,  and  in  which  the 
pathological  conditions  causing  the  obstruction  are  not  such  as  of  themselves  to 
constitute  a  danger  to  life.  Its  importance  in  connection  with  carcinoma  of  the 
pylorus  alone  may  be  imagined  from  the  fact  that,  in  Liicke's  clinic,  out  of  fifty- 
two  cases  selected  for  pylorectomy,  only  five  were  free  from  metastases,  and  that 
the  mortality  of  the  operation  was  75  per  cent. 

The  particular  name  of  the  operation  depends  upon  the  locality,  gastro-enter- 
ostomy,  jejuno-ileostomy,  ileo-ileostomy,  ileo-colostomy,  etc.  The  principle  is 
the  same  in  all  cases. 

Senn' s   Methods. 

I.  Where  the  two  Segments  are  Placed  Side  by  Side. — Decalcified  plates  of 
bone,  one  inch  wide  by  three  inches  long,  are  prepared  from  the  tibia  of  an  ox  by 
soaking  them  in  hydrochloric  acid  ;  when  sufficiently  flexible  they  are  washed  free 
from  acid,  dried  between  plates  of  tin  so  that  they  may  not  curl  up,  and  kept 
until  wanted  in  absolute  alcohol.  In  the  centre  of  each  plate  an  opening  is 
drilled  five-eighths  of  an  inch  by  one-sixth  ;  and  around  this  four  smaller  holes 
for  sutures,  one  on  each  side,  one  at  each  end,  about  one-sixth  of  an  inch  from 
the  central  opening.  The  sutures,  which  are  of  fine  China  twist  (catgut  of  suffi- 
cient strength  is  too  coarse  and  the  knots  too  large)  are  secured  beforehand  on 
the  inner  surface  of  the  plate  and  passed  through  the  holes  to  the  other  side. 

A  longitudinal  incision  is  made  on  the  convex  side  of  the  intestine,  away 
from  the  mesentery,  sufficiently  long  to  allow  the  plate  of  bone  to  be  slipped 
inside  and  arranged  parallel  to  the  bowel,  against  its  mucous  surface.  The  two 
end  sutures  are  allowed  to  hang  out  through  the  opening  ;  the  two  lateral  ones, 
which  have  needles  attached  to  them,  are  passed  through  the  wall  of  the  bowel, 
near  the  incision,  so  as  to  fix  the  plate  and  prevent  eversion  of  the  mucous  mem- 
brane. A  second  plate  is  arranged  in  a  similar  way  inside  the  other  portion  of 
intestine  ;  and  then  the  serous  surfaces  are  brought  together  so  that  the  orifices 
correspond,  and  the  opposite  sutures  tied.  The  knots  of  the  lateral  ones  lie  be- 
tween the  peritoneal  surfaces. 

By  this,  accurate  approximation  is  secured  over  a  surface  corresponding  to 
the  size  of  the  plates  ;  there  is  no  risk  of  cutting  off  the  blood-supply  by  the  mul- 
titude of  sutures  ;  the  plates  act  as  splints  and  secure  perfect  rest  ;  and  the  time  of 
the  operation  is  only  fifteen  minutes.  Senn  found  that,  in  dogs,  bone-plates,  if 
thoroughly  decalcified,  were  digested  too  soon  in  the  stomach  :  but  it  must  be  re- 
membered that  the  gastric  juice  is  much  more  acid  in  them  than  it  is  in  man. 

2.  Where  the  End  of  one  Segment  is  Implanted  into  the  Side  of  the  Other. — In 
this  case  the  proximal  end  of  the  distal  segment  must  be  thoroughly  invaginated 
and  closed  with  a  continuous  catgut  suture  pa.ssing  through  the  peritoneal  and 
muscular  coats.  Senn  has  shown  that  if  it  is  treated  in  this  way  it  soon  atrophies 
and  shrinks  up,  and  there  is  no  fear  of  its  becoming  the  seat  of  fKcal  accumula- 
tion. 

For  this  Senn  makes  use  of  the  modification  of  Joubert's  suture  already  de- 


ARTIFICIAL   ANUS  AND   F.HCAL   FISTULA. 


947 


scribed  (p.  944).  A  rubber  ring  is  secured  in  the  distal  end  of  the  proximal 
segment  ;  two  catgut  sutures,  each  jjrovided  with  two  needles,  are  passed  from 
within  out,  at  opposite  sides,  through  the  upper  margin  of  the  ring  and  the  whole 
thickness  of  the  bowel;  each  needle  is  then  passed  into  the  wall  of  the  colon, 
about  one-thirtl  of  an  inch  from  the  margin  of  the  opening,  penetrating  the  peri- 
toneal, muscular,  and  submucous  coats  only,  and  emerging  on  the  same  surface. 
As  soon  as  they  are  all  secured  at  corresponding  i)oints,  gentle  traction  is  made 
upon  them  while  the  end  of  the  proximal  segment  is  pushed  into  the  side  of  the 


Bone  Plate. 


Fig.  409 


Introducing  the  Bone  Plates. 
-Entero-Anastomosis.     {After  Senn.) 


distal  one,  so  as  to  form  a  limited  invagination.  The  sutures  are  then  tied  only 
sufficiently  to  prevent  any  disinvagination.  The  pressure  of  the  ring  keeps  the 
part  at  rest  and  secures  accurate  adaptation,  and  the  invagination  prevents  any 
escape  of  the  contents  and  secures  the  sealing  of  the  wound.  Superficial  sutures 
are  not  required. 

This  method,  of  course,  is  only  applicable  where  a  smaller  segment  can  be 
implanted  into  a  larger  one,  and  therefore  cannot  be  used  in  the  case  of  the 
stomach. 

Artificial  Anus  and  Faecal  Fistula. 

In  artificial  anus  there  is  a  free  communication  between  the  skin  and  the 
bowel,  the  whole  or  nearly  the  whole  of  the  intestinal  contents  escapes,  and  the 
part  below  shrinks  and  collapses.  In  faecal  fistula,  on  the  other  hand,  the  chan- 
nel is  narrow,  it  may  be  long  and  tortuous,  and  the  greater  portion  of  the  con- 
tents follow  the  natural  route.  The  one  arises  from  the  loss  of  a  loop  of  intestine, 
or  from  destruction  of  the  greater  portion  of  the  circumference  of  a  short  segment, 
the  bowel  being  sharply  bent  upon  itself;  the  other  from  sloughing  of  a  small  part 
only  of  the  wall. 

The  most  important  practical  distinction  is  the  existence  in  the  former  of  a 
spur  or  septum  opposite  the  opening,  which  prevents  the  contents  passing  on.  The 
posterior  wall  of  the  bowel  is  pu.shed  forward  from  behind  by  the  weight  of  the 
viscera  ;  a  ridge  is  formed  on  the  mucous  surface,  and  this  grows  more  and  more 
prominent  until  at  length  it  overlies  and  closes  the  opening  of  the  lower  segment ; 
the  vv-hole  of  the  faces  then  discharge  themselves  externally,  and  this  part  of  the 
bowel,  from  being  never  used,  shrivels  up  to  a  narrow  cord. 


94S    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

The  most  common  cause  is  hernia,  and  for  this  reason  the  opening  is  gen- 
erally situated  in  the  femoral  or  inguinal  region  ;  but  it  may  arise  from  injury,  car- 
cinoma, internal  strangulation,  fcecal  abscess  [tubercular],  circumscribed  peri- 
tonitis, and  many  other  causes  ;  and  the  communication  may  be  formed  with  the 
bladder  or  vagina,  or,  in  very  rare  cases,  with  other  parts  of  the  bowel.  If  the 
Oldening  is  of  any  size,  prolapse  of  the  mucous  membrane  is  almost  sure  to  occur  ; 
and,  sometimes,  owing  to  the  stretching  of  the  adhesions  between  the  two  por- 
tions of  bowel,  or  between  the  bowel  and  the  skin,  hernial  protrusions  make  their 
appearance  by  the  side, 

Treatment. — Where  there  is  merely  a  fistula,  and  the  passage  below  is  fairly 
open,  the  orifice  often  closes  in  of  itself.  The  discharge  becomes  less  ;  the  cica- 
tricial tissue  round  contracts  ;  the  patient  regains  strength  (unless  the  opening  is 
high  up  in  the  intestine)  ;  and,  even  if  the  cure  is  not  complete,  the  operation  is 
less  extensive,  and  the  condition  of  the  patient  more  satisfactory.  This  .some- 
times occurs  in  that  form  of  artificial  anus  which  follows  femoral  hernia  ;  and  the 
process  may  be  hastened  by  pressure  steadily  applied,  by  drawing  the  edges 
together  with  strapping,  button  sutures,  or  hare-lip  pins,  or  by  the  use  of  the 
actual  cautery.  Sometimes  a  small  plastic  operation  will  succeed.  In  most  cases 
of  artificial  anus,  and  whenever  the  orifice  is  high  up,  so  that  the  patient  is  in 
danger  of  starvation,  further  measures  are  essential. 

1.  Where  the  chief  difficulty  arises  from  the  presence  of  a  spur,  an  attempt 
may  be  made,  either  to  divide  it  or  to  press  it  back.  The  simi)lest  method  is  that 
suggested  by  Mitchell  Banks  :  a  stout  piece  of  rubber  tubing,  secured  by  a  liga- 
ture so  that  it  shall  not  escape,  is  passed  through  the  orifice  into  the  upper  and 
lower  ends  of  the  bowel,  resting  against  the  edge  of  the  spur.  The  contents  of 
the  intestine,  especially  if  the  opening  is  high  up,  pass  through  it  more  or  less, 
and  by  its  pressure  it  wears  the  jirojection  back,  and  brings  the  two  portions  into 
the  same  line  again. 

If  this  fails,  and  the  spur  is  very  distinct,  it  may  be  divided  by  means  of 
Dupuytren's  enterotome.  This  consists  essentially  of  a  pair  of  forceps,  the  ends  of 
which  are  broadened  out  into  flattened  discs  or  circles ;  one  of  these  is  passed  on 
each  side  of  th(*  septum,  and  then,  after  making  sure  that  there  is  no  loop  of  intes- 
tine caught  between,  they  are  slowly  and  cautiously  tightened  up  from  day  today, 
until  at  the  end  of  a  week  the  septum  sloughs  through.  Adhesions  meantime 
form  around  and  completely  shut  out  the  peritoneal  cavity.  The  mortality  attend- 
ing this  procedure  is  exceedingly  low  (no  more  than  8.5  per  cent.)  ;  but,  of 
course,  it  is  only  applicable  to  selected  cases. 

2.  Where  the  opening  is  very  high  up,  and  the  patient  is  gradually  losing 
ground  ;  where  there  is  no  well-defined  spur,  and  where  there  is  more  than  one 
opening,  resection  and  suture  of  the  bowel  afford  the  only  hope  of  cure.  This 
must  be  done  on  the  principles  that  have  been  already  described,  but  even  when 
every  precaution  has  been  taken,  the  mortality,  according  to  Makins,  amounts  to 
nearly  forty  per  cent.  The  patient,  for  a  day  or  two  before,  is  fed  wholly  with 
enemata  ;  the  bowels  and  the  skin  round  are  thoroughly  cleansed,  and  an  incision 
is  made  into  the  peritoneal  cavity  to  ascertain  the  amount  and  extent  of  the  adhe- 
sions, and  the  direction  of  the  bowel.  After  this,  the  ends  are  carefully  freed 
from  surrounding  structures,  drawn  well  out  of  the  wound  (which  is  immediately 
plugged  with  sponges ;  clamped  if  necessary,  resected,  and  sutured.  If  the  lower 
end  of  the  bowel  is  much  contracted,  there  may  be  great  difficulty  in  this,  and  it 
may  be  necessary  to  divide  it  obliquely  so  as  to  secure  a  full  extent  of  cut  surface  ; 
but  every  attempt  should  be  made,  both  before  and  during  the  operation,  to  dilate 
it  quietly  and  gradually.  Afterwards  the  bowel  is  returned  into  the  peritoneal 
cavity,  and  the  abdominal  wound  treated  as  in  laparotomy.  If  there  is  any  doubt 
as  to  the  security  of  the  sutures,  it  is  well  to  retain  the  bowel  close  to  the  surface. 

After-treatment. — The  after-treatment  of  operations  upon  the  intestine  is 
essentially  the  same  as  that  of  hernia ;  as  soon  as  the  jiatient  comes  round  from 
the  an?esthetic,  he  must  be  placed  under  the  influence  of  morphia  and  kejJt  tem- 


ABSCESS  OF  THE   LIVER. 


949 


porarily  ciuiet  for  at  least  eight  days.  A  little  ice  may  be  given  to  allay  thirst, 
but  he  must  not  be  allowed  to  suck  it  constantly  ;  the  temjierature  must  be  main- 
tained, and  where  the  ui)i)er  part  of  the  intestine  is  concerned,  the  strength  kept 
up  with  nutrient  enemata.  Barker  has  shown  that,  in  a  case  of  gunshot  wound, 
six  days  suffice  for  sound  union,  but  probably  the  time  required  in  obstruction 
would  be  considerably  longer.  Artificially  digested  food  should  be  given  at  first, 
and  in  very  small  (piantities.  In  colotomy,  of  course,  the  method  is  different, 
and  nourishment  may  be  taken  by  the  mouth  from  the  first. 

If  the  bowel  has  been  retained,  the  wound  does  not  require  dressing  for  five 
or  six  days,  unless  a  drainage  tube  is  used,  or  peritonitis  was  present.  Sometimes 
a  small  discharge  of  faices  takes  place  for  a  time,  and  then  gradually  ceases,  caused 
probably  by  the  giving  way  of  one  or  two  of  the  sutures.  Where  an  artificial 
anus  is  left,  large  absorbent  and  antiseptic  pads  should  be  used  and  changed  as 
often  as  required,  the  skin  being  protected,  as  far  as  possible,  by  vaseline  or  simple 
ointments.  When  the  opening  is  near  the  upper  end  of  the  intestine,  the  ex- 
coriation may  prove  a  difficulty. 


SECTION  VII.— SURGICAL  AFFECTIONS  OF  THE  LIVER  AND 

PANCREAS. 

ABSCESS  OF  THE  LIVER. 

Abscess  of  the  liver  may  arise  from  wounds  and  contusions,  from  exposure  to 
cold,  or  from  suppuration  in  connection  with  hydatid  cysts  ;  bul  in  most  instances, 
they  are  secondary  to  infection  from  the  intestine,  and  occur  chiefly  in  those  who 
have  lived  in  tropical  climates  and  have  suffered  from  dysentery.  Sometimes  they 
are  multiple,  scattered  through  the  liver  in  all  directions,  as  in  fatal  cases  of  pye- 
mia ;  more  frequently,  they  are  single  or  few  in  number,  though  they  may  have 
been  formed  by  the  gradual  coalescence  of  numerous  small  foci,  and  then  they 
may  be  very  large,  capable  of  holding  four  or  five  pints  of  fluid.  The  pus  is 
usually  dark  chocolate  in  color,  and  sometimes  fcetid.  At  first,  the  abscess  may 
be  deeply  seated  ;  as  it  enlarges,  it  approaches  nearer  the  surface,  until  either  it 
bursts  into  the  pleura,  peritoneum,  or  pericardium,  or  else,  if  this  is  prevented  by 
the  formation  of  adhesions,  discharges  itself  externally,  or  into  the  bowel. 

Diagnosis. — The  diagnosis  of  deep-seated  abscess  in  the  early  stage  is  ex- 
ceedingly difficult.  A  history  of  residence  in  a  hot  climate,  or  of  any  rectal 
trouble,  even  years  before ;  the  occurrence  of  rigors,  or  of  general  feverishness, 
with  pain  and  tenderness  over  the  region  of  the  liver  ;  a  muddy,  perhaps  jaundiced, 
complexion  ;  irritability  of  the  stomach,  with  vomiting  and  other  signs  of  hepatic 
congestion,  may  excite  suspicion,  but  no  positive  diagnosis  can  be  made,  without 
exploration  by  means  of  an  aspirator.  In  the  later  stages,  when  there  is  a  distinct 
enlargement  of  the  liver,  or  when  the  skin  over  the  surface  of  the  abdomen  is  red 
and  oedematous,  this  difficulty  disappears  ;  but  the  abscess  must  usually  attain  a 
very  large  size  before  it  can  produce  such  an  effect. 

Hydatids  of  the  liver  may  be  differentiated  by  the  slowness  of  their  growth, 
and  by  the  absence  of  pain  and  fever  ;  but  this  fails  if  the  cyst  is  suppurating. 
A  certain  amount  of  difficulty  may  arise  in  the  case  of  large  single  gummata  of 
the  liver,  and  of  rapidly-growing  tumors  either  of  this  organ  or  of  the  kidney. 
Pleurisy  and  pneumonia  are  not  unfrequently  pres^it,  especially  when  the  abscess 
is  situated  near  the  posterior  surface,  and  very  great  care  may  be  required  to 
make  certain  of  the  cause. 

Treatment. — i.  If  the  skin  over  the  swelling  is  red,  and  pits  on  pressure, 
there  can  be  little  doubt  either  as  to  the  existence  of  an  abscess  or  the  presence  of 
adhesions.     In  such  circumstances  an  aspirating  needle  may  be  used  as  a  prelimi- 


950     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

nary,  to  act  as  a  guide,  but  as  soon  as  it  has  entered  the  cavity  and  the  diagnosis 
is  confirmed,  the  opening  should  be  enlarged,  so  that  the  pus  can  escape  as  freely 
as  possible,  and  a  full-sized  drainage  tube  inserted.  The  following  day,  when  the 
adhesions  are  firmer,  the  abscess  cavity  may  be  explored  with  the  finger  to  make 
sure  there  are  are  no  other  sacs  in  the  immediate  neighborhood,  and,  if  necessary, 
washed  out  with  iodine  or  some  other  antisejjtic. 

2.  When  there  is  no  certainty  as  to  the  presence  of  adhesions  the  choice  lies 
between  aspiration,  drainage  with  a  trocar  and  cannula,  and  incision. 

Aspiration  is  chiefly  of  use  for  exploration  ;  it  rarely  happens  that  an  abscess 
cavity  is  comjjletely  emptied,  and  nearly  always  the  swelling  appears  again  within 
a  few  days.  In  a  few  instances,  however,  a  cure  has  followed  after  two  or  three 
repetitions. 

Puncture  with  a  trocar  and  cannula  is  also  open  to  grave  objections.  If  ad- 
hesions are  present  already,  it  is  more  satisfactory  to  make  a  free  incision  and  allow 
of  thorough  exploration  and  drainage ;  if  they  are  not,  the  peritoneal  cavity  is 
opened  without  any  safeguard  to  prevent  the  i)us  entering  it.  Further,  the  con- 
stant movement  of  the  liver  in  the  abdominal  cavity  frequently  renders  the  reten- 
tion of  a  tight-fitting  cannula  or  of  a  stiff  drainage  tube  a  matter  of  very  considerable 
difificulty. 

Incision  directly  into  the  abscess  sac  can  only  be  practiced  when  the  skin 
over  it  is  reddened  and  it  is  certain  that  the  walls  are  adherent.  If  this  is  not 
definite,  either  the  operation  must  be  carried  out  in  separate  stages  or  an  incision 
made  into  the  abdomen  over  the  swelling,  the  surface  of  the  liver  exposed,  and 
the  abscess  opened  with  the  usual  precautions  to  prevent  its  contents  entering  the 
peritoneal  cavity.  The  preliminary  steps  are  the  same  in  both,  but  while  in  one 
the  incision  is  only  carried  down  to  the  parietal  peritoneum,  and  is  then  plugged, 
so  that  adhesions  may  form  beneath,  in  the  other  the  abdominal  cavity  is  opened 
at  once  and  the  surface  of  the  liver  examined.  In  a  few  cases  omentum  has  been 
interposed,  or  it  has  been  found  that  the  abscesses  are  multiple  and  that  there  is 
no  hope  of  thorough  evacuation  ;  but  if  no  difficulty  of  this  kind  is  apparent,  the 
wound  is  carefully  packed  round  with  sponges  and  an  aspirating  needle  thrust  into 
the  swelling.  As  soon  as  the  pus  is  found  the  opening  is  enlarged  freely  with  the 
knife,  and  the  contents  of  the  abscess  allowed  to  escape  completely  ;  the  assistant, 
meanwhile,  carefully  supporting  the  liver  on  either  side  so  that  it  shall  not  fall 
away  from  the  surface  of  the  abdomen.  When  the  sac  is  emptied  the  cavity  may 
be  explored  with  the  finger  and  the  walls  stitched  to  the  skin  margins  of  the  wound 
all  round. 

An  aspirating  needle  may  be  thrust  through  the  two  layers  of  the  pleura  and 
the  diaphragm  for  the  sake  of  exploring  the  posterior  surface  of  the  liver  without 
risk  ;  but  if  a  permanent  drain  is  required,  a  free  incision  should  be  made  down 
to  the  parietal  pleura,  a  portion  of  one  of  the  ribs  being  resected  if  necessary,  the 
two  layers  of  the  pleura  accurately  sutured  together  with  catgut  (there  is  no  diffi- 
culty in  this  in  the  lower  intercostal  si)aces).  and  then  the  trocar  and  cannula 
thrust  through,  so  as  to  avoid  the  risk  of  air  or  pus  entering  into  the  pleural  space. 

Hydatid  Disease. 

Hydatid  cysts  are  of  common  occurrence  in  connection  with  the  liver,  and 
not  unfrequently  attain  an  enormous  size,  diverticula  having  been  known  to 
extend  down  into  the  iliac  fossa,  and  even  under  Poupart's  ligament.  As  a  rule 
they  are  single,  lined  with  a  characteristic  laminated  membrane,  and  contain  a 
clear,  non-albuminous  fluid,  the  sjjecific  gravity  of  which  is  under  1015  ;  but  more 
than  one  may  be  present,  and  most  of  the  larger  ones  contain  numbers  of  smaller 
ones  in  their  interior.  Outside  is  a  vascular  layer  formed  by  the  continued  irrita- 
tion of  the  surrounding  structures. 

The  symptoms  to  which  they  give  rise  are  very  obscure  at  first,  and  depend 
mainly  upon  the  locality.     Their  increase  is  slow  and  painless,  without  any  fever; 


DISEASES  OF  THE  GALL-BLADDER.  951 

they  may  occur  at  any  age,  forming  a  tense  elastic  swelling  which  slowly  extends 
in  the  direction  of  least  resistance.  Sometimes  there  is  a  smooth  rounded  promi- 
nence on  the  front  wall  of  the  abdomen,  dull  on  percussion,  and  tense,  without 
being  tender.  Occasionally  fluctuation  can  be  made  out,  or  what  is  known  as 
hydatid  fromitu.s — a  peculiar  thrill  only  felt  over  cysts  of  consideral)le  size.  Often 
the  cyst  grows  downward,  simulating  enlargement  of  the  liver,  and  in  a  few  cases 
it  has  reached  so  far  as  to  be  mistaken  for  hydronephrosis,  and  even  for  ovarian 
tumor.  Not  unfiecpiently  serious  consequences  arise  from  pressure  upon  neigh- 
boring organs.  Syncope  has  been  known  to  occur  ;  vomiting  is  not  uncommon  ; 
respiration  may  be  interfered  with  ;  or  jaundice,  ascites,  or  anasarca  may  follow. 

Rupture  of  the  cyst  into  the  peritoneal  cavity  may  occur,  as  the  vascular 
adventitia  is  often  defective  on  the  serous  surface,  and  is  generally  fatal  at  once. 
Communications  occasionally  form  with  the  lung,  so  that  the  cysts  are  coughed 
up  in  numbers  ;  but,  as  a  rule,  if  the  patient  recovers,  it  is  only  after  a  long  and 
severe  illness.  In  a  few  cases  the  hydatids  have  been  known  to  remain  stationary 
for  years  and  at  length  undergo  degeneration  and  dry  up  into  a  calcareous  mass  ; 
but  suppuration  with  high  fever  and  severe  constitutional  disturbance  is  more 
common. 

The  diagnosis  rests  mainly  upon  the  age  of  the  patient,  the  smooth,  even 
shape  of  the  swelling,  and  the  absence  of  pain  and  feverishness.  The  chief  diffi- 
culty arises  with  pleurisy,  hydronejjhrosis,  ovarian  cysts  and  tumors  of  the  liver  ; 
but  as  a  rule  exploratory  puncture  is  conclusive.  When  supi)uration  has  set  in  it 
is  impossible  to  distinguish  it  from  abscesses  due  to  other  causes. 

Treatment. — There  is  no  doubt  that  hydatid  cysts  are  easily  killed  by  with- 
drawing a  small  quantity  of  fluid  from  their  interior,  and  when  they  are  of  mode- 
rate size  and  are  deeply  imbedded  in  a  solid  organ,  there  is  a  reasonable  hope 
that  if  this  can  be  done  they  may  become  calcified.  In  the  case  of  larger  ones, 
however,  this  is  seldom  satisfactory,  partly  owing  to  the  risk  of  suppuration, 
partly  to  the  impossibility  of  getting  rid  of  the  daughter  cysts  they  so  often  con- 
tain.     For  these  free  incision  is  the  only  method. 

As  in  the  case  of  abscesses,  this  may  be  carried  out  in  two  steps,  an  incision 
being  made  down  to  the  parietal  peritoneum  and  plugged  so  as  to  procure  adhe- 
sion between  the  opposing  surfaces  some  few  days  before  the  cyst  is  opened  ;  or, 
preferably,  the  whole  operation  may  be  completed  at  once.  The  surface  of  the 
liver  where  the  cyst  projects  must  be  exposed  by  a  free  incision  through  the  abdo- 
minal wall,  the  opening  carefully  packed  with  sponges,  and  then,  while  an  assistant 
supports  the  liver  by  external  pressure,  a  free  incision  is  made  into  the  sac  and 
its  contents  evacuated.  The  side  of  the  cyst  is  hooked  up  with  the  finger,  the 
wall  of  the  sac  peeled  off,  disturbing  the  adventitia  as  little  as  possible,  and  the 
edge  accurately  sutured  to  the  skin.  In  some  cases  the  sac  has  been  sponged  out 
with  iodine  afterwards. 

Tapping  hydatid  cysts  with  an  aspirator  is  occasionally  followed  by  urticaria, 
vomiting,  and  other  symptoms  of  poisoning.  I  have  known  one  instance  in 
which  sudden  death  occurred,  and  Bryant  has  recorded  another  ;  it  may  have 
been  due  to  the  sudden  entry  of  some  of  the  cyst  fluid  into  one  of  the  large 
branches  of  the  hepatic  vein,  but  more  probably  to  shock. 


Diseases  of  the  G.\ll-Bl.a.dder. 

Biliary   Calculi. 

Gall-stones  are  generally  formed  in  the  gall-bladder,  although  a  itw  are  met 
with  in  the  hepatic  duct,  coming  from  the  liver,  and  they  may  become  impacted 
either  in  the  neck  of  the  gall-bladder,  probably  held  by  the  peculiar  folding  of 
the  mucous  membrane,  or  in  the  hepatic,  cystic,  or  common  ducts.  Sometimes 
they  are  single,   or,  at  least,  few  in   number,  and  of  very  large  size;  sometimes 


952     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

they  are  multiple,  occurring  by  the  hundred,  and  having  facets  from  mutual  fric- 
tion. Some  are  small,  rough,  and  soft,  composed  chiefly  of  bile  pigment,  others 
formed  of  cholesterine  are  hard  and  brittle.  They  are  most  common  in  women, 
and  after  middle  life,  although  instances  of  their  occurrence  in  children  are  not 
unknown. 

The  symptoms  to  which  they  give  rise  are  variable  :  it  is  not  uncommon  to 
f\x\6.  post-mortem  that  the  gall-bladder  is  full  of  them,  without  there  having  been 
any  reason  to  suspect  their  existence  during  life. 

In  some  cases  there  are  frequent  and  excessively  i)ainful  attacks  of  biliary 
colic,  with  or  without  jaundice,  according  to  the  exact  situation  of  the  obstruction. 
The  i^atient  is  never  free  from  pain,  there  is  a  constant  weight  or  dragging  in  the 
hepatic  region,  made  worse  by  movement,  and  coming  on  with  especial  severity 
a  few  hours  after  food,  causing  vomiting  and  great  prostration.  This  may  end  sud- 
denly and  finally  w'ith  the  passage  of  the  calculus,  or,  on  the  other  hand,  the  stone 
may  drop  back  into  the  gall-bladder,  and  all  the  symptoms  return  again  within  a 
few  hours. 

If  the  calculus  is  impacted,  the  consequences  are  still  more  serious.  When 
the  obstruction  is  in  the  cystic  duct,  the  gall-bladder  only  is  involved,  and  it  may 
either  become  immensely  distended  (dropsy),  or  inflamed  and  suppurate  (em- 
pyema) ;  when  it  is  in  the  common  duct,  in  addition  to  this,  the  liver  is  affected, 
jaundice  sets  in,  and  at  length,  unless  some  relief  is  given,  cholremia  follows. 
Usually,  this  proves  fatal  within  the  tw-elvemonth. 

[Occasionally  the  gall-stones  dilate  the  gall-bladder  so  there  is  a  distinct  pro- 
trusion of  the  abdominal  wall.  The  writer  cut  down  upon  such  a  swelling  in  the 
Saturday  clinic  at  Rush  Medical  College  in  1891,  and  removed  twenty-seven  small 
faceted  gall-stones.  These  were  contained  in  a  pouch  or  diverticulum  of  the  gall- 
bladder. A  fistula  persisted  for  some  weeks  after  the  operation,  but  finally  healed 
after  repeated  injections  of  tincture  of  iodine.] 

Dropsy  of  the  Gall- Bladder. 

Distention  of  the  gall-bladder  is  nearly  always  due  to  imjmcted  calculus ; 
in  some  rare  instances  other  foreign  substances,  fragments  of  carcinoma,  trema- 
todes,  etc.,  have  been  found  instead,  and  occasionally  it  results  from  stricture,  gum- 
mata,  or  peritoneal  inflammation.  The  contents  soon  become  altered  in  character  ; 
the  bile  becomes  more  watery  ;  after  a  time  it  loses  its  color  altogether,  and  at 
length  it  is  replaced  by  a  fluid  that  is  either  perfectly  clear  or  is  turbid  from  the 
amount  of  mucus  it  contains.  The  bladder  itself  swells  up  into  a  pear-shaped  or 
semi-globular  tumor  which  grows  downward  toward  the  umbilicus.  Usually  it  is 
overlapped  at  its  margin  by  intestine  and  there  may  be  a  clear  note  on  percussion 
between  it  and  the  liver.  The  surface  is  smooth  and  uniform,  firm  and  elastic  to 
the  touch,  but  sometimes  very  painfiil.  The  walls  are  nearly  always  thinned,  and 
there  is  practically  no  limit  to  the  size  it  may  reach. 

Empyema  of  the  Gall-Bladder. 

Suppuration  in  the  gall-bladder,  which,  according  to  Tait,  is  usual  when 
only  a  few  gall-stones  are  present,  rarely  leads  to  a  tumor  of  such  size.  The  walls 
are  thickened  in  some  parts  and  thinned  in  others,  adhesions  tying  it  down  to  all 
the  structures  near  ;  the  tissues  become  soft  and  easily  torn,  and.  if  the  gall-bladder 
itself  does  not  slough,  the  pus  gradually  works  its  way  through  the  wall  at  some 
point  or  other.  Sometimes  it  bursts  into  the  peritoneum,  causing  fatal  peritonitis  ; 
more  often  it  discharges  itself  either  into  the  stomach,  duodenum,  or  colon  \  per- 
haps most  frequently  of  all,  adhesions  form  between  the  fundus  and  the  abdominal 
parietes,  and  the  abscess  is  either  opened  or  breaks  externally.  If  the  obstruction 
is  in  the  cystic  duct  this  may  give  complete  relief;  if,  however,  the  common  duct 
is  involved,  a  permanent  biliary  fistula  is  left,  which  usually  proves  fatal  in  the 
course  of  a  year  or  two,  from  exhaustion. 


OPERATIONS  UPON  THE  GALL-BLADDER.  953 

Diagnosis. — Malignant  disease  of  the  liver,  pancreas,  ])ylorus,  or  of  the 
gall-bladder  itself,  may  cause  a  certain  amount  of  difficulty.  This  is  especially 
the  case  with  the  first  mentioned,  as  biliary  calculi  are  not  unfrequently  associated 
with  carcinoma,  though  it  is  not  easy  to  say  in  what  relation  they  stand  to  each 
other.  According  to  Tait,  the  presence  of  jaundice  jjoints  distinctly  to  malignant 
disea.se,  and,  so  far  from  rendering  an  operation  advisable,  suggests  exactly  the 
opposite  conclusion,  unless  it  is  done  merely  as  a  temporary  expedient  for  the  re- 
moval of  an  obstructing  calculus  or  the  relief  of  biliary  colic.  Out  of  twenty 
cases  operated  on,  carcinoma  was  i)re.sent,  or  was  very  highly  probable,  in  every 
one  in  which  there  was  jaundice. 

Tumors  of  the  kidney,  ])articularly  hydronei)hrosis  and  floating  kidney,  have 
often  been  mistaken  for  distended  gall-bladder,  especially  when  there  has  been  a 
history  of  the  previous  passage  of  gall-stones,  and  vice  versa.  The  shape  of  the 
tumor  and  the  relation  that  it  bears  to  the  bowel  are  the  most  important  diagnostic 
points  ;  but  in  many  ca.ses  it  is  im])o.ssible  to  be  certain  without  a  preliminary  ex- 
ploratory incision. 

Hydatid  cysts,  dermoid  cysts,  tumors  in  connection  with  the  omentum, 
ovarian  cysts,  and  other  rarer  forms  of  tumors,  have  occasionally  given  rise  to 
difficulty.  In  any  such  case,  a  small  exploratory  operation  is  infinitely  more  safe 
and  more  certain  than  needling  or  aspiration. 

Operations  Upon  the  Gall-Bladder. 

According  to  Greig  Smith,  operation  is  required  in  all  cases  of  empyema, 
dropsy,  and  persistently  recurring  colic.  When  jaundice  is  present,  the  prognosis 
is  much  more  grave,  not  only  for  the  reasons  mentioned  above,  but  because  of  the 
much  greater  risk  of  hemorrhage  and  the  feeble  power  of  repair.  Still,  it  may 
be  necessary  to  avoid  the  occurrence  of  cholsemia,  and  sometimes,  even  under 
these  conditions,  it  is  possible  to  effect  a  permanent  cure — by  crushing,  for  example, 
a  calculus  impacted  in  the  common  duct. 

Aspiration  through  the  abdominal  wall  cannot  be  recommended  ;  it  is  not 
likely  to  effect  a  permanent  cure,  and  it  may  lead  to  leakage  through  the  puncture 
and  peritonitis. 

Free  incision  can  only  be  practiced  where  there  is  an  abscess  pointing  through 
the  skin. 

Incision  into  the  gall-bladder  after  exposure  through  an  opening  in  the  ab- 
dominal parietes  (^c  hole  cystotomy)  is  a  most  successful  operation.  A  vertical  incision 
is  made  over  the  most  prominent  part  of  the  swelling,  and  the  muscles  and  periton- 
eum divided  in  the  ordinary  way  ;  the  finger  is  then  introduced  to  ascertain  the 
condition  of  the  gall-bladder,  and,  if  it  is  much  distended  and  not  too  much 
bound  down  by  adhesions,  a  fine  trocar  and  cannula  is  thrust  into  it  to  draw 
off  some  of  the  contents,  and  allow  it  to  be  pulled  out  through  the  wound,  the 
greatest  care  being  taken  to  allow  none  of  the  fluid  to  enter  the  peritoneal  cavity. 
If  catch  or  tooth  forceps  are  used,  they  should  be  placed  above  and  below  the 
opening  of  the  trocar,  so  that  if  the  tissues,  which  are  often  very  thin,  are  bruised, 
the  injured  part  may  lie  in  contact  with  the  parietal  peritoneum.  As  soon  as  the 
wall  of  the  bladder  is  drawn  out  through  the  wound,  a  free  incision  is  made  into  it, 
the  rest  of  the  contents  allowed  to  escape,  the  interior  carefully  sponged  out,  and 
the  finger  introduced  to  ascertain  if  there  is  any  obstruction  present.  Loose  calculi 
present  no  difficulty,  but  if  they  are  impacted  far  down  in  the  neck,  or  in  the  cystic 
duct,  the  greatest  care  is  required  to  avoid  injury.  Sometimes  they  may  be  removed 
by  special  forceps,  the  surface  being  gradually  nibbled  away,  while  the  stone  is  fixed 
by  the  forefinger  of  the  other  hand  pressing  against  it  from  outside  the  duct.  On 
one  or  two  occasions  the  stone  has  been  broken  by  pressure  from  the  outside,  for- 
ceps guarded  with  rubber  tips  being  used  to  avoid  bruising  as  far  as  possible. 
Needling  has  been  recommended  to  break  them  up.  The  mucous  membrane  has 
been  very  carefully  nicked  from  the  inside.  The  calculus  has  been  left  and  the 
61 


954    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

fistulous  opening  syringed  out  constantly  with  warm  water  for  a  fortnight,  and 
finally,  when  everything  else  has  failed,  the  gall-bladder  has  been  excised. 

In  a  few  cases  the  wound  in  the  gall-bladder  has  been  successfully  sewn  up 
and  the  emptied  sac  returned  into  the  abdomen,  but  Tait,  who  has  jjerformed 
more  of  these  operations  and  with  better  success  than  any  one  else,  condemns  this 
strongly.  The  walls  are  often  exceedingly  thin,  it  is  very  often  impossible  to 
make  sure  that  the  opening  into  the  bowel  is  patent,  and  if  any  further  operation 
is  required  it  is  decidedly  advantageous  to  have  the  fundus  of  the  gall-bladder  ad- 
herent to  the  cicatrix.  The  walls  of  the  sac,  the  parietal  peritoneum,  and  the 
skin,  should  be  accurately  sewn  together.  Tait  uses  two  continuous  sutures,  one 
for  each  side  of  the  wound,  the  ends  being  tied  together  afterward,  above  and 
below.  A  large  drainage  tube  is  inserted,  so  as,  if  possible,  to  carry  all  the  bile 
away  from  the  wound,  and  ordinary  absorbent  dressings  are  applied.  When  the 
wound  is  healed  the  drainage  tube  may  be  withdrawn.  If  the  obstruction  has 
been  removed  the  bile  soon  finds  its  way  into  the  intestine  again  ;  if,  on  the  other 
hand,  this  is  impossible,  a  biliary  fistula  is  left  which  may  be  dealt  with  later  on. 

Cholecystectomy,  or  removal  of  the  whole  gall-bladder,  is  a  more  serious  oper- 
ation, and  should  only  be  practiced  when,  from  the  condition  of  the  parts  at  the 
time  of  the  operation,  it  is  clear  that  incision  and  drainage  either  are  impracticable 
or  would  fail  to  give  relief.  Sometimes  this  occurs  after  prolonged  inflammation  ; 
the  gall-bladder  is  so  utterly  disorganized  that  it  is  not  possible  to  suture  it  securely 
to  the  abdominal  wound  ;  and  it  may  happen  in  cases  of  impacted  calculus,  if  it  is 
not  possible  to  extract  or  crush  the  stone  without  injuring  the  wall  of  the  duct. 
The  preliminary  steps  are  the  same ;  the  gall-bladder  must  be  separated  from 
adhesions,  all  hemorrhage  carefully  stopped,  the  peritoneal  flaps  united  with  a  con- 
tinuous suture,  and  the  end  of  the  cystic  duct  tied. 

Surgical  Diseases  of  the  Pancreas. 

Large  cysts,  associated  with  obstruction  of  the  main  duct,  are  practically  the 
only  form  of  disease  of  the  pancreas  that  comes  within  reach  of  the  surgeon.  They 
project  forward,  either  beneath  the  right  lobe  of  the  liver  or  in  the  left  hypochon- 
drium,  pushing  the  stomach  to  the  right,  the  spleen  to  the  left,  and  the  transverse 
colon  downward.  In  some  cases  fluctuation  is  very  plain  ;  in  others  there  is  com- 
municated pulsation  from  the  abdominal  aorta,  or  the  tumor  moves  up  and  down 
with  respiration. 

General  emaciation  is  not  uncommon  ;  as  it  occurs  even  with  small  cysts  it 
has  been  suggested  that  it  maybe  due  to  interference  with  the  solar  plexus.  There 
may  be  a  sense  of  oppression  or  paroxysmal  attacks  of  pain,  deep  between  the  ensi- 
form  cartilage  and  the  navel,  with  a  feeling  of  intense  anxiety.  Undigested  muscu- 
lar fibre  may  be  present  in  the  stools  ;  vomiting  is  not  unfrequent :  the  bowels  are 
often  very  irregular,  and  sometimes  at  least  the  complexion  becomes  peculiarly 
earthy.  The  diagnosis  can  only  be  verified  by  aspiration.  The  fluid  may  be  dark 
brown  and  turbid,  like  pea-soup,  or  the  contents  may  be  clear,  or  they  may  be 
mixed  with  pus  or  blood.  In  several  cases  the  presence  of  similar  ferments  to  those 
of  the  pancreatic  juice  has  been  ascertained  by  experiment.  Hydatids  of  the  liver 
and  other  organs,  ovarian,  mesenteric,  omental,  and  renal  cysts,  dropsy  of  the 
omental  bursa,  and  distention  of  the  gall-bladder,  closely  resemble  it,  and,  in  many 
cases,  have  only  been  distinguished  at  the  time  of  operation. 

Extirpation  may  be  practicable  occasionally ;  in  most  instances,  incision  and 
drainage  are  to  be  preferred.  The  openings  should  be  made  over  the  most  promi- 
nent portion  of  the  tumor,  the  contents  partially  removed  by  aspiration,  and  the 
cyst  drawn  out  and  secured  by  sutures  to  the  parietal  peritoneum  and  the  skin.  If 
the  discharge  irritates  the  skin,  boracic  acid  dressings  should  be  used. 


MALFORMATIONS  OF  THE   RECTUM  AND  ANUS.         955 


CHAPTER  XIX. 

INJURIES  AND  DISEASES  OF  THE  RECTUM. 
MALKnRMATIONS    OF    THE    ReCTUM    AND    AnUS. 

Of  these  there  are  two  chief  varieties. 

In  tlie  first  the  original  cloacal  outlet  persists  to  a  greater  or  less  extent,  and 
the  bowel  terminates  in  the  bladder,  vagina,  or  urethra. 

In  the  second  the  communication  with  the  genito-urinary  organs  is  shut  off, 
but  the  rectum  does  not  open  upon  the  surface  ;  like  the  former,  this  is  due  to  an 
arrest  of  development.  The  intestine  is  formed  from  the  innermost  of  the  germ- 
inal layers  ;  at  either  end  it  terminates  blindly,  the  anus  as  well  as  the  mouth  being 
developed  by  an  invagination  from  the  exterior.  Consequently  three  degrees  of 
defect  are  possible  :  the  anus  may  be  wanting,  and  the  rectum  well  formed  (the 
most  common)  ;  the  anus  may  be  well  formed  and  the  rectum  wanting  (the  most 
serious)  ;  or,  finally,  both  may  be  present,  but  the  septum  between  them  persist, 
either  as  a  definite  membrane  or  as  a  mere  epithelial  layer. 

Besides  these,  in  exceptional  cases,  the  orifice  of  the  anus  may  be  very  small, 
and  displaced,  either  forward,  or  to  one  side,  apparently  by  a  growth  prolonged 
forward  from  the  coccyx  in  the  middle  line  of  the  perineum. 

The  diagnosis  is  usually  apparent  at  once.  If,  however,  a  distinct  anal 
diverticulum  is  present,  the  malformation  of  the  rectum  may  be  overlooked  until 
suspicion  is  aroused  by  distention,  persistent  vomiting,  and  the  absence  of  meco- 
nium. The  condition,  if  unrelieved,  is  nearly  always  fatal  within  a  few  days  ;  a 
few  cases  have  lived  for  some  time,  even  years,  with  regular  fajcal  vomiting.  An 
exception  may  be  made  in  the  case  of  a  vaginal  opening,  as  this  may  not  be  dis- 
covered until  adult  life.  If  there  is  a  communication  with  the  urinary  passages, 
death  is  usually  caused  by  cystitis  and  pyelonephritis. 

Treatment. — The  child  must  be  held  in  the  lithotomy  position  (especial 
care  is  required  to  keep  it  straight),  a  catheter  is  passed  into  the  bladder  or  vagina, 
according  to  the  sex,  and  a  thorough  examination  made. 

In  the  slighter  cases  the  bulging  caused  by  the  rectum  when  the  child  cries  and 
the  dark  color  of  the  meconium  are  visible  at  once,  and  all  that  is  required  is  to 
tear  through  or  divide  a  thin  partition,  leaving  a  little  oiled  lint  in  the  opening  as 
soon  as  the  bowel  has  emptied  itself. 

In  most,  however,  either  from  the  anus  being  absent,  or  from  the  thickness  of 
the  tissues  between  it  and  the  bowel,  a  median  incision  must  be  made  through  the 
skin  from  the  site  of  the  anus  to  the  tip  of  the  coccyx,  and  the  dissection  carried 
backward,  guided  by  the  catheter  in  front  and  the  bone  behind.  If  the  bowel  is 
near  the  surface  it  may  be  drawn  down  and  sutured  to  the  margin  ;  but  this  is 
valueless  if  there  is  much  tension.  In  this  case  a  stricture  is  almost  sure  to  follow 
unless  special  precautions  are  taken,  a  catheter  or  the  tip  of  the  finger  being  intro- 
duced at  first  every  day.     After  a  time  the  tendency  to  contract  appears  to  diminish. 

If  the  rectum  is  not  exposed  in  this  w^ay,  firm  pressure  should  be  made  upon 
the  abdomen,  while  the  finger  is  in  the  perineal  wound  ;  sometimes  the  end  can  be 
felt,  or  the  bulging  is  so  plain  that  there  is  reason  to  believe  it  is  not  far  off,  and 
then  the  dissection  may  be  continued  along  the  sacrum  until  the  peritoneum  is 
reached,  the  coccyx  being  resected  if  necessary.  When  this  does  not  succeed,  the 
choice  lies  between  inguinal  and  lumbar  colotomy,  preference  being  generally  given 
to  the  former,  not  only  on  account  of  the  more  convenient  situation  of  the  anus, 
but  because  when  the  lower  part  of  the  rectum  is  not  developed,  the  rest  of  the 
large  intestine  is  very  likely  to  be  displaced  and  inaccessible  from  behind. 


956    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Opening  the  peritoneal  cavity  through  the  perineum  has  been  advocated,  on 
the  ground  that  it  saves  the  risk  of  a  double  operation,  and  that  as  the  external 
sphincter  is  usually  present  in  these  cases,  the  inconvenience  of  incontinence 
would  be  avoided  ;  but  the  difficulty  of  recognizing  the  character  of  the  intestine 
at  such  a  depth  is  very  great,  and  the  power  of  selection  very  small. 

When  there  is  a  communication  with  the  vagina  a  bent  jjrobe  may  be  passed 
through  it  into  the  rectum  as  a  guide  ;  but  it  rarely  happens  that  the  opening  is  on 
the  side  of  the  bowel,  with  a  blind  pouch  running  beyond  ;  nearly  always  it  lies 
at  the  end.  In  this  case,  and  also  when  the  rectum  communicates  with  the  urinary 
passages,  an  anus  must  be  formed,  if  possible  in  the  natural  situation,  and  the  com- 
munication closed  by  a  subsequent  operation. 

Examination  of  the  Rectum. 

In  many  cases  it  is  advisable  to  give  an  injection  beforehand,  so  as  to  bring 
down  the  upper  part  of  the  bowel.  The  patient  should  lie  well  over  on  the  left 
side  with  the  hips  and  knees  flexed,  and  the  back  to  the  light.  The  character  of 
the  skin  and  of  the  orifice  of  the  anus  is  noted  first,  whether  there  is  any  discolora- 
tion, swelling,  or  abnormal  opening.  Then  gentle  pressure  is  made  all  round  to 
ascertain  if  there  is  any  induration  or  fluctuation,  or  any  very  tender  spot,  espe- 
cially near  the  margin. 

The  mucous  surface  of  the  orifice  is  then  inspected.  The  fingers  are  placed 
upon  the  buttocks,  and,  with  the  thumbs  quite  close  to  the  anus,  the  sides  are  firmly 
separated  while  the  patient  strains  down.  Small  ulcers  and  fissures  at  the  margin, 
polypi,  and  internal  piles  can  often  be  seen  at  once. 

The  finger  is  then  introduced,  well  oiled,  and  the  angles  of  the  nail  filled  in 
with  soap.  The  pulp  should  be  placed  over  the  orifice  and  the  patient  told  to  bear 
down  ;  as  the  muscles  relax  they  carry  it  in  with  them.  If  there  is  any  evidence 
of  fissure  slight  pressure  should  be  made  toward  the  opposite  margin. 

Except  in  the  case  of  polypi,  the  marginal  part  of  the  mucous  membrane  is 
always  examined  first  ;  painful  ulcers,  the  orifices  of  fistulae,  and  the  like,  are  in 
the  majority  of  instances  within  an  inch  of  the  edge.  Then  the  investigation  is 
carried  higher,  the  character  of  the  surface  ascertained,  and,  by  deeper  pressure, 
the  condition  of  the  neighboring  organs.  By  making  the  patient  bear  down, 
especially  if  he  is  standing,  an  inch  or  more  of  the  rectum  can  be  brought  down 
on  to  the  fingers  :  but  in  cases  in  which  the  disease  is  situated  high  up,  or  there  is 
a  difficulty  of  diagnosis,  it  is  advisable  to  give  an  anaesthetic.  When  the  muscles 
of  the  floor  of  the  pelvis  are  well  relaxed,  the  perineum  can  be  pushed  in  in  front 
of  the  knuckles,  and  the  finger  can  generally  reach  the  promontory  of  the  sacrum. 
If  this  fail,  further  examination  may  be  carried  out  with  the  speculum,  the  long 
tube,  or  the  hand. 

The  most  convenient  form  of  speculum  is  a  short  conical  metal  tube,  open  at 
the  end  and  on  one  side  ;  but  thii,  of  course,  only  exposes  the  part  immediately 
inside  the  anus.  If  it  is  wished  to  inspect  the  deeper  portion  the  patient  must  be 
placed  under  an  anaesthetic,  in  the  lithotomy  position,  with  the  jjelvis  well  raised 
so  that  the  intestines  may  sink  toward  the  diaphragm,  and  the  sphincter  be  dilated. 
Metal  tubes,  then,  of  various  sizes,  may  be  very  carefully  introduced,  the  mucous 
membrane  being  lifted  from  off  the  opening  from  time  to  time  with  a  sponge  on  a 
holder. 

Rectal  bougies  as  a  means  for  diagnosis  are  dangerous  and  misleading.  They 
nearly  always  catch,  either  against  the  sacrum  or  behind  some  fold  of  mucous  mem- 
brane, and  very  often  give  rise  to  the  suspicion  of  a  stricture  where  none  exists. 
Enema  tubes  are  a  little  better,  as  by  injecting  fluid  through  them  the  mucous 
membrane  may  be  lifted  off  from  the  end  out  of  the  way.  Sometimes  then  the 
tube  can  be  passed  a  few  inches  further,  proving  that  there  is  no  stricture ;  but,  if 
it  cannot,  no  conclusion  can  be  drawn. 

Finally,  the  hand,  provided  it  is  under  seven  inches  in  circumference,  can  be 


HEMORRHOTDS.  957 

introduced  in  most  wcU-fornied  adults.  I'he  patient  must  be  under  an  anaesthetic  ; 
the  sphincter  very  gradually  dilated  ;  and  then  the  fingers  slowly  wormed  in  with 
a  screwing  action  until  the  broader  part  sli|)s  inside.  (Jil  or  vaseline  should  be 
freely  used.  1  have  on  several  occasions  done  this  myself,  and  have  found  it  once 
or  twice  of  very  great  use  in  diagnosis.  The  proceeding  is  not  without  danger  ; 
there  are  several  cases  on  record  in  which  sudden  death  occurred,  ])rol)abIy  from 
rupture  of  the  peritoneal  band  that  surrounds  the  bowel.  This  can  be  felt  like  a 
cord  passing  across  it  obliiiuely,  about  four  inches  up,  and  it  must  on  no  account 


Fig.  410. — Allingh.-im's  Rectal  Speculum. 

be  forced.     The  sphincter,  of  course,  loses  its  power  for  some  days,  but  I  have 
never  found  any  permanent  paralysis  follow. 

If  the  hand  cannot  be  introduced,  owing  to  the  peritoneal  fold,  a  combination 
of  these  two  methods  is  very  useful,  the  long  enema  tube  being  passed  up  the  pal- 
mar surface,  and  guided  by  the  fingers  into  the  smooth  tubular  portion  above. 

Injuries  of  the  Rectum. 

Lacerations  of  the  margins  of  the  anus  are  occasionally  caused  by  the  passage 
of  hardened  faeces,  or  by  the  rough  use  of  enema  tubes,  and  sometimes  they  degene- 
rate into  very  painful  ulcers.  The  anus,  too,  may  be  torn  in  parturition,  the  pe- 
rineum giving  way  completely. 

Foreign  bodies  of  all  sorts  occur  from  time  to  time,  some,  such  as  fish  bones, 
enteroliths,  gall-stones,  and  other  foreign  bodies,  coming  down  from  the  bowel, 
others  introduced  from  below  ;  and  it  may  require  very  great  ingenuity  to  extract 
them  without  inflicting  serious  injury. 

Hemorrhoids. 

The  veins  that  surround  the  lower  part  of  the  rectum  are  exceedingly  liable 
to  become  distended  and  varicose.  Sometimes  they  remain  in  this  condition  ; 
more  frequently,  owing  to  the  congestion  and  oedema,  and  from  the  constant  irri- 
tation to  which  they  are  subjected,  the  cellular  tissue  around  becomes  inflamed  ; 
the  lymph  that  is  poured  out  becomes  organized,  and  at  length  distinct  tumors, 
known  as  hemorrhoids,  are  formed.  These  maybe  classed  as  external,  internal,  or 
intermediate,  according  to  their  situation  under  the  skin,  under  the  mucous  mem- 
brane, or  partly  under  the  one,  partly  under  the  other. 

Their  frequency  is  due  to  the  structure  of  the  part.  The  hemorrhoidal  plexus 
lies  under  the  mucous  membrane,  inside  the  margin  of  the  anus,  and  a  short  dis- 
tance up  the  bowel.  The  blood  from  this  returns  partly  by  the  superior  hemor- 
rhoidal veins,  which  commence  close  to  the  edge,  and  run  up  in  the  sub-mucous 
layer  before  piercing  the  muscular  coat ;  partly  by  the  middle  and  inferior  ones. 


958    DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 

which  end  at  length  in  the  internal  iliac.  Of  these  the  first  are  by  far  the  most 
important  ;  the  others  merely  drain  the  anal  margin  and  the  region  of  the  external 
sphincter  ;  and  the  communicaticJa  between  the  two  is  so  poorly  developed  that  it 
is  of  little  use  in  affording  relief ;  an  injection  thrown  into  the  hemorrhoidal  i)lexus 
through  the  inferior  mesenteric  does  not  pass  on  into  the  iliac  veins.  This  plexus, 
therefore,  lies  at  the  root  of  the  valveless  portal  system,  and  feels  the  strain  first 
and  most  severely  when  anything  impedes  the  flow  of  blood  upward  through  the 
abdomen  and  liver. 

Another  point  is  that  while  the  veins  of  the  rest  of  the  abdomen  are  sup- 
l)orted  by  the  walls,  and  jjrevented  from  becoming  distended  when  the  muscles  of 
the  abdomen  contract,  the  hemorrhoidal  plexus  is  entirely  unprotected,  and, 
owing  to  the  peculiar  laxity  of  the  tissue  in  which  it  lies,  is  quite  incapable  of 
resisting  the  increased  blood-pressure.  Straining  or  bearing  down,  if  there  is  the 
least  dilatation,  makes  the  veins  swell  out  at  once,  and  the  mucous  membrane 
becomes  ])uri)le.  This,  of  course,  subsides  again  as  the  muscles  relax,  but  it  can 
easily  be  understood  how  the  frequent  repetition  slowly  but  surely  makes  the  dila- 
tation worse  and  worse. 

Verneuil  attributes  much  imijortance  to  the  su]:)erior  hemorrhoidal  veins  pass- 
ing through  valvular  openings  in  the  muscular  wall  of  the  bowel  a  short  distance 
above  the  anus,  believing  that  the  contraction  tends  to  constrict  them  and  check 
the  flow.  If,  however,  this  were  the  case,  it  would  easily  relieve  them  from  the 
backward  pressure  of  the  blood  higher  up  in  the  portal  system. 

The  exciting  causes  are  of  the  most  varied  description.  Every  impediment 
to  the  return  of  the  blood  helps  :  valvular  disease  of  the  heart  ;  chronic  bronchitis 
and  emphysema  ;  cirrhosis  of  the  liver  ;  abdominal  tumors  ;  pregnancy;  accumu- 
lation of  fKces  ;  everything,  in  short,  that  directly  or  indirectly  checks  the  return 
circulation. 

Constant  straining,  whether  arising  from  constipation  or  from  causes  con- 
nected with  the  urinary  tract,  calculus,  stricture,  or  enlarged  prostate,  acts  in  the 
same  way,  perhaps  more  rapidly. 

Active  congestion,  such  as  arises  from  the  repeated  use  of  unsuitable  purga- 
tives, over-indulgence  in  alcohol,  sexual  excesses,  and,  in  women,  from  uterine 
or  ovarian  affections,  often  brings  them  on.  Still  more  frequently  it  precipitates 
an  acute  attack,  and  is  the  immediate  cause  of  the  patient  applying  for  relief. 

Whether  hereditary  influence  has  any  effect  of  itself,  as  distinct  from  that 
which  is  due  to  the  same  habits  and  the  same  mode  of  life,  is  very  doubtful.  Few 
people  attain  old  age  without  some  enlargement  of  the  hemorrhoidal  veins  ;  this 
is  the  natural  result  of  the  anatomy  of  the  part.  In  the  majority  of  cases,  unless 
there  is  some  additional  reason,  causing  hyperoemia  for  some  considerable  time, 
and  leading  either  to  inflammation  or  to  chronic  congestion  and  oedema,  the  con- 
sequences are  not  sufficiently  serious  to  make  them  apply  for  relief. 

External  hemorrhoids  differ  from  internal  ones  in  so  many  respects  that  it  is 
advisable  to  deal  with  them  separately.  There  is  rarely  any  difficulty  in  distin- 
guishing one  from  the  other.  The  former  are  covered  with  skin,  and,  unless  there 
is  a  large  throml)us  in  some  superficial  vein,  are  some  shade  of  pink,  according  to 
the  pigmentation  present  and  the  degree  of  inflammation.  Moreover  they  cannot 
be  returned  into  the  bowel  by  pressure.  The  latter  are  covered  with  mucous 
membrane  ;  their  surface  is  soft  and  smooth,  and  their  color  bright  red  or  purple. 
If  they  have  been  prolapsed  for  some  time  they  become  dry  and  rough  ;  but  they 
can  always  be  returned  as  soon  as  the  sphincter  is  relaxed. 

Intermediate  ones,  partly  subcutaneous,  partly  submucous,  with  the  white 
line  that  marks  the  junction  of  the  two  surfaces  passing  over  them,  are  very  com- 
mon.     Clinicallv  thev  resemble  internal  ones  in  most  of  their  features. 


EXTERNAL   AND   INTERNAL   ILEMORRHOIDS.  959 

External  Hk.mourhoids. 

These  liegin  as  dilated  veins  around  the  margin  of  the  anus  and  form  soft, 
livid  swellings  which  disajjpear  on  pressure  and  grow  firm  and  hard  when  the 
patient  strains.  As  such  they  may  last  for  an  indefmite  time  without  the  least 
inconvenience.  Sooner  or  later,  however,  chronic  congestion  and  (jedema  set  in  ; 
lymph  is  poured  into  the  cellular  tis.sue  ;  the  veins  are  obstructed  ;  and  then,  as 
the  exudation  becomes  organized,  the  skin  grows  out  into  thickened,  irregular 
folds,  which,  when  once  developed,  are  permanent.  These  are  sometimes  called 
cutaneous  piles. 

When  these  are  irritated  or  become  inflamed,  all  the  symptoms  are  aggra- 
vated. In  some  cases  the  central  vein  is  plugged  with  a  thrombus  ;  and  a  hard 
and  tender  knot,  dark  i)urple  in  color,  forms  in  the  centre  of  the  pile.  In  others 
the  cellular  tissue  is  chiefly  concerned  ;  the  pile  becomes  many  times  its  former 
size  ;  and  the  skin  over  it  grows  tense  and  pale  from  the  amount  of  fluid  it  con- 
tains. Very  often,  just  inside  the  anus,  at  the  base  of  the  pile,  there  is  a  small 
crack  or  abrasion  from  which  the  inflammation  starts.  In  severe  cases  the  whole 
circumference  is  involved,  so  that  the  opening  seems  buried  in  the  centre  of  a 
swollen  ring.  When  the  vein  is  primarily  affected  the  pile  is  sometimes  called 
thrombotic  ;  when  it  is  chiefly  the  skin  and  cellular  tissue,  Kciematous ;  but  in  many 
instances  it  is  impossible  todistinguish  them. 

Symptoms. — In  the  slighter  cases  there  is  merely  a  sense  of  heat  and  irrita- 
tion about  the  anus,  with  itching,  especially  at  night.  Defecation  is  attended 
with  a  certain  amount  of  pain,  and  there  is  rather  a  tendency  to  strain  ;  but,  so 
long  as  the  bowels  are  moderately  relaxed,  there  is  little  more  than  discomfort  in 
the  intervals  between  the  motions.  When  the  inflammation  is  severe,  the  paiYi 
may  be  intense,  especially  if  the  part  is  touched,  and  when  the  bowels  are  acting ; 
in  some  cases  it  is  almost  as  bad  as  in  fissure,  though  it  rarely  lasts  so  long.  The 
throbbing  is  constant;  there  is  a  persistent  sense  of  fullness;  the  sphincter  is  in 
a  state  of  spasmodic  contraction  ;  and,  if  the  bowels  are  confined,  the  straining 
and  tenesmus  scarcely  cease.  Sometimes  the  constitutional  disturbance  is  very 
severe,  and  in  nervous,  excitable  people,  there  may  be  a  high  degree  of  fever. 
Suppuration  is  not  uncom<mon,  and  though  the  abscesses  are  superficial,  and  break 
soon,  they  may  leave  troublesome  fistula  behind  them. 

Treatment. — If  the  case  is  seen  before  the  inflammation  is  severe,  the  symp- 
toms are  easily  relieved.  The  patient  must  remain  quiet,  as  much  as  possible  in 
the  recumbent  position  ;  walking  is  painful  and  very  injurious  ;  the  diet  must  be 
restricted  ;  no  stimulants  or  highly  seasoned  food  allowed  ;  and  the  bowels  kept 
open  with  sulphate  of  magnesia  or  some  appropriate  mineral  water.  Small  doses 
of  calomel,  or  of  podophyllin  with  taraxacum,  may  be  given  with  advantage.  A 
warm  bath  should  be  taken  night  and  morning,  and  the  skin  around  the  anus 
should  be  kept  supple  with  a  mild  astringent  ointment,  of  calomel,  lead,  or  nitrate 
of  mercury. 

When  there  is  evidence  of  thrombosis  or  of  suppuration  more  active  treat- 
ment is  required.  If  there  is  a  small,  hard  lump,  like  a  foreign  body,  in  the 
centre  of  the  pile,  it  should  be  transfixed,  the  clot  turned  out,  and  the  vein  allowed 
to  bleed.  Afterward  it  may  be  left  to  granulate.  Large  cedematous  piles  usually 
shrink  of  themselves  as  soon  as  the  fissure  or  excoriation  on  which  they  depend  is 
healed.  Afterward,  if  thickened  folds  of  skin  are  left  around  the  anus,  they  may 
be  removed  with  scissors  curved  upon  the  flat ;  but  care  should  be  taken  not  to 
cut  them  off  at  the  base,  for  fear,  when  the  wound  heals,  that  the  contraction 
may  cause  a  stricture. 

Internal  Hemorrhoids. 

Of  these  there  are  two  chief  varieties — the  sessile  or  capillary,  and  the  venors 
or  pedunculated.      Not  unfrequently  they  occur  together,  and  probably  they  are 


96o    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

really  due  to  the  same  cause ;   but  there  is  sufficient  difference  in  their  symptoms 
and  treatment  to  warrant  a  separate  description. 

I.    Capillary  Hemorrhoids. 

These  scarcely  project  above  the  surface ;  they  are  never  extruded  from  the 
anus  unless  dragged  down  by  pedunculated  ones  ;  and  the  veins  are  not  much 
dilated.  The  capillaries  and  minute  blood-vessels  are  chiefly  involved  ;  the  sub- 
mucous tissue  is  a  little  thickened  ;  the  epithelium  is  thinned  and  detached  in 
places  ;  while  the  mucous  membrane  is  converted  into  a  soft,  spongy  network  of 
dilated  vessels,  so  that  it  stands  out  from  the  smooth,  even  surface  around  like  a 
bright  red  patch  of  florid  granulations,  which  bleed  at  the  slightest  touch.  It 
has  been  compared  in  appearance  to  a  raspberry. 

2.   Venous  Hemorrhoids. 

These,  like  external  ones,  are  at  the  first  merely  varicose  veins.  If  the  finger 
is  introduced  into  the  rectum,  all  that  can  be  felt  is  a  soft,  smooth  swelling  under 
the  mucous  membrane,  which  disappears  with  the  least  pressure,  and  grows  rather 
more  'firm  when  the  patient  strains.  In  many  cases  it  is  more  easy  to  see  than  to 
feel  them ;  if  the  rectum  is  washed  out  with  a  warm  injection  and  the  patient  is 
directed  to  strain,  as  the  mucous  membrane  becomes  everted,  the  veins  gradually 
swell  up  and  stand  out  like  lobulated  bluish  masses.  After  a  time,  if  the  conges- 
tion continues  and  becomes  chronic,  the  tissue  around  them  becomes  thickened  ; 
they  grow  firmer  and  more  solid  ;  a  sense  of  resistance  is  experienced  by  the  finger  ; 
they  stand  distinctly  above  the  surface,  and  no  longer  disappear  when  touched  ; 
afid  at  length  they  develop  into  definite  tumors. 

As  soon  as  this  occurs,  owing  to  the  constant  irritation  to  which  they  are  ex- 
posed, the  mucous  membrane  over  them  becomes  thinned  and  ulcerated.  Inflam- 
mation sets  in  ;  lymph  is  poured  out ;  the  neighboring  blood-vessels,  arteries  as 
well  as  veins,  dilate ;  and  at  length,  as  the  exudation  becomes  organized,  fibrous 
tumors  are  formed,  springing  from  the  submucous  layer,  filled  with  varicose  veins, 
and  not  unfrequently  containing  arteries  of  considerable  size,  which  they  have 
dragged  down  with  them.  In  many  instances  there  are  three  or  four  of  these,  well 
inside  the  anus,  some  still  sessile,  others  pedunculated,  and  hanging  by  stalks  of 
various  sizes. 

The  mucous  membrane  covering  them  does  not  long  retain  its  smooth  and 
soft  appearance.  Very  often  it  becomes  affected  by  the  continued  irritation  ; 
sometimes  it  is  roughened  and  covered  with  florid  granulations,  as  in  capillary 
piles ;  more  often  it  is  thinned  and  ulcerated,  so  that  the  deeper  tissues,  perhaps 
the  veins  themselves,  are  exposed  ;  here  and  there  along  the  under  surface  it  grows 
thick  and  dense.  In  older  cases,  in  which  the  piles  protrude  from  the  anus,  it 
becomes  changed  beyond  recognition.  Where  they  only  descend  at  long  intervals, 
and  return  easily  of  themselves,  the  surface  may  still  be  bright  and  smooth,  though 
deeply  congested  ;  but  if  they  protrude  frequently  it  is  sure  to  become  inflamed 
and  ulcerated,  or  converted  by  the  continued  friction  into  a  dry,  hard  substance, 
almost  like  leather.  When  in  this  condition  it  is  not  always  easy  to  distinguish  it 
from  skin. 

Piles  that  protrude  are  always  in  danger  of  being  caught  and  held,  so  that  it 
is  difficult  to  return  them.  The  sphincter  is  in  a  state  of  painful  spasm  ;  tbe  neck 
of  the  pile  is  tightly  constricted  ;  congestion  and  strangulation  follow  ;  and  unless 
it  is  soon  released  the  protruding  part  may  become  gangrenous.  A  large  inflamed 
purple  mass  projects  from  the  anus,  surrounded  l)y  a  broad  band  of  everted 
muscle  and  mucous  membrane.  The  skin  all  round  is  inflamed  ;  the  surface  of 
the  pile  is  greenish-black  in  color  ;  the  mucous  membrane  sloughs  ;  and  some- 
times the  whole  mass  perishes  and  is  cast  off.  Occasionally  a  natural  cure  is 
effected  in  this  way  ;  much  more  often  part  only  is  lost,  and  the  rest  is  retracted 
inside  the  anus. 


INTERNAL  HEMORRHOIDS.  961 

Symptoms. — The  only  direct  syiuptoni  of  sessile  piles  is  hemorrhage,  Ijut 
this  may  l)c  so  profuse  and  so  constant,  and  recurring  on  every  occasion  when  the 
bowels  act,  that  the  patient  becomes  absolutely  blanched.  There  is  no  protrusion 
or  pain  unless  the  vascular  patch  is  near  the  orifice. 

In  \\\Q.  pedunculated  ioxxw  bleeding  is  less  constant  and  the  amount  more  vari- 
able. At  first  there  is  merely  a  stain  ;  later  the  blood  may  drip  for  a  few  minutes 
after  every  action  of  the  bowels  ;  occasionally  it  is  profuse  and  comes  in  jets 
through  a  small  opening  in  the  wall  of  a  vein,  the  sijasmodic  contraction  of  the 
muscles  making  it  shoot  out  as  if  an  artery  had  been  divided. 

At  first  the  piles  return  into  the  bowel  at  once,  either  of  themselves  or  when 
the  patient  lies  down,  with  an  immediate  sense  of  relief.  In  a  little  while,  how- 
ever, it  requires  pressure  to  get  them  back  ;  there  is  a  deep  throbbing  pain,  extend- 
ing up  the  back  and  down  the  thighs;  the  sphincter  is  in  a  state  of  spasmodic 
contraction,  the  rectum  feels  as  if  it  were  distended  to  its  utmost,  and  every 
attempt  at  procuring  relief  only  makes  the  condition  worse  by  the  straining  that 
accompanies  it.  Even  when  they  are  replaced  it  is  some  time  before  the  patient  is 
comfortable  again.  Sometimes,  in  these  cases,  they  become  strangulated  and 
slough  ;  the  symptoms  grow  more  and  more  severe  ;  the  parts  around  the  anus  are 
acutely  inflamed,  the  inguinal  glands  enlarge,  there  is  a  very  considerable  degree  of 
fever,  and  then,  after  the  slough  has  separated,  the  inflammation  gradually  sub- 
sides. Sometimes,  on  the  other  hand,  the  sphincter  loses  its  power  and  becomes 
relaxed  ;  the  severity  of  the  symptoms  diminishes,  but  the  piles  are  constantly 
down.  They  descend  on  the  least  exertion,  and  at  the  most  inconvenient  times  ; 
there  is  a  constant  and  most  annoying  discharge  of  mucus  ;  the  skin  around  the 
anus  becomes  sore  and  covered  with  vegetations  ;  the  mucous  membrane  at  length 
becomes  prolapsed  as  well ;  and  in  cases  of  long  standing,  there  may  be  total  in- 
ability to  retain  loose  dejecta,  or  flatus. 

Diagnosis. — External  piles  present  no  difficulty  ;  condylomata,  vegetations, 
cancerous  nodules,  and  other  growths  around  the  anus  can  be  distinguished  at  once. 
Internal  piles,  at  the  first  commencement,  when  there  is  nothing  but  a  varicose 
condition  of  the  veins,  may  escape  notice  unless  digital  examination  is  carefully 
conducted  ;  the  soft  loose  folds  of  mucous  membrane  are  emptied  with  the  least 
pressure  and  disappear ;  but  if  the  patient  is  desired  to  strain,  or  if  the  mucous 
membrane  is  gently  everted  after  a  warm  injection,  there  can  be  no  mistake. 
Later,  when  they  protrude,  it  is  sometimes  difficult  to  distinguish  them  from  pro- 
lapse of  the  mucous  membrane,  with  which  they  are  often  associated  ;  in  the  one, 
however,  the  protrusion  is  irregular  in  shape,  and  covered  over  with  bosses  ;  in  the 
other  it  is  smooth  and  uniform. 

In  all  cases  of  hemorrhoids,  external  as  well  as  internal,  it  is  very  essential 
that  a  thorough  examination  should  be  made,  not  only  of  the  rectum,  but  also  of 
the  neighboring  organs ;  otherwise  the  cause  may  be  overlooked  while  a  symptom 
is  being  treated. 

Treatment. — i.  Palliative. — In  the  early  stage  this  may  be  efficient  of 
itself;  in  the  later,  and  after  operations,  it  is  no  less  essential  to  prevent  piles 
already  present  becoming  worse  and  others  forming. 

Diet  demands  the  greatest  care.  Meals  should  be  as  sparing  as  consistent 
with  health  ;  all  highly  seasoned  dishes,  and  alcohol,  especially  beer  and  heavy 
wines,  strictly  prohibited,  and  the  allowance  of  meat  limited.  A  fair  amount  of 
exercise  must  be  taken,  but  long  railway  journeys  should  be  avoided.  The  bowels 
must  be  made  to  act  regularly  every  day,  and  the  motions  kept  as  soft  as  possible. 
Confection  of  senna,  saline  water,  compound  liquorice  powder,  or  other  laxatives 
may  be  taken  the  first  thing  in  the  morning.  After  each  motion  the  rectum  should 
be  washed  out  with  cold  water,  or  with  a  weak  astringent,  to  constrict  the  walls  of 
the  vessels.  If  the  piles  protrude  they  may  be  smeared  over  with  an  ointment  of 
sulphate  of  iron  or  some  other  mild  astringent  before  returning  them.  If  they  do 
not,  a  similar  preparation,  or  the  ointment  of  galls  and  opium,  may  be  introduced 
either  as  a  suppository,  or  with  one  of   the  special  instruments  devised  for  the 


962    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

purpose.  Bleeding,  when  it  comes  from  a  capillary  pile,  may  be  checked  in  the 
same  way ;  but  if  it  persist  a  more  efficient  application  is  desirable.  In  all  cases 
careful  inquiry  should  be  made  that  there  is  no  latent  cause  at  work,  especially 
connected  with  the  urinary  organs  in  men,  and  the  uterus  and  ovaries  in  women. 

2.  RaiUcal. — If  the  hemorrhage  persists  or  is  severe,  even  for  a  short  time  ; 
if  the  piles  are  large  and  fibrous,  so  that  they  form  distinct  and  solid  tumors,  or  if 
they  are  constantly  descending,  or  constantly  giving  rise  to  pain  and  inflammation, 
something  further  is  recpiired. 

Inflamed  and  prolapsed  piles  may  be  returned  and  the  sphincter  dilated, 
operation  being  postponed  until  the  sloughs  have  separated  ;  but  in  most  cases 
there  is  no  reason  why  they  should  not  be  dealt  with  at  once. 

Operations  should  not  be  performed  during  pregnancy  or  shortly  after  partu- 
rition, an  exception  being  made  in  the  event  of  hemorrhage  ;  nor  should  anything 
be  done  if  there  is  a  definite  local  cause,  such  as  displacement  of  the  uterus,  stric- 
ture of  the  rectum,  carcinoma,  enlargement  of  the  prostate,  or  other  affections  of 
the  urinary  organs.  These  must  first  be  relieved  ;  then,  if  the  piles  persist,  some- 
thing may  be  done  for  them;  otherwise  healing  is  delayed,  and  rapid  recurrence 
is  sure  to  take  place. 

A  great  variety  of  operations  have  been  devised  for  internal  hemorrhoids  ;  some 
of  them  have  been  "  invented  "  over  and  over  again,  but  many  are  only  used  in 
special  ca.ses.  For  all  alike  the  patient  requires  preparation.  The  large  intestine 
must  be  emptied,  and  the  bowels  made  to  act  freely  before  the  operation.  As  a 
rule,  it  is  sufficient  to  give  a  dose  of  castor  oil  the  night  before,  and  an  injection 
the  morning  of  the  operation  ;  but  if  the  patient  has  been  living  freely,  and  the 
liver  is  congested,  small  doses  of  calomel  or  blue  pill,  followed  up  with  some 
aperient  mineral  water  in  the  morning,  may  be  given  for  several  days  previously. 
An  ancesthetic  is  necessary  in  all  but  the  most  trivial  cases  (in  which  cocaine 
suffices)  and  where  carbolic  acid  is  injected.  Generally,  it  must  be  given  freely, 
as  the  anus  retains  its  sensitiveness  longer  than  almost  any  other  part  of  the  body. 

For  all  but  Whitehead's  operation,  for  which  the  lithotomy  position  is  prefer- 
able, the  patient  should  lie  upon  his  side,  with  the  back  to  the  light  and  the  knees 
well  drawn  up  ;  and  the  table  should  be  of  a  convenient  height.  The  upper  buttock 
is  raised  by  an  assistant,  who  also  prevents  the  legs  being  straightened  out. 

I .   Di/atation. 

Simple  dilatation  may  prove  an  effectual  cure  when  the  piles  are  recent,  especi- 
ally if  there  is  much  spasm  or  hypertrophy  of  the  sphincter,  such  as  is  often  com- 
bined with  ulcer  or  fissure  of  the  rectum.  In  other  cases,  in  which  a  more  serious 
measure  is  inadvisable,  it  often  gives  great  relief;  and  (unless  the  muscles  are 
relaxed  already)  it  is  always  a  most  useful  addition  to  ligature  and  other  opera- 
tions, preventing  spasmodic  contraction  afterward.  No  instrument  is  required. 
The  thumbs  are  inserted  into  the  rectum,  taking  care  to  introduce  them  sufficiently 
far  to  catch  the  whole  of  the  sphincter  ;  and  the  anus  gently  dilated,  first  in  one 
direction,  then  in  another,  until  the  contraction  is  thoroughly  overcome  and  the 
muscle  feels  soft  and  pulpy.  The  skin  is  not  torn,  but  bruising  is  generally  appar- 
ent afterward.  The  patient  should  be  kept  in  bed  for  two  or  three  days,  on  light 
diet,  and  if  there  is  much  soreness  about  the  part  a  morphia  suppository  may  be 
given  ;  but  care  must  be  taken  that  the  bowels  are  not  confined.  At  the  end  of 
that  time  he  may  be  allowed  to  sit  up,  and  it  will  be  found  that  the  veins  have 
relieved  themselves  and  to  a  great  extent  recovered  their  tone.  It  must  not  be 
forgotten,  however,  that,  if  the  original  causes  are  allowed  to  continue,  and  the 
bowels  are  not  carefully  attended  to,  the  symptoms  are  sure  to  return. 

2.   Injection  of  Carbolic  Acid 

is  of  very  limited  application.  Its  chief  merit  is  that  it  is  not  necessary  to  confine 
the  patient  to  bed  for  more  than  one  day  ;  but  it  is  very  uncertain  ;  it  may  produce 


INTERNAL   HEMORRHOIDS.  963 

too  great  an  effect  or  too  little  ;  and  as  it  is  necessary,  if  the  ])iles  are  numerous, 
to  repeat  it  again  and  again,  the  benefit  is  more  than  doubtful.  Three  or  four 
drops  of  a  strong  solution  of  carbolic  acid  (gr.  x,  ad  ^ij)  (.60  ad  32  c.c.)  are  in- 
jected with  a  hypodermic  needle  into  the  centre  of  the  jiile,  taking  care  not  to 
allow  any  to  come  in  contact  with  the  surface.  It  swells  up  immediately  and 
must  be  returned  at  once.  There  is  little  pain,  and  in  many  cases,  as  the  inflam- 
mation subsides,  the  pile  gradually  shrivels  up  and  disapj^ears.  I  have  tried  it  on 
several  occasions,  and  no  doubt  it  is  effectual  in  the  slighter  cases,  for  a  time  at 
least ;  but  it  is  not  a  radical  operation  in  any  sense  of  the  term. 

3.   Application  of  Acids. 

Sessile  piles,  when  there  is  a  bright  granular  patch  of  mucous  membrane  which 
bleeds  at  the  least  touch,  may  be  cured  in  this  way  ;  for  all  other  forms  it  is  useless. 
Nitric  acid  or  the  acid  nitrate  of  mercury  is  generally  used  ;  but  chromic  acid  and 
strong  carbolic  acid  have  been  recommended.  The  patient  must  be  anaesthetized  ; 
the  sphincter  stretched  and  the  patch  well  exposed  with  a  speculum.  The  surface 
is  then  dried  with  cotton-wool,  and  the  acid  painted  over  it  with  a  glass  brush, 
taking  care  that  none  comes  in  contact  with  the  skin  or  the  margin  of  the  anus. 
Any  excess  should  be  mopped  up  at  once.  A  morphia  suppository  is  introduced 
afterward  to  prevent  pain  and  spasms,  and  the  speculum  withdrawn.  A  superficial 
slough  usually  comes  away  in  the  course  of  a  few  days  without  being  noticed,  and 
the  granulating  surface  left  contracts  and  obliterates  the  deeper  part  of  the  vessels. 

4.    The  Actual  Cautery. 

This  may  be  used  in  two  ways.  In  one  the  pile  is  drawn  down,  seized  with 
a  clamp  (the  surface  of  which  is  faced  with  ivory  or  some  other  non-conducting 
substance),  and  tightly  compressed.  The  projecting  portion  is  then  cut  off;  the 
clamp  unscrewed,  and  each  point  as  it  bleeds  touched  with  the  cautery  at  a  dull 
red  heat.     As  soon  as  the  whole  surface  is  seared  the  clamp  is  removed  and  the 


Fig.  411. — Clamp  with  Parallel  Blades  for  use  with  the  Cautery. 

process  repeated  upon  another.  This  has  been  strongly  recommended,  but  it  is 
more  liable  to  secondary  hemorrhage  than  a  ligature  properly  applied  ;  and  it  is 
not  easy  to  control  the  extent  of  mucous  membrane  that  is  destroyed.  The  cica- 
trices left  by  burns  are  notoriously  prone  to  contract  and  become  rough  and  irreg- 
ular afterward.  In  the  intermediate  form  of  pile  it  certainly  should  not  be  used, 
as  the  actual  cautery  applied  to  the  skin  is  excessively  painful. 

In  the  other  method  a  pointed  iron  or  platinum  cautery  (Paquelin's  is  the 
most  convenient),  at  a  white  heat,  is  thrust  quickly  into  the  centre  of  a  pile, 
allowed  to  remain  a  second  or  two,  and  then  withdrawn.  There  is  no  hemor- 
rhage and  very  little  inflammation.  This  method  is  scarcely  applicable  to  piles 
of  any  size,  but  where  one  or  two  small  outlying  ones  are  left  after  ligature,  and 
it  is  not  considered  advisable  to  take  up  any  more  mucous  membrane,  it  answers 
very  well. 


964    DISEASES  AND  INJURES  OF  SPECIAL  STRUCTURES. 

5 .    Crushing. 

In  this  the  base  of  the  pile  is  seized  in  a  clamp,  the  edges  of  which  are 
beveled  to  prevent  cutting  through,  and  crushed  by  means  of  a  screw.  The  anus 
must  be  dilated  first;  the  pile  drawn  down,  and  the  instrument  applied  so  as  to 


Fig.  412. — Screw  Clamp  for  Crushing  Piles. 

avoid  injuring  the  skin.  The  projecting  part  is  cut  off,  and  the  clamp  unscrewed, 
after  keeping  up  the  pressure  for  at  least  two  minutes.  For  small  detached  piles 
there  is  no  doubt  this  method  is  valuable.  If  the  pressure  is  maintained  for  a 
sufficient  time  there  is  little  risk  of  hemorrhage  :  the  wounds  heal  more  quickly 
than  after  ligature  ;  and  in  most  cases  the  pain,  when  the  bowels  act  for  the  first 
time,  is  less  ;  but,  especially  in  the  case  of  broad-based  vascular  piles,  care  is 
required  to  prevent  the  mucous  membrane  being  too  much  involved. 

6.   Ligahtre. 

For  all  ordinary  cases,  ligature  is  safe  and  effectual ;  it  may  be  applied  to 
every  form  of  pedunculated  pile,  though,  as  already  mentioned,  one  or  two  varieties 
are  capable  of  being  treated  at  least  as  well  as  in  other  ways. 

The  sphincter  is  dilated  ;  the  most  prominent  pile  seized  and  drawn  down 
with  vulsellum  forceps,  and  an  incision  made  three-quarters  around  its  base  with 
a  pair  of  .sharp,  spring  scissors.  The  portion  left  is  the  mucous  membrane  that 
comes  down  from  the  bowel  on  to  its  upper  surface  ;  if  there  are  any  large  ves- 
sels, especially  arteries,  in  the  pile,  when  it  is  drawn  down  in  this  way,  they  lie 
close  beneath.  The  cut,  therefore,  runs  along  the  white  line  between  the  skin 
and  the  mucous  membrane,  or  just  above  this,  and  up  each  side  of  the  base,  par- 
allel to  the  bowel.  A  well-waxed  piece  of  whipcord  is  now  placed  at  the  bottom 
of  this  groove  and  tied  high  up,  as  tightly  as  possible.  The  first  knot  should  be 
a  double  one,  to  prevent  slipping. 

'J'wo,  or  perhaps  three  sets  of  piles  may  require  tying  in  this  way.  If  they 
are  very  large,  the  strangulated  part  may  be  cut  off.  but  care  must  be  taken  to 
leave  enough  to  prevent  the  ligature  slipping.  Any  external  or  intermediate  piles 
left  should  be  dealt  with  at  the  same  time,  or  they  are  very  liable  to  swell  up  and 
become  inflamed.  Finally,  a  morphia  suppository  is  introduced  to  prevent  strain- 
ing, and  a  T  bandage  with  a  firm  pad  placed  over  the  anus.  The  patient  should  be 
kept  in  bed  for  at  least  a  week,  on  light  diet,  and  the  bowels  prevented  from  acting 
for  four  or  five  days  ;  at  the  end  of  that  time,  if  they  do  not  move  of  themselves, 
a  full  dose  of  castor  oil  may  be  given,  or  a  compound  colocynth  pill,  followed 
next  morning  by  an  aperient  draught.  The  first  action  of  the  bowels  is  always 
painful,  and  it  is  essential  to  avoid  straining.  The  ligatures  usually  separate  and 
come  away  about  the  fifth  day,  leaving  comparatively  small  granulating  surfaces. 
[Ligatures  are  also  introduced  by  transfixion  with  an  ordinary  transfixion  needle. 
The  pile  is  first  drawn  out  with  a  tenaculum  ;  the  needle  passed  through  the  pile 
at  its  base  ;  astout,  silk  ligature  is  threaded  in  the  eye  of  the  needle,  which  is  then 
withdrawn,  carrying  with  it  the  doubled  ligature.  The  ligature  is  then  cut,  and 
the  ends  tied  at  the  base  of  the  pile.] 


INTERNAL   HEMORRHOIDS.  965 

If  all  goes  well,  the  patient  may  be  allowed  to  lie  upon  a  sofa  at  the  end  of  a 
week  or  ten  days.  'i"he  anus  should  be  sponged  with  warm  water  and  some  mild 
antiseptic  every  night  and  morning  ;  or,  as  soon  as  the  jiatient  can  sit  up,  a  warm 
hip-bath  may  be  taken  once  a  day.  If  there  is  much  inflammation  about  the  part, 
a  pad  wet  with  lead  lotion  may  be  kept  upon  it ;  or,  if  this  f;iils,  hot  fomentati(Mis 
may  be  tried.  The  wounds  generally  heal  readily,  but  the  recumljent  position  is 
essential.  A  mild  astringent  ointment  may  sometimes  be  introduced  into  the 
rectum  with  advantage,  after  the  ligatures  have  separated. 

7.    Excision  i^]\'hitchcad'' s  Opcratioti). 

The  anus  is  dilated  ;  an  incision  is  made  through  the  mucous  membrane  just 
inside  the  orifice  all  the  way  round  ;  the  sphincter  is  exposed  ;  and  the  mucous 
membrane,  with  the  attached  hemorrhoids,  is  stripped  from  the  muscles  beneath, 
until  the  whole  pile-bearing  area  is  detached,  and  can  be  brought  outside.  This 
dissection  (excejjt  above  and  below)  may  be  readily  managed  with  the  closed 
scissors,  without  any  serious  hemorrhage.  The  upper  part  should,  of  course,  be 
left  to  the  last.  As  soon  as  this  is  thoroughly  separated,  the  lower  end  of  the  pro- 
jecting tube,  with  the  hemorrhoids  attached  to  it,  is  cut  off  transversely,  bit  by 
bit  (the  arteries  being  tied  or  twisted  as  they  are  divided),  and  fastened  with 
sutures  accurately  to  the  divided  edge  just  inside  the  anus.  Union  ought  to  take 
place  by  the  first  intention. 

Where  there  is  a  ring  of  veins  forming  a  varicose  plexus  all  round  the  inner 
margin  of  the  anus,  this  method  is  most  effectual,  and  it  possesses  the  merit  of 
being  thorough.  It  is  not  probable,  however,  that  the  percentage  of  relapses 
after  ligature,  if  the  operation  is  properly  performed,  is  very  much  higher;  the 
cicatrization  that  follows  tends,  in  a  marked  degree,  to  constrict  the  rest  of  the 
blood-vessels  and  support  the  mucous  membrane,  and  there  is  no  comparison  as 
to  the  relative  facility  of  the  two  proceedings.  Whitehead's  may  secure  union  by 
the  first  intention  ;  but,  if  this  fail,  and  the  mucous  membrane  retracts,  a  granu- 
lating sore  is  left,  extending  all  round  the  bow-el,  and  this  is  not  unlikely  to  leave 
some  constriction  behind  it,  though  it  is  only  fair  to  say  this  never  occurred  in 
Whitehead's  practice. 

Complications  after  Operation. 

Retention  of  urine  is  exceedingly  common.  In  a  few  instances,  it  can  be 
relieved  by  loosening  the  bandage  and  applying  warm  fomentations  to  the  pubic 
region  ;  but,  as  a  rule,  it  requires  a  catheter,  and  sometimes  this  continues  neces- 
sary for  ten  days  or  a  fortnight. 

Recurrent  or  secondary  hemorrhage  may  be  very  serious.  A  little  oozing  is 
not  uncommon  a  few  hours  after  the  operation,  and  again  when  the  ligatures  sepa- 
rate ;  but  sometimes  a  large  vessel  gives  way,  or  the  tissues  are  so  soft  and  vascular 
that  blood  seems  to  pour  out  from  the  whole  surface.  There  may  be  no  external 
sign  for  a  long  time;  the  patient  complains  of  feeling  faint  and  of  a  desire  to  go 
to  the  closet;  there  is  a  moment's  straining,  and  an  immense  quantity  of  blood- 
clot  is  suddenly  poured  out.  Slight  hemorrhage  may  be  checked  by  placing  small 
lumps  of  ice  in  the  rectum,  or  by  washing  it  out  with  ice-cold  water.  If,  how- 
ever, there  is  any  considerable  loss,  the  patient  must  be  placed  under  an  anaesthetic, 
and  the  bowel  thoroughly  explored,  the  mucous  membrane  being  pulled  down,  bit 
by  bit,  through  the  dilated  anus.  Sometimes  the  bleeding  point  can  be  seized 
with  pressure  forceps,  or  it  is  possible  to  apply  a  ligature ;  in  many  cases,  how- 
ever, either  it  cannot  be  found,  or  the  tissues  are  too  soft  to  hold,  and  the  only 
means  of  arresting  the  hemorrhage  is  to  plug  the  rectum.  This  is  best  done  with 
a  tampon,  similar  to  that  used  after  lithotomy,  only  much  larger.  There  is  a  cen- 
tral tube,  through  which  flatus  and  liquid  faeces  can  escape,  and  around  this  a  very 
soft,  distensible  rubber-bag,  which  can  be  dilated  to  almost  any  extent  by  injecting 
air  or  water.      If  this  is  not  at  hand,  a  conical  sponge,  with  a  double  ligature 


966    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

passed  through  the  apex,  may  be  used,  as  AHingham  suggests.  The  point  of  the 
cone  is  thrust  at  least  five  inches  up  the  bowel,  leaving  the  ends  of  the  ligature 
hanging  out ;  the  whole  of  the  space  beneath  is  plugged  with  cotton-wool  pow- 
dered over  with  alum  or  sulphate  of  iron,  and  then  the  apex  of  the  sponge  is  pulled 
down  by  the  ligature,  while  the  cotton-wool,  at  the  same  time,  is  thrust  upward 
with  the  fingers,  so  as  to  spread  the  intervening  substance  out,  and  press  against 
the  walls. 

[A  common  cylindrical  speculum  of  convenient  size,  wrapped  with  iodoform 
gauze,  sometimes  answers  a  useful  i)urpose  in  these  cases.] 

Contraction  at  the  orifice  may  be  caused  by  removing  external  hemorrhoids 
too  freely,  and  sometimes  the  same  thing  occurs  an  inch  or  two  inside  the  anus. 
For  this  reason  it  is  always  advisable  to  examine  the  bowel  with  the  finger  during 
the  process  of  cicatrization.  It  is  said  to  be  most  common  after  the  application 
of  the  cautery. 

The  opposite  condition — loss  of  tone  in  the  external  sphincter — is  not  uncom- 
mon in  cases  of  longstanding.  Usually,  it  recovers  of  itself ;  but  it  may  be  assisted 
by  washing  out  the  bowel  with  cold  water  after  each  motion. 

If  there  is  much  suppuration,  or  if  the  patient  is  allowed  to  get  about  too  soon, 
fissure,  fistula,  or  troublesome  ulceration  may  follow.  Occasionally,  there  is  a 
certain  amount  of  tenderness  about  the  inguinal  glands. 

Pyaemia  and  tetanus  are  occasional  causes  of  death.  The  former  may  be  due 
to  the  objectionable  plan  of  transfixing  the  base  of  a  pile,  so  as  to  tie  it  in  two 
halves.  The  latter  is  said  to  have  been  caused  by  the  ligature  involving  a  nerve 
at  the  orifice. 

Prolapse  of  the  Anus  and  Rectum. 

Protrusion  of  the  mucous  membrane  only  is  known  as  prolapse  of  the  anus. 
In  prolapse  of  the  rectum,  all  the  coats  of  the  bowel  are  involved,  mucous,  mus- 
cular, and,  when  it  is  of  any  size,  peritoneal  as  well,  the  recto-vesical  or  recto- 
vaginal fold  being  dragged  down  until  it  forms  a  hernial  sac  :  the  one,  however, 
is  merely  an  exaggeration  of  the  other.  The  mucous  membrane  is  always  everted 
to  a  certain  extent  during  the  act  of  defecation,  returning  as  soon  as  the  pressure 
is  removed  ;  if  an  unusually  large  amount  is  protruded,  it  is  caught  and  held  by  the 
sphincter,  the  submucous  tissue  stretching,  so  that  one  layer  glides  upon  the  other. 
When  this  occurs  repeatedly,  and  the  sphincter  and  levator  ani  are  too  weak  to 
prevent  it,  the  muscular  coat  is  at  length  dragged  down  as  well,  and  the  prolapse 
becomes  complete. 

Prolapse  of  the  anus  only,  is  never  of  great  size  ;  there  is  merely  a  ring  of 
mucous  membrane  surrounding  the  anus,  and  directly  continuous  with  that  cover- 
ing the  sphincter.  If  recent,  it  retains  its  normal  color  and  bright  appearance; 
but  it  may  be  dark  and  congested,  even  purple  or  black,  and  sloughing.  In  old 
cases  it  becomes  dry,  and  the  surface  rough  and  granular  from  friction. 

Prolapse  of  the  rectum  may  protrude  five  or  six  inches,  forming  a  great 
cylindrical  mass,  wide  at  the  base  and  tapering  more  or  less  abruptly  toward  the 
orifice.  Congestion  and  sloughing  sometimes  occur,  but,  owing  to  the  sphincter 
soon  losing  its  power,  they  are  not  common  ;  but  the  mucous  membrane,  espe- 
cially near  the  base,  is  liable  to  become  hard  and  dry,  like  leather,  from  the  con- 
stant exposure  and  friction.  The  hernial  sac,  when  it  is  present,  always  lies  in 
front ;  in  old  cases  it  attains  a  considerable  size,  and  alters  the  axis  of  the  bowel 
so  that  the  orifice  looks  backward  toward  the  sacrum,  instead  of  vertically  down- 
ward or  a  little  forward. 

Causes. — The  immediate  cause  is  persistent  straining,  whether  this  is  occa- 
sioned by  diarrhoea,  by  hemorrhoids  or  polypi,  or  by  affections  of  other  organs, 
phimosis,  vesical  calculus,  stricture  of  the  urethra  or  enlargement  of  the  prostate. 
The  natural  eversion  grows  more  marked,  until  finally  it  becomes  a  prolapse  ; 
but  this  does  not  take  place  until  the  muscles  that  support  the  mucous  membrane 
are  exhausted  and  the  tissue  stretched.     In  children  prolapse  is  exceedingly  com- 


PROLAPSE  OF  THE   ANUS  AND   RECTUM.  967 

mon  ;  the  sacrum  is  strai^hter  in  them  than  in  adults,  their  tissues  are  weaker 
and  more  delicate  ;  and  probably  the  way  they 

are  left  to  strain  at  stool  for  an  indefinite  time  is  "y — "^"^C^ 

of  considerable  help.   Summer  diarrhoea,  from  its  ^^  ^^^v. 

weakening  effect,  and  from   the  constant  strain-  y  j. 

ing,  is  the  most  common  cause  of  all.  ■^  / 

Prolapse  of  the  rectum  rarely  occurs  until  the  ^  f.    .  _  /f 

sphincter  and  levator  ani  have  lost  their  power,  /  /  l^t^'X 

whether  this  arises  from  neglect,  the  muscles  hav-       //  ^^il^iiii 

ing  at  length  become  overstretched,  or  from  other    ,  ■  {  ^^^Br^'/  ^ 

causes,  debility,  prolonged  residence   in  hot  cli-     \^  ^  ^^^L-''7     I 

mates,  or,  in  women,  loosening  of  all  the  parts     ""^  ^wM      I 

around  the  perineum,   consequent    on    repeated  ^^  '•s*'^       i 

pregnancies.    In  some  cases  the  weakness  appears  Ciiii^v 

to  be  congenital,  for  prolapse  of  the  rectum  may  -'"-^       ''"'T'  /' 

occur    in  young  adult  life  without   any  definite  Fig.  413.— Prolapsus  Recti. 

cause.      In  the  worse  form  the  anus  becomes  so 

wnde  and  loose  that  the  hand  can  be  introduced  into  it  with  ease;  no  trace  of  a 
sphincter  is  left ;  and  the  bowel  descends  every  time  the  patient  coughs  and  strains. 
Symptoms. — These  depend  more  upon  the  condition  of  the  sphincter  and 
the  tightness  of  the  constriction  than  upon  the  amount  of  bowel  that  descends.  In 
chronic  cases,  in  which  the  prolapse  is  the  result  of  muscular  weakness,  and  is 
constantly  coming  down,  there  may  be  extreme  inconvenience  and  discomfort, 
but  there  is  no  constitutional  disturbance.  The  parts  are  constantly  moist  with 
an  offensive  discharge  ;  bleeding  is  not  uncommon,  from  the  irritation  of  the 
mucous  membrane  ;  the  skin  around  is  excoriated  and  grows  out  into  loose  pen- 
dulous folds,  radiating  from  the  anus  ;  sitting  down  or  walking  is  attended  with 
pain,  and  the  patient's  health  and  strength  are  seriously  impaired,  but  there  is 
little  or  no  fever.  When,  however,  the  prolapse  is  tightly  nipped,  the  symptoms 
are  much  more  striking,  especially  if  the  whole  wall  of  the  bowel  comes  down. 
There  is  a  hot  burning  pain  about  the  anus ;  it  feels  as  if  there  was  a  foreign 
body  inside  ;  the  mucous  membrane  is  swollen  and  livid  ;  ulceration  and  even 
sloughing  may  occur  ;  the  discharge  is  intensely  foetid  ;  the  parts  around  are  hot, 
oedematous  and  swollen,  and  violent  throbbing  pain  and  high  fever  may  set  in. 
Actual  gangrene  from  the  tightness  of  the  constriction  is  unusual,  but  a  consider- 
able extent  of  mucous  membrane  may  slough,  and  leave  a  dense  and  unyielding 
stricture. 

The  diagnosis  is  not  difficult.  It  may  be  confused  with  hemorrhoids  or 
polypus,  but  the  shape  is  distinctive.  Not  unfrequently  they  are  present  as  well, 
and  cause  the  prolapse  by  dragging  the  mucous  membrane,  and  then  the  muscular 
coat  down  with  them.  Intussusception  of  the  rectum  may  be  distinguished  by  the 
deep  sulcus  that  surrounds  the  protrusion  ;  in  true  prolapse  the  finger  cannot  be 
passed  into  the  anus  by  the  side  for  more  than  an  inch  ;  there  is  no  break  between 
the  mucous  surface  and  that  of  the  sphincter. 

Treatment. — Prolapse  of  the  Amis. — The  cause  must  be  removed  at  once, 
whether  it  is  diarrhoea,  phimosis,  calculus,  oxyurides,  or  anything  else  that  in- 
duces straining.  The  protrusion  itself  should  be  washed  with  cold  water  or  with 
a  mild  astringent  lotion  (ferri  sulph.  gr.  ij  ad  5  j  (.12  gramme  to  32  c.c.)  ), 
and  returned  wath  gentle  pressure  ;  in  very  bad  cases  it  may  be  necessary  to  give 
an  anaesthetic  and  slowly  empty  the  blood-vessels  of  the  part ;  and  then  the  nates 
must  be  drawn  together  with  a  broad  piece  of  strapping  passing  from  one  to  the 
other.  Afterward  the  patient  must  not  be  allowed  to  sit  and  strain  at  stool  ;  the 
motions  must  be  passed  in  a  recumbent  position,  and  during  the  act  of  defecation 
the  orifice  of  the  anus  must  be  kept  tense  by  one  buttock  being  drawn  away  from 
the  other.  Tonics,  good  feeding,  and  cod-liver  oil  are  generally  requisite  as  well, 
for  the  children  in  whom  this  occurs  are  nearly  always  either  weakly  and  delicate 
or  pulled  down  by  severe  illness. 


968    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

If  this  fail  nitric  acid  may  be  tried  ;  an  anaesthetic  mnst  be  given,  the  pro- 
trusion dried,  and  brushed  over  with  strong  acid,  care  being  taken  that  none  conies 
in  contact  with  the  skin.  Then  the  part  must  be  returned,  a  small  plug  of  cotton- 
wool being  left  in  the  rectum,  and  a  large  pad  placed  over  the  anus  and  held 
firmly  in  position  with  strapping.  The  bowels  must  be  kept  confined  for  four  or 
five  days,  the  patient  being  in  bed,  and  when  they  are  allowed  to  act,  every  pre- 
caution must  be  taken  to  keep  the  motions  soft  and  to  prevent  the  sphincter  yield- 
ing again. 

If  hemorrhoids  are  present  they  should  be  removed  ;  and  sometimes  the  con- 
striction of  the  mucous  membrane  and  the  organization  of  the  lymph  effused  effect 
a  cure.  Should,  however,  the  whole  of  the  prolapse  be  covered  with  a  network  of 
varicose  veins,  as  it  often  is,  it  is  better  to  perform  Wheelhouse's  operation  at  once 
— excise  the  affected  part,  and  suture  the  lower  end  of  the  tul)e  of  mucous  mem- 
brane to  the  anal  orifice. 

Prolapse  of  the  Reetitni. — This  is  much  more  serious,  not  only  from  the  local 
condition,  the  enormous  dilatation  of  the  lower  part  of  the  bowel  and  of  the  anal 
orifice,  but  from  the  state  of  health  of  the  patient.  Many  of  these  cases  occur  in 
women  past  middle  life,  who  have  had  large  families,  and  who  are  suffering  from 
obesity  and  fatty  degeneration  of  the  heart,  or  chronic  bronchitis  ;  and  for  such 
only  palliative  treatment  is  available.  An  abdominal  belt,  wnth  a  rubber  pad  made 
to  fit  over,  but  not  in  the  orifice,  is  the  most  useful,  and  if  careful  attention  is  paid 
to  the  condition  of  the  bowels,  is  usually  sufficient,  as  these  patients  are,  for  other 
reasons,  seldom  able  to  undertake  much  exertion. 

In  younger  subjects  excision  or  cauterization  may  be  advised.  The  patient 
is  placed  under  an  anaesthetic,  in  the  lithotomy  position,  and  the  prolapse  pulled 
down  and  held  with  vuUsellum  forceps,  or  with  a  ligature  passed  through  the  apex. 
Then  either  triangular  portions  of  the  mucous  membrane  (the  base  of  the  triangle 
being  within  a  half  an  inch  of  the  sphincter),  are  dissected  up  and  removed,  the 
edges  being  brought  together  with  sutures  afterward,  or  four  or  six  longitudinal 
stripes  drawn  with  the  cautery  from  base  to  apex,  avoiding  the  large  veins  that  lie 
upon  the  surface.  Allingham  recommends,  in  addition,  that  the  sphincter  should 
be  divided  on  both  sides  with  the  hot  iron,  so  as  to  ensure  contraction  of  the  ori- 
fice. Of  these  two  methods  the  cautery  is  to  be  preferred,  partly  from  the  risk  of 
hemorrhage  not  being  so  great,  but  mainly  because  the  cicatrices  left  are  so  firm 
and  rigid.  The  contraction  not  only  narrows  the  bowel,  but,  to  a  certain  extent, 
shortens  it  as  well,  protecting  it  from  further  descent ;  while  the  sphincter,  having 
a  better  and  a  firmer  base  to  act  from,  not  unfrequently  regains  some  of  its  former 
power. 

After  the  operation  a  small  plug  of  oiled  lint  is  inserted  ;  the  bowels  are 
confined  for  a  day  or  two,  and  then  kept  gently  relaxed.  The  i)atient  is  not  al- 
lowed to  get  up  until  the  wounds  are  thoroughly  healed  ;  and  for  some  time  after 
that  it  is  advisable  that  all  motions  should  be  passed  in  the  recumbent  position.* 

In  slight  cases  this  generally  succeeds,  and  if  sufiicient  care  is  taken,  there  is 
no  relapse.  Unhappily,  the  same  causes  usually  continue  at  work  ;  the  constricted 
extremity  of  the  gut  gradually  yields  ;  and  at  length  the  prolapse  returns.  Under 
these  circumstances  the  hope  of  permanent  cure  lies  in  shortening  the  rectum. 
The  patient  is  prepared  in  the  same  way,  two  ligatures  are  passed  through  the  apex 
of  the  protrusion,  not  only  to  make  the  bowel  tense  and  hold  it  in  any  required 
position,  but  to  prevent  retraction  when  the  tube  is  divided  and  the  weight  of  the 
part  taken  off.  A  transverse  incision  is  made  through  the  anterior  layer  of  the 
prolapsed  mass  half  an  inch  below  the  skin  line,  until,  if  there  is  any  jieritoneum 
present,  its  outer  surface  is  exposed.  If  it  is  not  very  extensive  the  hernial  sac  is 
detached  from  its  surroundings  and  pushed  upward  out  of  the  way,  to  avoid  open- 

*  [Another  method  of  using  the  cautery,  is,  after  replacing  the  bowel,  make  a  linear  cauteriza- 
tion through  the  posterior  wall  of  the  rectum,  deeply  into  the  underlying  tissues.  Its  success 
depends  on  the  nirrowing  of  the  bowel,  and  the  adhesions  formed  by  deep  cicatrization.] 


POLYPUS  OF  THE  RECTUM.  96.; 

ing  the  peritoneum  ;  if  it  is  too  large  the  oi)posing  surfaces  are  carefully  sutured 
together  before  anything  further  is  done.  As  soon  as  this  is  secure  the  inner  tube 
is  opened  by  a  transverse  incision  corresponding  in  length  to  the  size  of  the  ])eri- 
toneal  pouch,  and  the  cut  edges  of  the  muscular  and  mucous  coats  of  the  two  tubes 
accurately  fastenetl  with  a  double  row  of  sutures.  'I'he  posterior  half  of  the 
circumference  is  then  divided,  and  sutured  in  the  same  manner,  and  the  whole 
prolapsed  i)ortion  detached.  The  vessels,  which  are  often  numerous  and  of  con- 
siderable size,  lie  for  the  most  part  in  the  posterior  half. 

A  similar  operation  has  been  performed  in  intussuscejjtion  when  the  invagi- 
nated  part  protrudes  from  the  anus. 

Polypus  of  the  Rectum. 

The  term  polypus  has  been  erroneously  applied  to  almost  any  outgrowth  from 
the  mucous  membrane  that  projects  into  the  cavity  of  the  bowel.  A  polypus 
should  be  pedunculated,  but  it  may  be  sessile,  provided  the  base  is  relatively  small ; 
and  it  may  be  a  new  growth  altogether — adenoma  or  fibroma — or  a  mere  over- 
growth of  the  normal  tissue  of  the  part.  Generally  polypi  are  single,  growing 
within  a  short  distance  of  the  anus,  from  the  dorsal  surface  of  the  bowel ;  but 
sometimes  there  are  two  or  three,  and  in  a  {^w  instances  there  have  been  hundreds. 
As  a  rule,  their  size  is  not  great ;  the  fibrous  ones  are  .seldom  larger  than  a  walnut, 
and  adenomata  in  most  instances  are  not  so  large  ;  but  when  there  are  two  or 
three  together,  they  have  been  known  to  block  up  the  interior,  and  give  rise  to 
symptoms  of  obstruction. 

The  soft  polypus  is  most  frequent  in  children.  It  is  generally  the  size  of  a 
raspberry,  bright  red  in  color,  smooth  or  slightly  granular  on  the  surface,  and 
bleeds  at  the  least  touch.  It  is  composed  mainly  of  tubules  lined  with  columnar 
epithelium,  like  Lieberklihn's  follicles,  held  together  with  a  delicate  connective 
tissue,  and  dilated  in  places  into  cysts  ;  sometimes  there  is  a  little  more  fibrous 
tissue,  and  occasionally  a  few  unstriped  muscular  fibres.  At  first  they  are  sessile, 
but  as  they  rarely  give  rise  to  symptoms  until  they  protrude  from  the  anus,  a  long 
and  slender  pedicle  is  generally  present  by  the  time  the  diagnosis  is  made. 

Fibrous  polypi,  on  the  other  hand,  are  rare  except  in  adults.  They  spring 
apparently  from  the  submucous  layer,  and  are  composed  of  fibrous  tissue,  which 
may  be  so  hard  as  to  creak  when  divided  with  a  knife.  It  has  been  suggested 
that  they  are  really  adenoid  polypi,  which  in  course  of  time  have  become  hardened 
and  condensed  by  constant  irritation.  Occasionally  it  is  almost  impossible  to  dis- 
tinguish them  from  internal  hemorrhoids. 

Besides  these,  polypoid  outgrowths  of  mucous  membrane,  hypertrophied  from 
persistent  irritation,  are  often  present  in  cases  of  fissure  just  inside  the  anus. 

Symptoms. — These  are  not  definite  until  the  pedicle  is  long  enough  to  be 
grasped  by  the  bowel.  In  children,  bleeding  from  the  anus  is  often  the  first  thing 
noticed,  and  in  the  absence  of  injury  may  be  regarded  as  almost  conclusive. 
Sometimes  the  growth  is  extruded  during  defecation,  and  is  caught  by  the  sphinc- 
ter, giving  rise  to  pain  and  spasm  ;  and  it  may  even  slough  off,  and  undergo 
spontaneous  cure.  In  adults  hemorrhage  is  not  so  conspicuous,  but  there  is  usually 
a  considerable  discharge  of  mucus,  like  thin  starch  or  white  of  egg,  not  only 
with  the  motions,  but  in  the  intervals.  If  the  polypus  comes  down,  the  pain  and 
irritation  may  be  very  severe,  and  it  may  drag  the  bowel  down  with  it  so  as  to 
cause  prolapse,  or,  if  it  is  situated  higher  up,  intussusception. 

A  protruding  polypus  can  be  recognized  at  once  by  its  appearance.  If  it  is 
not  visible  at  first,  an  injection  may  be  given,  and  the  part  examined  immediately 
after.  When  the  finger  is  introduced  it  is  advisable  to  pass  it  up  to  its  full  length 
at  once,  and  search  the  mucous  membrane  as  it  is  withdrawn  ;  otherwise  a  polypus 
with  a  slender  pedicle  may  be  pushed  up  in  front  of  it  and  missed. 

Treatment. — Polypi  may  be  removed  by  torsion  and  ligature.  The  former 
answers  very  well  in  children,  and  if  the  pedicle  is  really  twisted  off,  is  not  fol- 
62 


970    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

lowed  by  hemorrhage  ;  the  latter  is  better  if  the  pedicle  is  of  any  size,  and  for 
fibrous  growths.  An  anaesthetic  is  advisable,  and  advantage  should  l)e  taken  of 
the  opportunity  to  make  sure  that  only  one  is  present.  If  a  ligature  is  used,  the 
same  precautions  should  be  adopted  as  after  operations  on  hemorrhoids,  for  fear  of 
ulceration. 

Pruritus. 

Many  affections  of  the  anus  and  lower  part  of  the  rectum  are  attended  by  a 
sense  of  itching,  which  may  become  so  intolerable  as  to  render  the  patient's  life 
utterly  wretched.  It  usually  begins  at  night,  as  the  body  is  getting  warm  in  bed, 
and  it  may  entirely  prevent  sleep ;  in  the  worst  cases  it  lasts  more  or  less  all  day, 
and  the  least  friction  brings  it  on.     Scratching  makes  it  tenfold  worse. 

The  skin  around  the  anus  in  an  old  case  is  thickened,  hardened,  excoriated, 
and  often  eczematous,  from  the  constant  irritation.  Sometimes  nothing  else  can 
be  found  ;  the  original  cause  may  have  disai)peared,  the  complaint  being  kept  up 
afterwards  by  this  alone  ;  more  often  there  is  some  affection  of  the  rectum — 
hemorrhoids,  prolapse,  stricture,  or  a  profuse  mucous  secretion  that  keeps  the 
part  continually  moist.  Venous  congestion  is  the  exciting  cause  in  most  cases  ; 
it  is  very  common  in  connection  with  gout ;  many  people  only  suffer  from  it  when 
the  liver  is  congested  or  the  bowels  constipated  ;  in  others  an  attack  is  always 
brought  on  by  certain  articles  of  diet,  especially  alcohol  and  highly  seasoned  food  ; 
in  women  it  may  be  due  to  uterine  disease,  and  in  a  few  cases  it  seems  to  be  asso- 
ciated with  mental  worry.  Sometimes  it  is  a  pure  neurosis,  occurring  whenever 
the  patient  is  out  of  health  ;  as  a  rule,  however,  some  definite  exciting  cause  can 
be  found. 

Treatment. — The  first  thing  to  do  is  to  remove  every  local  affection  that 
can  act  as  a  cause.  If,  however,  the  complaint  has  lasted  any  time  and  the  skin  is 
altered  in  texture,  it  may  be  very  obstinate.  The  bowels  must  be  made  to  act 
regularly  ;  the  diet  must  be  restricted,  especially  in  the  direction  of  beer  and 
spirits  ;  small  doses  of  calomel  or  of  podophyllin  given  from  time  to  time,  and 
if  there  is  any  suspicion  of  gout,  lithia  or  potash,  with  sufficient  fluid.  A  fair 
amount  of  exercise  should  be  taken,  and  the  part  should  be  sponged  well  night 
and  morning,  and  after  each  action  of  the  bowels.  A  lotion  of  milk  and  acetate 
of  lead  may  be  used  afterward,  or  the  glycerole  of  starch  and  borax.  Cocaine 
always  gives  temporary  relief,  and  is  especially  useful  at  night,  securing  some 
chance  of  sleep.*  If  the  skin  is  reddened  and  excoriated  from  constant  scratch- 
ing, mild  astringent  ointments  are  sometimes  beneficial.  In  other  cases,  in  which 
it  is  thick  and  hard,  a  strong  solution  of  nitrate  of  silver  or  of  acetic  acid  may 
be  applied  to  the  surface,  taking  care  that  none  comes  into  contact  with  the  anal 
margin.  The  patient  must  be  kept  in  the  recumbent  position  until  the  epidermis 
is  restored  again. 

Dilatation  of  the  sphincter  succeeds  sometimes  after  everything  else  has  failed, 
especially  if  the  spasm  is  severe.  AUingham  mentions  that  in  one  instance  relief 
was  obtained  by  the  patient  wearing  a  bone  plug  in  the  anus  at  night. 

Proctitis. 

Catarrhal  inflammation  of  the  mucous  membrane  may  arise  from  various 
causes  :  gonorrhoeal  infection,  especially  in  women  ;  syphilis  during  the  secondary 
stage  ;  abuse  of  purgatives  ;  gout ;  errors  in  diet,  etc.  Except  when  it  is  due  to 
the  first  of  these,  it  is  rarely  severe;  there  is  a  .sense  of  heat  and  weight  in  the 
perineum,  with  a  constant  desire  to  defecate.  The  sphincter  is  in  a  state  of 
painful  spasm  ;    the  anus  is  hot  and  tender  ;    the  amount  of  mucus  is  increased  ; 

*  [Sponging  with  hot  water  is  equally  effective.  In  severe  cases  the  sponge  may  be  allowed  to 
remain  against  the  itching  part  until  the  paiient  sleeps.  Hot  mercuric  or  carbolic  solution  is  prefer- 
al)le  to  plain  water  in  these  cases,  for  obvious  reasons.] 


PROCTITIS.  971 

and  this  escaping  externally  leads  to  excoriation  and  perhaps  superficial  ulceration. 
As  a  rule  the  symptoms  subside  as  the  cause  is  removed  ;  sometimes,  however, 
they  become  chronic;  and  occasionally,  when  severe,  painful  catarrhal  ulcers 
develop,  recpiire  special  treatment. 

Ulceration  of  the  rectum  is  much  more  serious,  not  only  for  itself,  but  from 
the  way  in  which  it  leads  to  stricture  and  fistula.  In  some  cases  it  is  the  result  of 
injury,  the  introduction  of  foreign  bodies,  the  use  of  enema  tubes  or  the  passage  of 
hard  scybalous  masses,  especially  as  the  circulation  is  often  sluggish  and  the  tissues 
badly  nourished,  from  the  i^resence  of  varicose  veins.  In  others  it  arises  directly 
from  thrombosis  and  inflammation  of  the  veins;  or  from  dysentery  involving  the 
rectum  as  well  as  colon.  When  this  occurs  the  ulcers  it  leaves  are  of  a  peculiarly 
irregular  character ;  they  spread  in  all  directions,  forming  little  islands  which,  as 
cicatrization  takes  place,  stand  out  as  hard  warty  excrescences  ;  or  they  under- 
mine the  mucous  membrane,  so  that  it  leaves  rigid  cords  passing  across  the  interior 
from  one  part  to  another  ;  and  the  scars  are  of  such  extreme  density  that  not 
improbably  many  of  them  have  been  mistaken  for  scirrhus. 

In  other  cases  ulceration  is  due  to  syphilis.  In  its  earlier  stages  this  attacks 
the  anus  chiefly  ;  condylomata  and  superficial  sores  occur  round  the  margin,  leaving 
irregular  folds  of  skin  with  painful  fissures  in  between,  not  unlike  those  at  the  angles 
of  the  mouth  and  nose.  In  the  latter  it  breaks  out  on  the  mucous  membrane,  some 
distance  from  the  anus,  forming  deep  serpiginous  sores,  which  may  extend  almost 
round  the  bowel. 

Tubercle  is  still  more  common,  beginning  in  the  adenoid  tissue  between  and 
beneath  the  follicular  glands.  Little  nodules  make  their  appearance  first,  not 
larger  than  millet  seeds,  and  only  slightly  raised  above  the  surface  ;  after  a  time 
these  become  caseous  and  break  down,  leaving  shallow  depressions,  which  grow 
larger  and  deeper,  until  at  length  they  become  circular  sores  with  overhanging 
edges.  In  other  cases,  the  caseous  deposit  seems  to  infiltrate  the  adenoid  tissue  in 
the  mucous  and  submucous  layers  before  the  surface  gives  way,  and  deep,  irregular 
ulcers  are  formed,  which  almost  at  once  become  the  orifices  of  tuberculous 
fistulse. 

Ulceration  somewhat  similar  in  character  is  not  unfrequently  associated  w'ith 
albuminuria  ;  probably  it  originates  as  catarrhal  inflammation  ;  after  a  time  the 
lymphatic  follicles  become  affected,  and  break  down  ;  and  then,  as  there  is  no 
longer  any  protection  against  septic  infection,  the  deeper  tissues  become  inflamed 
as  well.  In  many  cases  it  is  difficult  to  distinguish  this  from  the  preceding  ;  they 
both  occur  in  patients  whose  health  is  broken  down,  and  whose  tissues  are  badly 
nourished  ;  and  they  both  lead  to  ulceration,  and  not  unfrequently  to  fistulous 
channels  of  very  much  the  same  description. 

In  addition  to  these,  lupoid  ulceration  may  attack  the  skin  around  the  anus 
and  the  mucous  membrane  of  the  rectum.  It  is  essentially  destructive  in  character 
and  cicatrization  is  unusual.  The  edges  and  base  are  not  hard,  as  in  malignant 
disease  ;  and  the  former  are  undermined  and  overhanging.  Sometimes  it  remains 
stationary  for  a  time,  and  is  apparently  beginning  to  heal ;  then  it  all  breaks  down 
again.  It  is  only  met  with  in  tuberculous  subjects,  and  probably  is  itself  tubercu- 
lous. The  only  treatment  that  has  proved  of  any  use  is  scraping  and  the  actual 
cautery  ;   sometimes  the  pain,  at  least,  can  be  relieved  in  this  way  for  a  time. 

Symptoms. — In  acute  inflammation  of  the  rectum  the  patient  complains  of 
a  sense  of  heat  and  weight  in  the  perineum,  spreading  over  the  back  and  thighs, 
and  of  violent  straining  and  spasm  of  the  sphincter.  The  skin  is  dry  and  feverish  ; 
the  anus  is  very  tender  ;  the  finger,  if  it  is  introduced,  is  tightly  gripped  ;  and  the 
mucous  membrane  feels  burning  hot.  In  severe  cases  the  constitutional  symptoms 
are  very  marked  ;  the  pain  radiates  over  the  whole  of  the  lower  part  of  the  body, 
and  there  is  nearly  always  retention  of  urine. 

The  symptoms  of  ulceration  depend  upon  its  situation.  \\'hen  the  anal 
margin  is  involved,  they  are  so  striking  and  so  severe  that  this  aftection  is  de- 
scribed by  \\s>Q\i  d&  fissure  of  the  anus  ;  when,  on  the  other  hand,  they  are  higher 


972    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

up,  above  the  level  of  the  external  sphincter,  they  are  at  first  very  vague.  Diar- 
rhoea is  the  most  prominent ;  as  soon  as  the  patient  gets  out  of  bed  there  is  an 
immediate  desire  to  go  to  the  closet,  and  a  small  quantity  of  liquid  faeces  with 
some  mucus,  like  white  of  egg,  comes  away.  The  same  thing  occurs  perhaps 
once  or  twice  in  the  morning;  and  then,  if  the  ulceration  is  not  far  advanced, 
the  rest  of  the  day  is  passed  in  comparative  comfort;  the  rectum  is  empty  and 
there  is  nothing  to  irritate  it.  In  all  but  the  slightest  ca.ses,  however,  there  is  a 
constant  .sense  of  fullness  and  tenesmus  ;  normal  motions  are  never  passed  ;  the 
amount  of  discharge  increases  ;  it  loses  its  simple  mucous  character,  and  becomes 
dark,  like  coffee-grounds.  Control  over  the  sphincter  is  lost  ;  the  skjn  around 
the  anus  is  constantly  moist ;  it  becomes  covered  with  vegetations  and  excres- 
cences, between  which  fissures  form.  Then  the  pain  becomes  more  severe  ;  after 
each  motion  it  is  intense,  and  in  the  intervals  there  is  always  a  constant  dull 
aching.  Finally,  the  diarrhoea  becomes  almost  continuous  ;  health  and  strength 
fail;  the  appetite  is  lost;  colicky  spasms  and  pains  over  the  lower  part  of  the 
abdomen  grow  more  frequent  ;  abscesses  and  fistulae  form  around  the  bowel ;  the 
emaciation  becomes  extreme;  and  the  patient  sinks  from  exhaustion,  if  he  is  not 
carried  off  by  some  intercurrent  disorder. 

Diagnosis. — In  advanced  cases  the  appearance  of  the  anus  at  once  suggests 
the  presence  of  more  serious  mischief.  The  thickened  and  pigmented  folds,  with 
deep  and  painful  ulcers  in  between,  and  the  eczematous  condition  of  the  skin,  can 
only  be  caused  by  long-continued  irritation  ;  but  the  diagnosis  can  only  be  made 
with  the  finger  or  the  speculum.  The  former  is  nearly  always  sufficient ;  the  latter 
can  only  be  used  with  an  anaesthetic,  and  with  either  the  utmost  gentleness  is 
es.sential.  Immediately  inside  the  anus  the  mucous  membrane  is  generally  un- 
affected, though  both  in  syphilis  and  advanced  tubercular  or  lupoid  disea.se  it  may 
be  nearly  as  bad  as  the  rest ;  higher  up  the  normal  soft  character  of  the  bowel  is 
entirely  lost.  The  surface  is  rough  and  irregular  ;  hard  nodules  project  here  and 
there ;  in  some  places  the  walls  are  dense  and  thick,  like  stricture  tissue,  and  the 
passage  is  narrowed  ;  in  others  there  are  soft  smooth  patches,  surrounded  with 
overhanging  edges,  which  bleed  at  the  least  touch  ;  and  the  finger  when  it  is  with- 
drawn is  smeared  with  blood-stained  mucus. 

Sometimes  it  is  jjossible  from  this  alone  to  form  an  opinion  both  as  to  the 
extent  and  cause  of  the  disease.  Syphilitic  ulceration  is  often  accompanied  by 
other  signs  ;  tubercle  rarely  leads  to  the  formation  of  dense  cicatrices,  and  nstulae 
generally  make  their  appearance  very  soon.  Dysentery,  on  the  other  hand,  may 
destroy  all  trace  of  normal  mucous  membrane,  and  often  extends  far  beyond  the 
reach  of  the  finger.  In  the  majority,  however,  a  careful  inquiry  into  the  history, 
and  into  the  other  symptoms  that  are  present,  is  essential  ;  and  even  then  it  is 
sometimes  difficult  to  exclude  the  idea  of  malignant  disease. 

Treatment. — Rest  is  the  first  consideration.  The  patient  must  lie  down  for 
at  least  the  greater  i)art  of  the  day,  with  the  foot  of  the  bed  raised  to  prevent 
venous  congestion.  The  faeces  must  be  kept  as  soft  and  as  small  as  possible  ; 
everything  that  is  stimulating  or  indigestible,  or  likely  to  leave  a  bulky  residue, 
must  be  strictly  avoided.  Pure  milk  diet  for  a  time  is  often  advantageous.  All 
straining  must  be  prevented  ;  the  bowel  must  be  washed  out  night  and  morning 
with  warm  water  or  an  astringent  lotion — nitrate  of  silver  in  the  ca.se  of  dysen- 
tery, lotio  nigra  for  syphilis  ;  and  after  this  a  simple  unirritating  ointment  (calo- 
mel, gr.  X  ad  5J  (.60  ad  32),  nitrate  of  bismuth,  iodoform,  or  nitrate  of  mercury), 
may  be  applied  either  as  a  supi)ository  or  with  a  suitable  ointment  introducer. 
Starch  and  opium  injections  are  excellent  means  of  controlling  the  diarrhoea. 

In  the  meanwhile  constitutional  treatment  must  not  be  neglected.  Iodide  of 
potash  must  be  given  in  syphilitic  cases.  Cod-liver  oil.  if  the  patient  can  take  it, 
often  answers  better  than  anything,  as  there  is  nearly  always  great  loss  of  flesh  and 
strength,  and  it  tends  to  keep  the  motions  soft  ;  if  iron  is  given  care  must  be 
taken  that  the  bowels  are  not  confined.  In  a  few  cases  where  the  ulcer  is  low 
down,  and  the  spasmodic  contraction  of  the  sphincter  is  severe,  perfect  rest  may 


PERIPROCTITIS.  973 

be  obtained  by  subcutaneous  division  of  the  nuisclc  or  by  stret(  hinj;  it ;  but  this 
is  seldom  of  any  good  in  the  more  severe  forms.  In  these,  when  all  local  treat- 
ment tails,  colotomy  is  the  only  resource. 


Periproctitis. 

Inflammation  around  the  rectum  may  occur  at  the  anus,  in  the  ischio-rectal 
fossa,  or  higher  up  in  connection  with  the  insertion  of  the  levator  ani  and  the 
recto-vesical  fascia. 

1.  Injlamination  around  tlic  margin  of  the  anus  in  many  cases  is  symptomatic 
of  some  deeper  di.sorder  :  there  is  a  constant  offensive  discharge  from  the  anus; 
the  ])arts  are  continuall)'  moist ;  the  ejiidermis  is  macerated  ;  and  the  deejjer 
papillary  layer  of  the  skin  exposed.  Inflamed  external  hemorrhoids,  small 
cutaneous  boils,  suppuration  in  connection  with  the  hair  follicles,  and  syphilitic 
eruptions  are  not  uncommon.  Very  often  it  is  due  to  injury,  repeated  straining, 
the  passage  of  hardened  fseces,  or  the  abuse  of  enemata  ;  or  it  may  occur  after 
parturition.  Of  itself  it  may  be  trivial  in  character,  but  it  becomes  of  great 
importance  from  the  tendency  it  has  to  leave  behind  it  painful  fissures  and  super- 
ficial fistulae. 

2.  Ischiorectal  abscess  \i  \\\\\c\\  more  serious.  It  maybe  acute  or  chronic. 
In  the  former  case  the  symptoms  closely  resemble  those  of  i:»roctitis.  It  may  com- 
mence with  a  rigor  ;  the  pulse  is  quick,  the  tongue  furred  ;  there  is  the  most  intense 
throbbing  in  the  perineum  ;  sitting  down  is  almost  impossible  ;  the  rectum  feels 
as  if  it  were  loaded  with  fjeces,  but  the  least  attempt  at  relief  brings  on  the  most 
violent  pain  and  straining.  On  examination  there  is  a  hard,  brawny  swelling  by 
the  side  of  the  anus ;  the  skin  is  red  and  oedematous,  pitting  on  pressure  ;  and  if 
the  finger  ia  introduced  into  the  bowel,  the  hardness  can  be  felt  through  the  wall 
for  some  distance  above.  Sometimes  the  inflammation  is  even  more  acute  than 
this,  and  a  form  of  gangrenous  cellulitis  which  may  prove  fatal  sets  in. 

In  the  chronic  form,  on  the  other  hand,  the  swelling  is  painless,  and  often 
lasts  for  weeks.  There  is  merely  a  soft  fluctuating  swelling,  filling  the  whole  of 
the  ischio-rectal  fossa  and  extending  up  by  the  side  of  the  bowel,  covered  in  with  a 
thin  layer  of  discolored  skin.  Not  unfrequently  the  patient  is  almost  unaware  of 
its  existence,  and  it  may  attain  a  very  large  size  and  burrow  for  a  considerable 
distance  before  the  skin  gives  way.  When  this  happens,  the  opening  is  always 
large  and  ragged,  with  thin,  overhanging  edges,  like  those  of  a  scrofulous  sore,  and 
a  fistula  is  almost  certain  to  be  left. 

The  frequency  with  which  these  abscesses  occur  is  accounted  for  partly  by  the 
ease  with  which  septic  absorption  takes  place  through  abrasions  of  the  mucous 
surface,  partly  by  the  anatomy  of  the  region.  Owing  to  the  rapid  variations  in 
size  of  the  bowel,  the  tissues  are  badly  supported  ;  the  circulation  is  feeble ;  there 
is  a  large  amount  of  loo.se  fat  with  dilated  veins  ;  and  the  vessels  have  even  a 
greater  tendency  to  become  varicose  than  those  of  the  lower  extremities. 

Phlegmonous  inflammation  is  rare,  except  in  those  who  are  thoroughly  broken 
down  ;  most  of  the  cases  recorded  have  been  in  persons  who  were  suffering  from 
sj)ecific  fevers.  Acute  abscess  may  usually  be  traced  to  exposure  to  cold  ;  injury  ; 
perforation  of  the  mucous  membrane  from  the  inside  by  a  fish-bone  or  other  foreign 
body  ;  tearing  of  the  mucous  surface  from  straining  or  the  passage  of  hardened  faeces, 
or  bruising  of  the  subcutaneous  tissue,  leading  to  extravasation  in  the  ischio-rectal 
fossa  or  venous  thrombosis.  The  chronic  form  is  probably  due  in  a  very  large 
number  of  cases  to  the  breaking  down  of  tubercular  deposit  in  connection  with 
the  adenoid  tissue  of  the  rectum  ;  or  it  may  be  a  complication  of  stricture,  begin- 
ning either  from  an  ulcer  on  the  mucous  surface,  or  independently  of  this  in  the 
lowly  organized  inflammatory  exudation  surrounding  the  bowel. 

In  addition  to  this,  suppuration  may  extend  into  the  ischio-rectal  fossa  from 
distant  organs  :   urinary  abscess  is  not  uncommon  ;    necrosis  of  the  sacrum    or 


974    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

coccyx  occasionally  gives  rise  to  it ;  coccygeal  dermoid  cysts  may  cause  it ;   and  it 
has  been  known  in  caries  of  the  lumbar  vertebrae. 

Ischio-rectal  abscesses  should  be  oj^ened  at  once  and  freely,  or  a  fistula  is  almost 
certain  to  form.  Even  if  there  is  merely  a  tense,  hard,  and  j)ainful  swelling,  it  is 
better  to  run  the  risk  of  not  finding  pus.  If  the  abscess  is  small  and  close  to  the 
rectum,  so  as  to  give  rise  to  the  suspicion  that  it  is  really  intramural,  the  patient 
should  be  placed  upon  his  side,  with  the  knees  drawn  up,  and  the  finger  introduced 
into  the  bowel  to  fix  the  swelling  and  make  it  project  toward  the  skin.  Then  a 
straight  bistoury  is  introduced,  and  an  incision  sufficiently  free  to  give  exit  to  the 
])us,  made  radially  from  the  anus.  Some  of  the  outer  fibres  of  the  external 
sphincter  are  divided,  and  the  opening  will  not  close  too  soon.  True  ischio-rectal 
abscesses,  on  the  other  hand,  must  be  laid  freely  open  by  a  longitudinal  incision, 
parallel  to  the  anus,  midway  between  it  and  the  ischium  ;  and  as  soon  as  the  pus 
has  escaped,  the  finger  must  be  introduced,  the  cavity  explored,  and  the  partitions 
inside  broken  down.  Afterward  the  opening  must  be  kept  patent  to  ensure  the 
abscess  healing  from  the  bottom.  Lint  should  be  avoided,  as  the  discharge  is 
liable  to  collect  behind  it,  and  its  removal  is  very  painfiil.  Gutta-percha  tissue, 
folded  irregularly  so  as  to  fit  inside  the  orifice  without  blocking  it,  is  the  most  con- 
venient. The  cavity,  if  the  dressing  does  not  come  away  easily,  can  be  syringed 
out  behind  it,  and  it  does  not  absorb  the  discharge.  The  patient  should  be  kept 
in  bed,  or  at  least  lying  down,  until  the  abscess  has  healed.  If  it  is  an  acute  one, 
this  will  not  be  many  days  ;  if  it  is  chronic,  the  greatest  care  is  necessary  to  pre- 
vent it  degenerating  into  a  fistula.  The  bowels  should  be  well  opened  once,  and 
then  kept  confined  for  several  days,  the  diet  being  very  light,  so  that  there  may 
not  be  an  accumulation  of  fceces.  When  they  are  opened  an  effectual  purge  should 
be  given  to  avoid  straining. 

3.  Inflamination  oti  the  Visceral  Surface  of  the  Levator  Ant. — This  is  nearly 
always  caused  by  extension  from  some  of  the  neighboring  viscera,  and  i-f  it  involves 
the  rectum  is  nearly  always  associated  with  stricture.  Occasionally  it  originates 
from  the  bowel,  much  more  frequently  from  the  uterus,  following  parturition  or 
metritis,  and  probably  it  is  for  this  reason  that  stricture  of  the  rectum  is  so  much 
more  common  in  women  than  in  men. 

The  inflammation  may  be  acute,  attended  with  high  fever,  and  soon  ending 
in  suppuration  ;  or  chronic,  spreading  from  one  part  to  another  until  they  are 
firmly  bound  down  to  each  other  and  to  the  pelvis  by  bands  of  cicatricial  tissue 
which  may  be  almost  of  cartilaginous  hardness.  When  it  starts  from  the  region  of 
the  uterus,  the  anterior  surface  of  the  rectum  is  first  involved.  'I'he  inflammatory 
exudation  spreads  into  the  substance  of  the  muscles  until  the  fibres  become  atrophied 
and  the  walls  hard  and  unyielding;  the  mucous  membrane  becomes  rigid  and 
unable  to  unfold  itself;  the  constant  irritation  caused  by  the  passage  of  the  f^ces 
gradually  leads  to  hypergemia  and  thickening  of  the  submucous  tissue  ;  and  at 
length  a  definite  stricture  is  formed,  which  maybe  either  tubular  in  shape,  extend- 
ing for  some  distance  along  the  bowel,  especially  on  the  anterior  surface,  or  sharp, 
well-defined,  and  annular,  about  an  inch  and  a  half  or  two  inches  above  the  anus. 

If  suppuration  occur  the  abscesses  may  break  into  the  bladder  or  vagina,  or 
they  may  extend  through  the  sacro-sciatic  foramina,  or  even  burst  into  the  peritoneal 
cavity. 

Fissure  of  the  Anus. 

A  distinctive  name  has  been  given  to  a  small  ulcer  which  occurs  on  the  margin 
of  the  anus  or  on  the  mucous  membrane  just  inside,  because  of  the  extraordinary 
severity  of  the  symj^toms  to  which  it  gives  rise. 

It  usually  lies  upon  the  posterior  wall,  very  often  hidden  by  a  small  external 
pile  ;  and  so  long  as  the  anus  is  contracted,  it  has  the  appearance  of  a  fissure  lying 
between  two  rather  oedematous  muco-cutaneous  folds.  If,  however,  these  are 
separated  and  the  anus  distended,  it  is  seen  to  be  a  circular  or  oval  ulcer,  lying 
sometimes  on  the  white  line  at  the  junction  of  the  skin  and  mucous  membrane, 


FISSURE  OF  THE   ANUS.  975 

sometimes  wholly  on  the  latter  ;  in  this  case  the  symptoms  are  less  severe.  In  some 
instances  it  is  ijuite  superficial ;  in  others,  it  extends  completely  through  the  mu- 
cous and  submucous  tissues,  and  exposes  the  fibres  of  the  sphincter  beneath.  As 
time  passes,  the  edges  become  thick  and  oedematous,  and,  not  unfrequently,  the 
mucous  membrane  is  undermined,  so  that  a  short  sinus  runs  upward  in  the  sub- 
mucous tissue.  Occasionally,  a  fold  grows  out  into  a  polypoid  form,  and  lies  in 
the  fissure  when  the  anus  is  closed  ;  and,  if  the  disease  lasts  any  time,  the  sphincter 
and  the  levator  ani  always  become  hypertro[)hied,  from  their  persistent  contrac- 
tion, so  that  the  orifice  is  tightly  drawn  up  when  the  least  attempt  is  made  to 
expose  the  ulcer. 

An  ulcer  of  this  kind  may  be  formed  by  any  slight  tear  or  abrasion  ;  very 
often,  patients  assign  it  to  the  passage  of  some  especially  hard  motion  ;  it  is  not 
uncommon  after  parturition  ;  it  may  follow  diarrhoea,  and,  not  unfrequently,  some 
syphilitic  abrasion  forms  the  starting  point ;  or  it  may  be  due  to  an  inflamed  ex- 
ternal pile,  an  irritating  discharge,  or  chronic  congestion  kept  up  by  uterine  dis- 
placement. In  some  people,  the  orifice  of  the  anus  seems  almost  as  prone  to 
crack  as  the  mucous  membrane  of  the  lips,  but,  fortunately,  most  of  these  little 
sores  get  well  of  themselves,  or  with  very  simple  treatment ;  it  is  only  a  few  of 
the  cracks  and  fissures  that  give  rise  to  the  characteristic  symptoms  of  fissure  of 
the  anus. 

Symptoms. — Of  these  the  chief  is  pain — pain  of  the  most  excruciating 
character,  coming  on  as  the  bowels  are  acting,  and  lasting  perhaps  for  hours  with- 
out abating.  It  is  usually  described  as  the  pain  of  a  red-hot  iron,  or  of  violent 
tearing  ;  the  patient  is  in  a  state  of  collapse,  unable  to  move  ;  the  pulse  is  scarcely 
perceptible  ;  and  the  forehead  covered  with  perspiration  ;  and  this,  in  the  worst 
cases,  may  continue  for  almost  the  whole  day.  In  others,  it  is  less  severe  ;  when, 
for  example,  the  ulcer  lies  above  the  white  line,  it  often  does  not  come  on  at  once, 
and  may  only  last  for  a  short  time  ;  but,  even  so  the  patient  may  be  entirely  pre- 
■  vented  from  doing  any  active  work.  Often  the  symptoms  are  aggravated  by  con- 
stipation ;  the  patient  dreads  each  action  of  the  bowels,  and  postpones  it  as  long 
as  possible,  so  that  the  faeces  become  hard  and  dense,  and  the  suffering  tenfold 
more  severe.  Retention  of  urine  is  a  common  consequence  in  men,  and  menstrual 
disorders  in  women.  Dyspepsia,  loss  of  strength,  extreme  anaemia,  violent  pains 
down  the  back  and  loins,  and  other  effects  soon  make  their  appearance,  until  at 
length  the  sufferer  and  his  friends  are  firmly  convinced  that  symptoms  of  such 
intensity  can  only  arise  from  malignant  disease. 

The  diagnosis  rarely  presents  any  difficulty  ;  neuralgia  of  the  rectum  is  the 
only  trouble  likely  to  be  mistaken  for  it ;  no  other  affection  causes  such  peculiar 
and  severe  pain.  Sometimes  a  stain  of  blood  or  mucus  is  noticed  upon  the  mo- 
tions, or  there  is  a  slight  mark  upon  the  skin.  The  anus,  when  it  is  inspected,  is 
tightly  drawn  up  and  contracted,  the  glutei  closely  approximated,  and  the  sphinc- 
ter feels  hard  and  firm  ;  sometimes,  there  is  a  small  external  hemorrhoid  near  the 
margin,  or  the  edge  of  the  ulcer  may  be  seen.  Examination  with  the  finger  is  so 
painful  that,  where  the  symptoms  are  well  marked,  it  is  always  advisable  to  give 
an  antesthetic.  The  orifice  then  can  be  dilated,  and,  as  the  mucous  membrane  is 
everted  with  the  pressure  of  the  fingers,  the  whole  of  the  ulcer  becomes  visible, 
first  as  a  fissure,  and  then  as  a  small,  round,  granulating  surface,  the  base  of  which 
is  sometimes  covered  with  a  thin  slough. 

The  extreme  severity  of  the  symptoms  is  accounted  for  by  the  exposure  of 
some  nerve-filament  upon  the  floor  of  the  ulcer.  The  degree  of  pain  varies  very 
much  in  different  cases  ;  it  is  always  less  when  the  mucous  membrane  only  is 
affected,  and,  not  unfrequently,  the  excessive  sensitiveness  of  the  surface  is  limited 
to  one  or  two  small  points,  evidently  spots  where  the  nerve-fibres  are  lying  bare. 

Treatment. — In  the  early  stages  the  ulcer  can  sometimes  be  cured  by  keep- 
ing the  motion  soft,  and  applying  a  mild  astringent  ointment,  nitrate  of  mercury, 
calomel,  or  sulphate  of  zinc,  night  and  morning,  and  after  every  action  of  the 
bowels;  but,  as  a  rule,  something  further  is  required.     The  object  is  to  give  the 


976    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

ulcer  perfect  rest ;  if  this  can  be  done,  and  if  there  is  no  ]jolypoid  growth  hanging 
over  it,  i)reventing  its  closing,  it  will  generally  heal  in  the  course  of  a  few  days. 
The  simi)lest  i)lan  is  to  apply  caustic  to  the  surface — nitrate  of  silver  or  the  acid 
nitrate  of  mercury.  The  patient  must  be  placed  under  an  anaesthetic  ;  the  floor 
of  the  ulcer  freely  exposed,  and  then  well  cauterized,  so  as  to  cover  it  with  a  pro- 
tecting layer.  Afterward  the  bowels  must  be  prevented  from  acting  for  a  day  or 
two,  and  the  patient  kei)t  in  the  recumbent  position,  until  the  .sore  has  healed. 

If,  however,  the  sphincter  is  hypertrophied,  or  if  there  is  a  ])olyi)oi(l  growth 
overhanging  the  ulcer,  this  is  not  enough,  and,  in  most  cases,  even  when  neither 
of  these  conditions  is  present,  it  is  advisable  to  adopt  a  more  thorough  i)roceeding 
from  the  first,  dividing  the  superficial  fibres  of  the  muscle,  or  stretching  it  so  that 
it  cannot  contract.  A  coml)ination  of  the  two  is  the  most  useful,  though  either 
will  succeed  alone  ;  the  patient  is  i)laced  under  an  anaesthetic,  and  the  anus  thor- 
oughly dilated  with  the  fingers  ;  then,  when  the  floor  of  the  ulcer  is  exposed,  an 
incision  is  made  across  it,  about  a  quarter  of  an  inch  in  depth,  so  as  to  divide  the 
superficial  fibres  of  the  sphincter.  If  there  is  a  small  sinus  under  the  mucous 
membrane,  it  should  be  slit  up  at  the  same  time  ;  overhanging  edges  of  mucous  mem- 
brane should  be  excised,  and  any  small  polyi)oid  outgrowth  or  hemorrhoid  removed 
as  well.  Complete  division  of  the  external  sphincter  is  an  unnecessarily  severe 
proceeding  ;  a  very  slight  cut  is  usually  sufficient,  especially  in  those  cases  in 
which  there  is  one  exceedingly  painful  spot ;  if  the  nerve  upon  which  this  depends 
is  divided,  the  pain  ceases,  the  spasmodic  contraction  of  the  sphincter  begins  to 
relax  ;  the  ulcer  is  placed  at  perfect  rest,  and  begins  to  heal  at  once.  It  is  diffi- 
cult, however,  to  make  sure  of  doing  this,  and  if  the  sphincter  is  very  tense,  stretch- 
ing or  superficial  division  is  usually  advisable.  Sometimes  the  ulcers  are  multiple, 
but  only  one  incision  is  required. 

While  the  patient  is  under  the  anaesthetic,  the  opportunity  should  be  taken 
for  thoroughly  examining  the  rectum  higher  up.  If  there  is  any  complication 
present,  or  if  in  women  there  is  any  displacement  of  the  uterus,  and  this  remains 
unrectified,  it  is  highly  probable  either  that  the  ulcer  will  not  heal,  or  that,  if  it 
does,  it  will  form  again  as  soon  as  the  patient  begins  to  get  about. 

Fistula   in  Ano. 

By  fistula,  in  the  general  sense  of  the  term,  is  meant  a  sinus  in  the  neighbor- 
hood of  the  anus,  left  by  an  abscess  which  has  healed  up  to  a  certain  point,  and 
then  either  remained  stationary,  or  even  grown  worse.  It  may  be  complete  with 
one  opening  in  the  bowel  and  the  other  on  the  skin  ;  or  incom])lete,  the  internal 
or  external  o])ening  only  being  present.  The  former  of  these  is  known  as  a  blind 
internal  fistula,  the  latter  as  a  blind  external  one. 

In  point  of  importance,  fistulae  may  be  divided  into  anal  or  rectal.  The 
former  merely  occur  near  the  margin  of  the  anus,  and  are  either  entirely  subcuta- 
neous, or  are  merely  covered  in  by  some  of  the  fibres  of  the  external  sphincter; 
the  latter  are  larger  and  deeper,  running  from  the  ischio-rectal  fossa,  between  the 
sphincters,  or  even  above  the  internal  one,  and  are  often  com])licated  by  sinuses 
under  the  skin  or  in  the  submucous  tissue. 

The  causes  of  fistulx  are  essentially  those  of  the  abscesses  which  give  rise  to 
them  ;  injury  to  the  mucous  membrane,  from  fish  bones  or  other  foreign  bodies  ; 
tubercular  deposits;  stricture;  extravasation  in  the  loose  fatty  tissue  of  the  ischio- 
rectal fossa;  inflamed  hemorrhoids  ;  cutaneous  boils,  etc.  The  reason  of  their 
persistence  is  to  be  found  in  the  mobility  of  the  part,  the  spasmodic  contraction 
of  the  sphincter  and  the  levator  ani,  and,  if  there  is  an  internal  opening,  the  con- 
stant entrance  of  irritating  substances  from  the  bowel.  Blind  internal  fistulae  are 
the  most  rare  ;  complete  ones  by  far  the  most  common,  although  it  is  sometimes 
a  little  difficult  to  find  the  internal  opening.  Prol)ably,  most  are  incomi)lete  at 
first,  but  the  second  opening  is  soon  formed  ;  the  abscess,  as  it  enlarges,  works 
its  way  simultaneously  toward  the  bowel  and  the  skin,  and,  unless  it  is  opened 


FISTULA    IN  A  NO.  977 

early,  the  mucous  membrane  is  separated  from  thesul)jacent  tissue  to  such  a  degree 
that  it  gives  way  by  ulceration  even  after  the  pressure  of  the  jnis  is  relieved. 

A  fistula  may  be  either  a  straight  passage  from  the  skin  to  the  bowel,  or  it 
may  be  complicated  by  sinuses  running  from  it  in  every  direction.  The  most 
common  of  these  is  in  the  submucous  tissue  ;  the  internal  orifice  is  nearly  always 
on  a  level  with  the  internal  sphincter,  seldom  more  than  an  inch  or  an  inch  and  a 
half  from  the  anus ;  but  the  sinuses  may  run  \\\i  from  this  under  the  mucous  mem- 
l)rane  for  several  inches.  More  rarely,  instead  of  taking  this  direction,  it  passes 
round  the  bowel,  causing  what  is  known  as  horsc-shoc  fistiihe,  and  opening  some- 
times on  one  side,  sometimes  on  both.  In  other  cases,  especially  where  there  is  a 
stricture  of  the  rectum,  these  offshoots  extend  under  the  skin  of  the  buttock,  and 
even  open  several  inches  away. 

The  walls  of  a  recent  fistula  are  covered  over  with  granulations,  and  secrete  a 
thin,  purulent  fluid  ;  after  repeated  attacks  of  inflammation,  they  become  thick  and 
dense,  the  lining  smooth  and  glistening,  like  the  surface  of  a  chronic  ulcer  on  the 
leg.  The  external  orifice  may  be  a  mere  pin-hole,  or  lie  in  the  centre  of  a  little 
button-like  mass  of  granulations;  or,  in  tubercular  patients  and  after  the  rupture 
of  a  chronic  abscess,  there  may  be  a  large,  irregular  opening  with  undermined 
edges,  like  a  scrofulous  ulcer  on  the  neck.  The  internal  orifice  presents  very  much 
the  same  character  ;  sometimes  it  feels  like  a  distinct  little  papilla  resting  on  a  base 
that  is  firmer  than  the  surrounding  parts  ;  sometimes,  on  the  other  hand,  especially 
in  the  case  of  blind  internal  fistulae,  it  is  a  large,  irregular  ulcer. 

Symptoms. — So  long- as  there  is  free  exit  for  the  discharge,  fistulas  merely 
give  rise  to  inconvenience  and  discomfort.  The  skin  around  the  anus  is  constantly 
moist,  the  surface  becomes  tender  and  eczematous,  and  little  cutaneous  boils  are 
apt  to  form.  In  the  worst  cases  there  may  be  an  escape  of  f^ces  and  flatus  through 
the  orifice,  but  there  is  never  the  agonizing  pain  of  fissure.  Now  and  then  the 
orifice  becomes  blocked  ;  the  discharge  collects  ;  the  skin  becomes  hot,  and  red, 
and  tender  ;  the  action  of  the  bowels  is  attended  with  pain,  and  a  small  abscess 
forms.  When  this  breaks,  or  is  opened,  the  symptoms  subside  again,  but  each 
time  it  means  either  an  increase  in  the  density  of  the  tissues  around  or  the  forma- 
tion of  an  outlying  sinus. 

Diagnosis. — There  is  rarely  any  difficulty  in  this  :  the  patient  is  usually 
aware  already  of  the  cause  of  his  suffering ;  and  the  presence  of  a  small  orifice  by 
the  side  of  the  anus,  from  which  a  drop  or  two  of  thin  semi-purulent  fluid  can  be 
squeezed,  is  conclusive  ;  but  this  is  not  sufficient.  It  is  necessary  to  ascertain  the 
kind  of  fistula  ;  whether  it  has  an  internal  opening,  and  where  it  is  ;  whether  there 
are  many  sinuses  in  connection  with  it,  and  where  they  run  ;  and,  particularly, 
whether  there  is  any  cause  for  its  persistence  other  than  the  action  of  the  sphincter 
and  the  mobility  of  the  part.  There  may  be,  for  example,  a  stricture  of  the 
rectum,  high  up,  and  a  complete  fistula  with  its  internal  orifice  in  the  usual  situa- 
tion near  the  anus  ;  or,  what  is  even  more  perplexing,  there  may  be  a  complete 
fistula  and  necrosis  of  the  sacrum  or  coccyx  at  the  same  time  ;  the  diseased  bone 
has  caused  the  formation  of  an  ischio-rectal  abscess,  and  this  has  led  to  the  devel- 
opment of  the  fistula.  Of  course,  in  either  of  these  cases,  an  operation  upon  the 
fistula  only  is  worse  than  useless. 

The  patient  should  lie  upon  a  couch,  on  the  affected  side,  with  the  knees 
drawn  up.  In  most  cases  the  orifice  of  the  sinus  is  visible  at  once,  but  sometimes 
it  is  very  small,  concealed  behind  folds,  or  closed  for  the  time  being.  If  it 
cannot  be  seen,  the  induration  can  nearly  always  be  felt,  even  when  the  fistula  is 
a  blind  internal  one,  and  very  often  a  little  pressure  causes  a  drop  of  pus  to  exude. 
Sometimes  the  whole  track  of  the  sinus  can  be  made  out  with  the  finger. 

When  there  is  an  opening  a  probe  may  be  gently  passed  into  it  before  any- 
thing further  is  done,  in  the  hope  that  it  may  succeed  in  reaching  the  internal 
orifice  without  exciting  the  action  of  the  sphincter.  Usually  the  sinus  runs  almost 
under  the  skin  toward  the  bowel.  If  this  does  not  succeed  the  finger  must  be 
introduced  and  the  mucous  surface  carefully  explored  just  inside.     Generally  there 


978    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

is  no  difficulty  in  feeling  the  opening;  if,  however,  it  cannot  be  found,  either  a 
speculum  may  be  used  or  some  milk  or  other  colored  fluid  injected  into  the  orifice  ; 
nearly  always  some  of  it  finds  its  way  into  the  bowel.  It  is  a  common  mistake  to 
pass  the  finger  in  too  far  at  first  and  overlook  the  opening. 

Blind  internal  fistulae  differ  from  the  others.  They  usually  communicate  with 
the  bowel  by  an  aperture  of  some  size  ;  and  from  the  fact  that  fnecal  matter  is  con- 
stantly entering  and  setting  uj)  inflammation,  they  are  very  often  attended  with  a 
good  deal  of  i)ain.  There  is  no  discharge  externally  ;  but  the  i)atient  is  usually 
aware  of  a  swelling  by  the  anus  emptying  itself  every  now  and  then  into  the  bowel 
with  tem])orary  relief.  Digital  examination  nearly  always  reveals  a  hard  and 
painful  mass  in  the  ischio-rectal  fossa,  and  an  irregular  ulcer  often  of  considerable 
size  in  the  bowel.  Occasionally  the  sac  can  be  emptied  by  jjre.ssure  ;  but  to  make 
the  diagnosis  certain,  a  probe  bent  like  a  hook  must  be  passed  down  into  the  sinus 
through  the  anus.  Fistulae  of  this  kind  are  usually  caused  by  a  foreign  body  per- 
forating the  mucous  surface  of  the  bowel,  or  by  the  softening  of  some  tubercular 
deposit  in  the  wall. 

Treatment. — As  a  rule,  fistulas  can  only  be  cured  by  operation.     In  ex- 


Fic.  414. — Grooved  Probe  passed  through  Anal 
Fistula  before  its  Division. 


Fig.  415. — Method  of  Dividing  Anal  Fistula. 


ceptional  cases,  in  which  there  is  no  internal  opening  and  in  which  the  patient 
will  submit  to  prolonged  treatment,  the  sphincter  may  be  stretched,  the  sinus 
stimulated  with  strong  carbolic  acid  or  tincture  of  iodine,  and  the  external  orifice 
kept  widely  open  in  the  hope  that  it  will  close  ;  but  it  nearly  always  ends  in  failure, 
after  a  long  waste  of  time.  The  only  method  that  deserves  reliance  is  division  of 
all  the  structures  between  the  fistula  and  the  anus,  so  as  to  lay  it  open  from  one 
end  to  the  other  and  give  it  complete  rest. 

An  aperient  is  given  the  night  before  and  an  enema  the  morning  of  the  oper- 
ation. The  patient  is  placed  under  an  anaesthetic,  and  laid  on  the  affected  side, 
close  to  the  edge  of  the  table,  with  the  knees  well  drawn  up,  and  held  by  an  assist- 
ant, who  also  raises  the  upper  gluteal  fold.  The  sphincter  is  gently  dilated  and  a 
director  passed  from  the  external  orifice  along  the  sinus  into  the  bowel.  Care  must 
be  taken  to  bring  it  out  at  the  internal  opening  and  not  make  a  fresh  one,  except 
in  the  case  of  a  blind  external  fistula.  Then  the  point  of  the  director  is  brought 
out  through  the  anus,  so  that  the  structures  to  be  divided  are  stretched  over  it  like 
a  bridge,  and  a  clean  incision  made  through  them  with  a  sharp-pointed  bistoury 
(Fig.  414). 


FISTULA   IN  A  NO.  979 

If  this  cannot  be  done,  the  finger  is  introduced  into  the  bowel,  a  blunt- 
pointed  bistoury  i)assed  along  the  director  until  its  end  can  be  felt  coming  through 
the  orifice,  and  then,  after  withdrawing  the  director,  the  finger  and  the  bistoury 
are  brought  out  together  so  as  to  divide  with  one  sweep  all  the  structures  that  lie 
between  them  (I'ig.  415)- 

After  this.  exi)loration  must  be  made  for  outlying  sinuses.  A  submucous  one 
may  be  laid  open  with  a  pair  of  blunt-pointed  scissors  ;  or  if  from  its  position  there 
is  any  risk  of  serious  hemorrhage,  an  elastic  ligature  may  be  passed  through  it  by 
means  of  a  suitable  probe  and  tied  as  tightly  as  possible.  Those  under  the  skin 
are  treated  in  the  same  way  ;  or  if  they  are  of  great  length  a  drainage  tube  may  be 
passed  along  them  and  brought  out  through  an  incision  at  the  other  end.  If  one 
is  overlooked,  an  abscess  is  almost  sure  to  form  before  the  wound  is  healed,  and 
render  a  second  operation  necessary.  In  the  case  of  old  fistuhe  lined  with  a 
smooth  layer  of  false  mucous  membrane,  the  walls  must  be  scraped  out  thoroughly, 
with  the  sharp  spoon,  so  as  to  insure  removal  of  all  the  indurated  mass.  Polypoid 
outgrowths  and  hemorrhoids  are  dealt  with  at  the  same  time  ;  and  loose  and 
undermined  flaps  of  skin  are  cut  away,  though  discretion  is  necessary. 

Any  bleeding  point  is  tied  or  twisted  at  once,  the  wound  packed  with  iodo- 
form gauze,  and  a  firm  pad  placed  over  the  anus  and  secured  in  position  with  a  T 
bandage.  The  following  day  all  external  dressings  are  removed  and  the  deeper 
layer  allowed  to  separate  in  a  bath.  The  wound  is  cleansed  night  and  morning 
and  after  each  motion,  pain  being  prevented  by  cocaine,  and  a  single  fold  of  lint 
laid  between  the  edges.  The  application  should  be  varied  from  time  to  time,  ac- 
cording to  the  state  of  the  granulations.  The  bowel  should  not  act  for  four  or 
five  days  after  the  operation,  and  the  motions  should  be  kept  soft  until  the  wound 
is  perfectly  sound.  The  recumbent  position  is  essential  until  healing  is  completed, 
although  it  is  not  necessary  for  the  patient  to  be  kept  actually  in  bed  for  more 
than  a  week  or  ten  days. 

I  have  succeeded  in  obtaining  union  by  the  first  intention  by  thoroughly  re- 
freshing the  base  of  the  sinus  after  the  sphincter  had  been  divided,  and  bringing 
the  surfaces  together  in  accurate  contact  with  deep  wire  sutures.  It  is  necessary, 
however,  to  remove  them  at  the  least  sign  of  suppuration,  or  secondary  sinuses 
may  form.  Probably  buried  catgut  sutures  would  answer  better  ;  but  this  can  only 
be  tried  when  the  fistula  is  recent  and  simple  in  character,  and  when  the  patient 
is  young  and  healthy. 

In  cases  in  which  there  are  deep  sinuses,  where  there  is  much  reason  to  fear 
hemorrhage,  or  where  the  patient  is  exceedingly  nervous,  an  elastic  ligature  may 
be  used  to  divide  the  tissues  gradually.  It  should  be  a  solid  cord,  passed  through 
from  the  bowel  into  the  sinus,  drawn  as  tightly  as  possible,  and  secured  by  means 
of  a  leaden  clamp.  Generally  it  cuts  through  in  from  six  days  to  a  fortnight, 
and  without  pain;  but  sometimes  it  is  followed  by  serious  inflammation,  and  if 
there  are  any  secondary  sinuses  present  (and  it  often  happens  that  this  cannot  be 
determined  until  the  fistula  is  laid  open),  it  is  almost  sure  to  fail.  The  length  of 
time  that  the  wound  takes  in  healing  is  approximately  the  same  as  after  other 
methods  of  division. 

Incontinence  of  faeces  is  always  present  for  two  or  three  weeks  after  the  opera- 
tion, and  inability  to  control  flatus  for  some  time  longer;  but  if  the  sphincter  is 
divided  at  right  angles,  and  in  only  one  place,  there  is  seldom  any  permanent  loss 
of  power.  According  to  Allingham,  it  is  fairly  safe  if  ever  so  narrow  a  ring  of 
the  upper  part  of  the  band  of  the  internal  sphincter  is  left.  An  exception,  how- 
ever, must  be  made  in  the  case  of  anterior  fistulcC  in  women  ;  the  sphincter  vaginje 
and  the  sphincter  ani  decussate  in  the  perineum,  and  a  free  incision  through  the 
front  part  of  the  anus  is  not  unlikely  to  be  followed  by  incontinence.  It  is  recom- 
mended in  these  cases  to  apply  the  actual  cautery  freely  to  the  old  cicatrices,  and 
to  the  external  and  internal  sphincters  as  well,  in  several  places,  so  as  to  narrow 
the  orifice  of  the  anus  by  the  subsequent  contraction  ;  and  it  is  said  that  the  mus- 
cular fibres,  which  are  always  very  much  degenerated,  soon  regain  a  considerable 


9So    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

degree  of  their  former  power,  probably  because  the  dense  scars  formed  in  tliis  way 
afford  a  firmer  and  l)etter  l)ase  for  their  action. 

Phthisical  patients  are  exceedingly  liable  to  fistula,  but,  except  in  cases  of 
rapid  tuberculosis,  or  where  the  patient's  health  is  distinctly  failing,  this  is  not  of 
necessity  a  bar  to  operation.  Very  great  care,  however,  is  e.ssential ;  the  sphinc- 
ters are  often  weak  and  should  be  interfered  with  as  little  as  possible  ;  the  diet 
must  be  good  ;  the  patient  must  not  be  kept  in  bed  too  long,  and  a  time  should  be 
chosen  when  the  cough  is  not  very  troublesome  ;  but  even  then  the  wounds  are  not 
unfrequently  exceedingly  slow  in  healing. 


Stricture  of  the  Rectum. 

Stricture  of  the  rectum  may  be  simple  or  malignant.  The  former  is  either 
congenital  or  the  result  of  injury  and  inflammation  ;  the  latter  is  always  due  to 
cylindrical  epithelioma  starting  from  the  follicles  of  the  mucous  membrane  and 
gradually  extending  into  the  submucous  tissue. 

In  addition  to  this  sym]>toms  of  obstruction  may  be  caused  by  foreign  bodies, 
by  new  growths  occupying  the  interior  of  the  bowel,  or  by  tumors  pressing  upon 
it  from  the  outside  so  as  to  close  it  more  or  less  completely. 

Congenital  stricture  occurs  a  very  short  distance  inside  the  anus,  where  the 
rectal  and  anal  portions  of  the  intestine  meet  in  the  course  of  development.  It 
usually  takes  the  form  of  an  annular  constriction,  and  is  really  a  minor  degree  of 
the  defect  which  gives  rise  to  one  variety  of  imperforate  anus. 

Simple  Stricture. 

This  is  much  more  common  among  women  than  among  men,  in  the  propor- 
tion of  at  least  six  to  one.  It  may  be  annular  or  tubular,  situated  near  the  orifice, 
or  at  the  junction  of  the  anus  and  rectum,  or  higher  up  in  the  bowel.  Generally 
it  is  single  ;  but  it  may  be  multiple,  or  it  may  spread  over  a  considerable  extent. 
Sometimes  it  feels  like  a  cord  tied  around  the  bowel ;  more  often  the  surface  is 
rough  and  irregular,  deeply  ulcerated  in  places,  and  covered  with  cicatrices  in 
others  ;  and  the  walls,  instead  of  being  soft  and  yielding,  are  hard  and  rigid.  The 
muscular  fibres  are  wasted,  and  the  connective  tissue  in  and  around  the  bowel  so 
hard  and  dense,  that  the  portion  involved  is  converted  into  a  rigid  tube,  down 
which  the  faeces  are  forced  by  the  accumulation  above.  Generally  the  anterior  part 
of  the  rectum  is  more  affected  than  the  rest,  and  not  unfrecjuently  the  fibrous  tissue 
around  it  for  a  considerable  distance  is  as  dense  and  hard  as  cartilage.  Above, 
the  bowel  is  distended  and  its  muscular  coat  hypertrophied  ;  very  often  there  is 
ulceration  from  the  pressure  of  the  f?eces,  and  occasionally  small  hernial  protru- 
sions of  the  mucous  membrane  are  formed,  like  those  of  the  bladder  in  chronic 
cystitis.  Below,  the  mucous  membrane  is  always  in  a  .state  of  chronic  congestion  ; 
and  catarrh,  piles,  prolapse,  and  fistula  commonly  occur.  Outside,  in  the  cellular 
tissue  around,  suppuration  always  breaks  out  sooner  or  later,  sometimes  starting 
from  the  mucous  surface,  sometimes  independently  ;  and  pelvic  abscess,  recto- 
vesical or  recto-vaginal  fistula,  or  even  general  peritonitis  from  rupture  into  the 
peritonea]  cavity,  may  follow. 

Causes, — Stricture  close  to  the  orifice  may  result  from  imperforate  anus  (the 
after-treatment  not  having  been  properly  carried  outj  or  from  injury,  ulceration 
around  the  margin,  or  operations  upon  external  hemorrhoids.  Higher  up  in  the 
rectum,  it  may  commence  from  the  outside — inflammation  of  the  cellular  tissue 
extending  into  the  bowel  from  the  uterus  or  other  organs  ;  or  from  the  interior, 
the  mucous  membrane  becoming  ulcerated  and  the  submucous  and  other  coats 
involved.  The  latter  may  be  due  to  dysentery,  a  large  portion  of  the  sigmoid 
flexure  and  even  of  the  colon  being  implicated  ;  or  to  tubercle  or  syphilis,  the 
ulceration  extendinjj  more  or  less  round  the  bowel.  Sometimes  it  is  the  immediate 
result  of  operation,  too  much  of  the  mucous  membrane  having  been  removed  with 


STRICTURE  OF  THE   RECTUM.  981 

internal  hemorrhoids  or  jirolapse  ;  more  often  it  is  due  to  the  wound  that  is  left 
failing  to  heal  for  a  long  time.  Owing  in  part  to  venous  congestion,  in  part  to 
the  irritation  of  the  faeces  and  the  constant  contact  with  septic  material,  wounds 
of  the  bowel  sometimes  refuse  to  heal,  and  gradually  extend  by  ulceration  until, 
■when  at  last  cicatrization  does  occur,  the  scars  are  rigid  and  hard  and  extend  over 
a  considerable  area.  Finally,  many  of  these  cases  are  assigned  to  parturition, 
whether  they  are  due  to  sloughing  of  the  mucous  membrane  from  injuries  received 
at  the  time,  or  to  inflammation  of  the  cellular  tissue  around  the  bowel  afterward. 

Spasmodic  stricture  of  the  bowel,  as  such,  has  no  existence,  but  there  is  no 
doubt  that  many  cases  of  ulceration  and  of  organic  stricture  are  complicated,  and 
the  symptoms  made  infinitely  more  severe,  by  spasmodic  contraction  of  the  invol- 
untary muscular  fibre  in  the  wall,  and  perhaps  of  the  levator  ani  as  well.  Whether 
this,  if  long  continued,  can  at  length  lead  to  atrophy  and  fibroid  degeneration  is 
open  to  question. 

Symptoms. — The  symptoms  of  stricture  of  the  rectum  are  partly  those  of 
obstruction,  i)artly  those  of  irritation  and  inflammation.  Generally  the  latter  are 
present  first,  but  sometimes,  when  the  stricture  is  higher  up  in  the  bowel  than  ustial, 
obstruction  occurs  almost  without  warning.  Diarrhoea  in  the  morning,  on  first 
getting  out  of  bed,  and  again  after  food  ;  a  constant  discharge  from  the  anus, 
keeping  the  skin  moist  and  sore,  and  leading  to  the  formation  of  tags  and  fissures  ; 
a  sense  of  fullness  about  the  part,  with  persistent  desire  to  strain  ;  and  general 
uneasiness  about  the  loins  and  down  the  thighs,  are  nearly  always  present.  After 
a  while  there  is  difficulty  of  defecation  ;  attacks  of  constipation  alternate  with 
diarrhoea  ;  normal  motions  are  never  passed  ;  the  fseces  are  in  small,  hard  pellets, 
mixed  with  mucus,  like  white  of  egg  at  first,  later  with  coffee-ground  debris.  The 
pain  becomes  more  severe,  radiating  from  the  perineum  all  over  the  branches  of 
the  sacral  plexus  ;  the  griping  never  ceases  \  the  abdomen  becomes  distended  with 
flatus  ;  there  is  loss  of  power  over  the  sphincter,  so  that  wind  and  liquid  faeces  are 
constantly  escaping  ;  sympathetic  troubles  about  the  bladder  and  uterus  set  in  ; 
and  the  patient  rapidly  becomes  worn  out  by  the  constant  suffering. 

If  the  disease  is  allowed  to  continue,  the  ulceration  of  the  bowel  becomes 
deeper  and  deeper;  suppuration  occurs  in  the  tissues  around,  leaving  fistulae, 
which  may  open  on  the  exterior  or  communicate  with  some  of  the  neighboring 
viscera  ;  the  suffering  becomes  intense  ;  and  death  ensues  at  length  from  exhaus- 
tion, hectic,  and  profuse  suppuration,  or  from  peritonitis  or  intestinal  ob- 
struction. 

Diagnosis. — The  diagnosis  of  fibrous  stricture  of  the  rectum  must  be  made 
by  digital  examination  ;  the  finger  meets  either  with  an  annular  constriction,  or  a 
hard  tubular  canal,  the  walls  of  which  are  rigid  and  unyielding.  Only  in  a  very 
few  cases  is  it  too  high  up.  By  placing  the  patient  under  an  anaesthetic,  slightly 
dilating  the  anus,  and  pushing  the  perineum  well  up,  the  whole  of  the  region  in 
which  fibrous  stricture  occurs  can  generally  be  explored.  If  nothing  is  felt,  and 
the  symjjtoms  point  definitely  to  obstruction,  an  attempt  may  be  made  to  carry 
the  examination  further  by  the  long  enema  tube,  or  by  passing  the  hand  into  the 
bowel  wMth  the  precautions  already  described. 

Occasionally  olive-headed  bougies,  similar  to  those  used  for  examining  the 
urethra,  only  on  a  larger  scale,  are  of  use  for  determining  the  length  of  a  stricture. 

Treatment. — i.  General. — The  diet  must  be  nutritious,  but  such  as  to  leave 
a  very  small  residue  ;  the  motions  kept  soft ;  the  bowels  not  allowed  to  act  too 
often,  and  every  assistance  given  them  in  the  shape  of  enemata  of  glycerine  or  oil. 
Inflammation  and  ulceration  of  the  mucous  membrane  are  always  present  in  bad 
cases  of  stricture  as  a  consequence,  if  they  are  not  the  cause,  and  no  pains  should 
be  spared  to  relieve  them,  and  i)rocure  cicatrization,  by  rest  and  mild  astringent 
ointments. 

Iodide  of  potash  should  be  given  if  there  is  any  evidence  of  syphilis,  with 
enemata  of  lotio  nigra  ;  but  it  is  only  of  use  when  there  are  specific  ulcers ;  it  has 
no  effect  upon  the  scars.      Cod-liver  oil  is  of  great  benefit  even  in  cases  that  are 


982    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

not  tubercular  ;  jjure  milk  diet  may  be  tried  with  advantage  for  a  time  ;  and,  in 
short,  every  attempt  nuist  be  made  to  restore  strength,  while  soothing  the  affected 
parts  as  much  as  ])Ossible. 

2.  Local.  —  Gradual  dilatation'x-r,  the  most  successful  ;  forcible  stretching,  un- 
less the  stricture  is  actually  at  the  orifice,  is  dangerous.  Where  the  opening  is 
small  and  the  tissues  dense,  a  laminaria  tent  may  be  used  ;  but  in  most  cases  gum- 
elastic  bougies  of  different  sizes,  well  softened  and  well  greased,  are  preferable.  A 
small  injection  of  oil  is  given  first,  the  patient  lying  on  his  side,  and  the  bougie 
very  gently  guided  into  the  narrowed  part,  remembering  that,  particularly  in  old- 
standing  cases,  the  walls  are  very  soft  in  places  and  easily  torn.  As  a  rule,  the 
bougie  should  not  fit  the  stricture  closely,  but  if,  after  one  or  two  trials,  there  is  no 
pain  or  sign  of  irritation,  tapering  ones  may  be  used  with  caution.  In  some 
patients  the  bougie  must  be  withdrawn  after  a  few  minutes;  others  will  tolerate 
them  for  several  hours,  so  that  no  definite  time  for  their  withdrawal  can  be  men- 
tioned. A  suppository  of  acetate  of  lead  and  opium,  or  a  small  injection  of  starch 
and  laudanum,  should  be  introduced  as  soon  as  the  bougie  is  removed.  It  is  suffi- 
cient in  most  cases  if  this  is  done  every  second  or  third  day,  gradually  increasing 
the  size.  Where  it  is  possible,  the  treatment  should  be  kept  up  until  a  bougie  an 
inch  and  a  quarter  or  an  inch  and  a  half  in  diameter  will  pass  with  ease  ;  and 
even  then  it  is  essential  to  make  use  of  them  occasionally  afterward,  in  order  to 
prevent  a  relapse. 

Xot  unfretiuently,  after  the  treatment  has  been  carried  out  for  a  short  time, 
the  rectum  becomes  irritable  ;  the  skin  round  the  anus  red  and  tender  ;  the  amount 
of  discharge  increases  ;  and  there  is  a  certain  degree  of  feverishncss.  In  this  case, 
the  bougies  must  be  left  off  at  once,  the  patient  confined  to  bed,  and  local  seda- 
tives applied  until  the  inflammation  has  subsided  again.  If  the  treatment  is  per- 
sisted in,  ulceration,  and  perhaps  abscesses  and  fistula,  will  follow. 

Internal  division  o{  rtctdX  stricture  has  little  to  recommend  it;  sometimes, 
when  the  constriction  is  near  the  anus  and  the  mucous  membrane  only  is  involved, 
it  may  be  jtracticed  ;  but  unle.ss  great  care  is  taken,  it  is  not  unlikely  to  be  followed 
by  ulceration,  which  may  be  very  persistent.  In  the  congenital  annular  form, 
where  the  surface  is  healthy,  and  there  is  no  induration  beneath,  there  is  not  the 
same  objection.  The  bowels  are  thoroughly  opened,  the  anus  stretched  under  an 
anaesthetic,  and  the  sharp  margin  of  the  projecting  ring  divided  at  three  or  four 
points,  care  being  taken  not  to  penetrate  too  deeply.  The  patient  is  kept  lying 
down,  and  the  bowels  confined  for  three  or  four  days  ;  then  a  purgative  is  given, 
and,  after  the  motion,  the  mucous  membrane  is  thoroughly  washed  out  with  a  weak 
antiseptic.  Bougies  should  not  be  passed  for  two  or  three  days,  and  the  finger 
should  be  carefully  introduced  first  to  make  certain  that  the  wounds  are  healed. 

Electrolysis  has  been  tried  for  stricture  of  the  rectum,  as  for  the  stricture  of  the 
urethra,  the  negative  electrode  being  applied  to  the  face  or  the  interior  of  the  nar- 
rowed part;  but,  except  that  it  is,  perhaps,  more  rapid  in  its  action,  it  is  doubtful 
if  it  possesses  any  advantage  over  gradual  dilatation,  and  it  is  certainly  more 
likely  to  be  followed  by  irritation  and  ulceration. 

Linear  Proctotomy. — Unless  great  care  is  taken,  and  bougies  are  passed  at  fre- 
quent intervals,  relapses  are  almost  sure  to  occur,  sooner  or  later,  except,  perhaps, 
in  the  congenital  form.  P2ach  time  the  stricture  becomes  harder  and  denser,  and 
at  length  more  or  less  of  the  bowel  is  converted  into  a  rigid,  unyielding,  cartilagi- 
nous tube,  with,  perhaps,  abscesses  and  fistulse  around  it.  If  this  is  within  a  short 
distance  of  the  anus,  an  attempt  may  be  made  to  relieve  it  by  what  is  known  as 
linear  proctotomy.  The  rectum  is  thoroughly  washed  out,  the  patient  placed  in 
the  lithotomy  position,  and  the  finger  passed  through  the  stricture,  some  of  its 
fibres  being  divided  to  effect  this  if  necessary;  and  then,  with  a  long,  curved, 
sharp-pointed  bistoury,  the  whole  of  the  stricture-tissue  is  divided  as  near  the  mid- 
dle posterior  line  as  possible,  right  down  to  the  sacrum,  and  out  at  the  anus. 
Sometimes  there  is  free  hemorrhage,  especially  high  up  at  the  angle  of  the  wound, 
and  to  avoid  this  it  has  been  recommended  to  use  the  ecraseur  ;  but  it  can  usually 


MALIGNANT  STRICTURE.  983 

be  checked  without  difficulty  by  pressure.  The  operation  is  followed  by  profuse 
suppuration  ;  but  the  drainage  is  good  ;  there  is  free  escape  for  the  pus  ;  and  the 
part  is  placed  at  perfect  rest.  All  that  is  required  is  that  the  cavity  should  be 
well  irrigated  once  or  twice  a  day.  As  soon  as  the  wound  is  granulating  freely 
and  the  sloughs  have  separated,  generally  at  the  end  of  a  week  or  ten  days,  a  soft 
bougie  may  be  passed,  to  prevent  recontraction. 

Colotomy. — Finally,  where  this  has  failed  or  is  impracticable,  when  there  is 
obstruction  owing  to  stricture  high  up  in  the  bowel,  or  when  there  are  fistula, 
especially  if  they  communicate  with  neighboring  viscera,  colotomy  is  the  only 
resource. 

Malig/iant  Stricture. 

Epithelioma  of  the  anus  is  not  a  very  common  affection.  It  is  always  the 
squamouscelled  variety,  and  usually  commences  a,s  a  small  nodule  or  wart,  which 
may  at  first  be  mistaken  for  an  external  pile.  Before  long,  however,  the  surface 
breaks  down  and  ulcerates,  and  a  sore  is  left,  which,  if  it  lies  on  the  junction  of 
the  skin  and  mucous  membrane,  may  be  as  painful  as  fissure. 

Epithelioma  of  the  rectum,  on  the  other  hand,  is  of  very  frequent  occurrence, 
and  like  that  which  is  met  with  elsewhere  in  the  large  intestine,  may  appear  not 
only  in  old  age  but  during  young  adult  life.  It  may  involve  any  portion  of  the 
bowel;  but  usually  there  is  a  clear  ring  of  mucous  membrane  for  an  inch  or  so 
just  inside  the  anus  ;  and  not  unfrequently  the  surface  is  free  as  far  as  the  junction 
of  the  sigmoid  flexure  with  the  rectum,  so  that  the  growth  is  out  of  reach  of  the 
finger. 

Its  appearance  varies  very  much  in  different  cases.  At  the  very  commence- 
ment there  may  be  merely  a  hardened,  slightly  raised  patch,  seemingly  covered  by 
the  mucous  membrane  ;  soon,  however,  this  begins  to  spread,  both  in  extent  and 
depth.  The  surface  becomes  rough  and  uneven  ;  sometimes  it  grows  out  in  the 
form  of  a  nodule,  which  projects  into  the  bowel  and  attains  a  very  considerable 
size  before  it  breaks  down  ;  more  often  it  begins  to  ulcerate  almost  at  once,  and 
the  destruction  may  extend  so  deeply  as  to  leave  but  little  of  the  growth  at  the 
base.  The  margins  of  the  sore  are  raised,  thickened,  and  hard  ;  generally  they 
are  very  irregular  in  outline  ;  the  base  is  exceedingly  uneven,  not  unfrequently 
covered  with  sloughs,  and  at  times  bleeds  freely;  and  the  tissues  lying  beneath  it 
are  as  hard  as  cartilage,  and  so  fixed  as  to  be  quite  immovable.  Very  often  the 
ulcer  surrounds  the  intestine  like  a  ring,  and  the  contraction  of  the  tissues  outside 
is  so  great  that,  in  spite  of  the  destruction,  the  canal  is  almost,  if  not  altogether, 
closed  ;  in  other  cases  it  forms  a  deep  excavated  sore  on  one  side  or  behind,  ex- 
tending far  beyond  the  limits  of  the  bowel ;  and  in  others,  again,  the  whole  of 
the  interior  of  the  tube  for  some  inches  is  ragged  and  irregular  on  the  surface,  so 
that  nothing  can  be  felt  but  the  breaking  down  epithelial  growth. 

The  starting  point  of  the  growth  is  undoubtedly  in  connection  with  Lieber- 
kiihn's  follicles,  and  in  every  example  some  portion  of  the  tumor  can  be  found 
with  the  characteristic  adenoid  structure  of  cylindrical  epithelioma ;  but  in  some 
cases  the  epithelial  element  is  in  excess,  and  large  vascular  masses  of  new  growth 
are  formed,  soft,  like  encephaloid,  and  sprouting  into  the  interior  of  the  bowel ;  in 
others  the  fibrous  part  is  more  developed,  and  the  base  of  the  ulcer,  the  muscular 
coat  of  the  bowel,  and  the  fatty  tissues  around  are  infiltrated  with  a  dense  cica- 
tricial mass  to  such  an  extent  that  when  cut  across  it  has  all  the  appearance  of 
scirrhus.  The  sacral  and  coccygeal  glands  are  not  involved  till  late  :  secondary 
deposits,  unless  the  case  terminates  early,  are  usually  found  in  the  liver. 

Colloid  degeneration  of  small  portions  of  the  growth  is  not  uncommon,  and 
little  masses  like  boiled  sago  may  be  frequently  found  here  and  there  in  its  sub- 
stance ;  much  more  rarely  the  whole  growth  is  involved.  Other  forms  of  malig- 
nant disease  are  very  rare.  One  or  two  examples  of  sarcoma  are  recorded,  and 
melanotic  growths  have  been  known  to  occur. 

Symptoms. — The  onset  is  peculiarly  insidious,  and,  especially  when  the 


984     DISEASES  AND  INJURIES   OF  SPECIAL  STRUCTURES. 

growth  involves  the  uiijier  i)art  of  the  rectum,  and  assumes  the  annular  type,  com- 
plete obstruction  may  occur  sucUlenly  and  without  warning  of  any  kind,  the  orifice 
being  blocketl  either  with  a  small  mass  of  hardened  f;^ices  or  by  a  fold  of  the 
mucous  membrane.  As  a  rule,  however,  all  the  symptoms  of  non-malignant 
ulceration  and  stricture  are  present  in  an  aggravated  form. 

At  first  there  is  merely  an  uneasy  consciousness  of  the  existence  of  the  part, 
with  a  certain  amount  of  irritation  about  the  anus ;  or  there  is  a  slight  discharge 
of  blood-stained  mucus,  and  the  i)atient  imagines  that  he  has  piles;  then  it  be- 
comes distinctly  painful,  especially  after  exercise  or  when  the  bowels  have  acted. 
Sometimes  this  pain  is  of  a  dull,  aching,  continuous  character;  or  more  often  it 
takes  the  form  of  violent  neuralgia,  shooting  down  all  the  l)ranches  of  the  sacral 
plexus,  especially  on  the  left  side.  Occasionally  it  is  relieved  by  the  passage  of 
the  faices  ;  much  more  often  every  action  of  the  bowels  makes  it  tenfold  worse, 
and,  in  spite  of  the  constant  desire  and  sense  of  fullness  in  the  rectum,  the  patient 
looks  forward  to  it  with  dread.  As  the  passage  becomes  narrowed,  the  straining 
and  tenesmus  grow  more  and  more  severe ;  the  faeces  come  away  in  hardened 
lumps;  attacks  of  constipation  alternate  with  a  kind  of  spurious  diarrhoea;  a 
blood-stained  and  very  offensive  discharge  is  continually  oozing  out;  the  skin 
becomes  inflamed  and  sore;  prolai)se  of  the  mucous  membrane  or  hemorrhoids 
occur;  abscesses,  with  violent  throbbing  and  high  fever,  form  in  the  cellular  tissue 
around,  and  leave  behind  them  fistulre,  which  may  open  on  the  exterior  or  com- 
municate with  the  bladder  or  vagina;  and  at  length  the  patient  becomes  utterly 
worn  out  by  the  suffering. 

Death  may  be  caused  at  any  time  by  peritonitis,  hemorrhage,  or  obstruction  ; 
or,  if  no  com])lication  of  this  kind  sets  in,  secondary  deposits  make  their  appear- 
ance in  the  liver,  the  legs  begin  to  swell,  there  is  complete  inability  to  take  any 
food,  night  sweats  come  on,  and  the  patient  sinks  from  exhaustion,  worn  out  by 
the  constant  pain,  and  emaciated  to  the  last  degree.  The  duration  is  very  vari- 
able, and,  owing  to  the  insidious  character  of  the  earlier  symptoms,  exceedingly 
hard  to  estimate.  As  a  rule,  it  is  very  much  more  rapid  in  the  young  than  in  the 
old  ;  some  of  the  quickly-growing  {"ungating  forms  prove  fatal  within  a  few  months  ; 
others,  in  which  the  hard  and  dense  fibrous  stricture  tissue  predominates,  last  for 
five  and  even  six  years.  Unless  some  accidental  complication  appears,  three 
years  may  be  taken  as  the  average. 

Diagnosis. — In  advanced  cases  there  is  no  difficulty  ;  the  severity  of  the 
pain,  the  peculiarly  offensive  character  of  the  blood-stained  discharge,  and  the 
appearance  of  the  anus,  surrounded  with  piles  and  inflamed  folds  of  skin,  are  suf- 
ficient. If  the  finger  is  introduced,  it  comes  into  contact  with  a  hard,  uneven 
stricture,  generally  about  two  inches  from  the  anus.  The  orifice  is  often  very 
small,  and  any  attempt  to  pass  even  the  tip  through  is  attended  with  extreme 
pain  ;  the  surface  is  rugged  and  dense,  but  breaks  down  at  once  with  pressure, 
bleeding  freely  ;  and  above  there  is  a  large,  irregular  cavity,  the  walls  of  which 
are  ulcerated  all  over.  It  is  only  in  very  extreme  cases  of  syphilitic  or  dysenteric 
ulceration  that  anything  similar  is  produced.  In  the  earlier  stages  of  the  disease, 
which  are  rarely  seen,  careful  examination  is  necessary,  especially  as  this  form 
of  carcinoma  is  not  at  all  uncommon  in  young  adult  life,  and  any  growth  in  the 
bowel  \vhich  is  surrounded  by  induration,  or  which  cannot  be  moved  freely  upon 
the  subjacent  tissue,  should  be  regarded  with  very  grave  suspicion,  and  a  thorough 
investigation  under  an  anaesthetic,  with  the  anus  well  dilated,  insisted  upon. 

When  the  growth  occurs  in  the  higher  part  of  the  rectum,  above  the  reach  of 
the  finger,  the  patient  may  complain  of  attacks  of  diarrhcea  alternating  with  con- 
stipation, but  asa  rule  nothing  else  is  noticed,  until  the  constriction  is  far  advanced 
and  obstruction  imminent. 

Treatment. — i.  Radical. — In  all  cases  in  which  it  is  possible  to  remove  it 
thoroughly,  the  affected  portion  should  be  excised  without  delay.  It  is  very  diffi- 
cult to  say  how  long  a  patient  affected  with  carcinoma  of  the  rectum  may  live 
without  operation,  but  there  is  no  question  that,  if  the  diagnosis  is  made  before 


MALIGNANT  DISEASE  OF  THE  RECTUM.  985 

the  disease  is  far  advanced,  and  the  whole  of  it  is  removed,  it  may  be  years  before 
there  is  any  recurrence  ;  and,  in  the  meanwhile,  at  the  risk  of  what  is  not  at  that 
time  a  serious  operation  (whatever  it  may  be  later),  the  patient  is  relieved  from  a 
source  of  unceasinjj;  i)ain.  For  this  to  succeed,  however,  certain  conditions  are 
essential.  The  patient  must  be  in  a  good  state  of  health  ;  extreme  old  age  is,  of 
course,  a  bar,  but  even  (juite  late  in  life,  if  the  kidneys  are  sound  and  the  patient  is 
not  ])lethoric,  excision  is  successful,  provided  the  local  conditions  are  good.  The 
growth  must  be  within  a  reasonable  distance  of  the  anus  ;  that  is  to  say,  the  finger 
must  be  able  easily  to  reach  above  its  highest  limit  all  round  the  bowel.  In  the 
female,  the  peritoneal  fold  is  usually  less  than  three  inches  from  the  anus ;  in  the 
male  it  is  an  inch  higher,  and  it  may  be  raised  still  more  by  moderate  distention 
of  the  bladder  ;  so  that,  especially  in  the  latter  case,  a  very  considerable  portion 
of  the  bowel  may  be  removed.  If,  however,  the  anterior  surface  is  involved  high 
up,  an  operation  is  rarely  advisable,  not  so  much  from  the  fear  of  opening  the 
peritoneum,  as  because  the  growth  is  almost  sure  to  have  extended  to  it.  Further, 
the  wall  of  the  rectum  must  be  freely  movable  on  the  outside  tissues.  The  case  is 
most  favorable  when  the  disease  is  limited  to  the  posterior  wall  or  the  sides  of  the 
bowel.  If  it  involves  the  anterior  surface  to  any  extent,  or  if  it  has  formed  a 
complete  ring,  there  is  almost  sure  to  be  extensive  infiltration  of  one  part  or  an- 
other. In  this  respect,  again,  the  prospect  is  distinctly  not  so  good  in  women  as 
it  is  in  men  ;  the  vagina  becomes  implicated  much  sooner  than  the  prostate ;  and 
though,  according  to  Cripps,  the  operation  is  practicable  so  long  as  the  vaginal 
mucous  membrane  remains  free,  it  becomes  very  much  more  serious.  Finally, 
there  must  be  no  secondary  deposit  in  the  liver,  and  no  glandular  enlargement, 
either  sacral,  or,  if  the  anus  is  involved,  inguinal. 

Excision  of  the  Rectiun. — The  patient  is  prepared  in  the  usual  way,  by 
enemata,  placed  under  an  anaesthetic,  and  secured  with  Clover's  crutch.  The 
incisions  are :  (i)  a  crescentic  one  on  each  side,  surrounding  the  anus  (through 
the  skin,  if  the  external  sphincter  must  be  removed;  through  the  mucous  mem- 
brane inside  the  bowel,  if  this  is  not  affected),  and  (2)  a  median  one  nmning 
back  from  this  to  the  tip,  or  a  little  to  the  left  side  of  the  coccyx.  The  former 
should  open  up  the  ischio-rectal  fossae  thoroughly  on  each  side  ;  the  latter  should 
divide  the  posterior  wall  of  the  bowel,  from  above  the  growth  down  its  whole  length. 
It  is  usually  recommended  to  make  the  vertical  one  first,  by  transfixion  with  a 
sharp-pointed  bistoury,  from  within  the  bowel,  as  this  enables  at  once  a  thorough 
examination  of  the  growth  to  be  made  in  every  direction. 

The  levator  ani  must  be  cut  through  with  scissors,  the  anterior  wall  dissected 
off  the  prostate  or  vagina,  as  the  case  may  be  (a  catheter  or  the  finger  being  used 
to  give  notice  of  any  approach  to  these  organs),  and  the  sides  of  the  bowel 
separated  as  high  up  as  required.  As  soon  as  it  is  thoroughly  detached,  the 
lower  end  is  carefully  cut  off  with  stout  curved  scissors,  clamps  being  placed 
at  once  on  any  vessels  that  bleed.  If  the  peritoneum  is  widely  opened,  it  must 
be  secured  with  sutures  ;  under  other  circumstances  the  sides  of  the  wound  fall 
together. 

The  bowel  should  not  be  drawn  down  and  sutured  ;  the  tension  is  too  great, 
and  it  encourages  the  retention  of  the  wound  secretion.  A  large  drainage  tube 
should  be  inserted,  and  the  whole  cavity  lightly  plugged  with  iodoform  gauze. 
This  may  be  allowed  to  come  away  of  itself  in  forty-eight  hours,  by  placing  the 
patient  in  a  warm  boracic  bath. 

As  a  rule,  granulation  and  cicatrization  are  very  rapid,  and  but  little  after- 
treatment  is  required  ;  the  upper  end  of  the  bowel  is  drawn  down  and  the  sides  fall 
together.  As  soon  as  healing  is  well  established,  a  bougie  should  be  passed  at 
frequent  intervals  as  often  as  required  ;  or  if  this  is  not  sufficient,  the  patient  should 
wear  a  suitably  shaped  vulcanite  plug. 

The  operation  is  a  severe  one  even  when  the  peritoneum  is  not  opened  ;  but  if 
the  removal  is  complete  and  early,  there  is  no  doubt  the  duration  of  life  is  pro- 
longed. The  degree  of  comfort  depends  upon  the  success  with  which  contraction 
63 


9S6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

is  avoided.  In  rare  cases  the  patient  regains  control  (this  is  one  reason  for  leaving 
the  external  sphincter  when  possible)  ;  more  frecjuently  they  are  comfortable  so 
long  as  there  is  no  diarrhuea,  but  a  bougie  must  be  used  regularly.  Occasionally 
the  cicatrization  is  very  obstinate.  If  a  strip  of  mucous  membrane  can  be  left  the 
contraction  is  less  .severe,  but  the  risk  of  recurrence  is  greater. 

Resection  of  the  Rectum. — In  Germany  operations  on  the  rectum  have  been 
carried  very  much  further  than  in  England.  Kraske,  of  Freiburg,  for  example,  does 
not  hesitate  to  remove  the  coccyx,  divide  the  left  sacro-sciatic  ligament,  and,  if 
necessary,  chisel  off  part  of  the  sacrum.  In  this  way  the  side  of  the  rectum  is 
exposed,  the  diseased  part  can  be  freely  excised,  and  the  upper  end  of  the  bowel 
drawn  down  and  secured  to  the  lower. 

Bardenheuer  does  not  limit  the  operation  to  malignant  growths,  but  includes 
cases  of  recto-vaginal  fistulas  with  a  very  large  defect  or  with  considerable  kinking 
of  the  bowel,  and  some  cases  of  stricture  (although  the  presence  of  inflammatory 
adhesions  usually  prevents  this).  The  whole  of  the  rectum  and  part  of  the  intestine 
above  (upward  of  ten  inches)  have  been  removed. 

The  incision  runs  from  the  posterior  margin  of  the  anus  to  the  middle  of  the 
sacrum  ;  the  soft  parts  are  detached  from  the  bone,  the  sacro-sciatic  ligaments 
divided,  and  the  sacrum  itself  cut  across  at  the  level  of  the  third  vertebra.  The 
wound  is  widened  by  tearing  the  tissues  in  the  middle  line  with  the  index  fingers, 
and  everything  on  the  inner  aspect  of  the  levator  ani  that  surrounds  the  bowel  is 
detached  by  degrees  until  the  rectum  (below  the  growth)  is  thoroughly  isolated. 
A  loop  is  then  passed  round  it,  the  peritoneum  separated  off  (opened  if  necessary), 
and  the  bowel  drawn  down  and  divided  about  an  inch  and  a  half  above  the  growth. 
The  mucous  and  muscular  coats  are  then  united  by  separate  sets  of  sutures  and  the 
wound  plugged  with  iodoform  gauze. 

2.  Palliative. — Where  excision  of  the  disease  is  impracticable  the  only  thing 
left  is  to  render  the  patient's  life  as  endurable  as  i)ossible  and  treat  the  symptoms 
as  they  arise.  The  general  treatment  must  be  the  same  as  in  ulceration  and  stricture 
due  to  other  causes:  the  motions  must  be  kept  soft  and  small,  the  diet  must  be 
nutritious  and  easily  digested,  and  the  pain  relieved  by  sedative  injections,  but  care 
should  be  taken  to  avoid  establishing  a  morj^hia  habit  in  the  earlier  days  of  the 
disease  ;  in  the  later  ones  it  cannot  be  helped.  Diarrhcea  must  be  checked  at  once 
by  starch  and  opium  ;  the  less  frequently  the  bowels  act  the  better,  so  long  as  there 
is  no  obstruction.  Constipation  caused  by  early  contraction  of  the  stricture  is  more 
difficult  to  deal  with  ;  as  a  rule,  when  the  disease  is  high  up,  it  is  an  indication  for 
colotomy  ;  but  if  it  is  quite  close  to  the  anus,  and  an  operation  is  not  thought 
advisable,  relief  maybe  obtained  by  bougies  ;  this,  however,  is  only  jjracticable  in 
exceptional  cases,  and  even  then  the  pain  is  so  severe,  and  the  risk  of  perforating 
the  bowel  and  setting  up  inflammation  around  it  so  great,  that  it  can  scarcely  be 
recommended.  Sometimes,  when  there  is  a  great  fungating  mass  in  the  interior 
of  the  bowel,  it  is  possible  to  tear  it  away  or  scrape  it  out,  the  anus  having  been 
dilated  first,  so  that  there  may  be  free  access  to  every  part ;  and  it  is  said  that  if  the 
operation  is  rapidly  performed,  there  is  but  little  hemorrhage  ;  but  every  precaution 
should  be  taken  beforehand.  Finally,  if  obstruction  sets  in,  if  fistulce  form, 
whether  they  open  on  the  exterior  or  into  one  of  the  neighboring  viscera,  or  if 
there  is  intense  pain  caused  by  the  passage  of  the  faeces  over  the  ulcerated  surface, 
colotomy  should  be  performed,  as  already  described,  either  in  the  inguinal  or 
luml)ar  region.  Unhappily,  it  can  do  little  or  nothing  in  the  way  of  relieving 
the  intense  neuralgia  which  is  caused  by  the  disease  involving  the  sacral  plexus. 

Villous  Tumor  of  the  Rectum. 

Villous  growths,  similar  to,  but  rather  coarser  than  the  fimbriated  papilloma 
of  the  bladder,  are  occasionally  met  with  in  the  rectum.  AUingham,  who  has  had 
the  widest  experience  of  them,  describes  them  as  forming  a  soft,  lobulated,  spongy 
mass,  either  sessile,  or  with  a  pedicle  formed  from  the  subjacent  mucous  membrane. 


VILLOUS  TUMOR  OF  THE  RECTUM.  987 

In  most  cases  they  grow  from  the  posterior  wall  rather  hi^'h  up,  and  by  far  the 
greater  number  occur  in  people  over  fifty  years  of  age.  \x\  some  they  caused 
severe  hemorrhage,  and  the  growth  occasionally  became  prolapsed  ;  but  the  most 
striking  feature  is  the  constant  discharge  of  large  (piantities  of  thin,  watery  mucus. 
The  diagnosis,  unless  some  portion  of  the  growth  is  forced  out  through  the  anus, 
is  exceedingly  difficult,  owing  to  the  jjeculiar  soft,  velvety  feel  of  the  mass,  which 
prevents  its  being  distinguished  from  the  natural  folds  of  the  mucous  membrane. 
The  only  treatment  is  free  excision  ;  and  this  is  especially  necessary,  as  in  a  large 
proportion  of  cases  malignant  disease  followed. 

Nrevus  of  the  rectum  is  occasionally  met  with,  and  may  give  rise  to  very  pro- 
fuse hemorrhacre. 


988    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  XX. 

INfURIES  AND  DISEASES  OF  THE  KIDXE  VS. 
ABNORMALITIES. 


Form  and  Number. 

The  kidneys  are  occasionally  united  together  more  or  less  closely.  There 
may  be  only  a  fibrous  band  between  them,  or  the  upper  or  lower  ends  may  be  joined 
together,  so  as  to  form  a  horseshoe-shaped  mass  in  front  of  the  vessels  ;  or  they 
may  be  fused  into  an  irregular  disc,  lying  somewhere  near  the  middle  line  and  not 

un frequently  as  low  down  as  the  sacnmi 
(Fig.  416).  As  a  rule  there  is  but  little 
inconvenience  from  this  ;  but  cases  are 
recorded  in  which  thrombosis  of  the  great 
veins  and  hydronephrosis  have  occurred  ; 
and  in  one  instance  the  pain  during  the 
menstrual  period  was  so  great  that  an  opera- 
tion was  undertaken  for  the  removal  of  the 
offending  mass  without  its  being  known  that 
it  was  the  only  kidney. 

Size  and  Position. 

Variations  in  size  are  still  more  com- 
mon.     One  kidney  may  be  absent,  and  that 
too  without  the  other  showing  any  remark- 
able change.      Both  ureters  may  be  present 
coming  from  the  single  kidney,  one  crossing 
to  the  other  side.     More  often,  without  being 
altogether  deficient,  one   kidney  is  so  small 
that  it  is  doubtful  whether  it  could,  single- 
handed,  be  sufficient   for  the   work    of  the 
/t  a       body.     This  occurs  so  frequently  as  the  con- 
y  F-al       sequence  of  disease  that  in  all  cases  in  which 
/  f       ^  I'fA      ^^^  removal  of  a  kidney  is  contemplated  it 

1  //^i^     ^^  essential  to    obtain   definite  information 

X_,       j  ^  y  [j  with  regard  to  the  efficiency  of  the  other. 

The  vessels  are  often  abnormal,  both  in 
position  and  origin.  The  most  serious 
deviation  is  when  an  artery  arises  from  the 
aorta  higher  up  or  lower  down  than  ordinary, 
or  from  the  common  iliac.  This  is  said  to 
occur  about  once  in  seven.  The  ureter  may 
be  double  either  at  its  commencement  or  for  the  whole  of  its  course.  Usually  its 
direction  is  fairly  straight ;  but  sometimes  it  is  seriously  distorted  or  compressed  by 
tumors ;  and  occasionally,  just  where  it  springs  from  the  pelvis,  there  is  a  valve  of 
mucous  membrane  which  may  act  as  a  very  grave  obstruction  to  the  flow  of  urine. 
The  kidneys  are  not  unfrequently  found  lower  down  in  the  abdomen  or  in 
front  of  the  vessels,  especially  when  there  is  any  malformation.  Sometimes  they 
lie  over  the  sacro-iliac  synchondrosis,  or  even  in  the  iliac  fossa  ;  and  they  may  be 
the   source  of  very  serious  trouble  from  enlargement  at  the  menstrual  period, 


-'uUV 


\\. 


\N 


Fig.   416. — Single    Median    Kidney    lying    below 
the  Bifurcation  of  the  Aorta. 


DISEASES  OF  THE  KIDNEYS.  989 

or  from  acting'  as  an  obstruction  during  i)arturition.  Pressure  as  a  rule  causes 
a  i)eculiar  sickening  pain,  and  sometimes  after  handling  blood  appears  in  the 
urine. 

Movable  and  Floating  Kidneys. 

Owing  to  the  loose  character  of  the  surrounding  tissues,  the  kidneys  are  always 
slightly  movable.  If  the  lower  end  is  exposed  from  the  loin  it  may  be  seen  to 
ascend  and  descend  with  resjiiration  ;  and  it  can  be  pressed  forward  with  the 
finger  or  pushed  back  again  by  the  hand  upon  the  abdomen.  When  this  move- 
ment is  so  free  that  it  can  be  felt  plainly  from  the  outside,  the  kidney  is  said  to  be 
movable  ;  it  is  floating  if  the  range  is  greater  still,  so  that  it  comes  into  contact 
with  the  front  wall  of  the  abdomen.  In  the  latter  case  there  may  be  a  mesone- 
phron,  or  fold  of  ])eritoneum  investing  the  kidney  like  a  portion  of  the  small 
intestine,  but  it  is  very  unusual. 

Movable  kidney  is  more  common  on  the  right  side  than  on  the  left,  and  in 
women  than  in  men.  The  former  fact  is  probably  to  be  accounted  for  by  the 
downward  pressure  of  the  liver  and  by  the  shortness  of  the  left  renal  artery  ;  the 
latter  by  various  reasons,  of  which  the  use  of  stays,  the  effect  of  repeated  preg- 
nancies, causing  great  relaxation  of  the  abdominal  wall  after  great  tension,  and 
the  comparatively  sudden  alterations  in  the  amount  of  perirenal  adipose  tissue 
common  under  the  same  circumstances,  are  the  most  important.  Conditions  like 
hydronephrosis,  calculus,  or  new  growths,  which  increase  the  weight  of  the  organ, 
may  assist,  but  of  themselves  are  scarcely  sufficient.  In  most  cases  the  immediate 
cause  is  stated  to  be  an  accident  of  some  kind,  such  as  a  fall  in  the  sitting 
position. 

Symptoms. — Sometimes  a  floating  kidney  merely  causes  inconvenience; 
sometimes,  on  the  other  hand,  even  when  it  is  only  slightly  movable,  it  gives  rise 
to  intense  suffering.  A  feeling  of  weight  or  of  dragging,  or  of  something  being 
loose,  is  always  present,  and  during  the  menstrual  period  and  after  exertion  is  very 
severe  ;  riding  is  out  of  the  question  ;  and  stooping  and  walking  are  very  painful. 
Attacks  resembling  renal  colic,  attended  with  vomiting  and  great  prostration,  are 
of  frequent  occurrence  ;  occasionally  there  is  jaundice,  or  oedema  from  pressure 
upon  the  veins  ;  sometimes  the  ureter  becomes  partially  blocked  from  twisting, 
causing  temporary  hydronephrosis  ;  dyspepsia  and  loss  of  health  and  strength  are 
almost  always  present,  and  in  many  cases  the  patients  become  hysterical  or 
hypochondriacal,  so  that  they  have  even  been  known  to  make  away  with  them- 
selves. 

The  shape  of  the  kidney  can  sometimes  be  recognized  through  the  abdominal 
wall  ;  the  patient  should  be  placed  in  the  recumbent  position  with  the  hips  well 
flexed  ;  and  if  there  is  much  pain  or  tension,  an  anaesthetic  may  be  given.  If  the 
organ  is  not  much  out  of  place,  it  can  usually  be  grasped  between  the  hands,  one 
buried  deep  in  the  flank,  outside  the  erector  spinse,  the  other  working  downward 
on  to  it ;  in  other  cases,  when  it  lies  in  the  iliac  fossa  or  on  the  crest,  the  outline 
can  be  felt  at  once.  Very  often  a  better  idea  may  be  obtained  by  placing  the 
patient  upon  the  hands  and  knees,  that  the  weight  of  the  organ  may  bring  it  for- 
ward. Percussion  in  the  flanks  is  rarely  of  much  service  ;  and  unless  the  handling 
is  very  rough  or  the  kidney  disea.sed,  there  is  no  reason  why  the  secretion  of  urine 
should  show  any  change. 

There  is  some  reason  to  believe  (though  it  cannot  be  considered  proved)  that 
movable  kidneys,  independently  of  the  accidents  that  may  befall  them  from  twist- 
ing of  the  ureter,  are  more  liable  to  be  affected  by  disease  than  others. 

Diagnosis. — Floating  kidney  itself  is  rarely  mistaken,  but  many  other  con- 
ditions have  been  taken  for  it.  Distended  gall-bladders,  facal  masses  in  the 
colon,  omental  cysts,  tumors  of  the  pancreas,  carcinoma  of  the  pylorus,  ovarian 
cysts,  floating  spleen,  and  many  others  having  been  diagnosed  as  such,  and  in 
some  instances  the  mistake  was  not  apparent  until  the  abdomen  had  been  opened. 
Even  when  the  tumor  is  superficial,  it  is  easy  to  be  misled  by  a  vague  resemblance 


990    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

in  sha]ie  ;  when  it  is  deep  and  scarcely  movable,  there  may  be  nothing  but  the 
peculiar  character  Of  the  renal  pain  to  serve  as  a  guide. 

Treatment. — In  the  slighter  cases  the  patient  may  be  fitted  with  an  elastic 
abdominal  belt,  reaching  well  down  to  the  pubes  and  Poupart's  ligament,  with  an 
air-pad  over  the  displaced  organ  to  hold  it  up  and  press  it  back  into  the  loin. 
^'iolent  exercise,  especially  riding,  or  anything  attended  with  jolting,  must  be 
avoided.  If  attacked  by  renal  colic,  the  patient  should  be  placed  in  bed,  the 
bowels  well  opened,  and  dry  cups  and  hot  fomentations  applied  over  the  loins.  If 
this  does  not  give  relief,  and  the  condition  of  the  patient  is  such  that  it  is  necessary 
to  adopt  a  more  active  line,  the  kidney  may  be  exposed  in  the  loin  and  stitched 
in  situ  {jicphrorrhaphy) .  The  incision  is  almost  the  same  as  for  lumbar  colotomy  ; 
the  structures  are  divided  in  the  same  way,  and  the  perirenal  fat  exposed.  This 
should  be  freely  divided,  and  (while  an  assistant  from  in  front  pushes  the  kidney 
back  into  its  place)  several  catgut  sutures  passed  through  its  capsule,  so  as  to  fasten 
it  to  the  lumbar  aponeurosis  over  as  wide  an  area  as  jjossible.  A  drainage  tube 
should  be  introduced  down  to  the  surface  of  the  kidney,  with  the  view  of  exciting 
a  certain  degree  of  inflammation.  Probably,  the  ultimate  benefit  many  of  these 
cases  derive  is  dependent  more  upon  the  adhesions  that  form  around  the  kidney 
than  upon  the  sutures,  which  must  soon  be  absorbed. 

A  healthy  kidney  should  never  be  removed  merely  because  it  is  floating,  but 
a  large  proportion  of  true  floating  kidneys  are  diseased  in  some  way  or  other,  and 
then  the  conditions  are  completely  altered.  The  abdominal  operation  is  always 
preferred  in  these  cases,  as  it  enables  a  better  idea  to  be  formed,  not  only  of  the 
diseased  kidney,  but  of  the  other  one. 


INJURIES  OF  THE  KIDNEY. 

Contusions  and  Lacerations. 

Tearing  or  bruising  of  the  kidney  is  usually  the  result  of  direct  violence,  such 
as  a  blow  upon  the  lumbar  region,  or  crushing,  as  in  railway  accidents  ;  or  it  may 
be  produced  by  a  sudden  fall  in  a  sitting  position.  The  extent  varies  from  merely 
a  superficial  contusion  to  complete  disorganization,  and  the  symj^toms  depend 
partly  upon  the  hemorrhage  and  the  escape  of  urine,  partly  upon  the  injury 
inflicted  on  neighboring  structures. 

Hemorrhage. — The  amount  of  blood  lost  is  very  variable;  in  injuries  of  the 
cortex  only  there  is  rarely  very  much,  but  if  the  rent  traverses  the  hilum,  or  one 
of  the  larger  arteries  has  given  way,  particularly  if  the  peritoneum  is  torn  so  that 
there  is  a  large  space  for  it  to  collect  in,  the  patient  may  bleed  to  death.  Usually, 
it  pours  down  the  ureter  and  collects  in  the  bladder,  either  at  once,  or  after  an 
interval  of  a  few  hours.  If  the  quantity  is  large,  coagulation  is  not  uncommon, 
and  long,  worm-like  clots  may  form  in  the  ureter,  giving  rise  to  the  symj^toms  of 
renal  colic,  or  even  causing  obstruction  and  hydronephrosis.  In  other  ca.ses,  the 
bladder  becomes  filled  ;  there  is  severe  pain  over  the  pubes  and  at  the  end  of  the 
penis,  and,  if  means  are  not  taken  to  break  up  and  remove  the  coagula.  decom- 
position may  occur,  and  cause  acute  cystitis.  The  color  at  first  is  bright ;  but, 
unless  the  hemorrhage  persists,  in  a  day  or  two  it  becomes  smoky,  and  then  grad- 
ually clears  up. 

Hemorrhage  around  the  kidney  may  occur  in  severe  injuries  ;  a  swelling 
forms  rapidly  over  the  loins,  and,  later,  staining  makes  its  appearance  in  the  in- 
guinal region,  and  even  in  the  scrotum,  as  the  blood-stained  serum  travels  down- 
ward along  the  course  of  the  vessels. 

Extravasation  of  urine  is  rare,  unless  the  pelvis  of  the  kidney  or  the  ureter 
is  torn.  Sometimes  it  escapes  into  the  peritoneal  cavity  ;  more  frequently  it  col- 
lects in  the  loose  cellular  tissue  around  the  kidney,  and,  setting  up  a  certain 
amount  of    inflammation,  gradually  forms  a  thin-walled  cyst,  which  grows  larger 


INJURIES  OF  THE   KIDNEY.  991 

and  larger,  until  it  can  be  felt  from  the  loins  to  the  abdomen.  This  has  been 
called  spurious  or  traumatic  hyJronephrosis,  but  the  condition  is  entirely  different. 
As  a  rule,  after  a  few  days  or  weeks,  the  extravasation  becomes  general,  and  either 
acute  peritonitis  sets  in,  or  the  patient  sinks  from  septic  absorption,  caused  by  the 
suppuration  and  sloughing  around  the  kidney. 

The  other  symptoms  are  not  characteristic.  Pain  is  always  present,  usually  of 
a  peculiar,  sickening  character,  especially  when  any  pressure  is  made  upon  the 
part,  and,  in  many  cases,  it  radiates  down  the  thigh  or  to  the  testicle.  All  over 
the  lumbar  region  there  is  great  tenderness.  The  muscles,  both  of  the  abdomen 
and  in  the  loins,  are  rigidly  contracted  ;  the  body  is  bent  to  the  injured  side  and 
the  hip  is  kept  in  the  flexed  position.  Sometimes  there  is  pain  along  the  course 
of  the  lumbar  plexus,  and  very  often  the  testicle  is  retracted  up  to  the  ring ;  but, 
if  the  injury  is  confined  to  the  kidney,  shock  is  rarely  very  severe.  When  the 
patient  is  much  collapsed,  there  is  always  reason  for  fear  either  that  the  peritoneum 
has  given  way,  or  that  the  hemorrhage  has  been  extensive. 

Injuries  of  the  kidney  may  be  followed  by  true  hydronephrosis  from  occlu- 
sion of  the  ureter  ;  by  peritonitis  from  extravasation  of  the  urine  or  extension  of 
the  inflammation  ;  or  by  suppurative  nephritis  and  pyonephrosis,  the  suppuration 
occurring  partly  in,  partly  around  the  kidney.  When  this  happens,  if  the  patient 
survives,  urinary  fistulas  are  sometimes  left,  discharging  through  an  opening  in  the 
loin,  or  in  the  inguinal  region.  In  one  or  two  instances,  total  suppression  of 
urine  has  followed,  possibly  from  obstruction  to  the  renal  vessels,  but  almost  cer- 
tainly in  one  case  at  least  from  the  reflex  influence  of  the  nervous  system.  The 
same  thing  has  been  known  to  occur  after  operations  on  the  kidney. 

The  prognosis  depends  upon  the  extent  of  the  injury  and  the  nature  of  the 
complications  that  follow.  The  majority  recover  without  consequences  of  any 
kind  ;  but,  if  there  is  extravasation  of  urine,  or  much  loss  of  blood,  either  at  once 
or  later,  from  giving  way  of  the  clot  or  the  formation  of  an  aneurysm,  the  ques- 
tion becomes  very  serious.  Recovery,  either  complete  or  with  the  formation  of  a 
fistula,  may  take  place  even  after  suppuration  ;  general  peritonitis  is  almost  hope- 
less, as  this  rarely  comes  on  unless  the  injury  is  very  extensive. 

Treatment. — In  the  slighter  cases  all  that  is  necessary  is  to  confine  the  pa- 
tient to  bed  on  low  diet,  and  empty  the  colon  thoroughly  by  enemata.  If  bleeding 
continues,  the  side  may  be  bandaged,  or  Leiter's  coils  arranged  over  the  lumbar 
region,  and  half-drachm  doses  of  liquid  extract  of  ergot  given  every  two  or  three 
hours,*  only  allowing  the  patient  small  quantities  of  ice  to  suck.  A  small  amount 
of  clot  in  the  bladder  may  be  left  to  soften  and  come  away  of  itself;  but,  if  there 
is  much  distention  or  pain,  it  should  be  withdrawn  with  one  of  Bigelow's  evacu- 
ating tubes  and  a  suction  apparatus,  for  fear  of  decomposition  and  cystitis.  If  the 
hematuria  persi-sts,  and  it  is  almost  certain  from  the  amount  of  blood  that  is  lost, 
and  the  rapidity,  that  some  large  branch  is  torn,  an  incision  should  be  made  in 
the  loin,  and,  if  the  bleeding  cannot  be  checked  by  ligature  or  plugging,  the 
kidney  must  be  excised. 

Extravasation  of  blood  around  the  kidney  may  be  treated  in  the  same  way. 
If  the  swelling  is  very  large  and  threatens  to  suppurate,  the  bulk  of  it  may  be  re- 
duced by  aspiration,  and  subsequently  the  abscess  opened  and  drained.  When  it 
is  due  to  urine,  the  swelling  rarely  appears  until  some  days  have  elapsed,  and  the 
diagnosis  cannot  be  certain  until  some  of  the  fluid  is  withdrawn.  If  this  contains 
urea,  and  if  it  can  be  shown  by  the  aid  of  the  cystoscope  that  no  urine  enters  the 
bladder  from  the  corresponding  ureter,  nephrotomy  should  be  performed  at  once, 
the  most  convenient  time  being  chosen  after  the  patient  has  rallied  from  the  shock, 
before  there  is  any  septic  absorption.  In  other  cases  aspiration  may  be  tried,  and 
then,  if  necessary,  incision — the  fistula,  if  it  persists,  being  dealt  with  later. 


*  [Pills  of  gallic  acid  will  also  be  found  useful.] 


992     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Wounds  of  the  Kidnf.y. 

The  kidney  may  be  wounded,  either  through  the  loin  or  the  abdomen  ;  in  the 
latter  case  the  peritoneal  cavity  is  opened,  and  probably  other  organs  injured  as 
well.  In  one  or  two  cases  prolapse  has  occurred,  the  whole  organ  being  S(jueezed 
out  through  a  wound  in  the  loins. 

The  symptoms  are  the  same  as  in  contusion  of  the  kidney,  with,  in  addition, 
those  due  to  the  wound.  The  prognosis  dejjends  upon  the  nature  of  the  injury; 
incised  wounds  heal  readily;  gunshot  injuries,  on  the  other  hand,  are  very  likely 
to  be  followed  by -suppuration  and  sloughing  ;  but  extensive  urinary  infiltration  is 
not  common.  The  lumbar  ple.xus  may  be  torn,  the  colon  opened,  and  even  the 
peritoneal  cavity  traversed  by  a  bullet,  without  the  result  being  fatal.  Fistula 
however,  and  serious  bladder  troubles,  phosphatic  calculus  and  cystitis,  not  un- 
fre<]uently  make  their  appearance  afterward. 

Hemorrhage  should  be  checked  as  soon  as  possible,  and  any  foreign  bodies 
that  can  be  found  removed  at  once,  but  prolonged  exploration  with  a  probe  in 
order  to  find  a  bullet  is  not  advisable.  The  wound  should  be  left  open  ;  and,  as 
there  is  always  a  tendency  for  it  to  become  valvular,  a  large  tube  should  be  intro- 
duced down  to  the  bottom.  Later  on,  if  suppuration  occurs,  free  incisions  are 
necessary.  In  prolapse  of  the  kidney,  if  it  is  much  injured,  a  ligature  should  be 
placed  around  the  pedicle  and  the  organ  removed  ;  in  other  cases  an  attempt  may 
be  made  to  return  it. 


SURGICAL  AFFECTIONS  OF  THE  KIDNEYS. 

Suppression  of  Urine. 

The  secretion  of  urine  may  be  checked  in  various  ways.  A  calculus  may  be 
impacted  in  the  ureter ;  acute  nephritis  may  set  in  ;  or  some  sudden  shock  may 
give  the  circulation  such  a  check  that  the  blood  pressure  falls  too  low  ;  and  this 
may  happen  even  when  the  kidney  is  healthy.  If  it  is  already  diseased — if  there 
is,  for  example,  chronic  interstitial  nephritis,  so  that  the  secreting  power  is  already 
impaired,  and  the  fibrous  tissue  is  hard  and  unable  to  accommodate  itself  to  rapid 
changes  in  the  blood  supply — a  very  trivial  reason  is  sufficient,  and  a  cause  that  in 
a  healthy  kidney  is  scarcely  enough  to  bring  on  a  transient  flushing,  may  be  fol- 
lowed by  such  congestion  as  to  stop  the  secretion  altogether. 

Causes. — i.  Shock. — Suppression  of  urine  may  come  on  suddenly  from  one 
instant  to  another,  from  shock.  The  passage  of  a  catheter  may  cause  it,  even  when 
the  kidneys  are  sound  ;  if  they  are  diseased,  not  only  is  this  more  likely  to  happen, 
but  when  it  does  it  is  infinitely  more  serious.  In  the  one  case  it  is  transient 
(though  instances  to  the  contrary  are  not  unknown)  ;  in  the  other  it  may  be  final. 
This  is  one  of  the  chief  reasons  why  operations  on  the  urinary  organs  are  a  matter 
of  such  grave  consideration  when  the  kidneys  are  diseased.  So  long  as  no  extra 
strain  falls  upon  them  they  may  be  equal  to  their  work  ;  the  least  disturbance, 
reflex  or  direct,  is  enough  to  stop  the  secretion  altogether. 

The  way  in  which  the  sui)pression  is  caused  is  not  always  the  same.  It  is 
due,  no  doubt,  to  the  influence  of  the  nervous  system  ;  but  in  some  instances  the 
nerves  of  the  kidneys  only  are  involved,  in  others  the  effect  is  general.  In  the 
former  case  there  is  intense  renal  congestion  ;  only  a  small  amount  of  fluid  is 
excreted  ;  its  specific  gravity  is  high,  and  often  it  is  mixed  with  blood.  In  the 
latter  the  pressure  is  so  low  that,  as  in  injuries  to  the  upi)er  part  of  the  spinal  cord, 
or  in  the  shock  that  is  associated  with  injury  to  the  ])eritoneum,  the  blood  lies 
almost  stagnant,  and  no  urine  at  all  is  formed.  In  the  vast  majority  the  secretion 
recommences  of  itself;  but  the  result  may  ])rove  fatal,  either  from  general  shock 
or  from  persistence  of  suppression,  especially  when  the  cause  is  a  continuous  one, 
such,  for  example,  as  a  catheter  tied  in  the  urethra.  It  happens  in  women  as  well 
as  in  men  ;   it  has  been   known   in   children  ;  and  it  is  especially  common  after 


SUPPjRESSION  of  urine.  993 

injury  to  the  urinary  organs,  excluding  the  i)enile  urethra.  Nephrotomy  on  one 
side  has  been  known  to  cause  su|)pression  on  the  other,  so  that  there  was  for  some 
time  reason  to  fear  tliat  there  might  be  only  one  kidney  ;  calculus  impacted  in 
the  ureter  nearly  always  gives  rise  to  it ;  there  is  hardly  an  operation  about  the 
bladder  which  it  has  not  some  time  followed  ;  while  it  is  notorious  after  passing  a 
catheter  through  the  fixed  portion  of  the  urethra,  especially  in  cases  of  recent 
stricture  ;  in  old  ones  the  mucous  membrane  and  the  nerve  endings  in  it  seem  to 
lose  their  sensitiveness  altogether. 

2.  Acute  Inflammation. — Scarlet  fever,  cold,  cantharides,  extensive  lesions  of 
the  cutaneous  surface,  and  other  causes  occasionally  lead  to  such  extreme  conges- 
tion as  to  cause  suppression.  The  kidney  becomes  immensely  swollen  ;  the  cap- 
sule is  so  stretched  that  it  flies  apart  if  it  is  divided  with  a  knife ;  the  cortex  is 
thickened  and  either  deeply  congested  or  paler  than  natural,  according  to  the 
relative  amount  of  vascular  and  epithelial  change  ;  and  the  urine  (such  as  is 
secreted)  is  stained  with  blood,  of  high  specific  gravity,  and  loaded  with  albumin. 

Gradual  sui)pression  is  met  with  chiefly  in  suppurative  pyelonephritis.  This 
is  the  condition  which  has  received  the  exceedingly  misleading  name  of  surgical 
kidney,  and  which  so  frequently  proves  the  cause  of  death  in  cases  of  long  stand- 
ing stricture  or  enlargement  of  the  prostate.  The  kidney  is  already  in  a  state  of 
chronic  inflammation,  the  interstitial  connective  tissue  is  hard  and  den.se,  the 
secreting  structure  proportionately  degenerated,  and  the  specific  gravity  of  the 
urine  constantly  too  low;  suddenly  some  irritant  (a  catheter,  or  ammoniacal  de- 
composition of  the  urine)  causes  acute  inflammation  of  the  bladder ;  the  ureters, 
the  pelvis,  and  the  substance  of  the  kidney  speedily  become  involved  by  direct 
extension  ;  suppurative  pyelonephritis  sets  in  ;  a  number  of  minute  absce.sses  make 
their  appearance  in  the  cortex  ;  the  circulation  becomes  more  and  more  embar- 
rassed, the  secretion  more  and  more  difficult,  and  in  a  few  days  or  weeks  the 
patient  sinks  into  a  low  typhoid  state  with  partial  suppression  of  urine. 

3.  Obstruction  of  Ureter. — Sudden  closure  of  one  ureter  is  usually  followed 
by  intense  congestion  of  the  corresponding  kidney,  and  partial  suppression  of  urine 
in  the  other  from  shock.  If  the  obstruction  continues  the  latter  usually  recovers, 
but  the  former  gradually  becomes  more  and  more  dilated,  until  at  length  hydro- 
nephro-sis  follows. 

If  one  kidney  is  destroyed  in  this  way,  the  other,  provided  it  is  healthy, 
undergoes  compensative  hypertrophy  to  make  up  the  deficiency ;  and  the  urine 
that  collects  behind  the  obstruction  is  pale,  of  low  specific  gravity,  with  a  dimin- 
ished amount  of  urea,  and  sometimes  a  small  quantity  of  albumin.  If,  on  the 
other  hand,  the  second  kidney  is  actually  or  practically  non-existent,  suppression 
is  complete  from  the  first,  without  any  warning  other  than  that  given  by  the  pre- 
vious attacks  of  renal  colic. 

In  one  lady  under  my  care  total  suppression  had  already  lasted  nine  days 
(there  was  a  history  of  a  previous  attack  that  had  continued  for  six,  and  had  at 
length  yielded  with  the  passage  of  much  blood  and  gravel).  On  the  tenth  day  I 
opened  the  kidney  on  the  left  side  through  the  loin,  and  found  the  pelvis  at  an 
enormous  depth,  but  no  calculus  could  be  detected,  even  with  a  probe.  The 
patient,  who  was  at  the  time  suffering  from  the  most  intense  muscular  weakness, 
rallied  and  lived  for  a  month.  Post-mortem  it  was  found  that  the  right  kidney  and  • 
the  right  ureter  were  completely  absent ;  the  left  measured  eight  inches  by  four, 
and  was  somewhat  displaced  ;  there  was  a  large  calculus  impacted  low^  down  at  the 
junction  of  the  pelvis  with  the  ureter. 

Symptoms. — Suppression  of  urine  is  in  itself  only  a  symptom,  and  the  con- 
sequences that  follow  naturally  depend  upon  the  cau.se.  JV/ien  it  is  the  result  of 
shock,  whether  this  is  due  to  severe  injury  to  another  part  of  the  body,  or  is  the 
consequence  of  an  operation  upon  the  urinary  organs,  the  secretion  may  return 
within  a  few  hours,  before  any  harm  is  done,  or  the  shock  may  prove  fatal. 

In  nephritis  the  symptoms  are  to  some  extent  the  result  of  the  suppression. 
The  acute  form — that,  for  e.xample,  which  occurs  after  scarlet  fever — is  seldom 


994     niSEASES  AND   INJURIES   OF  SPECIAL   STRUCTURES. 


met  with  in  surgery,  and  cases  are  rarely  seen  with  the  tyi)ical  symptoms  of  rapid 
anasarca,  coma,  and  convulsions.  The  chronic  variety,  however,  that  which 
follows  irritation  of  the  urinary  organs  in  cases  of  stricture  and  enlargement  of 
the  prostate,  is  exceedingly  common.  The  symptoms  are  slow  in  their  onset  and 
very  insidious  ;  there  is  no  rigor,  though  the  temperature  may  rise  in  the  course 
of  a  day  or  two  to  102°  F.  or  103°  F.  ;  the  pulse  is  (juick  and  feeble,  the  tongue 
hard,  dry,  and  l)rown,  and  the  strength  fails  rai)idly.  The  patient  lies  i)rostrate, 
in  a  state  of  semi-unconsciousness  ;  the  mind  is  constantly  wandering  ;  there  is 
total  inability  to  take  food  ;  vomiting  is  not  unfre(iuent ;  very  often  there  is 
great  restlessness,  and  toward  the  end,  sometimes  coma;  but  convulsions  are 
rarely  present. 

Obstructive  suppression,  on  the  other  hand,  or  that  which  follows  the  removal 
of  the  only  working  kidney,  is  totally  different.  For  the  first  three  or  four  days 
there  is  nothing  at  all  remarkable  ;  then  gastric  disturl)ance,  with,  ])erhaps,  vomit- 
ing, sets  in  ;  but  the  most  striking  symptom  is  the  failure  of  the  muscular  strength. 
The  mind  is  quite  undisturbed,  the  temperature  is  not  raised,  and  the  j^ulse  is 
scarcely  quickened.  Generally  at  the  end  of  a  week,  but  sometimes  not  for  ten 
days,  a  change  sets  in,  and  then  the  end  comes  rapidly.  The  pujiils  become 
contracted,  the  muscles  begin  to  twitch,  the  temperature  falls  below  normal  ; 
the  respiration  becomes  difficult  and  panting,  owing  to  the  weakness  of  the 
muscles ;  the  patient  is  confined  to  bed  ;  sometimes  there  is  apathy  or  drowsi- 
ness, but  never  coma  or  convulsions,  and  intelligence  is  retained  to  the  last. 
Death  seems  to  be  due  to  resjiiratory  and  cardiac  failure  ;  a  week  or  ten  days  is 
not  an  unusual  time ;  in  a  few  instances  life  has  been  prolonged  for  even  greater 
periods. 

Hydronephrosis. 

By  this  is  meant  a  gradual  dilatation  of  the  pelvis  and  calyces  of  the  kidney, 
with  absorjition  of  the  secreting  part,  until  at  length  a  sac  is  formed,  large  enough 

perhaps,  to  contain  a  gallon  of  fluid,  or,  if  it 
occurs  before  birth,  to  prove  an  obstacle  to 
parturition. 

It  may  be  congenital  or  actjuired,  though 
the  latter  is  the  more  common  ;  and,  accord- 
ing to  the  cause,  it  may  affect  one  side  or 
both.  In  all  cases  it  appears  to  arise  from  an 
obstruction  to  the  outflow  of  urine  ;  the  se- 
cretion continues,  gradually  stretching  all  the 
surrounding  structures,  until  at  length  the 
renal  substance  is  so  thinned  that  it  is  no 
longer  able  to  work  ;  and  then  sometimes, 
l)ut  very  rarely,  the  fluid  may  lie  absorbed 
again.  The  secretion,  under  these  circum- 
stances, differs  from  normal  urine  in  con- 
taining all)umin  and  mucin  with  very  little 
urea.  Whatever  the  explanation  may  be,  this 
always  hapi)ens  when  there  is  any  hindrance 
to  the  flow  ;  it  may  be  noticed  even  when 
the  obstruction  is  only  of  a  temporary  cha- 
racter, as  in  renal  colic  ;  and,  if  the  cause  is 
removed  before  the  kidney  has  undergone 
atrophy,  the  percentage  of  urea  may  rise 
again  to  the  normal,  and   the  albumin  and 

Fig.  4' 7— Hydronephrosis  with  Complete  Atrophy  :       flicqnnpar 

of  Renal  Tissue,  but  not  much  Enlargement.         mUClIl   Uisappeai . 

In  the  slighter  cases  the  shape  of  the 
kidney  is,  to  a  certain  extent,  retained  ;  there  is  merely  dilatation  of  the  ]:)elvis 
and  calyces,  with  widening  of  the  collecting  tubules,  and  increase  in  the  amount 


H  YDR  ONEPHR  OS  IS. 


995 


of  intersitial  connective  tissue  ;  in  extreme  ones,  nothing  is  left  but  a  thin-walled 
cyst,  generally  rather  elongated,  especially  if  the  obstruction  is  low  down,  but  so 
modified  by  pressure  that  it  cannot  be  said  to  possess  any  form  of  its  own.  Pro- 
bably the  largest  cysts  arise  from  comparatively  sudden  obstruction  in  a  healthy 
kidney  ;  when  it  is  gradual  the  wasting  of  the  cortical  part  prevents  much  accumu- 
lation. 

Causes. — The  obstruction  is  generally  in  the  ureter,  but  in  the  bilateral 
forms  it  may  be  in  the  bladder  or  the  urethra  ;  and  it  may  be  the  result  of  some 
foreign  body  in  the  interior,  of  some  structural  change  in  the  wall  itself,  or  of 
pressure  from  the  outside. 

1.  Of  these  the  impaction  of  a  calculus  is  by  far  the  most  common.  Usually 
it  is  caught  either  at  the  commencement,  just  where  the  pelvis  grows  narrow,  or  at 
the  end,  perhaps  half  projecting  into  the  bladder  ;  but  it  may  occur  at  any  point. 
Clots  of  blood  and  hydatid  cysts  are  said  to  have  produced  the  same  result. 

2.  Structural  changes  may  arise  from  various  causes.  Stricture  of  the  ureter 
may  occur  from  inflammation.  Granulations  may  form  on  the  mucous  surface  and 
become  coated  over  with  phosphates.  Papillomata  similar  to  those  found  in  the 
bladder  are  occasionally  met  with.  Cancer  of  the  pelvis  of  the  kidney  may  lead 
to  the  same  result ;  or  there  may  be  a  fold  of  mucous  membrane  just  at  the  com- 
niencement  of  the  ureter  acting  as  a  valve.  In  a  few  instances  congenital  atresia 
and  absence  of  a  ureter  have  been  recorded.  Imperforate  urethra  ;  stricture  and 
other  affections  of  the  urinary  passages  ;  even  phimosis,  and  great  increase  in  the 
frequency  of  micturition,  sometimes  occasion  a  slight  degree  of  it  in  both  kidneys, 
with  or  without  dilatation  of  the  bladder. 

3.  Very  slight  external  pressure  is  sufficient  to  cause  it.  Mere  twisting  or 
looping  of  the  ureter  is  enough,  or  the  pressure  of  a  tumor,  such  as  the  retro- 
flexed  uterus.  It  has  even  been  caused  by  an  abnormal  renal  artery  crossing 
the  ureter,  and  by  one  ureter  opening  so  close  to  the  other  as  to  impede  the  flow 
from  it. 

Symptoms. — Hydronephrosis  is  rarely  discovered  until  the  swelling  has 
reached  a  considerable  size.  It  begins  first  high  up,  under  the  last  rib,  and  spreads 
downward  into  the  iliac  fossa,  and  forward  to  the  middle  line,  carrying  the  colon 
inward  in  front  of  it.  If  there  is  any  doubt  as  to  the  position  of  the  intestine,  it 
can  generally  be  made  out  by  inflating  it  with  air.  Fluctuation  is  usually  distinct ; 
there  is  absolute  dullness  on  percussion,  and  a  sense  of  deep-seated  resistance  on 
palpation.  Sometimes  the  distention  is  so  great  as  to  interfere  with  the  action  of 
the  boAvels  and  with  respiration. 

If  the  obstruction  is  sudden,  there  may  be  a  great  deal  of  pain,  with  blood  in 
the  urine ;  in  most  cases  there  is  little  more  than  a  sense  of  discomfort  with  con- 
stant dull  aching.  Occasionally  the  volume  varies  in  size  ;  the  obstruction  sud- 
denly gives  way  ;  there  is  a  profuse  discharge  of  clear  or  slightly  turbid  fluid,  and 
the  tumor  disappears.  Intermittent  hydronephrosis,  the  fluid  being  expelled  as 
soon  as  the  tumor  reaches  a  certain  size,  and  then  collecting  again,  is  not  unknown. 
It  may  arise  in  some  few  cases  from  spasmodic  muscular  contraction  ;  but  more 
probably  from  bending  or  looping  of  the  ureter,  as  in  floating  kidney,  or  from 
compression  by  a  tumor. 

Diagnosis. — From  pyonephrosis  it  can  only  be  distinguished  by  the  consti- 
tutional signs.  Hydatids  of  the  liver,  spleen,  or  kidneys  are  almost  as  difficult 
until  they  have  been  tapped  ;  the  fluid  they  contain  is  of  higher  specific  gravity, 
loio,  or  1012,  instead  of  1004,  and  the  proportion  of  sodium  chloride  is  much 
higher.  Ovarian  cysts,  as  a  rule,  are  more  mobile  ;  they  begin  in  the  pelvis  and 
spread  upward  ;  and  the  relation  they  bear  to  the  intestine,  and  especially  to  the 
colon,  is  not  the  same.  Ascites  in  certain  very  rare  cases  is  so  limited  by  adhesions 
that  it  presents  a  close  resemblance  ;  and  a  few  instances  are  recorded  of  perirenal 
cysts  wdiich  scarcely  admit  of  diagnosis  during  life. 

Rupture  of  the  ureter  occasionally  leads  to  a  subperitoneal  collection  of 
urine,  which  has  been  called  spurious  hydronephrosis,  but  the  condition  is  very 


996     DISEASES  AND   INJURIES   OE  SPECIAL   STRUCTURES. 

different.  Renal  and  perincphritic  abscesses  are  quicker  in  their  course  and  are 
attended  with  a  much  greater  amount  of  pain. 

Hydroneplirosis,  if  left  to  itself,  may  prove  fatal  either  from  exhaustion,  or 
pressure  upon  other  organs,  or  from  rupture  into  the  jieritoneal  cavity.  Occasion- 
ally it  remains  stationary  for  years,  until  perhajjs  the  secreting  power  of  the 
kidney  is  completely  destroyed  ;  sometimes  then  the  fluid  is  al)sor])ed  again,  and 
in  a  few  instances  spontaneous  cure  has  resulted  from  the  sudden  yielding  of  the 
obstruction. 

Treatment. — The  slighter  degrees,  those  which  arise  from  gradual  or  partial 
obstruction,  are  rarely  diagnosed.  When  it  is  so  large  as  to  form  a  distinct  tumor, 
it  is  usually  necessary  to  take  some  steps  for  its  removal.  In  a  few  cases  manijju- 
lation  and  gentle  kneading  over  the  ureter,  assisted  by  opiates  and  warm  baths, 
have  proved  successful.  Occasionally  the  tumor  can  be  raised  by  external  ])ressure, 
or  shifted  by  changing  the  position  of  the  body,  so  as  to  release  the  ureter  for  a 
time  and  allow  the  fluid  to  escape  ;  and  in  one  or  two  instances  ureterotomy  has 
been  performed  with  a  good  result  ;  but,  as  a  rule,  the  obstructing  cause  is  either 
beyond  this  or  the  walls  of  the  sac  are  so  softened  and  thinned  that  the  danger  of 
rupture  into  the  peritoneal  cavity  is  too  great. 

Repeated  puncture,  aspiration,  and  injection  with  iodine  have  been  tried  in 
cases  in  which  the  renal  substance  has  disappeared  and  there  is  nothing  but  the 
cyst  to  deal  with.  In  the  majority,  however,  free  incision  through  the  lumbar  re- 
gion, with  drainage,  affords  a  better  prospect ;  especially  as  it  is  sometimes  possible, 
by  examining  the  upper  end  of  the  ureter  in  this  way,  to  find  and  remove  the 
cause.  The  great  objection  is  that  urinary  fistula  is  liable  to  form,  and  that,  if 
suppuration  should  occur  as  a  consequence  of  defective  drainage,  the  structures 
around  the  cyst  wall  are  so  matted  together  as  to  render  its  removal  subserjuently  a 
matter  of  greater  difficulty.  In  many  instances,  however,  the  fistula  gives  rise  to 
but  little  inconvenience  ;  and  if  it  does,  and  if  it  is  proved  that  the  other  kidney 
is  sufficiently  active,  the  renal  substance  can  as  a  rule  be  enucleated  much  more 
easily  through  the  wound,  and  with  much  less  danger  to  the  patient,  after  the  cyst 
has  contracted  to  moderate  dimensions,  than  while  it  is  still  so  large  as  to  displace 
and  compress  all  the  neigh])oring  organs. 

If,  however,  the  condition  at  the  time  of  the  operation  is  plainly  irremediable, 
and  the  cyst  wall  can  be  separated  easily,  nephrectomy  may  be  performed  at  once. 

Tumors  of  the  Kidney. 

Diagnosis. — New  growths  in  the  kidney  must  be  distinguished  from  cystic 
degeneration,  hydronephrosis  and  i)yonephrosis,  from  abscesses  around  the  kidney 
in  connection  with  the  vertebrae,  i)leura,  caecum,  colon,  liver,  or  the  pelvic,  uri- 
nary, and  genital  organs  ;  from  dermoid  and  hydatid  cysts  ;  from  cysts  of  the  ovary 
and  pancreas;  from  enlargement  of  the  spleen,  and  in  children  from  enlargement 
of  the  mesenteric  glands. 

The  history  (family  as  well  as  personal)  and  the  general  synq)toms  (especially 
if  there  is  any  pyrexia,  or  evidence  of  any  diathesis)  are  of  very  great  importance  ; 
the  urine  must  be  carefully  investigated,  not  only  once,  but  for  days  together ;  the 
abdomen  and  the  loins  thoroughly  examined  ;  and  finally,  if  there  is  still  any 
doubt  as  to  the  nature  of  the  swelling,  it  must  be  explored  with  an  aspirating 
needle. 

To  examine  the  kidney,  the  patient  should  be  under  an  anaesthetic,  to  relax 
the  muscles;  one  hand  should  be  placed  in  the  hollow  of  the  flank,  between  the 
last  rib  and  the  crest  of  the  ilium,  the  other  just  below  the  cartilages  of  the  ribs, 
on  the  front  wall  of  the  abdomen.  In  this  way  the  lower  third  of  the  organ* can 
be  felt  and  fairly  grasped,  even  when  it  is  not  enlarged,  and  the  size,  shape, 
mobility,  and  consistence  can  usually  be  made  out.  As  it  enlarges,  it  extends 
toward  the  middle  line  in  front — (it  never  causes  any  prominence  behind,  although 
it  may  fill  up  the  hollow  of  the  loins) — but,  except  in  the  case  of  sarcomata  or 


TUMORS  OF  THE  KIDNEY.  997 

cystic  disease,  it  rarely  reaches  the  middle  line,  or  extends  so  far  down  into  the 
pelvis  that  the  hand  cannot  be  introduced  beneath  it.  New  growths  of  the  kidney 
are  usually  so  soft  as  to  give  the  sensation  of  fluctuation. 

The  relation  of  the  tumor  to  the  colon  is  most  important.  It  depends  to 
some  extent  upon  the  side  ;  on  the  right,  as  the  kidney  enlarges,  the  caecum  and 
the  lower  part  of  the  colon  are  pushed  back  to  the  outer  side  of  the  tumor,  while 
the  upper  part  crosses  obliquely  in  front.  On  the  left  side  the  colon  lies  well  in 
front,  and  can  be  felt  as  a  rounded  cord  rolling  over  and  over  under  the  finger  ; 
or,  if  it  is  fdled  with  air,  a  line  of  resonance  can  be  made  out  where  the  kidney  is 
percussed.  It  very  rarely  happens  that  a  coil  of  intestine  intrudes  itself  between 
the  liver  or  the  spleen  and  the  abdominal  wall.  Resonance  in  the  flanks  is  never 
present  when  there  is  a  renal  tumor  of  any  size. 

Finally,  in  case  of  doubt,  the  kidney  may  be  explored  behind  the  peritoneum 
with  an  aspirating  needle.  It  may  be  introduced  just  at  the  outer  edge  of  the 
erector  spin^,  on  a  level  with  the  first  lumbar  vertebra,  or,  if  the  kidney  is 
enlarged,  midway  between  the  last  rib  and  the  crest  of  the  ilium  ;  and  the  direction 
of  the  needle  should  be  forward  and  a  little  downward — in  fact,  as  nearly  as  pos- 
sible toward  the  umbilicus.  As  a  rule,  if  the  trocar  is  about  four  inches  long, 
there  is  no  fear  of  injuring  any  important  structure,  and  the  sudden  cessation  of 
resistance,  as  soon  as  the  shoulder  of  the  instrument  enters  an  open  space,  can  be 
felt  at  once. 

Cysts. 

Cystic  disease  of  the  kidneys,  like  hydronephrosis,  may  be  either  congenital 
or  acquired,  and  may  occur  on  one  side  or  both.  In  many  instances  the  whole 
organ  consists  of  nothing  but  cysts,  of  all  sizes,  from  a  pea  to  an  orange,  so  that 
if  both  are  affected,  there  is  practically  no  secreting  substance  left.  Not  unfre- 
quently,  on  the  other  hand,  its  existence  is  never  suspected  at  all,  and  it  is  only 
discovered /(?jY-/;wr/i'OT  /  the  only  symptom  is  the  persistent  low  specific  gravity  of 
the  urine,  and  even  that  is  not  invariable.  Occasionally,  in  adult  life,  the  cysts 
enlarge  to  such  an  extent  that  the  tumor  becomes  the  source  of  serious  trouble 
from  pressure  upon  neighboring  organs. 

The  cysts  usually  contain  an  albuminous  fluid  with  a  small  quantity  of  urea  : 
occasionally  uric  acid  is  found  as  well,  and  not  unfrequently  traces  of  old  hemor- 
rhages. The  consistence,  however,  may  be  so  thick  as  to  resemble  colloid.  The 
walls  are  always  thin,  and  lined  with  a  single  layer  of  flat  epithelium.  In  most 
cases  they  originate  from  the  urinary  tubules,  which  have  been  blocked,  either  by 
inflammation  and  degeneration  of  the  epithelial  cells  (caused  possibly  by  the 
infarcts  of  uric  acid  that  are  found  in  the  kidneys  shortly  after  birth),  or  by  the 
organization  of  lymph  thrown  out  around  them.  Sometimes  they  may  be  derived 
from  the  glomeruli. 

As  a  rule,  these  cases  do  not  admit  of  treatment.  When  there  is  an  enormous 
enlargement  on  one  side,  an  attempt  may  be  made  to  obtain  relief  by  aspiration 
or  by  nephrotomy;  and  if  it  can  be  shown  that  the  opposite  kidney  is,  if  not 
intact,  at  least  capable  of  doing  the  whole  work  of  the  body,  nephrectomy  may  be 
performed,  but  not  otherwise. 

Besides  these,  cysts,  sometimes  of  considerable  size,  are  of  common  occurrence 
in  granular  kidneys,  but  they  seldom  require  treatment.  Dermoid  cysts  are  occa- 
sionally met  with,  and  they  have  been  diagnosed  by  the  passage  of  hair  and  debris 
wdth  the  urine.  Hydatids  are  not  common  ;  when  they  occur  in  the  substance  of 
the  kidney  they  usually  rupture  into  the  pelvis,  and  the  discharge  of  the  daughter- 
cysts  may  give  rise  to  repeated  attacks  of  renal  colic.  They  may  be  treated  either 
by  aspiration  or  by  free  incision  and  drainage  ;  if  left  to  themselves,  they  some- 
times dry  up  and  give  no  further  trouble ;  but  not  unfrequently  they  sui)purate, 
and  then  they  must  be  treated  by  free  incision,  in  the  same  way  as  other  renal 
and  perinephritic  abscesses. 


998     DISEASES  AND   INJURIES   OF  SPECIAL  STRUCTURES. 

Solid  Gro7oths. 

New  growths  in  connection  with  the  kidney  are  nearly  always  malignant  (car- 
cinoma or  sarcoma).  Tubular  adenoma,  fibroma  (originating  from  the  capsule), 
papilloma  (growing  in  the  jjelvis,  and  resembling  the  villous  tumors  of  the 
bladder),  angeioma,  and  lymphadenoma,  have  been  described,  but  they  are  all 
very  rare.  Besides  these,  fatty  tumors  are  said  to  occur,  but  it  seems  probable 
that  they  are  really  derived  from  portions  of  the  supra-renal  capsule  detached  from 
the  main  body  in  the  course  of  development. 

Carcinoma  rarely  occurs  before  adult  life,  and  is  most  common  after  forty. 
It  seems  especially  prone  to  attack  floating  kidneys,  and  is  not  unfrcipiently  asso- 
ciated with  calculus,  though  it  is  difficult  to  be  certain  of  the  relationship  that 
exists  between  them.  It  is  nearly  always  encephaloid,  though  a  few  cases  are 
recorded  in  which  the  fibrous  stroma  was  so  dense  as  to  deserve  the  name  of 
scirrhus  ;  colloid  may  occur  secondarily.  In  many  cases  they  originate  in  the 
structures  about  the  hilum,  and  only  penetrate  the  pelvis  after  a  certain  length  of 
time,  pushing  the  renal  structure  before  them  ;  and  perhaps  this  may  explain  the 
frequent  absence  of  diseased  products  in  the  urine. 

Sarcomata  maybe  congenital,  and  are  much  more  common  in  the  young  than 
in  the  old.  For  the  most  part  they  are  small-celled  and  very  vascular.  In  a  few 
cases  they  have  been  found  to  contain  large  quantities  of  fibrillated  bundles  arranged 
in  different  planes,  crossing  one  another  in  all  directions,  and  composed  for  the 
most  part  of  striped  muscular  fibres. 

Symptoms. — The  signs  of  malignant  disease  of  the  kidney  are,  as  a  rule, 
very  obscure,  until  it  has  reached  an  advanced  stage  and  formed  a  definite  tumor. 
Haematuria  may  be  present,  and  when  it  is,  it  is  generally  profuse,  but  it  may 
remain  absent  almost  through  the  whole  course.  Pain  is  rarely  wanting ;  usually 
there  is  a  dull  aching  in  the  loin  ;  and  later,  violent  neuralgia  shooting  down  the 
branches  of  the  lumbar  plexus  ;  and  sometimes  there  is  intense  irritability  of  the 
bladder.  Contraction  of  the  psoas  muscle,  leading  to  lameness  and  a  suspicion 
of  hip  disease  ;  jaundice,  especially  when  the  right  side  is  concerned  ;  (Aidema  of 
the  legs  from  obstruction  to  the  circulation;  constipation  from  pressure  upon  the 
colon,  and  vomiting,  probably  reflex  in  character,  are  not  uncommon.  The  urine 
may  show  no  sign  ;  more  frequently  there  is  haematuria  at  one  time  or  another  ; 
albumin  is  only  present  when  there  is  blood,  and  renal  colic  may  occur  under  the 
same  conditions. 

The  question  of  operation  under  such  circumstances  is  very  doubtful.  It 
rarely  happens  that  a  diagnosis  can  be  made  until  the  kidney  is  definitely  enlarged, 
and  then  complete  removal  is  almost  hopeless.  Sarcoma  in  children  is  probably 
the  worst,  and  it  is  very  rare  to  meet  with  a  case  in  which  nei)hrectomy  is 
justifiable ;  in  the  case  of  adults,  and  with  carcinoma,  there  is  a  little  more  hope  ; 
it  is  known  that  patients  have  lived  for  a  considerable  ])eriod  without  recurrence  ; 
but  the  operation  cannot  be  recommended  unless  it  is  probable,  from  the  duration 
of  the  case,  that  the  disease  is  still  limited  to  the  kidney. 

Rknal  Calculu.s. 

Renal  calculus  may  occur  at  any  period  of  life,  but  is  most  common  at  the  two 
extremes;  and  it  may  be  formed  either  of  urate  of  ammonium,  uric  acid,  oxalate, 
phosphate,  or  carbonate  of  lime,  ammonio-magnesium  i)hosi)hate.  cystin,  or 
xanthin.  Of  these  the  first  is  most  common  in  infants  ;  the  next  two  during  adult 
life  ;  while  the  rest,  especially  the  last  two,  are  very  rare.  Not  unfreiiuently  the 
calculi  are  laminated,  layers  of  different  substances,  more  or  less  pure,  alternating 
with  each  other,  according  to  the  reaction  and  character  of  the  urine  at  the  time. 

Some  are  developed  in  the  calyces,  others  in  the  epithelium  of  the  urinary 
tubules.  The  former  are  composed  of  triple  phosphate,  and  are  either  formed 
around  blood- clots,  or,  in  cases  of  pyelitis,  as  concretions  on  the  roughened  and 


RENAL  CALCULUS.  999 

ulcerated  surtace  of  the  mucous  membrane  when  the  urine  becomes  ammoniacal. 
The  cause  of  the  latter  is  more  obscure.  Some  originate  from  the  infarcts  in  the 
renal  tubules  of  infants  ;  and  these,  though  they  may  be  multiple,  if  once  removed, 
never  return  ;  the  condition  which  gives  rise  to  them  disapi)ears  as  soon  as  the 
urinary  secretion  is  well  established.  In  the  case  of  others,  the  fault  appears  to  lie 
in  the  e})ithelial  cells  ;  their  energy  becomes  impaired,  whether  from  long-con- 
tinued overwork,  old  age,  or  disease;  they  lo.se  their  power  of  discharging  into 
the  urinary  tubules  the  materials  withdrawn  from  the  blood  ;  and,  as  a  result,  the.se 
increase  and  accumulate  until  at  length  a  nucleus  is  formed.  It  is  i)rol)able  that 
this  only  takes  place  when  there  is  at  the  same  time  a  morbid  condition  of  the 
urinary  passages  leading  to  the  production  of  a  suitable  colloid  medium.  There 
is  evidence  to  show  that  when  a  material  of  this  kind  is  present  the  urinary  salts 
are  precipitated,  not  as  perfect  crystals,  but  in  a  modified  form,  similar  to  the 
rounded  masses  that  are  found  as  nuclei ;  and  it  is  certain  that  the  mere  increase 
in  the  amount  of  urinary  salts  is  not  a  sufficient  explanation.  However  this  may 
be,  these  calculi  differ  in  one  very  im])ortant  resj^ect  from  those  that  occur  in 
infants  :  they  are  the  result  either  of  inheritance  or  of  faulty  modes  of  life,  such  as 
excess  of  nitrogenous  food  or  of  strong  wines  ;  and  as  the  causes  usually  continue 
in  activity  after  the  calculus  is  removed,  recurrence  is  not  uncommon. 

Symptoms. — Renal  calculi  may  be  small,  round,  and  freely  movable  ;  en- 
cysted, so  that  they  are  practically  fixed  ;  or  large,  branching  masses,  reproducing 
somewhat  the  shape  of  the  pelvis  and  calyces  after  the  secreting  part  ha.s  been  par- 
tially destroyed  (Fig.  419)-  •  The  general  symptoms  are  the  same  in  all,  but  they 
vary  greatly  in  intensity.  In  every  case  the  family  and  personal  history  should  be 
thoroughly  investigated  ;  the  tendency  to  the  formation  of  calculi  is  undoubtedly 
inherited,  and  recurrence  very  common. 

Pain  is  always  present.  Two  chief  varieties  can  be  distinguished,  though  there 
is  every  intermediate  gradation  ;  one  is  dull,  aching,  and  continuous,  felt  mainly  in 
the  loins,  but  radiating  down  the  thigh,  into  the  groin,  and  especially  into  the 
testicle.  It  is  present  in  nearly  all,  and  is  especially  severe  after  moving  or  jolting, 
as  in  riding,  and  after  the  pelvis  has  become  inflamed.  The  other  {f-enal  colic) 
only  occurs  with  small  and  movable  calculi  when  they  drop  into  the  orifice  of  the 
ureter  and  throw  its  muscular  fibres  into  a  state  of  spasmodic  contraction.  It  is 
usually  brought  on  by  some  sudden  movement ;  often  it  begins  with  a  rigor,  and 
it  is  of  the  most  intense  description,  shooting  down  to  the  testicle,  into  the  thigh, 
and,  perhaps,  over  the  whole  of  that  side  of  the  body.  Nausea  and  vomiting 
generally  occur  at  the  same  time  ;  the  patient  rolls  over  and  over  with  agony,  lying 
curled  up  as  much  as  possible  to  relax  the  muscles  ;  the  face  is  pale  and  shrunken  ; 
there  is  extreme  collapse  ;  the  forehead  is  covered  with  perspiration  ;  the  skin  is 
cold  and  clammy  ;  and  the  pulse  at  the  wrist  can  scarcely  be  felt.  It  is  not  con- 
tinuous, but  comes  on  in  paroxysms,  and  may  end  quite  suddenly;  many  patients 
never  suffer  from  it  at  all ;  in  others  it  returns  again  and  again  at  intervals  of  a 
few  weeks  or  months,  each  time  causing  fresh  mischief  in  the  kidney,  until  the 
calculus  is  either  passed  or  becomes  so  large  and  so  surrounded  by  inflammatory 
exudation  that  it  can  no  longer  occupy  the  narrow  part  of  the  pelvis.  The  same 
symptoms  may  be  caused  by  the  passage  of  blood  clots,  and  even  by  hydatid  cysts 
set  free  in  the  pelvis.  In  many  cases  the  pain  is  referred  to  other  parts  of  the  body, 
especially  to  the  genito-urinary  tract  and  along  the  course  of  the  lumbar  and  upper 
sacral  roots.  Neuralgia  of  the  testis  is  of  frequent  occurrence  ;  sometimes  it  is  so 
tender  that  it  can  scarcely  be  touched  ;  irritability  of  the  bladder  is  often  present, 
and  may,  as  in  strumous  pyelitis,  be  exceedingly  severe ;  sometimes  there  are 
paroxysms  of  pain,  shooting  down  the  foot  or  leg,  similar  to  the  lightning  pains 
of  locomotor  ataxy  ;  or  a  constant  burning  sensation  in  the  heel ;  or  intense 
sciatica.  In  fact,  wherever  paroxysmal  pain  occurs  in  the  lower  extremities, 
especially  if  it  is  attended  by  nausea  and  retching,  or  with  any  alteration  in  the  con- 
dition of  the  urine,  the  possibility  of  renal  calculus  must  always  be  borne  in  mind. 

Refraction  of  the  testis  is  very  significant.     When  the  calculus  is  in  the  ureter. 


looo     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

it  is  rarely  absent,  and  the  gland  may  be  held  tightly  up  against  the  abdominal 
ring.  It  is  not  so  well  marked  or  so  constant  while  the  stone  occupies  the  pelvis. 
The  examination  of  the  urine  is  most  important.  IHood  is  almost  always 
present  at  one  time  or  another,  esi)ecially  after  e.xertion,  and  it  is  always  evenly 
mi.xed  with  the  urine.  If  the  hemorrhage  is  recent,  the  color  is  bright  red  ;  if 
some  time  has  passed,  dark  brown  or  smoky,  or  even  almost  black,  like  porter. 
The  amount  is  rarely  large,  and  coagula  are  not  often  met  with,  except  after  the 
spasm  of  renal  colic ;  then  the  whole  organ  becomes  tender  and  congested,  and  it 
may  pour  out  in  considerable  quantity.  In  other  cases  large  quantities  of  gravel 
or  brick-red  crystals  of  uric  acid  may  be  found  from  time  to  time.  Mucus  is 
always  j^rcsent  and  sometimes  epithelium,  which  may  be  recognized  as  coming  from 
the  pelvis  ;  so  long  as  the  urine  is  acid,  the  quantity  may  not  be  great,  but  in  the 
more  severe  cases,  where  the  calculus  is  large  or  irregular  in  shape,  and  especially 
where  the  urine  has  undergone  decomposition,  and  suppurative  pyelitis  is  present 
as  well,  the  discharge  is  profuse  and  loaded  with  crystals  of  triple  phosphate. 
When  this  occurs  other  symptoms  soon  follow  ;  the  temperature  rises,  especially  in 
the  evening,  sometimes  as  much  as  two  or  three  degrees ;  headache  and  drowsiness 
are  of  common  occurrence  ;  the  appetite  fails  completely  ;  the  tongue  is  dry  and 
cracked  ;  nausea  is  almost  constant ;  and  the  patient  rapidly  loses  flesh  and  strength. 
Tenderness  in  the  loins  and  rigidity  of  the  museles  are  always  present.  If  there 
is  more  than  one  calculus,  grating  can  sometimes  be  made  out  by  deep  palpation 
when  the  patient  is  under  an  anaesthetic.  ICnlargement  of  the  kidney  is  more 
common  ;  sometimes  it  is  real,  due  to  congestion  ;  but  more  often  it  is  caused  by 
condensation  of  the  fibrous  tissue  around  from  continued  irritation  ;  and  not  un- 
commonly it  is  only  apparent,  the  kidney  being  dragged  downward  by  the 
spasmodic  contraction  of  the  muscular  fibres  of  the  ureter. 

Diagnosis. — When  there  are  repeated  attacks  of  renal  colic  without  the  stone 
passing  into  the  bladder,  and  apparently  causeless  vesical  irritability,  with  the  pres- 
ence of  blood  and  mucus  in  the  urine,  the  diagnosis  of  renal  calculus  is  easy.  In 
many  instances,  however,  it  is  a  matter  of  the  greatest  difficulty.  Nephralgia, 
closely  resembling  renal  colic,  may  occur  in  delicate  women,  during  the  menstrual 
period,  from  the  physiological  enlargement  of  the  kidney  ;  it  may  be  present  with 
haematuria  in  chronic  interstitial  nephritis  ;  biliary  colic  and  duodenal  inflam- 
mation may  imitate  it  closely  on  the 
right  side;  while  there  are  many  cases 
on  record  in  which  there  has  been  great 
/6,  '>;■,  difficulty  in  distinguishing  it  from  vesi- 

/"^  "■  ;\  cal   calculus,    lumbago,    typhlitis,    and 

/■  \  even  aneurysm. 

:  Cancer  and   tubercle  affecting  the 

/  >^,  *  '-  '  kidney  are  the  most  difficult,  particu- 

/:  //  \  <}g^'^'^  larly  in   the   early   stages;  renal   colic 

y,  .         ^  "■  may  occur  in  both,  due  either  to  coag- 

Y:  ula  or  to  broken-down  caseous  masses 

^  v;  traversing    the    ureter;     lumbar    pain, 

:  '%-  %.  hematuria,  and  vesical  irritability  are 

^|;'  usually    present ;    and    in    many    cases 

;"  X_  there  is  nothing  distinctive  in  the  urine. 

:;^     '  In    malignant    growths,    however,    the 

'  ^  hemorrhage   is   usually   profuse   and  is 

'■i;  \ U     rather  the  cause  of  colic  ;  while  in  tu- 

V  |i|l    bercular  pyelitis  the  amount  of  pus  is 

V":  '  *'|]    always  greater  than  in  the  case  of  cal- 

..■   ,-  jpll    cuius,  unless  this  is  complicated  by  the 

.-^  '■'•^    presence    of  alkaline  urine  and  septic 

decomposition  ;    and    true   renal    colic 

Fig.  4.8.-Calculus    Encysted  in  Lower  Part   of    Pelvis.    nCVer    OCCUrS    UUtil     the    CaSeOUS    maSSCS 


RENAL   CALCULUS.  looi 

have  begun  to  undergo  disintegration.  Searcli  should  always  be  made  for  cancer 
cells  and  for  tul)ercle  bacilli ;  but  unless  the  greatest  precautions  are  taken  they 
are  very  difficult  of  identification,  esi)ecially  the  latter  ;  and  the  fact  of  their  not 
being  found  even  after  repeated  examination  cannot  be  regarded  as  evidence  of 
their  non-existence. 

It  is  not  uncommon  for  calculi  to  remain  latent  in  the  kidney  for  years  with- 
out causing  active  mi.schief,  and  in  many  instances  they  have  been  found  post- 
mortem without  their  presence  having  been  suspected  during  life.  In  the  majority, 
however,  they  give  rise  to  symptoms  of  greater  or  less  severity  ;  and  in  a  very 
large  number  they  lead  to  such  extensive  destruction  of  the  kidney,  and  such  seri- 
ous interference  with  health  and  strength,  that  the  question  of  removal  becomes 
imperative. 

It  is  least  serious  when  the  calculus  is  encysted  in  one  of  the  calyces  or  fixed 
between  the  pyramids  (Fig.  418)  ;  the  renal  substance  around  becomes  absorbed 
and  indurated  ;  a  sac  of  dense  fibrous  tissue  is  formed  ;  and  the  amount  of  int'er- 


nil 


/ 


^-> 


Fig.  419. — Suppurative  Calculous  Pyelitis  with  Destruction  of  Renal  Tissue        (n)  The  Calculus  Removed  from 

its   Bed. 


stitial  connective  tissue  throughout  the  organ  is  increased  ;  but  provided  the  size 
remains  moderate,  and  suppuration  does  not  set  in,  the  stone  may  remain  quiet 
and  undisturbed  for  years. 

Small  calculi  lying  loose  in  the  pelvis  are  infinitely  worse.  On  the  one  hand 
they  cause  repeated  attacks  of  renal  colic,  which  end  at  length  in  hydronephrosis 
and  interstitial  nephritis  ;  on  the  other,  they  set  up  acute  inflammation  of  the 
pelvis,  which  spreads  to  the  secreting  tubules  and  finally  destroys  them.  The 
mucous  membrane  first  becomes  irritated  ;  then  the  apices  of  the  pyramids  disap- 
pear ;  the  kidney  substance  is  broken  down  and  eaten  away ;  and  at  length,  partly 
by  absorption  and  dilatation,  partly  by  ulceration  and  sloughing  (especially  after 
the  urine  has  begun  to  decompose),  a  large  irregular  cavity  is  formed,  in  the 
centre  of  which  lies  the  calculus,  grown  perhaps  into  a  branching  mass  which  al- 
most fills  the  interior.  In  extreme  cases  nothing  is  left  but  a  shapeless  bag  of 
pus,  formed  by  the  capsule  and  the  fibrous  tissue  condensed  together,  with  perhaps 
some  shreds  of  cortex,  coated  with  a  slimy  mass  of  phosphates,  still  left  upon  the 
inner  surface  (Fig.  419). 
64 


I002    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Treatment. — In  acute  renal  colic,  the  pain  and  spasm  must  be  relieved  with 
as  little  delay  as  possible,  in  the  hope  that  the  calculus  may  reach  the  bladder  ;  as 
soon  as  it  leaves  the  ureter,  the  symptoms  begin  to  subside.  Opium  is  of  the 
greatest  value,  and,  if  the  kidneys  are  sound,  must  be  given  freclv,  either  the 
tincture  mixed  with  an  e(]ual  (juantity  of  water,  so  that  the  amount  of  fluid  is 
small,  or  morphia,  with  a  minute  (juantity  of  atropia,  hyi)odermically.  Chloro- 
form is  of  use  when  the  spasm  is  severe,  but  the  inhalation  should  not  be  pro- 
longed. The  bowels  should  be  emptied  at  once  with  a  hot-water  enema,  not  only 
because  this  prevents  the  pain  caused  by  the  pressure  of  a  loaded  colon,  but  be- 
cause it  relieves  the  spasm  of  the  ureter,  and  by  the  effort  at  expulsion  helps  the 
passage  of  the  calculus ;  the  patient  should  be  placed  in  a  full-length  hot  bath 
(temperature  98°  F.  gradually  raised  to  101°  or  102°  F.)  for  twenty  minutes  to 
half  an  hour  ;  and  if  this  does  not  soon  give  relief,  the  loins  should  be  dry-cupped 
on  both  sides.  Hot  distilled  water,  or  very  weak  tea,  or  barley-water  may  be 
taken  freely  ;  there  is  no  object  in  limiting  the  amount  if  the  patient  can  take  it, 
but  not  unfreijuently  it  merely  increases  the  sickness. 

Generally  speaking,  after  twenty-four  hours  the  paroxysms  become  less  severe  ; 
if  the  stone  passes  into  the  bladder,  they  stop  suddenly  ;  if  it  remains  in  the  ureter, 
they  continue  longer,  and  cease  very  gradually,  often  returning  again  in  a  milder 
form  with  the  least  movement.  In  either  case  the  patient  is  left  in  a  state  of  ex- 
treme prostration,  utterly  worn  out ;  and  though  the  color  may  return,  and  the 
face  resume  its  natural  expression  within  a  few  hours,  it  is  not  unfrequently  many 
days  before  the  strength  is  regained  and  the  patient  is  able  to  move  about  again 
without  the  dread  of  recurrence. 

Impaction  in  the  Ureter. — The  calculus  may  be  arrested  at  any  point,  but 
nearly  always  it  is  either  at  the  commencement,  where  the  pelvis  narrows  into  the 
ureter,  or  at  the  end,  so  that  it  projects  slightly  into  the  bladder.  In  the  latter 
case  it  can  be  felt  as  a  round,  hard  mass,  through  the  w-all  of  the  rectum  or  vagina. 
In  women  the  bladder  can  be  explored  with  the  finger  under  an  anaesthetic  ;  but 
in  men,  unless  the  stone  j)rojects  so  far  into  the  cavity  that  it  can  either  be  seen 
with  the  endoscope  or  felt  with  a  sound,  this  help  is  lost. 

The  treatment  must  be  guided  by  the  symptoms,  and  particularly  by  the  con- 
dition of  the  other  kidney.  If  the  amount  of  urine  secreted  does  not  fail,  manip- 
ulation may  be  tried  under  an  anaesthetic  ;  copious  hot  enematamay  be  given  with 
opiates  and  warm  baths  ;  and  if  the  calculus  can  be  felt  near  the  end,  an  attempt 
may  be  made  to  hook  it  down  further  by  means  of  the  finger,  or  to  extract  it 
through  a  suprapubic  or  a  perineal  incision,  making  a  small  nick  in  the  mucous 
membrane  at  the  orifice  if  necessary.  If  the  impaction  is  not  relieved  the  symp- 
toms become  le.ss  urgent  as  time  passes,  the  colic  subsides,  the  kidney  wastes,  and 
hydronephrosis  follows. 

It  is  much  more  serious  when  the  other  kidney  is  already  disabled,  whether 
this  arises  from  a  similar  accident  (which  is  not  at  all  uncommon),  congenital 
defect,  or  disease ;  the  secretion  of  urine  is  then  arrested  altogether,  and  unless 
relief  is  sjjeedily  obtained,  the  condition  must  prove  fatal.  The  same  measures 
may  be  tried  first,  but  if  they  do  not  succeed,  either  an  incision  must  be  made  in 
the  loin  to  drain  the  kidney,  or  the  abdomen  must  be  opened  and  the  ureter 
traced  until  the  obstruction  is  found.  If  the  calculus  is  felt,  the  peritoneum  and 
the  wall  of  the  ureter  may  be  incised,  the  stone  removed,  the  cavity  cleansed,  the 
wound  in  the  ureter  stitched  together  again,  and  the  peritoneum  united  over  it; 
or,  if  the  obstruction  is  due  to  any  other  cause,  it  may  be  dealt  with  according  to 
circumstances.  Which  of  these  operations  should  be  performed  depends  upon  the 
condition  of  the  patient.  The  latter  is  the  more  thorough,  and  as  both  ureters 
can  be  examined,  there  is  less  likelihood  of  an  operation  on  the  wrong  side,  but  it 
is  the  more  serious  ;  the  former,  unle.ss  the  calculus  is  lying  in  the  i)elvis  within 
reach,  can  only  be  regarded  as  a  temporary  measure,  leaving  behind  it  a  renal 
fistula  in  the  loins,  through  which  the  whole  of  the  urine  must  flow. 

///  the  Pelvis. — .\  calculus  in  the  pelvis  may  sometimes  be  so  reduced  in  size 


INFLAMMATION  OF  TIIF   KIDNEYS.  1003 

by  solution  or  disintegration  that  it  becomes  small  enough  to  pass  through  the 
ureter;  or  if  this  does  not  happen,  it  may  work  out  a  bed  for  itself,  and  become 
fixed  by  fibrous  tissue,  so  as  to  give  no  fiirther  trouble.  An  operation  should  not 
be  proposed  until  after  the  former  of  these,  at  least,  has  been  tried. 

Solution  can  only  succeed  with  small  calculi,  composed  of  uric  acid  or  urates  ; 
large  ones  are  out  of  the  question,  and  o.xalate  of  lime,  and  substances  deposited 
from  alkaline  urine  are  not  sufficiently  .soluble.  It  is  of  most  service  where  small 
masses  of  uric  acid  are  constantly  being  formed  in  the  urinary  tubules,  and  dropped 
into  the  pelvis,  as  in  the  case  of  the  pisiform  concretions  of  old  people,  causing 
them  to  be  dissolved  and  wasted  away  before  they  get  too  large,  and  acting  rather 
as  a  preventive  means  ;  but  even  after  being  in  the  ijelvis  some  time,  calculi  can 
be  so  reduced  in  size  as  to  pass  easily  down  the  ureter,  or  at  least  give  no  further 
trouble.  The  citrate  and  bicarbonate  of  potash,  which  are  often  given  in  large 
doses  for  this  purpose,  are  not  of  much  service  by  themselves  ;  the  urine  must  be 
very  concentrated  for  them  to  have  any  effect,  and  as  the  alkaline  fluid  simply 
passes  over  the  surface  of  the  calculus,  the  chance  of  any  appreciable  solution  is 
exceedingly  small.  Moreover,  there  is  the  danger  that,  if  large  or  long-continued 
doses  are  taken,  the  urine  may  become  too  alkaline,  and  deposit  a  layer  of  phos- 
phates. Distilled  or  soft  water,  on  the  other  hand,  taken  in  large  cpiantities,  four 
to  five  pints  a  day,  with  occasional  doses  of  citrate  of  potash,  or  of  some  alkaline 
water,  such  as  that  of  Vichy  or  Contrexeville,  is  often  most  effectual.  The  specific 
gravity  of  the  urine  is  diminished  ;  the  rate  of  secretion  is  increased  ;  it  acts  to  a 
slight  extent  as  a  solvent  and,  what  is  of  more  importance,  by  diminishing  the 
amount  of  inorganic  material,  it  assists  the  disintegration  of  the  external  laminae  ; 
but  for  this  to  answer,  the  treatment  must  be  continued  for  a  considerable  length 
of  time,  the  urine  must  never  be  allowed  to  become  concentrated,  and  the  diet 
must  be  carefully  restricted.  Fish  and  white  meat  are  to  be  preferred  ;  sweet 
fruits,  especially  cooked  sugar  and  rich  pastry,  should  be  avoided  ;  bread  should 
be  toasted  ;  and  the  amount  and  kind  of  alcohol  carefully  prescribed.  Probably 
patients  with  renal  calculi  would  be  better  without  any  ;  but  in  many  instances 
they  are  so  worn  out  by  suffering  that  depriving  them  of  it  altogether  would 
prevent  their  digesting  anything  else.  Beer  and  strong  wines,  containing  large 
quantities  of  sugar,  are  certainly  injurious ;  but  the  lighter  ones,  or  small 
quantities  of  spirits,  well  diluted,  and  taken  with  the  meals,  may  generally  be 
allowed. 

[Poland  Spring  Water  or  Chippewa  Spring  Water,  being  pure,  soft  waters,  free 
from  mineral  or  saline  constituents,  have  great  usefulness.] 

Small  doses  of  turpentine,  given  either  in  the  form  of  emulsion,  or,  better, 
in  capsules,  are  of  great  use  in  these  cases  ;  not  unfrequently  a  large  amount  of 
gravel  is  brought  away  in  a  very  few  days.  Probably  this  is  due  to  the  effect  that 
the  turpentine  has  upon  the  lining  membrane  of  the  pelvis  :  the  secretion  of  mucus 
is  checked  ;  the  growth  of  the  calculus  is  arrested ;  and  the  size  of  the  passage 
through  which  it  has  to  pass  is  materially  increased  by  the  diminution  of  the 
hyperaemia  and  swelling. 

If  these  measures  fail,  and  if  there  is  either  a  small  calculus  constantly  rolling 
about,  or  a  large  one  gradually  destroying  the  kidney,  an  attempt  should  be  made 
to  remove  it  by  operation.  In  the  one  case  it  will,  if  left  to  itself,  lead,  after 
repeated  attacks  of  renal  colic,  to  interstitial  nephritis  and  hydronephrosis,  with, 
very  possibly,  if  it  occurs  on  both  sides,  suppression  of  urine  ;  in  the  other  it  will 
end  at  length  in  septic  decomposition  and  suppuration,  which  will  spread  from  the 
pelvis  to  the  kidney  and  destroy  it. 

IXFL.AMMATION    OF    THE    KiDNEVS. 

Inflammation  of  the  kidneys  maybe  either  primary  (nephritis)  or  secondary, 
due  to  extension  from  the  pelvis  (pyelonephritis). 

I.   Acute  nephritis  is  not  common,  but  it  may  be  caused  by  exposure  to  cold 


IC04    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

and  wet,  by  extensive  lesions  of  the  cutaneous  surface,  and  by  irritating  sul>stances 
in  the  urine,  such  as  cantharides  or  turpentine.  Mild  forms  are  occasionally  met 
with  in  erysipelas  and,  very  rarely,  in  secondary  syphilis. 

Pathological  Appearance- — The  kidney  is  swollen  and  rounded  ;  the 
veins  are  prominently  marked  ;  the  capsule  strips  off  readily,  and  when  it  is  cut 
open  the  surface  is  deeply  congested  ;  it  may  even  drip  with  blood.  In  milder 
cases,  where  the  symptoms  have  lasted  longer,  the  cortex  is  paler,  owing  to  the 
great  increase  in  the  epithelial  elements  in  the  tubules,  and  the  contrast  of  the 
pyramids  is  still  more  marked. 

Symptoms. — Acute  nephritis  may  set  in  with  a  rigor.  The  temperature 
may  reach  103°  F.  the  first  day  ;  headache,  vomiting,  insomnia,  and  loss  of  appe- 
tite, are  always  present ;  the  pain  and  aching  over  the  loins  never  cease  ;  often  there 
is  the  most  intense  desire  to  micturate  ;  the  quantity  of  urine  is  greatly  diminished  ; 
in  severe  cases  there  is  almost  complete  suppression  ;  the  specific  gravity  is  high  ; 
it  is  loaded  with  blood  and  casts  ;  and  it  nearly  always  throws  down  a  turbid  deposit 
of  urates,  epithelium,  and  broken  down  corpuscles.  If  the  inflammation  is  severe 
and  the  excretion  of  urine  seriously  checked,  dropsy  may  set  in  within  twenty-four 
hours ;  more  frequently  it  does  not  aj^pear  until  the  second  or  third  day.  Some- 
times there  is  only  puffiness  about  the  eyelids  ;  sometimes,  on  the  other  hand,  there 
is  general  anasarca,  invading  the  serous  cavities,  and  even  causing  death  from 
oedema  of  the  glottis. 

Treatment. — The  chief  object  is  to  reduce  as  far  as  possible  the  amount  of 
work  and  to  relieve  the  congestion.  In  mild  "cases  it  is  sufficient  to  keep  the 
])atient  warm  in  bed,  at  an  even  temperature,  with  the  bowels  relaxed  and  the  diet 
restricted  ;  in  more  severe  ones  great  relief  may  be  obtained  by  the  use  of  hot-water 
and  vapor  baths.  Cupping  over  the  loins  is  often  beneficial  ;  and  where  the  fever 
is  high,  and  the  patient  young  and  vigorous,  venesection  may  be  performed  with 
advantage.  The  bowels  should  be  opened  with  castor  oil,  or  a  small  dose  of 
calomel,  and  then  kept  relaxed  with  sulphate  of  magnesia ;  it  is  doubtful  if  strong 
hydragogue  purgatives  do  not  do  more  harm  than  good.  Nitrogenous  food  should 
be  excluded  from  the  diet,  at  any  rate  for  the  first  few  days  ;  after  that  small  quan- 
tities of  milk  may  be  allowed  ;  but  eggs,  and  other  articles  of  food  that  consist 
largely  of  albumin,  should  be  forbidden.  As  the  symptoms  subside,  great  care  is 
necessary,  both  with  regard  to  this  and  to  the  temperature ;  relapses  very  easily 
occur,  and  there  is  great  danger,  if  the  symptoms  persist  for  any  length  of  time, 
that  the  condition  may  become  chronic. 

2.  Chronic  Nephritis. — Chronic  interstitial  nephritis  is  much  more  common 
and  is  more  important  ;  on  the  one  hand,  it  impairs  general  nutrition  to  such  an 
extent  that  the  tissues  slough  with  the  least  injury  ;  on  the  other  hand,  it  so  pre- 
disposes the  kidneys  to  the  influence  of  shock,  that  any  operation  upon  the 
urinary  organs  is  very  liable  to  be  followed  by  complete  or  partial  suppression  of 
urine. 

It  may  follow  an  acute  attack  ;  or  be  caused  by  the  same  influences  (such  as 
cold,  wet,  exposure,  or  irritating  conditions  of  the  urine),  acting  with  less  inten- 
sity but  greater  persistence  ;  or  it  may  be  the  consequence  of  certain  morbid 
conditions  of  the  bladder  or  urethra. 

One  of  these  is  an  impediment  to  the  outflow  of  urine.  Whenever  this  occurs, 
whether  it  arises  from  stricture,  enlargement  of  the  prostate,  or  any  other  cause, 
tension  is  exerted  on  the  part  behind,  and  this  leads  to  a  certain  degree  of  dilata- 
tion and  chronic  inflammation.  Even  undue  frequency  of  micturition,  such  as  is 
met  with  in  vesical  calculus,  is  sufficient. 

This,  however,  is  not  the  only  one.  Chronic  inflammation  (without  dilata- 
tion) may  be  caused  in  an  entirely  difi"erent  way.  The  passage  of  a  catheter  is 
followed,  in  many  people,  by  sudden  congestion  of  the  kidneys  ;  as  a  rule,  this 
subsides  of  itself  ;  but,  if  it  is  frequently  repeated,  or  if  there  is  a  stricture  in  the 
deeper  part  of  the  urethra,  causing  a  certain  amount  of  spasm  every  time  the  urine 
passes  over  it ;  or  a  vesical  calculus  constantly  falling  against   the  neck  of  the 


INFLAMMATION  OF  THE  KIDNEYS.  1005 

bladder  ;  or,  if  the  urethra  is  in  a  state  of  chronic  inflammation  from  repeated 
attacks  of  gonorrhtea,  this  congestion  practically  becomes  chronic  ;  the  connec- 
tive tissue  grows  more  dense  and  fibrous;  the  vitality  of  the  epithelium  is  im- 
paired, and  the  kidney  becomes  small,  hard,  and  cirrhotic.  It  must  remain,  in 
most  cases,  uncertain  how  far  this  disease  of  the  kidneys  is  the  result  of  tension 
only,  and  how  far  it  is  due  to  the  chronic  congestion  ;  but  this  is  certain,  that  no 
condition  of  the  bladder  or  urethra  which  interferes  in  any  way  with  their  proper 
function  can  exist  for  long  without  producing  a  most  serious  effect  upon  the 
kidneys. 

The  pathological  appearances  depend,  to  some  e.xtent,  upon  the  degree  of 
obstruction.  The  kidney  is  generally  smaller  than  natural,  hard,  and  dense  ;  the 
surface  is  irregular  ;  the  capsule  adherent,  so  that  it  tears  away  with  it  small  por- 
tions of  the  tubules  ;  the  cortex  thinned  and  w^asted,  with  small  cysts  scattered 
through  it,  and  the  pyramids  flattened  and  compressed.  The  pelvis  may  be  nor- 
mal, but,  especially  in  those  cases  in  which  the  interstitial  growth  is  due  to  obstruc- 
tion, it  is  dilated,  and  there  may  be  every  degree,  from  incipient  fibroid  change 
with  slight  expansion  to  extreme  hydronephrosis,  with  nothing  left  of  the  kidney 
but  a  thickened  disc  of  connective  tissue. 

Symptoms. — When  fully  developed,  these  are  characteristic  ;  in  the  early 
stages  the  patient  seldom  comes  under  notice.  There  is  a  slight  but  distinct  failure 
of  strength  ;  the  skin  is  dry  and  harsh,  itching  constantly  ;  headaches  are  of  com- 
mon occurrence;  occasionally,  there  are  attacks  of  vomiting;  neuralgia  is  not  in- 
frequent, and  is  often  very  obstinate  ;  the  patient  grows  thin  and  pale,  and  some- 
times hypochondriacal ;  there  is  loss  of  sexual  power  and  very  generally  increased 
frequency  of  micturition,  especially  at  night.  The  pulse  is  full  and  incompres- 
sible ;  the  left  ventricle  is  hypertrophied  ;  there  is  a  tendency  to  epistaxis,  and 
other  hemorrhages,  and  in  the  final  stages  a  certain  amount  of  oedema. 

The  urine  is  greatly  increased  in  quantity,  and  its  specific  gravity  is  exceed- 
ingly low  ;  the  color  is  generally  bright,  and  there  is  rarely  much  deposit,  though 
a  very  few  casts  with  some  epithelial  cells  and  crystals  of  oxalate  of  lime  are  occa- 
sionally to  be  found.  Very  often  there  is  no  albumin,  but,  as  the  disease  advances, 
especially  if  the  amount  of  urine  begins  to  fail,  it  may  make  its  appearance, 
though  never  in  any  large  f]uantity. 

Toward  the  end  hemorrhages  occur,  in  the  retina  among  other  places  ;  vis- 
ceral complications  arise,  and  the  patient  may  be  carried  off  by  pleurisy  or  pneu- 
monia;  oedema  sets  in  ;  the  vomiting  becomes  more  frequent ;  muscular  twitch- 
ings  make  their  appearance  and  grow  worse  and  worse,  until,  at  length  ur^emic 
convulsions  and  coma  end  the  scene. 

Treatment. — The  first  thing  is  to  remove  the  cause,  whether  it  is  stricture, 
calculus,  or  anything  else.  It  is  true  that  the  risk  of  shock  and  suppression  is 
very  much  greater  than  in  ordinary  circumstances,  but  waiting  longer  than  is  abso- 
lutely necessary  to  bring  the  patient  into  the  best  condition  will  not  make  it  less. 
After  this  has  been  done,  the  kidneys  must  be  saved  as  much  as  possible  and  pro- 
tected from  injurious  influences.  Iodide  of  potash  and  bichloride  of  mercury,  in 
very  small  doses,  may  have  some  influence  in  checking  the  hypercemia  and  assist- 
ing the  absorption  of  the  lymph,  if  given  before  the  contraction  is  too  dense,  and 
in  the  later  stages  chloral  allays  the  irritability  of  the  skin,  and  checks  muscular 
twitching.  Most  reliance,  however,  must  be  placed  upon  rest,  warmth,  and  diet. 
During  the  subacute  attacks  that  are  frequently  present,  the  patient  should  be  con- 
fined to  bed  ;  exertion,  both  mental  and  bodily,  should  be  avoided  ;  long  rail- 
way journeys  are  particularly  injurious  ;  the  clothing  should  be  warm  ;  damp  and 
chilly  residences  are  especially  injurious  ;  the  diet  must  be  light  but  nutritious  ; 
alcohol  should  only  be  taken  so  far  as  is  necessary  for  digestion  ;  eggs  and  other 
substances  that  contain  a  large  amount  of  albumin  should  be  partaken  of  very 
sparingly  ;  milk  may  be  allowed  freely,  especially  with  farinaceous  food  and  the 
lighter  forms  of  meat ;  but  great  care  should  be  taken  not  to  overload  the  digestive 
organs,  or  to  run  the  risk  of  causing  dyspepsia. 


ioo6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

PVKI.ms    AND    PVEI.ONEI'HKiriS. 

Inflammation  of  the  mucous  membrane  of  the  pelvis  of  the  kidney  is  rarely 
met  with  by  itself.  Except  in  the  mildest  cases,  such  as  those  caused  by  the  accu- 
mulation of  gravel  in  gout,  the  kidney  almost  always  becomes  involved  before  the 
disease  has  lasted  any  length  of  time  ;  and,  in  those  in  which  suppuration  breaks 
out,  its  whole  substance  may  be  destroyed,  nothing  being  left  but  a  sac  distended 
with  pus,  with  scarcely  a  trace  of  the  original  structure  visible. 

Causes. — These  are  almost  the  same  as  tho.se  of  inflammation  of  the  bladder. 
Cold  is  occasionally  one.  Injury  is  more  common,  whether  it  is  mechanical,  due 
to  the  irritation  of  a  calculus,  or  chemical,  arising  from  the  action  of  no.xious  sub- 
stances in  the  urine.  Tubercle  is  not  at  all  rare,  while,  in  exceptional  cases,  new 
growths,  carcinoma,  and  villous  tumors  similar  to  those  in  the  bladder,  have  been 
the  cause.  Finally,  it  is  often  due  to  extension,  especially  from  the  ureters.  At 
first,  the  inflammation  is  limited  to  the  pelvis,  but,  if  the  cause  is  a  large  calculus 
with  spreading  branches,  or  if  it  is  foul  and  sej^tic  urine,  or  if  the  deposit  of  tubercle, 
instead  of  being  confined  to  the  pelvis,  is  scattered  through  the  substance  of  the 
organ,  the  kidney  rapidly  becomes  involved  as  well,  and  in  a  very  short  time  the 
whole  of  it  is  either  riddled  wath  minute  abscesses,  or  converted  into  a  sui^purating 
sac.  Sometimes  the  ureter  is  obstructed,  so  that  the  pus  is  unable  to  escape,  and 
then  a  huge  swelling,  pyonephrosis,  forms  in  the  loins.  In  very  rare  cases  the 
closure  is  incomplete,  and  there  is  an  intermittent  discharge  of  fluid,  as  occasionally 
happens  with  hydronephrosis. 

Pathological  Appearances. — These  differ  very  considerably.  ///  simple 
catarrhal  pyelitis,  the  mucous  membrane  is  swollen,  thickened,  and  redder  than 
natural ;  the  surface  is  raw  from  the  loss  of  its  protecting  epithelium,  and  in  severe 
cases  is  coated  over  with  lymph,  mixed  perhaps  with  blood.  Sometimes  there  are 
older,  darker  extravasations,  and,  when  the  disease  is  of  long  standing,  the  color 
post-mortem  may  be  almost  black. 

In  calculous  pyelonephritis,  when  the  stone  is  the  only  cause,  the  mucous  mem- 
brane may  show  no  further  change  ,;  or,  if  the  irritation  has  been  of  long  duration, 
the  substance  of  the  kidney  may  be  eaten  away — the  medulla  esi)ecially  having  suf- 
fered— and  the  interstitial  connective  tissue  thickened  and  hardened.  Unfortu- 
nately in  most  cases  the  urine  decomposes  and  suppurative  ])yelonephritis  makes 
its  appearance  in  addition.  When  this  occurs,  the  mucous  lining  becomes  thick- 
ened, ulcerated,  and  coated  with  a  slimy  deposit  of  pus  and  phosphates  ;  the  whole 
of  the  medulla  and  most  of  the  cortex  are  eaten  away,  and  nothing  is  left  but  a 
large  irregular  cavity  full  of  foul  and  decomposing  pus,  with  roughened  and  rugged 
walls  lined  with  the  debris  of  the  broken-down  and  ulcerated  cortex  (Fig.  419)- 

Tubercular  pyelonephritis  may  occur  in  the  course  of  general  miliary  tubercu- 
losis, or  at  first,  at  least,  as  a  local  affection.  In  the  latter  case  it  may  begin  in 
the  bladder  or  in  the  kidney  ;  but  often  before  the  disease  has  lasted  any  length  of 
time,  it  extends  from  one  to  the  other,  and  not  infrequently  involves  both  the 
kidneys,  although  in  different  degrees.  In  the  earlier  stages  the  mucous  mem- 
brane of  the  pelvis  is  thick  and  soft,  and  the  surface  like  sodden  wash-leather  ; 
here  and  there  are  small  superficial  ulcers  with  sloughing  and  ragged  edges,  due  to 
the  breaking  down  of  the  caseous  deposit ;  the  pelvis  is  enlarged  owing  to  increased 
difficulty  in  the  discharge  of  the  urine  ;  and  according  to  the  situation  of  the 
growth,  there  are  either  numerous  small  ca-seous  foci  in  the  .substance  of  the  kidney, 
or  the  apices  of  the  pyramids  are  eaten  away.  When  the  disease  is  of  longer  stand- 
ing, the  tissue  around  the  kidney  is  condensed  and  indurated  ;  the  capsule  is  thick- 
ened and  cannot  be  separated  from  the  cortex  ;  the  medulla  is  almost  destroyed, 
and  the  cortical  part  is  softened  and  disintegrated  (Fig.  420).  Ultimately 
suppuration  occurs,  as  in  other  forms  of  advanced  pyelitis,  and  the  whole  of  the 
renal  substance  may  disappear  and  nothing  be  left  but  a  thickened  shell  of  fibrous 
tissue,  preserving  somewhat  the  shape  of  the  kidney,  filled  with  a  slimy  mass  of 
tenacious  pus,  like  soft  putty. 


PYELITIS. 


1007 


^.*i^ 


Fig.  420. — Tuberculous  Pyelonephritis. 


Siipptiiative pyelonephritis  (surgical  kidney  so-called)  such  as  is  met  with  in 
old  cases  of  stricture,  vesical  calculus,  or  enlargement  of  the  prostate,  after  am- 
moniacal  decomposition  of  the  urine  has  set  in,  has  already  been  mentioned.  'J'he 
kidney  is  generally  small,  hard,  con- 
tracted and  granular  from  the  pre- 
existing interstitial  nephritis  ;  minute 
abscesses,  each  surrounded  by  its  zone 
of  congestion,  are  present  in  numbers 
under  the  capsule,  or  buried  in  the 
cortex,  or  extending  as  long,  slender 
streaks  in  the  substance  of  the  pyra- 
mids ;  here  and  there  between  them 
are  points  where  the  inflammation  has 
not  yet  culminated  in  suppuration  ; 
the  apices  of  the  pyramids  are  eaten 
away  ;  the  pelvis  and  calyces  are  irregu- 
larly dilated  from  the  old  standing 
obstruction  ;  and  the  mucous  membrane 
is  discolored,  ulcerated,  coated  over 
with  stinking  pus,  and  even  sloughing. 
Decomposition  has  occurred  in  the 
bladder  and  caused  acute  cystitis  ;  and 
the  poison  has  spread  directly  upward 
to  the  pelvis  and  into  the  substance  of 
the  kidney.  Very  rarely  the  pelvis  is 
healthy,  in  spite  of  the  presence  of 
advanced  nephritis,  the  germs  having, 
in   all  probability,   gained  the  kidney 

by  spreading  along  the  lymphatics  of  the  ureter  and  the  capsule,  until  at  length 
they  reach  the  interstitial  spaces  that  lie  between  the  tubules  and  surround  the 
glomeruli. 

Symptoms. — Pyelitis  may  affect  one  or  both  kidneys,  according  to  the 
cause.  When  it  is  due  to  septic  urine  and  cystitis,  it  is  nearly  always  bilateral ; 
the  tubercular  form  may  begin  in  one,  but  very  often  it  extends  to  the  other  at  an 
early  period  ;  and  though  the  retention  of  calculi  in  the  pelvis  is  in  some  measure 
the  result  of  accident,  their  formation  is  due  to  constitutional  causes,  and  if  they 
are  present  on  one  side  there  is  very  great  probability  of  their  occurrence  on  the 
other. 

Local. — In  the  early  stages  the  symptoms  of  pyelitis  are  very  indefinite,  unless 
the  attack  is  acute,  or  there  is  a  small  calculus  dropping  constantly  into  the  orifice 
of  the  ureter  ;  in  the  chronic  forms,  at  the  commencement  of  tubercular  disease 
for  example,  they  may  be  entirely  wanting.  As  the  inflammation  spreads  and 
involves  the  kidney,  there  is  a  constant  dull  aching  in  the  loins  ;  the  muscles  are 
rigid  and  tender  ;  there  is  stiffness  on  moving,  and  not  unfrequently  either  diar- 
rhoea or  constipation.  In  the  later  stages  of  calculus  and  tubercular  disease,  when 
the  tissues  around  are  involved  as  well,  the  pain  may  be  exceedingly  severe,  and 
the  kidney  may  feel  as  if  it  were  enlarged  ;  but  there  is  rarely  any  distinct  swell- 
ing unless  the  ureter  is  clo.sed  and  pyonephrosis  has  set  in. 

Neuralgia  radiating  down  some  or  all  the  branches  of  the  lumbar  plexus,  into 
the  groin,  down  the  inner  side  of  the  thigh,  or  into  the  testicle,  is  always  present, 
and  is  often  severe  when  there  is  a  calculus.  Irritability  of  the  bladder  is  almost 
as  general ;  in  renal  tuberculo.sis  it  is  one  of  the  earliest  signs,  and  it  is  not  un- 
common for  the  bladder  to  be  sounded  time  after  time  for  stone,  especially  in 
children,  before  the  real  cause  is  detected.  In  the  later  stages  it  may  be  simply 
agonizing. 

The  character  of  the  urine  is  most  important.  In  simple  catarrhal  pyelitis  it 
is  acid,  and  varies  but  little  in  quantity  or  specific  gravity  ;  but  it  is  turbid,  and 


ioo8    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

yields  on  standing  a  sediment,  in  which  the  characteristic  spindle-shajted  or  cau- 
date cells  of  the  pelvis  can  be  detected.  Blood-corpuscles  are  generally  jjresent  if 
there  is  a  calculus,  but  in  the  other  forms  they  often  do  not  appear  until  later.  As 
the  case  i)rogresses  the  epithelium  disappears,  the  amount  of  mucus  increases  ;  and 
this  in  its  turn  is  replaced  by  pus,  which  may  be  i)resent  in  such  (piantity  as  to 
form  a  thick  creamy  deposit  at  the  bottom  of  the  vessel. 

In  tubercular  and  calculous  jjyelitis,  the  urine  may  continue  acid  quite  to  the 
end,  in  spite  of  the  amount  of  i)us  that  is  added  ;  in  the  septic  form,  on  the  other 
hand,  it  is  alkaline  and  ammoniacal,  and  the  i)us,  mixed  with  phosphates,  forms  a 
dense,  viscid,  gelatinous  mass,  similar  to  that  secreted  by  the  bladder  under  the 
same  conditions. 

Constitutional. — These  depend  partly  upon  the  amount  of  sujipuration,  partly 
upon  the  extent  to  which  the  renal  substance  is  involved,  and  whether  both  kidneys 
are  implicated  or  only  one. 

In  the  so-called  surgical  kidney,  consequent  upon  vesical  disease,  the  symp- 
toms are  essentially  those  of  chronic  nephritis,  with  partial  and  increasing  sup- 
pression. There  is  rapid  emaciation,  with  loss  of  strength,  dryness  of  the  skin, 
headache,  neuralgic  pains  and  vomiting.  The  pulse  is  small,  (piick,  and  feeble  ; 
the  temperature  rises  to  102  F.  or  103°  F.  3  rigors  occasionally  occur  ;  and  the 
patient  gradually  passes  into  a  dreamy  state,  with  low  muttering  delirium,  until 
diarrhaa  with  a  subnormal  temperature,  or  coma,  and  perhaps  at  length  convul- 
sions, follow. 

In  tubercular  and  calculous  pyelonephritis,  if  only  one  kidney  is  affected,  the 
other  may  become  hypertrophied,  and,  so  far  as  the  urinary  secretion  is  concerned, 
compensate  perfectly  ;  and  sometimes  w^hen  this  occurs  the  pus  dries  up  (especially 
if  the  ureter  becomes  blocked),  and  the  kidney  is  at  length  converted  into  a  pasty,, 
mortary,  or  even  calcareous  mass,  surrounded  by  a  fil)rous  ca])sule.  Much  more 
often,  however,  suppuration  sets  in,  and  symptoms  similar  to  those  present  in  any 
case  of  ill-drained  abscess  make  their  appearance  ;  the  temperature  rises,  especially 
toward  evening,  or  rigors  occur ;  the  patient  becomes  weak  and  feeble  ;  night- 
sweats  and  diarrhcea  begin  ;  and  either  hectic  or  amyloid  disease,  which  is  especi- 
ally serious  when  there  is  only  one  kidney  active,  follows. 

If  both  kidneys  are  affected,  not  only  are  these  symptoms  greatly  intensified, 
but  in  addition  the  amount  of  urea  and  the  specific  gravity  of  the  urine  fall  lower 
and  lower  until  at  length  it  ends  in  suppression. 

Diagnosis. — The  diagnosis  of  pyelitis  at  its  commencement  is  often  very 
difficult,  and  rests  chiefly  upon  the  irritability  of  the  bladder,  for  which  no  cause 
can  be  found,  the  shape  of  the  epithelial  cells  in  the  sediment,  the  amount  of  mucus 
in  the  urine,  and  the  character  and  locality  of  the  pain.  When  cystitis  is  present 
as  well,  as  it  not  unfrequently  is  in  gout  and  tubercle,  the  difficulty  is  greater  still. 
In  older  cases,  when  the  kidney  becomes  involved,  there  is  little  or  no  trouble  ; 
either  the  urine  continues  acid,  in  spite  of  its  containing  an  enormous  amount  of 
pus,  or,  if  it  becomes  alkaline  and  ammoniacal,  the  diminution  in  the  amount  of 
urea,  the  low  specific  gravity,  the  emaciation,  and  the  other  constitutional  signs, 
render  it  clear  that  the  disease,  though  it  may  affect  the  bladder,  is  not  confined 
to  it. 

Calculous  pyelitis  may  generally  be  distinguished  from  the  others,  by  the  se- 
verity of  the  pain,  the  way  in  which  it  radiates  down  to  the  testicle,  the  occurrence 
of  renal  colic,  the  effect  of  exertion,  and  the  presence  of  blood-corpuscles  in  the 
urine  at  a  very  early  period.  When  the  inflammation  is  due  to  gravel,  genuine 
colic  is  rare,  though  there  may  be  a  great  deal  of  pain  ;  and  the  urine  is  of  high 
specific  gravity,  very  acid  and^  loaded  with  crystals.  In  either  case,  the  history, 
the  other  constitutional  symptoms,  and  the  occurrence  of  previous  attacks,  are  of 
great  importance. 

Tuberculous  pyelitis  is  more  difficult  to  distinguish,  especially  at  the  begin- 
ning, for  though  caseous  masses  and  bacilli  may  be  found  in  the  urine  when  the 
disease  is  advanced,  they  are  seldom  present  until  the  kidney  itself  begins  to  break 


P  YEL  ONEPHRITIS.  1 009 

down.  Very  often  the  diagnosis  has  to  be  made  l)y  a  process  of  exclusion  ;  there 
is  great  irritabiHty  of  the  bladder,  without  anything  local  to  account  for  it ;  the 
amount  of  mucus  in  the  urine  is  undoubtedly  excessive  ;  blood  is  seldom  present  ; 
the  pain  is  not  severe  ;  there  is  no  renal  colic  ;  and  the  urine  does  not  contain 
either  uric  acid  or  oxalate  of  lime  in  excess.  In  these  circumstances,  the  presence 
of  tubercle  elsewhere,  especially  in  connection  with  the  genito-urinary  organs, 
must  be  regarded  as  of  the  gravest  significance.  Later,  the  amount  of  pus,  the 
l)resence  of  caseous  masses  and  of  bacilli,  and  the  acid  reaction  of  the  urine,  are 
distinctive  ;  but  this  does  not  prove  that  both  kidneys  are  not  involved. 

Pyonephrosis  can  only  be  distinguished  from  hydronej^hrosis,  of  which  it  is 
not  an  infrecpient  termination,  by  the  pain,  fever,  and  rigors,  which  occur  with 
more  or  less  severity.  In  the  case  of  perinephritic  abscess,  the  shai)e  and  the  out- 
line of  the  swelling  are  not  so  distinct  ;  and  the  urine  is  not  affected.  Other  ab- 
scesses in  the  same  region,  due  to  disease  of  the  vertebrae,  caecum,  or  liver,  or  even 
to  an  empyema  working  its  way  down,  rarely  present  any  difficulty. 

In  a  very  few  cases  the  discharge  of  pus  is  intermittent,  and  there  is  a  pro- 
portionate variation  in  the  size  of  the  tumor. 

Treatment. — The  treatment  of  calculous  pyelitis  and  of  that  which  is  due 
to  the  presence  of  uric  acid  has  been  described  already.  If  there  is  a  stone,  an 
attemi)t  must  be  made  either  to  procure  its  disintegration  or  to  fix  it  in  some  out- 
lying part;  if  this  fails,  and  it  continues  to  give  inconvenience,  it  should  be  re- 
moved by  operation,  and  afterward  the  diet  and  mode  of  life  regulated,  so  as  to 
prevent  concentration  of  urine  and  the  accumulation  of  uric  acid. 

When  the  pyelitis  is  due  to  decomposition  of  urine  in  the  bladder,  the  growth 
of  the  ferment  must  be  stopped  by  antiseptics  and  drainage.  Meantime,  every 
attempt  must  be  made  to  restore  the  acidity  of  the  urine,  as  this  is  a  serious  hind- 
rance to  the  micrococcus,  and  to  spare  the  kidneys  as  much  as  possible  and  econo- 
mize the  patient's  strength  by  careful  dieting  and  attention  to  the  action  of  the 
skin  and  bowels. 

The  treatment  of  tuberculous  pyelonephritis  depends  upon  whether  it  is  merely 
part  of  a  general  tuberculosis,  or  of  an  affection  of  the  whole  urinary  system  ;  or 
whether  it  is  a  local  disorder,  and  still  confined  to  one  kidney.  In  the  former 
case  only  palliative  treatment  is  available  ;  the  strength  must  be  maintained  ;  the 
intense  vesical  irritation  must  be  relieved  by  morphia ;  and  any  symptoms  that 
arise  must  be  met  by  suitable  measures.  Median  cystotomy  and  drainage,  which 
are  of  such  service  when  the  strangury  is  due  to  local  causes,  such  as  malignant 
disease  of  the  bladder,  are  useless,  when  it  is  dependent  upon  the  reflex  action  of 
the  nervous  system. 

There  is  more  hope  when  it  can  be  shown  that  the  affection  is  limited  to  one 
kidney,  as  it  is  in  about  half  the  cases,  though  it  is  very  difficult  to  prove.  The 
specific  gravity  of  the  urine  may  be  good  ;  the  amount  of  urea  may  not  be  below 
the  normal  ;  and  there  may  be  an  entire  absence  of  pain  on  the  opposite  side  of 
the  body  ;  but,  unless  the  urine  can  be  collected  from  the  ureters  separately,  in  suf- 
ficient quantity  to  be  examined,  it  is  not  possible  to  be  certain.  In  some  of  these 
cases  the  pus  gradually  dries  up,  the  ureter  having  been  accidentally  blocked  in 
someway;  for  it  is  not  \\Xicon\vi\ox\,  post-mortem,  to  find  kidneys  consisting  of 
nothing  but  a  capsule  full  of  calcareous  or  cheesy,  mortary  substance,  years  after  all 
symptoms  have  subsided.  This,  however,  cannot  be  relied  upon  ;  the  disease  is 
much  more  likely  to  prove  fatal  by  involving  the  ureter  or  other  organs  near,  from 
general  miliary  tuberculosis,  or  after  prolonged  suffering,  from  hectic  and  exhaus- 
tion. Whether  nephrotomy  and  drainage,  or  nephrectomy  and  removal  of  the 
whole  mass,  afford  the  best  prospect  of  relief,  depends  upon  the  circumstances  of 
each  case.  If  the  patient  is  too  exhausted  to  withstand  the  shock  of  the  major 
operation  (and  it  often  happens,  from  the  dense  adhesions  between  the  capsule 
and  the  surrounding  structures,  that  a  very  long  time  is  required  for  complete 
enucleation),  or  if  there  is  any  doubt  as  to  the  condition  of  the  opposite  one, 
nephrotomy  is  the  more  suitable.     If  there  is  any  need  for  it,  the  shriveled  and 


loio    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

contracted  sac  can  be  removed  afterward.  W'licre,  on  the  other  hantl,  there  is 
nothing  left  but  a  fibrous  sac  without,  when  it  is  laid  open,  any  trace  of  secreting 
structure,  and  where  the  adhesions  can  be  broken  down  without  unduly  prolonging 
the  operation,  there  is  no  object  in  leaving  it  to  be  completed  at  a  later  date. 

Pkrinephritis. 

Inflammation  of  the  cellular  tissue  around  the  kidney  is  occasionally  primary, 
caused  by  injury  or  exposure  to  cold  ;  much  more  fretpiently  it  is  consecutive  to 
disease  elsewhere.  Sometimes,  as  in  calculous  and  tubercular  nephritis,  it  arises 
by  direct  extension  from  the  kidney,  the  pus  gradually  making  its  way  through 
the  capsule,  and  bursting,  i)eriiaps  externally,  so  that  the  stone  is  discharged 
through  an  opening  in  the  loins  ;  sometimes  it  originates  from  inflammation  about 
other  structures  near — the  colon,  crecum,  liver,  or  even  the  vertebrae.  In  a  large 
number  of  cases  it  is  due  to  the  inflammation  of  the  pelvic  cellular  tissue  extend- 
ing upward,  after  wounds  of  the  lower  part  of  the  vagina  or  uterus  ;  after  child- 
birth, or  after  operations  upon  the  testicle,  spermatic  cord,  or  rectum  ;  and, 
finally,  it  may  be  pyemic  in  character,  following  one  of  the  acute  exanthemata. 

Perinejjhritis  is  sometimes  chronic,  the  capsule  and  the  cellular  tissue  becom- 
ing thicker  and  denser,  until  the  kidney  is  invested  in  a  dense  fibrous  wall  which 
cuts  and  feels  like  cartilage  ;  but,  as  a  rule,  suppuration  soon  sets  in,  and  a  large 
irregular  abscess  forms  around  the  kidney,  and  spreads  upward  and  downward  as 
far  as  the  yielding  character  of  the  tissues  will  allow.  The  kidney  itself,  unless 
the  suppuration  originated  in  it,  usually  shows  no  change ;  but,  occasionally,  the 
cortex  is  softened,  in  a  state  of  cloudy  swelling,  and  even  filled  with  minute  abscesses. 
Both  sides  may  be  involved,  especially  when  it  is  the  result  of  pyaemia. 

Symptoms, — The  early  ones  are  very  perplexing  ;  very  often  there  is  a 
rigor  at  first,  with  constant  vomiting;  the  temperature  is  very  irregular;  the 
bowels  are  obstinately  constipated;  there  is  a  dull  aching  pain  across  the  back, 
and  the  patient  feels  perfectly  crippled.  The  body  is  inclined  toward  the  affected 
side,  and  slightly  bent  forward  ;  the  thigh  is  flexed  upon  the  abdomen,  and  the 
leg  is  rotated  outward,  as  in  the  second  stage  of  hip  disease.  The  least  move- 
ment makes  the  pain  tenfold  worse,  and  causes  it  to  radiate  down  the  lumbar 
plexus,  but  especially  into  the  groin  and  the  testicle  ;  and  with  all  this,  the  urine 
is  either  perfectly  normal  (unless,  of  course,  there  is  calculous  pyelitis),  or,  in 
some  exceptional  instances,  contains  a  certain  amount  of  albumin  and  a  few  tube- 
casts.  After  a  time,  the  tenderness  in  the  loin  becomes  more  localized  ;  there  is 
a  sense  of  deep  resistance  on  jialpation  ;  and  the  skin  becomes  shining  and 
oedematous,  or  even  reddened,  though  fluctuation  is  seldom  to  be  felt,  even  when 
the  abscess  contains  several  pints  of  fluid.  If  the  case  is  left,  and  the  constitu- 
tional disturbance  does  not  prove  fatal,  the  abscess  either  points  over  the  crest  of 
the  ilium,  between  the  obliquus  externus  and  latissimus  dorsi,  or.  else  extends 
under  Poupart's  ligament  into  the  thigh.  In  a  few  rare  cases  it  has  been  known 
to  burst  into  the  lungs  (so  that  an  enormous  amount  of  pus  was  suddenly  coughed 
up),  the  intestines,  the  jieritoneal  cavity,  or  even  the  ischio-rectal  fossa. 

Diagnosis. — Perinephritis  and  perinephritic  abscess  are  usually  much  more 
acute  than  hydronephrosis,  pyonephrosis,  and  the  other  diseases  that  cause  enlarge- 
ment of  the  kidney,  and  are  not  so  sharply  defined  in  outline.  At  first  there 
may  be  some  difficulty  in  distinguishing  it  from  perityphlitis,  and  even  from  en- 
teric fever  ;  and  it  has  been  confused  with  hip  disease  (owing  to  the  position  of 
the  limb),  with  caries  of  the  spine,  lumbago,  faecal  accumulations  in  the  colon, 
and  with  abscesses  resulting  from  disease  of  other  neighboring  structures. 

Treatment. — When  the  attack  is  subacute,  an  attemi)t  may  be  made,  by  ap- 
plying leeches  and  poultices,  and  by  keeping  the  patient  at  rest,  to  i)rocure  reso- 
lution, but  the  result  is  rarely  satisfactory.  As  a  rule,  rigors  occur  early,  and 
mark  the  beginning  of  suppuration.  The  bowels  should  be  well  cleared  out ;  hot 
water  enemata  are  often  of  some  relief;  the  pain  should  be  controlled  by  opium 


URINARY  FISTULA.  ion 

and  belladonna  ;  ami  as  soon  as  suppuration  is  suspected,  an  exploratory  punc- 
ture should  be  made  with  an  aspirating  needle.  In  a  very  few  instances,  if  the 
abscess  is  emptietl  in  this  way,  recovery  takes  j)lace  without  incision  ;  as  a  rule, 
it  is  necessary  to  open  it  freely,  wherever  it  is  most  prominent,  and  insert  a  large 
drainage  tube. 

Urinary  Fistula. 

Fistulous  channels  discharging  urine,  pus,  or  both  together,  are  sometimes 
formed  in  connection  with  the  kidney,  its  pelvis,  or  the  ureter  ;  and  they  may 
discharge  either  externally  in  the  loin  ;  or  on  the  front  wall  of  the  abdomen  in 
the  inguinal  region  ;  or  into  one  of  the  neighl)oring  viscera,  the  uterus  or  vagina 
most  commonly,  the  stomach,  intestine,  and  i)leura  very  rarely. 

The  most  frequent  cause  is  calculous  pyelitis  leading  to  suppuration  outside 
the  kidney  ;  after  the  abscess  had  been  opened  the  passage  contracts  down  to  a 
sinus,  the  walls  of  which  are  lined  with  a  kind  of  granulation  tissue,  and  perhaps 
coated  over  with  phosphates.  It  may  result,  however,  from  gunshot  wounds  or 
other  injuries,  from  operations  about  the  female  pelvic  organs,  especially  hyster- 
ectomy, and  occasionally,  from  tubercle.  In  some  cases,  as  in  cystic  disease  of 
the  kidney,  and  hydronephrosis,  a  urinary  fistula  is  formed  as  a  temporary  expe- 
dient, where  it  is  not  possible  to  obtain  at  the  time  exact  information  as  to  the 
condition  of  the  opposite  organ. 

After  nephrotomy  or  nephrolithotomy,  where  the  kidney  is  healthy  and  there 
is  no  obstruction  in  the  ureter,  the  wound,  though  it  may  continue  to  discharge 
urine  for  a  week  or  two,  usually  closes  of  itself.  If  it  persists  injections  of  iodine 
may  be  tried,  or  nitrate  of  silver  fused  upon  a  probe,  or  even  a  heated  wire. 
When,  however,  in  addition  to  the  urine,  there  is  a  profuse  discharge  of  pus,  so 
that  it  is  certain  that  the  kidney  is  extensively  disorganized,  and  there  is  fear  of 
amyloid  degeneration,  or  where  the  fistula  is  a  source  of  intense  annoyance  and 
distress,  and  it  can  be  proved  that  the  opposite  kidney  is  sound  and  not  the  seat 
of  calculous  disease,  the  best  plan  is  to  perform  nephrectomy. 

It  must  not  be  forgotten  that  fistulse  connected  with  the  bladder  and  the 
urethra  have  been  known  to  open  in  the  inguinal  region  and  even  in  the  loin.  In 
case  of  doubt  the  diagnosis  can  always  be  confirmed  by  the  injection  of  milk  or 
other  colored  fluids  into  the  bladder. 

Methods  for  Distinguishing  the  Secretion  of  the  Two  Kidneys. 

In  all  operations  about  the  kidneys,  but  especially  when  nephrectomy  is  con- 
templated, it  is  of  great  importance  to  obtain  definite  information  with  regard  to 
the  secreting  power  of  each  of  them.  As  already  mentioned,  it  is  not  uncommon 
to  find  that,  as  a  result  of  congenital  defect,  accident,  or  disease,  one  kidney  is 
either  actually  non-existent  or  else  is  so  small  as  to  be  practically  useless.  Even 
in  the  abdominal  operation  this  is  not  unnecessary,  for  all  that  can  be  ascertained 
by  this  is  the  size  of  the  organ  in  question  ;  it  tells  next  to  nothing  about  its 
condition. 

Various  methods  have  been  devised,  but  none  is  satisfactory.  The  simplest 
is  that  suggested  by  Polk :  one  of  the  ureters  is  compressed  just  before  its  termi- 
nation, between  a  piece  of  block  tin,  shaped  like  a  catheter  with  a  very  sharp 
curve,  introduced  into  the  bladder,  and  two  fingers  placed  in  the  rectum  ;  or,  if  it 
is  preferred,  a  curved  spatula  with  a  suitable  groove  on  its  upper  surface.  As 
soon  as  this  is  secured  in  position  the  bladder  is  washed  out,  and  the  urine  from 
the  other  ureter  allowed  to  collect,  but  it  is  very  difficult  to  obtain  more  than  half 
an  ounce  in  an  hour. 

Catheterization  of  the  ureters  can  be  managed  in  women  either  with  the  aid 
of  the  electric  light,  or,  the  patient  being  in  the  lithotomy  position,  by  placing 
the  fore  and  middle  fingers  of  the  left  hand  in  the  vagina,  one  on  either  side  of 
the  OS  uteri,  to  which  the  orifices  of  the  ureters  nearly  correspond,  and,  with  these 


I  o  1 2     DISEASES  A ND  INJURIES  OF  SPE  CIA  L  S TR  UCTURES. 

as  a  guide,  manipulating  the  catheter  with  the  other.  On  one  occasion  I  slit  up 
the  urethra  so  as  to  expose  the  orifices  more  thoroughly.  If  catgut  sutures  are 
used,  no  incontinence  should  follow.  Even  in  women,  however,  this  will  not 
always  succeed,  and  in  men  it  is  out  of  the  question. 

The  left  ureter  may  be  compressed  at  the  brim  of  the  pelvis  by  means  of 
Davy's  lever  introduced  into  the  rectum  ;  the  right  cannot,  unless  there  is  a  meso- 
rectum.  Even  when  used  for  a  short  time,  however,  this  is  not  without  risk  ; 
very  serious  bruising  of  the  mucous  membrane  has  occurred,  although  it  was  not 
I^ossible  to  assert  that  too  much  force  had  been  used;  and  certainly  it  would  not 
be  advisable  to  keep  up  a  sufficient  degree  of  pressure  for  an  hour.  The  same 
may  be  said  of  the  various  attempts  that  have  been  made  to  secure  the  orifices  of 
the  ureters  either  by  clamps  shaped  like  a  lithotrite  introduced  into  the  bladder, 
or  by  suction  api)lied  to  the  orifices  of  the  ureters  ;  they  have  only  met  with  very 
partial  success.  When  there  is  renal  hematuria,  the  cystoscope  is  of  some  service  ; 
the  jet  of  blood-stained  urine  may  be  seen  emerging  from  the  orifice  of  one  of  the 
ureters,  but,  unfortunately,  it  does  not  seem  probable  that  this  will  be  of  much 
avail  in  the  class  of  cases  that  need  it  most. 


OPERATIONS   UPON  THE   KIDNEY. 

Puncture  of  the  Kidney. 

The  chief  use  of  this  is  for  diagnosis  ;  it  may,  however,  be  required  either  as 
a  palliative  or  as  a  permanent  measure  in  cystic  disease,  hydatid  cysts,  and  even 
in  cases  of  hydronephrosis.  The  aspirator  should  be  introduced  into  the  most 
prominent  portion  of  the  swelling,  where  the  fluid  seems  to  lie  nearest  the  surface, 
taking  care  to  ascertain  the  position  of  the  colon  first  by  inflation,  if  necessary. 

Nephrotomy. 

Incision  of  the  kidney  may  be  required  for  suppuration,  consequent  on  cal- 
culous or  tuberculous  disease  (usually  as  a  preliminary  to  further  measures)  ;  for 
renal  retention  (when  the  ureter  is  blocked)  ;  or  for  hydronephrosis.  In  many  of 
these  cases  puncture  will  have  been  performed  first,  and  the  more  severe  and  radi- 
cal measvire  is  only  adopted  either  because  the  milder  plan  has  failed  (perhaps  in 
spite  of  repetition)  or  because  the  condition  it  has  revealed  is  such  as  to  require 
more  active  treatmeut.  An  operation  of  a  closely  similar  character  is  necessary 
in  cases  of  perinephritic  suppuration. 

The  incision  is  always  lumbar,  and  usually  oblique,  parallel  to  the  last  rib, 
and  an  inch  below  it.  The  skin,  superficial  structures,  muscles,  and  aponeurosis 
are  divided,  as  in  colotomy,  and  the  kidney  exposed.  If  it  is  distended  into  a 
sac  this  .should  be  opened  either  with  a  director  and  sinus  forceps,  or  with  a 
scalpel,  according  to  the  condition  found,  and  after  the  contents  have  escaped, 
the  space  left  should  be  explored  with  the  finger  to  ascertain  if  there  is  any  per- 
sisting cause,  and  drained.  If,  on  the  other  hand,  it  is  a  case  of  renal  retention, 
the  cortex  (which  is  always  hard  and  congested)  or  the  pelvis  must  be  opened 
sufficiently  freely  to  allow  the  urine  to  escape. 

Nephrolithotomy. 

There  are  two  methods  of  approaching  the  kidney  for  this  purjiose,  either 
from  behind  in  the  lumbar  region,  or  through  the  abdomen.  That  the  former  is 
the  more  suital)le  in  ca.ses  in  which  the  symptoms  are  definite  and  pointed  plainly 
to  one  side,  there  can  be  no  doubt,  but  it  is  still  an  ojjen  ([uestion  whether  abdom- 
inal exploration  is  not  advisable  in  some  as  a  preliminary.  A  certain  amount  of 
information  can  be  obtained  as  to  the  condition  of  the  opposite  kidney  ;  the  posi- 


NEPHR  OLITHO  TO  MY.  i  o  1 3 

tion  of  the  stone,  whether  it  is  in  the  ureter  or  not,  may  be  ascertained  ;  and  there 
is  less  risk  of  an  operation  on  the  wrong  side.  Moreover,  it  is  ])ossible  when 
operating  through  the  loin  to  be  misled  by  the  presence  of  a  perinephritic  abscess, 
the  interior  of  which  is  often  divided  into  chambers  like  a  sacculated  kidney  ;  and 
it  has  happened  before  now,  in  the  case  of  a  very  large  and  somewhat  diseased 
kidney,  that  the  finger  has  never  entered  the  pelvis  at  all,  but  detached  the  thick- 
ened mucous  membrane  from  the  pyramids  until  a  cavity  was  made  closely  resem- 
bling the  true  pelvis.  As,  however,  a  calculus  cannot  always  be  felt  after  the 
kidney  has  been  removed,  even  the  combined  abdominal  and  lumbar  method  does 
not  ensure  perfect  certainty. 

The  patient  lies  upon  the  opposite  side  with  a  firm  cushion  under  the  flank. 
The  kidney  is  supported  from  the  front  and  pressed  into  the  loin  by  an  assistant  ; 
but  if  the  walls  of  the  abdomen  are  rigid  and  dense  with  a  thick  layer  of  fat,  it 
answers  better,  as  soon  as  the  kidney  is  exposed,  to  roll  the  patient  nearly  on  to 
his  back  again,  so  that  the  convex  surface  may  drop  of  itself  upon  the  finger.  An 
oblique  incision,  four  inches  long,  parallel  to  and  an  inch  below  the  margin  of  the 
last  rib,  is  the  most  convenient.  It  should  commence  at  the  outer  edge  of  the 
erector  spinas,  and  should  not  come  closer  to  the  rib  for  fear  of  wounding  the 
pleura,  which  sometimes  descends  as  low  as  this.  The  superficial  muscles  are 
divided,  the  lumbar  aponeurosis,  which  here  is  very  thick,  cut  through  upon  a 
director,  additional  space  being  obtained,  if  necessary,  by  section  of  part  of  the 
quadratus  lumborum,  and  the  circumrenal  fat  exposed.  Any  point  that  bleeds 
should  be  tied  at  once,  but  generally  there  is  nothing  that  requires  it. 

As  a  rule,  the  tissue  around  the  kidney  is  so  loose  and  soft  that  it  can  be  sep- 
arated easily  with  the  finger  and  a  pair  of  forceps ;  sometimes,  however,  when 
there  has  been  much  inflammation,  it  is  tougher  ;  and  in  old  cases  of  suppurative 
pyelitis  it  may  be  exceedingly  dense.  As  soon  as  the  convex  surface  is  exposed, 
the  kidney  must  be  thoroughly  and  systematically  explored,  first  on  the  outside, 
passing  the  finger  over  the  anterior  surface  and  hooking  it  forward  into  the  wound 
until  the  pelvis  is  reached  ;  then,  as  far  as  possible  on  the  posterior,  the  fore  and 
middle  fingers  passing  behind  it,  while  the  thumb  rests  on  it  in  front  until  it  is 
fairly  grasped.  If  nothing  is  detected  in  this  way,  no  irregularity  of  surface  or 
sense  of  resistance,  the  next  step  is  to  explore  the  substance  of  the  kidney  with  a 
short  stout  needle  set  in  a  handle.  It  should  not  be  more  than  two  and  a  half 
inches  long,  for  fear  of  wounding  the  vessels  at  the  hilum.  A  number  of  punctures 
are  made  with  this  all  over  the  cortex,  always  pointing  in  the  direction  of  the  pelvis. 
Sometimes  a  calculus  is  struck  at  once,  but,  especially  when  it  is  small,  and  it  is 
often  no  larger  than  a  pea,  such  good  fortune  is  exceptional.  If  it  is  felt,  the  needle 
is  used  as  a  director  ;  an  incision  is  made  by  the  side  of  it  with  a  sharp  scalpel, 
and  a  pair  of  long  forceps,  like  polypus  forceps,  passed  along  it  until  the  blades 
are  in  a  position  to  grasp  the  stone. 

Where  this  does  not  succeed,  the  i)elvis  should  be  explored  with  a  sound 
similar  to  that  used  for  a  child's  bladder,  but  with  a  shorter  beak.  It  is  passed 
through  the  cortex  into  the  lowest  part  of  the  cavity,  and  the  whole  interior  and 
all  the  calcyces  systematically  examined,  the  sound  being  carried  at  once  to  the 
upper  end,  a  distance  of  nearly  four  inches,  and  working  gradually  down. 
Finally,  if  this  fails,  the  finger  must  be  used  in  the  same  way,  introducing  it 
through  the  same  opening,  and  gradually  dilating  and  tearing  the  kidney  substance. 
The  bleeding  at  the  moment  is  tolerably  free,  but  the  pressure  of  the  finger  soon 
arrests  it. 

With  a  large  branching  calculus  there  is  rarely  any  difficulty ;  when  it  is* 
small,  detection  is  often  impossible.  On  one  occasion  I  felt  a  small  movable 
stone  distinctly  with  the  needle,  but  was  quite  unable  to  detect  it  afterward  wnth 
the  sound,  forceps,  or  finger.  Another  case  is  recorded  in  which  the  kidney  was 
excised,  and  afterward  a  stone  was  found  in  it,  so  buried  that  it  could  not  be  felt 
from  the  exterior,  even  after  the  organ  has  been  removed.  In  a  third  case  the 
calculus  is  reported  to  have  come  away  subsequently  in  the  dressings  :   and  there  is 


IOI4    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

a  very  large  number  on  record  in  which  no  trace  of  a  calculus  was  found.  Fortu- 
nately the  operation  is  one  that,  so  long  as  the  stone  is  small,  is  very  rarely  fol- 
lowed by  serious  consequences  ;  and  in  most  cases,  even  when  nothing  has  been 
found,  the  relief  has  been  complete,  probably  from  the  calculus  becoming  fixed  in 
the  substance  of  the  kidney  by  inflammatory  adhesions  or  cicatricial  tissue. 

(ireat  care  should  be  taken  to  extract  the  stone  without  breaking  it,  and, 
especially  in  the  case  of  large  ones  with  long  slender  branches,  this  may  be  a 
matter  of  some  difficulty  ;  and  after  this  is  done  the  interior  of  the  cavity  must 
be  thoroughly  explored  to  see  that  nothing  is  left. 

The  treatment  of  the  wound  is  very  simple.  A  large  drainage  tube  should  be 
passed  into  the  kidney,  so  as  to  carry  away  at  once  all  the  urine  that  is  .secreted, 
and  the  fascia  lumborum  sutured  with  catgut,  leaving  only  an  orifice  at  the  posterior 
angle  for  the  drainage  tube.  Usually  the  wound  heals  without  suppuration.  The 
tube  should  be  removed  the  next  day  to  clear  it  of  any  coagula,  and  introduced 
again  down  to  the  surface  of  the  kidney  ;  the  third  or  fourth  day  it  may  be  short- 
ened so  as  to  project  only  through  the  opening  in  the  fascia.  The  urine  pa.ssed  by 
the  bladder  generally  contains  a  large  amount  of  blood  for  the  first  two  days,  then 
it  should  become  clear.  Retention  is  common  at  first,  and  may  continue  so  long 
as  the  tube  is  in  contact  with  the  kidney.  A  urinary  fistula  persists  for  a  week  or 
two  in  the  loin  ;  but  if  the  kidney  was  healthy  and  the  ureter  is  not  blocked,  it 
generally  closes  of  itself. 

In  cases  of  calculous  pyonephrosis,  when  there  is  a  large  tumor  in  the  loin,  and 
the  urine  is  loaded  with  pus,  nephrotomy  or  nephrolithotomy  should  be  adopted  in 
preference  to  nephrectomy.  It  is  true  that  the  statistics  of  the  latter  operation 
under  these  conditions  are  more  favorable,  but,  as  Brodeur  has  pointed  out,  it  is 
almost  impossible  to  form  a  definite  opinion  as  to  the  condition,  or  even  the  exist- 
ence of  the  opposite  kidney.  Later,  when  the  patient  has  rallied,  and  it  is  clear 
from  the  amount  and  specific  gravity  of  the  urine  secreted,  that  the  power  of  the 
other  kidney  is  not  impaired,  this  operation  may  be  performed,  if  the  fistula  per^ 
sists  and  gives  much  inconvenience,  or  if  the  discharge  of  pus  is  at  all  considerable. 
With  only  one  kidney  active,  there  is  naturally  greater  risk  if  there  is  any  amyloid 
change. 

It  must  always  be  recollected  that,  particularly  in  the  case  of  adults,  nephro- 
lithotomy can  only  be  looked  upon  as  giving  temporary  relief.  The  tendency  to 
the  formation  of  calculi  is  there  still,  and  the  same  precautions  as  to  diet  and 
regimen  must  be  taken  after  the  calculus  has  been  removed,  for  fear  of  recurrence. 

Nephrectomy. 

Excision  of  the  kidney  may  be  required  for  persistent  hemorrhage  following 
injury  ;  suppurative  pyelitis  (whether  calculous  or  tubercular)  in  which  the  renal 
tissue  is  hopelessly  destroyed  and  the  disease  limited  to  one  side  ;  sarcoma  or  car- 
cinoma :  and,  as  a  sequel  to  nephrotomy  when  (the  other  kidney  being  sound)  a 
fistulous  channel  is  left. 

It  may  be  performed  either  through  the  loin  or  the  abdomen. 

I.  Liunbar  Nephrectomy. — Morris  recommends  an  oblique  incision  parallel 
to  the  last  rib,  with,  if  more  space  is  required  for  dealing  with  the  pedicle,  a  ver- 
tical one  running  down  from  it,  just  in  front  of  its  posterior  extremity.  The  further 
steps  of  the  operation  are  the  same  as  in  nephrolithotomy  until  the  surface  is  ex- 
posed. As  soon  as  this  is  reached,  it  must  be  freed  from  the  tissues  around.  In 
•some  cases  there  are  no  adhesions  ;  in  others  they  are  so  dense  that  it  is  impos- 
sible to  divide  them  without  using  scissors.  Occasionally  it  is  better  to  open  the 
capsule,  and  try  to  shell  the  kidney  out  from  it. 

The  next  step  is  to  secure  the  pedicle.  It  may  be  possible  to  draw  the  kidney 
so  far  out  that  the  ureter  can  be  isolated  and  a  ligature  passed  round  the  vessels 
with  ease.  (Greig  Smith  recommends  that,  if  this  is  done,  all  traction  should  be 
taken  off  before  the  knot  is  tied,  for  fear  of  the  artery  slipping  back).      In  other 


SURGICAL   ASPECT  OF  THE  URINE.  1015 

cases  there  is  the  greatest  difficulty,  and  the  mass  must  be  secured  with  a  clamp, 
or  with  an  ccraseur,  and  cut  away  piecemeal  before  the  deeper  structures  are  suffi- 
ciently exposed.  The  artery  and  vein  may  be  tied  in  one  (if  an  abnormal  branch 
is  detectetl  it  should  be  dealt  with  by  itself),  and  as  soon  as  the  surgeon  has  satis- 
fieil  himself  tliat  the  ligature  is  safe,  the  kidney  tissue  or  the  ijelvis  divided  at  a 
sufficient  distance  and  the  rest  of  the  mass  removed.  The  ureter  should  be  brought 
out  at  the  lower  angle  of  the  wound,  and  fi.xed  by  a  suture  to  the  skin.  In  some 
cases  the  ligature  has  been  placed  almost  on  the  side  of  the  vena  cava,  but  where 
it  is  possible  a  sufficient  length  of  vessel  should  be  left  between.  Finally  the  wound 
must  be  thoroughly  dried,  the  peritoneum  examined  to  see  that  it  has  not  been 
rent,  and  a  large  drainage  tube  inserted. 

[When  oozing  persists,  or  indeed  as  a  routine  procedure,  it  is  well  to  pack  the 
wound  with  iodoform  gauze.] 

2.  Abdominal  Nephrectomy. — The  incision  is  made  through  the  corresponding 
linea  semilunaris  (after  Langenbeck's  method),  and  the  peritoneal  cavity  opened 
sufficiently  to  introduce  the  hand.  The  intestines  are  held  on  one  side  with  sponges, 
and  the  condition  of  the  opposite  kidney  ascertained  as  far  as  possible. 

The  posterior  layer  of  parietal  peritoneum  must  be  divided  on  the  outer  side 
of  the  colon  (so  as  to  avoid  injuring  its  vessels)  and  the  surface  of  the  kidney 
exposed  and  freed  from  its  surroundings.  As  soon  as  everything  is  clear  (the 
assistant  holding  up  the  torn  edges  of  the  peritoneum,  and  at  the  same  time  depress- 
ing the  margins  of  the  abdominal  wound)  the  vessels  are  isolated  and  a  ligature 
(double  if  possible)  passed  round  them  and  tied.  The  separation  is  then  com- 
pleted and  the  mass  removed. 

The  cut  edges  of  the  ureter  may  be  inverted  and  stitched  over,  so  that  the 
stump  may  be  left  secure;  or,  if  it  is  full  of  putrid  pus  or  tubercular  material,  it 
may  be  pushed  out  through  an  opening  in  the  loin  and  fastened  to  the  skin.  The 
plan  of  securing  it  in  the  anterior  wound  is  objectionable,  as  tending  to  disturb  the 
relation  of  the  peritoneum. 

The  cavity  left  behind  the  peritoneum  must  be  thoroughly  cleansed,  the  flaps 
that  have  been  detached  pressed  back  into  it  (they  need  not  be  fastened  with  any 
stitches),  and  then  the  abdominal  wound  dealt  with. 

The  relative  merits  of  these  operations  are  very  differently  appreciated.  There 
is  no  doubt  that  in  the  case  of  very  large  masses  the  abdominal  operation  is  the 
easier  of  the  two  (although  if  it  is  cystic,  the  size  may  be  considerably  reduced 
by  tapping)  ;  that  the  pedicle  is  more  accessible,  and  that  a  certain  (very  small) 
amount  of  information  about  the  condition  of  the  other  kidney  may  be  obtained. 
Further,  if  the  nature  of  the  tumor  is  doubtful,  there  is  very  much  greater  liberty 
of  action.  On  the  other  hand,  the  peritoneal  cavity  is  always  opened  ;  the  colon 
is  endangered  ;  the  ureter  is  difficult  to  deal  with  ;  if  the  operation  is  performed 
for  suppurative  or  tubercular  pyelitis,  there  is  considerable  danger  of  infecting  the 
peritoneum,  and  drainage  is  almost  out  of  the  question. 


SURGICAL  ASPECT  OF  THE  URINE. 

Examination  of  the  urine  is  essential,  not  only  for  diagnosis  in  diseases  of  the 
urinary  organs,  but  to  obtain  some  idea  concerning  the  activity  of  the  metabolism 
of  the  body  and  the  secreting  power  of  the  kidneys  Except  in  emergency,  no 
operation  should  be  performed  without  this  having  been  considered  ;  it  influences 
the  prognosis  more  than  anything  else,  especially  when  the  urinary  tract  itself  is 
concerned. 

1.  Quantity. 

The  amount  passed  during  twenty-four  hours  must  be  ascertained  in  order  to 
form  an  idea  as  to  the  reaction  and  the  proportion  of  solids.  It  is  sufficient  in 
most  cases  to  take  the  last  two  figures  of  the  specific  gravity  and  double  them,  or, 
if  the    urine  is  concentrated,  multiply    them  by   2.33.     This  gives  roughly   in 


ioi6     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

grammes,  the  total  solids  for  looo  c.c.  of  urine,  and  if  it  is  collected  for  twenty- 
four  hours  the  rest  is  easy.      Important  constituents  must  be  estimated  separately. 

When  a  i)atient  is  confined  to  bed  the  amount  of  urine  (as  regards  both  solids 
and  liquid)  is  always  diminished,  so  long  as  there  is  no  fever. 

The  quantity  may  be  lessened  by  general  causes,  such  as  fevers,  profuse  sweat- 
ing, diarrhoea,  etc.  ;  or  from  local  ones  affecting  the  circulation  of  the  kidney,  or 
its  secreting  power,  or  both  together.  Acute  nephritis,  for  example  ;  congestion 
from  cardiac  disease  ;  vasomotor  disturbance  excited  reflexly  by  irritation  of  the 
urethra,  especially  if  the  kidneys  are  diseased  already;  interstitial  nephritis  and 
amyloid  and  fatty  degeneration  in  their  later  stages  ;  hysteria  even  occasionally  ; 
and  shock,  as  after  railway  accidents,  are  all  attended  by  diminished  secretion. 
Sometimes  the  difference  is  only  slight ;  in  the  worst  cases  there  is  complete  sup- 
pression ;  no  urine  is  passed  for  days.  When  one  ureter  is  blocked  there  is  rarely 
much  difference  in  the  quantity,  even  at  the  first,  owing  to  the  increased  activity  of 
the  remaining  kidney  ;  but  when  both  are  affected,  as  when  there  is  an  insurmount- 
able obstacle  to  the  exit  of  the  urine,  suppression  must  occur. 

In  diabetes  there  is  a  great  increase  both  in  the  amount  of  solids  and  of  liquid  ; 
in  hysteria  and  simple  polyuria,  due  to  lesions  of  the  nervous  system,  only  the 
latter.  In  contracted  granular  kidney,  cystic  degeneration  and  the  early  stages  of 
amyloid  disease,  there  may  be  a  noticeable  increase  in  the  amount,  but  at  the  same 
time  the  specific  gravity  is  diminished  so  that  the  total  solids  may  fall  far  below  the 
normal.  In  the  matter  of  prognosis  this  is  scarcely  less  important  than  the  pre- 
sence of  albumin  ;  the  drain  upon  the  strength  may  be  less  severe,  the  loss  of  color 
and  condition  less  marked,  than  when  there  is  a  constant  daily  waste  of  nitrogen  ; 
but  the  elimination  of  effete  products  is  often  very  much  more  defective. 

2.   Color. 

This  depends  partly  upon  concentration,  partly  upon  the  addition  of  foreign 
substances,  such  as  blood,  bile,  melanin,  and,  under  certain  conditions,  indican. 
Carbolic  acid,  when  present  in  the  blood  in  excess,  gives  the  urine  a  peculiar  dark- 
green  smoky  tint,  which,  if  it  is  allowed  to  stand  for  some  time,  may  become 
almost  black. 

3.  Odor. 

In  chronic  cystitis  the  urine  is  often  offensive,  even  f?ecal  ;  or  it  may  be 
ammoniacal  Irom  decomposition.  Characteristic  odors  are  produced  by  turpentine 
and  other  drugs. 

4.   Reaction.  ' 

Normal  urine  is  acid,  and  this  becomes  more  marked  during  the  first  iew  hours, 
if  it  is  allowed  to  stand  in  a  clean  vessel.  Concentration,  an  excessive  amount  of 
nitrogenous  food,  and  diminution  in  the  quantity  of  alkaline  phosphates,  a  condi- 
tion frequently  found  in  ill-nourished  strumous  children,  increase  the  acidity. 
Associated  with  this  is  a  peculiar  train  of  symptoms,  such  as  are  common  in  gouty 
patients  ;  the  bladder  is  irritable,  there  are  frequent  attacks  of  dyspepsia,  neuralgia, 
cramp,  and  palpitation;  irritability  of  the  skin  is  not  uncommon;  sometimes 
eczema  and  psoriasis  occur  ;  gravel  is  present  from  time  to  time,  and  slight  attacks 
of  synovitis  are  of  frequent  occurrence. 

On  the  other  hand,  urine  may  be  neutral  or  alkaline,  from  the  presence  of 
fixed  alkali  or  of  ammonia. 

{a)  If  there  is  fi.xed  alkali,  the  blue  color  of  litmus  paper  is  i)ermanent.  This 
may  occur  temporarily  at  certain  hours  of  the  day,  depending  upon  the  meals, 
without  any  special  significance  ;  but  when  it  is  permanent,  it  usually  points  to 
some  serious  interference  with  the  metabolism  of  the  body.  It  has  been  noted  as 
a  precursor  in  affections  of  the  nervous  system,  and  in  the  early  stages  of  cancer. 

{b)  Carbonate  of  ammonia  is  always  due  to  a  micrococcus  growing  in  the 
urine ;  and  the  mucus  assists  it  by  rendering  the  urine  less  acid,  or  even  alkaline. 


.     SURGICAL   ASPECT  OF  THE  URINE.  1017 

Solid  Constituents. 

{a)  Normal. 

Urea. —  The  amount  depends,  to  a  certain  extent,  upon  the  age  and  the 
activity  of  the  individual.  According  to  Ralfe,  the  average  for  each  pound  of 
the  body  weight,  if  between  40  lbs.  and  60  lbs.,  is  41^  grains;  between  60  and 
120,  4  grains  ;  between  120  and  160,  3)4  grains;  and  between  160  and  175  lbs., 
only  3j<(  grains. 

For  clinical  purposes  the  urea  may  be  estimated  with  siifificient  accuracy  by 
the  sodium  hypobromite  method,  although  the  whole  amount  is  not  obtained  by 
about  8  per  cent. 

It  increases  in  fever,  after  excess  of  nitrogenous  food,  and  in  diabetes. 
Diminution  may  be  dependent  upon  diminished  formation,  as  in  diseases  of  the 
liver,  especially  acute  yellow  atrophy  and  extensive  carcinoma  ;  or  upon  diminished 
excretion.  The  latter  points  to  failing  kidneys,  and  is  a  very  serious  element 
in  prognosis  for  all  operations,  but  especially  for  those  involving  the  urinary 
tract. 

Uric  (?<7r/ either  occurs  as  such,  forming  a  brick-red  sandy  deposit,  or  united 
with  the  alkalies  or  alkaline  earths  as  a  salt.  I'hen  it  appears  as  a  pink  precipi- 
tate, rarely  crystalline,  which  gradually  settles  down  on  the  sides  of  the  vessel  as 
the  urine  cools.  Neutral  sodi.um  urate  is  the  most  abundant  in  normal  urine  ;  the 
acid  salt,  with  small  quantities  of  the  corresponding  calcium  one,  occurs  in  urinary 
calculi  and  gouty  deposits.  Acid  ammonium  urate  is  only  found  after  decomposi- 
tion of  the  urea.  Potassium  and  lithium  urates  are  more  soluble.  The  amount 
depends  partly  upon  the  supply  of  nitrogenous  food,  partly  upon  excessive  tissue- 
waste  and  diminished  oxidation.  In  gout,  chronic  diseases  of  the  liver,  and  general 
malassimilation,  it  increases  considerably,  and  is  deposited  wherever  the  circulation 
is  feeble. 

Whether  it  occurs  in  solution  or  as  a  sediment  depends  upon  the  concentra- 
tion and  reaction.  The  crystals  may  be  recognized  by  their  color  (in  the  urine), 
by  their  whetstone  shape,  or  by  their  being  aggregated  into  rhombic  bundles. 
Urates  are  generally  amorphous,  but  sometimes  they  crystallize  as  rhombic  needles, 
arranged  in  a  stellate  manner. 

Oxalate  of  lime  is  met  with  as  a  deposit  in  neutral,  acid,  and  faintly  alkaline 
urine.  The  crystals  are  either  octahedral  (envelope  crystals)  or  dumbbell-shaped. 
In  many  instances  it  is  only  accidental,  caused  by  the  presence  of  oxalate  of  lime 
in  the  food  fin  rhubarb,  tomatoes,  onions,  etc.),  or  by  malassimilation  ;  and  then 
it  is  usually  found  some  hours  after  meals.  In  those,  however,  who  are  harassed, 
careworn,  overworked,  and  hypochondriacal,  it  may  be  constant,  and  give  ri.se  to 
various  anomalous  nervous  symptoms,  such  as  frequency  of  micturition,  pains  across 
the  loins,  a  sense  of  tightness  round  the  chest,  etc. 

Oxalate  of  lime  is  closely  associated  with  the  decomposition  of  mucus.  It  is 
found  not  merely  in  that  which  is  secreted  by  the  urinary  passages,  but  in  that  from 
the  uterus,  gall-bladder,  vesicular  seminales  and  prostate,  sometimes  in  the  form  of 
crystals.  The  importance  of  this  in  the  causation  of  calculi  can  hardly  be  over- 
estimated. 

Phosphates. — Acid  sodium  and  potassium  phosphate  are  never  precipitated  ; 
phosphates  of  lime  and  magnesia  are  thrown  down  when  the  urine  is  alkaline,  or 
sometimes  if  it  is  boiled.  This  may  occur  even  when  the  urine  is  slightly  acid,  if 
the  reaction  is  due  to  the  presence  of  an  acid  salt. 

Phosphate  of  lime  is  usually  amorphous,  but  it  may  form  stellar  crystals  similar 
in  some  respects  to  those  of  uric  acid.  Acetic  acid,  however,  dissolves  them  at 
once.  Magnesium  phosphate  is  deposited  with  it  under  the  same  conditions.  If 
the  urine  is  alkaline  from  the  presence  of  bicarbonates,  they  may  be  precipitated 
without  being  in  excess  ;  but  under  some  circumstances,  particularly  in  that  state 
which  is  not  seldom  the  precursor  of  diabetes  and  cancer,  the  alkaline  and  the 
65 


loiS     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

earthy  phosphates  are  both  excessive.  If  they  are  deijosited  in  the  bladder,  they 
often  cause  a  certain  amount  of  irritation  by  collecting  toward  the  end  of  mictu- 
rition and  coming  away  in  a  thick,  creamy  mass,  which  leaves  a  wiiite  crust  as  it 
dries.      Fortunately,  they  rarely  form  calculi. 

When  the  urine  is  alkaline  from  ammonia,  the  tri])le  phosphate  of  ammonia 
and  magnesia  is  thrown  down  in  triangular  jjrisms  (coffin-lid  crystals;  which  form 
masses  entangled  in  mucus.  This  is  the  crust  that  develops  upon  calculi,  foreign 
bodies  introduced  into  the  bladder,  and  even  upon  the  surface  of  ulcers  in  the 
pelvis  of  the  kidney  and  bladder,  as  soon  as  the  urine  decomposes. 

(J))  Abnormal. 

Cystiii  is  an  occasional  cause  of  calculus.  It  may  be  recognized  by  its  being 
thrown  down  from  an  alkaline  solution  on  the  addition  of  acetic  acid.  The  crys- 
tals are  colorless  si.\-sided  plates,  and  are  readily  soluble  in  ammonia.  Its  patho- 
logical significance  is  unknown  ;  from  the  large  cpiantity  of  sulphur  that  it  contains 
Ralfe  is  disposed  to  connect  it  with  taurin.  I  have  met  with  two  families  in  which 
it  was  present ;  several  of  the  members  of  more  than  one  generation  were  affected, 
but  no  calculi  were  formed;  and  they  did  not  appear  to  be  in  any  way  inconveni- 
enced. The  sulphur  may  be  recognized  by  the  black  precipitate  obtained  by  boil- 
ing the  cystin  in  licpior  potassae,  and  adding  acetate  of  lead. 

Xanthin  is  still  more  rare.  It  has  been  met  with  as  gravel,  especially  in 
youths,  and  a  few  calculi  are  recorded.  It  is  readily  soluble  in  dilute  hydro- 
chloric acid,  from  which  it  may  be  obtained  on  evaporation  in  the  form  of  hexa- 
gonal crystals.  Like  cystin,  it  does  not  give  the  murexide  reaction,  but  if 
evaporated  with  nitric  acid  a  red  color  is  formed  on  the  addition  of  liquor 
potassae. 

Albumin. — The  ordinary  forms  are  serum  albumin  and  serum  globulin  ;  egg 
albumin  may  occur  in  cases  of  excessive  consumption  ;  hemialbumose  has  been 
noted  in  moUities  ossium  ;  and  peptones  have  been  found  in  acute  septic  diseases, 
but  they  are  hardly  of  surgical  importance. 

Its  presence  may  be  ascertained  by  boiling,  a  few  drops  of  acetic  acid  being 
added  if  the  urine  is  alkaline  ;  by  nitric  acid,  carefully  pouring  it  down  the  side 
of  the  tube  so  tiiat  the  urine  floats  at  the  top,  picric  acid,  or  acetic  acid  and  fer- 
rocyanide  of  potassium.  If  urates  are  present  they  must  be  dissolved  by  warm- 
ing, or  filtered  off;  phosphates,  which  are  precipitated  by  boiling  under  certain 
conditions,  are  soluble  in  nitric  acid.  The  total  amount  passed  within  a  certain 
time  can  be  estimated  by  precipitation  with  heat,  or  picric  acid,  and  allowing  it  to 
settle  in  a  graduated  tube ;  but  the  method  is  very  rough,  even  when  the  sample 
tried  is  taken  from  the  day's  collection. 

Excluding  functional  albuminuria  (which  may  arise  from  derangements  of 
digestion  or  of  the  nervous  system,  or  from  altered  conditions  of  the  blood),  the 
albumin  may  come  either  from  the  kidneys  or  from  .some  other  part  of  the  genito- 
urinary organs.  In  the  former  case  it  may  be  caused  by  inflammation  (as  in  all 
the  forms  of  nephritis)  ;  congestion,  as  in  cardiac  disease  ;  lardaceous  or  fatty  de- 
generation ;  or  the  presence  of  new  growths.  In  the  latter  it  is  derived  mainly 
from  the  secretion  of  mucous  membrane.  The  diagnosis  as  to  locality  must  be 
made,  either  from  the  constitutional  symptoms  that  are  present,  or  from  other 
features  of  the  urine,  such  a.s  alteration  in  specific  gravity,  the  presence  of  casts, 
blood,  epithelial  cells,  etc.  It  must  not  be  forgotten  that  the  two  not  unfrequently 
coincide. 

Renal  albuminuria  is  of  surgical  importance  for  two  chief  reasons. 

In  the  first  place,  the  daily  waste  of  so  much  nitrogenous  material  represents 
a  continual  loss  of  strength  and  diminished  power  of  repair.  In  the  second,  it 
points  to  a  morbid  state  of  the  kidneys,  in  which  they  are  scarcely  able  to  do  their 
work,  even  under  ordinary  conditions.  The  effect,  when  after  some  operation  or 
injury  an  immense  extra  strain  is  thrown  upon  them  can  be  imagined  :   the  albu- 


SURGICAL   ASPECT  OF  THE  URINE.  1019 

mill  increases  ;  the  excretion  of  urea  and  other  waste  becomes  more  difficult  • 
wounds  heal  less  rapidly  ;  and  there  is  a  much  greater  liability  to  inflammatory 
complications.  The  effect  is  the  same  in  contracted  granular  kidney,  when  ordi- 
narily there  is  no  albuminuria,  but  only  urine  of  low  specific  gravity  and  abundant 
quantity. 

In  operations  on  the  deeper  portions  of  the  urethra,  in  patients  suffering  from 
albuminuria,  there  is  a  still  further  reason  for  anxiety.  In  all  such  there  is  a  great 
liability  to  acute  renal  congestion,  probably  caused  by  the  vaso-motor  nerves. 
Even  when  the  kidneys  are  healthy,  the  secretion  may  sustain  a  sudden  check,  and 
albumin  and  even  blood  appear  in  the  urine  ;  if  they  are  inflamed  or  seriously 
degenerated,  the  secretion  may  stop  altogether,  and  the  operation  be  followed  by 
the  worst  and  most  fatal  form  of  urethral  fever. 

In  all  operations  of  expediency,  therefore,  the  presence  of  albumin  in  the 
urine  (and  the  specific  gravity,  if  it  is  persistently  low;  must  be  carefully  con- 
sidered side  by  side  with  the  physical  condition  of  the  patient,  before  anything 
is  settled.  Unhappily,  when  the  urinary  tract  is  involved,  the  operation  is  usually 
one  of  necessity  rather  than  expediency,  and  the  disea.se  itself  not  unfrequently 
the  cause. 

Albuminuria  due  to  amyloid  degeneration  of  the  kidneys  is  in  some  respects 
an  exception.  Even  when  it  is  constantly  present,  so  long  as  the  amount  is  small, 
complete  recovery  may  follow  the  removal  of  the  exciting  cause. 

Albumin,  derived  from  other  portions  of  the  urinary  tract,  whether  from  the 
pelvis  of  the  kidney,  the  bladder,  urethra,  or  vagina,  is  due  to  the  addition  of 
mucus,  blood,  or  pus  ;  very  rarely  from  the  admixture  of  spermatic  fluid.  Except 
in  the  case  of  pyelitis,  the  amount  is  always  small,  and  the  chief  importance  is  in 
the  diagnosis. 

Blood. — In  the  strict  sense  of  the  term,  haematuria  should  not  include  hemor- 
rhage from  the  walls  of  the  urinary  passages,  following  or  preceding  micturition  ; 
but,  for  the  sake  of  convenience,  they  are  always  considered  together,  and  the 
blood  may  come  either  from  the  kidney,  bladder,  or  urethra. 

The  color  depends  partly  upon  the  amount,  partly  upon  the  time  that  it  has 
been  mixed  with  the  urine.  If  the  hemorrhage  is  recent  and  profuse,  as  in  a 
villous  tumor  of  the  bladder,  or  rupture  of  the  kidney,  the  color  is  simply  that  of 
unaltered  blood  ;  when  it  is  poured  out  slowly  in  the  tubules,  or  allowed  to  collect 
in  the  bladder,  it  gradually  becomes  more  dusky,  until  the  tint  is  a  characteristic 
smoky  brown. 

Tests. — The  presence  of  blood  in  the  urine  may  be  recognized  : — 

(i)  By  the  color,  red  or  smoky,  as  the  case  may  be.  Carbolic  acid  gives 
urine  a  brownish  hue,  and  certain  drugs  (such  as  senna  and  rhubarb)  and  articles 
of  diet  (beet-root,  sorrel,  etc.)  in  quantity  turn  it  red,  but  they  can  easily  be 
distinguished.      In  hemoglobinuria  the  color  is,  of  course,  identical. 

(2)  By  the  Spectroscope. — There  is  a  broad,  dark  band  between  D  and  E, 
which,  on  dilution,  gradually  separates  into  two.  Sometimes  there  is  a  band 
between  C  and  D,  near  the  former  (acid  haematin),  or  midway  between  the  two 
(methaemoglobi  n) . 

(3)  By  the  Microscope. — Blood-corpuscles  retain  their  appearance  for  some 
time  in  acid  urine  ;  when  it  is  alkaline,  the  coloring  matter  soon  dissolves  out.  In 
haemoglobinuria  they  are  absent.  Hcemin  crystals  may  be  obtained  in  the  ordinary 
way. 

(4)  By  CJiemical  Reaction. — A  drachm  of  tincture  of  guaiacum  is  placed  in 
a  test-tube  ;  a  drop  of  the  urine  added,  and  then  some  ethereal  solution  of  per- 
oxide of  hydrogen  floated  upon  the  top.  A  blue  ring  develops  at  the  junction  if 
blood  is  present,  but  the  same  effect  is  produced  by  many  other  substances. 

The  source  may  be  conjectured  from  the  color,  reaction,  the  presence  of  clots 
or  of  casts,  the  uniformity  of  the  mixture,  and  the  presence  of  other  symptoms, 
such  as  renal  colic,  suprapubic  pain,  etc. 

{a)  Renal  Hcsmaturia. — The  blood  may  be  bright   red,    but  usually    it  is 


I020     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

smoky,  and  it  is  always  uniformly  diffused.  The  reaction  is  acid,  unless  the  quan- 
tity is  very  large  or  there  is  a  profuse  secretion  of  pus ;  tube  casts  may  be  present 
(they  are  of  themselves  distinctive)  ;  a  long,  worm-like  coagulum  may  comedown 
from  the  ureter,  and  the  attack  may  be  accompanied  by  severe  j^ain  in  the  loins, 
renal  colic,  or  retraction  of  the  testicle.    IMood  corpuscles  often  cannot  be  detected. 

(/;)  Vesica/  Ifu-matiiria. — The  color  is  usually  bright  red,  unless  the  urine 
has  been  retained  some  time  in  the  bladder,  and  the  mixture  is  rarely  uniform  ; 
the  last  drops,  as  a  rule,  contain  most,  whether  the  hemorrhage  is  still  going  on, 
or  whether  it  has  ceased  and  the  sediment  has  gravitated  to  the  bottom.  The 
reaction  may  be  acid  or  alkaline  ;  irregular  shapeless  clots  may  be  present  (they 
are  best  seen  floated  out  in  water),  but  too  much  reliance  must  not  be  placed 
upon  this,  for  the  blood  may  have  poured  down  from  the  kidney  and  coagulated 
in  the  bladder. 

{/)  Urethral  Iiemo?-rhage  is  always  bright  red,  the  blood  either  j^receding  or 
following  the  urine. 

Causes. —  Hcematuria  is  due  either  to  a  morbid  condition  of  the  blood  (pur- 
pura, scurvy,  etc.)  or  to  local  affections,  and  these  may  be  due  to  injury,  inflam- 
mation, or  new  growths. 

(«:)  Renal Hcematuria. — Blows  upon  the  loins  and  renal  calculus;  all  forms 
of  nephritis  (even  granular  kidney)  and  hypergemia,  whether  active  or  passive  ; 
carcinoma,  sarcoma,  and  tubercle. 

{b)  Vesical  Hwmatiiria.—  ^ o\.\Vi(\.^  {e.  g.,  rupture  of  the  bladder)  and  contu- 
sions caused  by  calculi,  catheters,  etc.;  cystitis  in  all  its  forms  and  ulceration  of 
the  mucous  membrane  ;  carcinoma,  villous  tumors,  and  tubercle. 

{c)  Urethral  Hemorrhage. — Injury,  such  as  impacted  calculus  or  the  passage 
of  a  catheter  ;   inflammation,  as  in  gonorrhoea;  or  new  growths,  such  as  tubercle. 

Treatment. — Perfect  rest  and  opium  (unless  there  is  nephritis,  or  renal 
congestion)  are  the  most  important.  Cold  may  be  applied  by  Leiter's  coils  to 
the  loins,  the  suprapubic  region,  or  the  penis  and  perineum,  according  to  the  seat 
of  hemorrhage.  Vesical  hematuria  may  be  checked  by  washing  out  the  bladder 
with  water  of  the  temperature  of  120°  F.,  or,  if  the  points  can  be  .seen,  by  touch- 
ing them  with  a  styptic.  In  urethral  bleeding,  a  catheter  may  be  passed,  and  the 
penis  gently  compressed  around  it  with  a  bandage  ;  or,  if  it  is  in  the  region  of 
the  bulb,  Otis's  crutch  may  be  employed.  Tincture  of  hamamelis  is  said  to  check 
vesical  hemorrhage  when  injected  into  the  bladder.  Infusion  of  matico  has  been 
used  in  the  same  way. 

Gallic  and  sulphuric  acids,  acetate  of  lead,  and  ergot  may  be  given  inter- 
nally, but  if  the  hemorrhage  comes  from  a  vessel  of  any  size  they  are  of  little 
service. 

Coagula  occasionally  give  rise  to  severe  pain,  and,  if  the  urine  is  septic  and 
the  bladder  atonic,  may  require  speedy  removal  for  fear  of  decomposition  and 
septic  absorption.  This  may  be  done  most  easily  by  means  of  a  soft  catheter  and 
a  lithotrity  evacuator,  the  clots  gradually  being  broken  up  and  sucked  away. 

Sugar. — Glucose  is  probably  always  present  in  the  urine  in  minute  quantities, 
and  in  certain  circumstances  the  amount  increases  without  very  special  signifi- 
cance. Thus  it  may  occur  from  excessive  consumption,  chronic  congestion  of 
the  liver,  prolonged  narcosis,  or  the  inhalation  of  amyl  nitrite  ;  or  it  may  be 
present  for  a  time,  without  any  cause  being  discovered,  in  members  of  diabetic 
families  ;  but,  though  this  is  always  to  be  noted  in  a  history,  it  is  not  of  the  same 
importance  as  ])ersistent  diabetes. 

Temi)orary  glycosuria  is  not  uncommon  after  injuries  of  the  head,  concussion 
of  the  spine,  fractures  of  the  vertebrae,  and  injuries  to  the  abdomen  and  kidneys. 
Sometimes,  but  much  more  rarely,  when  caused  in  this  way,  it  is  permanent. 

Many  of  the  skin  affections  in  diabetes  are  due  to  physical  causes,  such  as  the 
harsh,  dry  condition,  merging  into  pruritus,  and  the  eczema  which  is  so  com- 
mon about  the  genital  organs  in  women.  Others,  however,  are  due  to  the  mal- 
nutrition of  the  tissues.   Boils  and  carbuncles,  for  example,  are  of  frequent  occur- 


SURGICAL  ASPECT  OF  THE  URINE.  102 1 

rence,  and  the  latter,  in  i)articular,  are  of  very  grave  import ;  cataract  may  occur  in 
one  eye  or  both  ;  amblyopia,  sometimes  varying  according  to  the  state  of  health,  is 
not  unfrequent,  and,  what  is  more  serious  than  all,  gangrene,  esjjecially  of  the  ex- 
posed parts,  may  be  caused  by  the  least  injury.  It  resembles,  in  general  character, 
the  ordinary  senile  form,  but  it  is  usually  moist  and  much  more  rapid.  For  fear  of 
this,  from  the  susceptibility  to  shock,  and  the  tendency  to  hemorrhage,  operations, 
unless  absolutely  essential,  are  rarely  undertaken  in  diabetic  patients. 

Chyle  arid  lymph  are  occasionally  found,  coming  from  varicose  lacteals  or 
lymphatics,  in  the  wall  of  the  bladder.  In  the  case  of  the  former,  the  urine  is 
white,  like  milk  ;  when  the  latter  is  present,  it  remains  clear  ;  usually  it  coagulates, 
forming  a  loose,  soft  clot,  which  gradually  becomes  li(iuid  again.  Chyluria  is  of 
especial  interest  from  its  connection  with  the  filaria  sanguinis  hominum. 

Fat. — After  extensive  fractures,  a  delicate  pellicle  is  often  found  floating  on 
the  surface  of  the  urine,  and  the  same  thing  has  been  known  to  occur  in  diabetes. 
Occasionally,  smaller  quantities,  with  cholesterin,  etc.,  find  their  way  in  from  the 
breaking  down  of  caseous  mas,ses. 

Mucus. — A  slight  amount  is  always  present  ;  and,  especially  in  women,  it 
often  forms  a  light,  transparent,  floating  cloud,  without  having  any  pathological 
significance.  In  catarrh  it  increases  very  greatly,  and  is  mixed  with  young  epi- 
thelial cells  detached  from  the  walls. 

Pus  may  come  either  from  an  abscess  bursting  into  one  of  the  urinary  pas- 
sages, or  from  the  mucous  surfaces,  after  prolonged  irritation.  If  the  urine  is 
acid,  it  forms  a  thick,  creamy  layer  ;  as  the  reaction  becomes  alkaline,  it  collects 
into  dense,  stringy  masses  ;  and  if  liquor  potassse  is  added,  it  forms  a  viscid  gela- 
tinous deposit,  like  white  of  egg.  The  corpuscles,  as  a  rule,  have  more  than  one 
nucleus,  but,  unless  the  quantity  is  excessive,  it  is  difficult  to  distinguish  from 
mucus.  If  both  are  present,  the  best  plan,  as  suggested  by  Ralfe,  is  to  throw 
down  the  pyin  with  mercuric  chloride,  filter  it  off,  and  then  add  acetic  acid  to  the 
filtrate  to  precipitate  the  mucin. 

Pus  may  come  from  any  part  of  the  urinary  system,  and  in  general  the  diag- 
nosis as  to  locality  can  only  be  made  from  other  symptoms.  If  it  is  abundant, 
and  the  urine  remains  acid,  it  is  probably  derived  from  the  pelvis  of  the  kidney  ; 
when  it  is  ammoniacal,  and  contains  crystals  of  triple  phosphate,  some  of  it,  at  least, 
comes  from  the  bladder. 

Urinary  Deposits. 

Some  are  derived  from  the  urine ;  others  from  the  walls  of  the  urinary  pas- 
sages ;  others  again  are  living  organisms. 

I.   Deposits  from  the   Urine, 
{a)  From  acid  urine  :  oxalate  of  lime  ;  uric  acid  ;  urates  ;  cystin  and  tyrosin. 


Fig.  421. — Urates. 


I02  2    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


Fig.  422. — Uric  Acid. 


Fig.  423. — Oxalate  of  Lime. 


(/^)  From  alkaline  urine:  oxalate  of  lime;  phosphates  of  lime  and  mag- 
nesia ;  ammonio-niagnesian  phosphate  ;  acid  urate  of  ammonium  and  carbonate 
of  lime. 


Fi(;s.  424  and  425. —  Phosphates. 


2.   Deposits  from  the    Walls  of  the   Urinary  Passages. 

(a)  Epithelium  coming  from  the  kidney  ;   from  the  pelvis  and  ureter ;   from 
the  bladder  ;   or  from  the  urethra  or  vagina.     The  nucleus  is  usually  visible  under 


Fig.  426. — Epithelium  from  Urinary  Passages. 


Fig.  427. — Spermatozoa  and  Vaginal  Epithelium. 


the  microscope,  without  the  addition  of  any  reagent,  which  is  not  the  case  with 


SURGICAL   ASPECT  OF  THE  URINE. 


either  pus  or  mucus  corpuscles.  Ei)ithelial  cells  from  the  kidney  are  usually  either 
rounded  in  shape  or  cubical  ;  those  from 
the  pelvis  and  ureter  more  columnar,  but 
often  they  are  triangular  or  cauilate  ;  blad- 
der ei)itheliuin,  as  a  rule,  is  flatter;  and 
that  from  the  vagina  squamous;  but,  with 
the  excei)tion  i)erhapsof  the  last,  it  is  rare- 
ly ]iossible  to  be  certain  as  to  the  source, 
unless  the  cells  are  aggregated  together 
into  masses — unless,  that  is  to  say,  tube- 
casts  are  jiresent  from  the  kidney  or 
glandular  casts  from  the  prostatic  follicles, 
or  irregularly-shaped  collections  from  the 
walls  of  the  bladder. 

{J))  Blood,  sometimes  separate  corpus- 
cles ;  sometimes  casts  of  clots. 

(0    Pus. 

(d)  Mucus. 

{/)     Spermatozoa. 

(/)   Fragments  of  new  growths,  either  villi  or  broken  down  epithelial  masses, 
and  sometimes  cell-nests  from  epitheliomata. 


Fig.  428.— Urinary  Casts. 


4.  Living  Organisms. 

{(i)  Animal  Parasites. — The  ova  of  Bilharzia  h?ematobia — a  trematode  worm 
— are  the  most  common  ;  but  filaria  are  occasionally  found,  and  booklets  from 
broken  down  hydatid  cysts. 

{b)  Vegetable  Organisms. — Penicillium  and  torulse  are  found  growing  in  urine 
that  has  been  allowed  to  stand,  the  latter  only  when  there  is  sugar.  The  bacterium 
of  ordinary  putrefaction,  and  the  micrococcus  ureae,  are  of  common  occurrence. 
Tubercle  bacilli  may  be  found  and  recognized  by  proper  staining,  when  ca.seous 
masses  are  breaking  down  and  ulcerating. 

In  addition  to  these,  other  substances  occasionally  find  their  way  into  the 
urine,  either  from  ulceration  opening  up  a  passage  between  the  alimentary  canal 
and  the  urinary  tract,  or  from  accidental  discharges  from  the  rectum  or  vagina. 


1024     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  XXI. 

INJURIES  AND  DISEASES  OF  THE  BLADDER. 

Ectopia  Vesicae. 

Defective  development  of  the  anterior  wall  of  the  abdomen  and  front  of  the 
bladder  from  the  umbilicus  down  to  the  penis,  involving  the  pubic  symphysis.  It 
is  more  common  in  males  than  in  females,  and  is  due  to  the  deficient  growth  of 
the  mesoblast  in  the  embryo.  At  birth  there  is  a  thin  membrane  covering  in  the 
opening,  but  this  soon  dries  up  and  is  cast  off,  leaving  a  few  shreds  around  the 
margin.  It  is  known  as  extroversion  of  the  bladder,  from  the  way  in  which  the 
posterior  wall  with  the  orifices  of  the  ureters,  being  entirely  unsupported  in  front, 
is  pushed  forward  like  a  hernia  by  the  pressure  of  the  viscera  behind. 

The  appearance  is  characteristic  at  the  first  glance.  In  the  pubic  region, 
where  the  symphysis  should  be,  there  is  a  round,  red,  vascular  projection  of  mucous 
membrane,  which  becomes  more  prominent  whenever  the  child  cries  or  strains. 
On  the  front  of  this  are  the  ureters,  with  drops  of  urine  falling  from  them  at  regular 
intervals.  Above  is  the  linea  alba,  generally  very  much  widened,  so  that  the  two 
recti  are  far  apart ;  below  is  the  flattened  penis,  with  on  its  .surface  the  urethral 
groove  and  the  openings  of  the  prostatic  follicles  ;  and  on  each  side  is  a  rounded 
projection,  caused  by  the  pubic  bones,  which  do  not  meet  in  the  middle  line.  The 
testes  may  be  present  in  the  scrotum,  or  they  may  still  be  in  the  inguinal  canal ; 


i  rci'^j' 


Fig.  429. — Ectopia  Vesicae  in  the  Male. 


Fig.  430. — Ectopia  Vesicse  in  the  Female. 


and  there  may  be  a  hernia  as  well  on  either  side.  The  thighs  are  widely  separated 
from  each  other,  so  that  the  gait  is  waddling,  and  if  the  skeleton  is  examined  the 
obturator  foramina  are  smaller  than  natural,  the  iliac  bones  straighter,  and  the  pubic 
ones  separated  by  an  interval  of  from  two  to  four  inches. 

In  the  female  the  appearances  are  so  much  the  same  that  sometimes  there  is  a 
little  difficulty  in  determining  the  sex.  The  testes,  however,  or  the  body  of  the 
uterus,  as  the  case  may  be,  can  usually  be  made  out  without  much  difficulty. 

In  older  cases  the  skin  around  becomes  sodden  and  excoriated  ;  the  surface 
of  the  projection  becomes  rough  and  granular  from  the  constant  friction  and  irri- 
tation to  which  it  is  subjected  ;  papillary  growths  spring  up  around  the  ureters,  so 
as  to  cause  a  slight  degree  of  obstruction  :  this  leads  to  dilatation,  and  at  length 
the  pelves  of  the  kidneys  become  involved,  the  secreting  substance  is  absorbed,  and 
interstitial  nephritis  sets  in.     Suppurative  inflammation,  however,  is  rare,  owing 


ECTOPIA   VESIC/E.  1025 

to  the  very  free  drain  that  exists  for  the  urine.  Sometimes,  when  the  nreters  are 
dilated,  the  urine  is  ejected  in  small  jets  when  any  pressure  is  made  upon  the 
abdomen. 

Treatment. — Many  attempts  have  been  made  by  reflecting  flaps  of  skin  to 
cover  in  the  opening  and  form  an  anterior  wall  for  the  bladder  ;  of  the.se  the  most 
successful  is  Wood's,  but  even  with  this  the  greatest  benefit  that  can  be  hoped  for 
is  the  formation  of  a  cavity  which  will  retain  urine  for  a  short  time  with  the  aid  of 
an  appliance.  In  general,  all  that  is  possible  is  to  cover  in  and  j^rotect  the  surface, 
leaving  at  the  lower  part  an  orifice  through  which  the  urine  can  drain  into  a 
urinal. 

Some  time  beforehand  the  hair  follicles  must  be  destroyed  by  epilation  and 
nitric  acid  ;  if  left,  i)hosphatic  concretions  are  liable  to  form  upon  the  hairs  and 
become  the  source  of  much  annoyance.  The  flaps  are  arranged  so  that  there  is  a 
double  layer  in  front,  one  with  its  epidermis  facing  the  bladder,  the  other  laid 
over  this,  raw  surface  to  raw  surface,  facing  the  other  way.  The  former  of  these, 
if  the  opening  is  of  any  size,  is  reflected  down  from  the  abdominal  wall  above  the 
umbilicus,  giving  it  as  wide  a  pedicle  as  possible,  and  making  it  sufficiently  large 
to  reach  the  soft  tissues  on  either  side,  and  come  well  down  on  to  the  root  of  the 
penis.  Care  must  l^e  taken  in  doing  this  that  the  abdominal  cavity  is  not  opened, 
for  the  aponeurosis  beneath  is  very  much  stretched  and  thinned.  The  flaps  to 
cover  this  in  are  taken  from  either  side,  the  root  of  each  being  formed  by  the  side 
of  the  scrotum  and  the  urethral  groove  ;  and  they  should  be  large  enough  when 
brought  together  and  united  in  the  middle  line  to  cover  in  the  whole  of  the  vesical 
flap,  and  reach  well  on  to  the  raw  surface  above  it  and  at  its  sides. 

In  dissecting  up  these  the  greatest  care  must  be  taken  not  to  bruise  the  edges 
or  score  with  the  knife  the  under  surface  of  the  skin.  Hemorrhage  should  be 
checked  at  once  by  torsion.  The  vesical  flap  is  laid  in  position  first,  being  turned 
down  on  itself  so  that  the  epidermic  surface  faces  the  bladder.  The  apex  is 
secured  by  two  stout  wire  sutures,  one  on  either  side,  to  the  margins  of  the  urethral 
groove,  close  to  the  roots  of  the  lateral  ones ;  and  the  edges,  if  necessary,  to  the 
margins  of  the  raw  surface  at  the  sides  with  catgut.  Meanwhile,  its  surface,  as  well 
as  that  of  the  lateral  flaps,  is  gradually  becoming  glazed  over.  When  all  oozing 
has  ceased,  a  stream  of  some  warm  antiseptic  is  gently  poured  over  to  wash  away 
any  clot,  and  when  they  are  thoroughly  clean  and  dry  the  two  side  flaps  are 
brought  over  the  vesical  one,  pressed  down  firmly  upon  it  by  means  of  a  sponge, 
and  secured  to  each  other  and  to  the  margins  with  wire.  This  covers  in  the  whole 
of  the  bladder,  leaving  at  its  lower  end  an  opening  on  the  dorsum  of  the  penis 
tightly  embraced  by  the  roots  of  the  side  flaps.  The  edges  of  the  wounds  from 
which  the  vesical  flaps  have  been  reflected  should  be  brought  together  as  far  as  pos- 
sible by  means  of  harelip-pins ;  the  rest  may  be  left  to  granulate,  broad  bands  of 
strapping  being  fastened  over  the  dressings  to  support  the  whole. 

After  the  operation  the  patient  must  be  kept  absolutely  quiet,  in  a  sitting 
position,  with  the  knees  well  supported  and  secured  by  bandages,  so  that  there  is 
no  strain  upon  the  sutures ;  and  as  this  becomes  very  irksome,  it  may  be  necessary 
to  keep  him  under  the  influence  of  some  narcotic.  If  all  goes  well,  the  sutures 
may  be  removed  at  about  the  end  of  the  week.  Very  often  there  is  some  yielding 
at  the  upper  angles,  especially  if  the  flaps  are  rather  short,  and  this  may  give  rise 
to  troublesome  fistulae.  Even  in  the  most  successful  cases  the  orifice  usually  en- 
larges, owing  to  the  pressure  on  the  tissues  behind  it,  and  at  length  requires  to  be 
covered  in  by  some  operation  similar  to  that  practiced  for  epispadias. 

When  the  opening  is  not  so  large,  Wood  recommends  that  two  lateral  flaps 
only  should  be  used,  each  having  a  pedicle  springing  from  the  scrotum  and  the 
side  of  the  urethral  groove.  The  size,  of  course,  varies  with  the  case,  but  they 
must  be  each  of  them  sufficiently  large  to  cover  in  the  whole  of  the  bladder.  The 
same  precautions  are  retjuired  as  in  the  previous  case.  When  the  surfaces  are 
glazed  one  is  twisted  round  and  laid  with  its  epidermis  toward  the  cavity,  and  the 
other  is  laid  upon  this  and  secured  to  it  and  to  the  margins. 


I026    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Thiersch's  method  is  simpler,  and  succeeds  better,  as  some  of  the  cases  acquire 
a  certain  degree  of  control.  A  new  urethra  is  formed  first.  In  the  region  of  the 
glans  a  deep  groove  is  cut  on  either  side  of  the  mucous  membrane,  and  the  edges 
are  l)rought  over  and  united  by  twisted  sutures.  Behind,  in  the  jienile  i)art,  a  new 
roof  is  formed  from  rellecteil  nai)s  of  skin.  One  of  these  is  taken  from  each  side, 
and  they  are  so  arranged  that  while  the  first  is  reflected  toward  the  groove  (so 
that,  when  it  is  in  position,  the  epidermic  surface  faces  the  mucous  one),  the 
second,  which  should  be  considerably  larger,  is  slid  over  the  raw  surface  of  the 
other. 

As  soon  as  this  is  accomplished,  and  the  parts  are  fairly  firm,  the  front  of  the 
bladder  is  closed  in.  Two  longitudinal  flaps  of  skin  are  dissected  up,  one  from 
each  side,  of  sufficient  length  and  breadth  combined  to  cover  the  exposed  mucous 
membrane.  Each  is  separated  at  the  sides  and  beneath,  but  left  attached  at  the 
ends,  so  that  the  under  surface  may  cover  itself  with  granulations.  At  the  end  of 
a  fortnight  or  three  weeks,  when  they  are  thick  and  vascular,  the  ui)per  end  of  the 
lower  one  is  divided,  so  that  it  can  be  twisted  on  its  lower  attachment  (which  lies 
close  by  the  root  of  the  penis),  and  placed  acro.ss  the  lowest  part  of  the  bladder, 
just  above  the  new  urethra  (a  groove  is  cut  in  the  opposite  side,  by  the  border  of 
the  mucous  membrane,  to  receive  its  upper  end).  Then,  a  short  time  later,  the 
other  one,  which  lies  on  a  slightly  higher  level,  is  divided  in  the  .same  manner 
and  carried  over  the  upper  half.  By  means  of  these  two  flaps  the  greater  portion 
of  the  cavity  is  covered  in  ;  the  little  angle  above  is  patched  up  from  the  front  of 
the  abdomen,  and  the  similar  one  below  by  means  of  a  loop  from  the  scrotum. 

More  recently,  Trendelenburg  has  advocated  the  division  of  the  sacro-iliac 
synchondrosis  from  behind,  and  the  gradual  approximation  of  the  pubic  bones,  by 
properly  contrived  splints,  until  the  sides  of  the  cleft  are  sufficiently  close  to  be 
united.  The  operation  is  performed  during  infancy.  The  left  fore-finger  is  kej^t 
in  the  rectum  to  ascertain  the  position  of  the  sciatic  notch  and  avoid  the  gluteal 
artery.  An  incision  from  two  to  three  inches  in  length  is  made  through  the  soft 
structures  on  the  back  of  the  joint,  from  the  posterior  superior  spine  downward  ; 
the  posterior  ligaments  are  divided,  and  then  the  interosseous  ones,  until  the  joint 
can  be  forced  open  by  lateral  pressure,  and  the  pubic  bones  brought  together.  The 
wounds  behind  are  dressed  and  drained  ;  and  the  child  is  ])laced  in  a  V-shaped 
splint,  well  padded,  to  protect  the  bony  prominences,  until  the  healing  is  complete. 
Afterward,  the  edges  of  the  cleft  are  deeply  pared  and  brought  together.  Unless 
the  pubic  bones  can  be  placed  in  apposition  and  sutured  together,  the  operation 
cannot  be  considered  successful ;  later,  the  cavity  of  the  bladder  must  be  dilated 
by  continuous  pressure  with  a  rubber  bag,  and  the  urethra  comi)leted. 

The  same  thing  has  been  attempted  by  gradual  pressure  without  division  of 
thfe  ligaments,  the  prominences  being  protected  by  means  of  rubber  rings  and  the 
points  varied  as  much  as  possible. 

Injuries  of  the  Bladder. 

The  bladder  may  be  injured  by  stabs  or  gunshot  wounds  through  the  abdo- 
minal wall,  the  rectum,  or  the  vagina  ;  it  has  been  punctured  through  the  sacro-sci- 
atic  foramen  ;  it  may  be  torn  by  one  of  the  pubic  bones  in  fracture  of  the  pelvis, 
or  wrenched  from  the  triangular  ligament  by  separation  of  the  symphysis  ;  it  may 
be  bruised  to  such  an  extent  in  parturition,  or  by  the  presence  of  the  retroverted 
uterus,  that  the  wall  sloughs  and  gives  way  ;  and  when  it  is  distended  it  may  be 
ruptured  by  compression.  If  the  tissues  are  healthy,  the  force  neces.sary  to  effect 
this  must  be  considerable  ;  if,  on  the  other  hand,  they  are  diseased  in  any  way,  it 
may  be  altogether  insignificant :   even  muscular  action  is  enough. 

Rupture  of  the  bladder,  therefore,  is  said  to  be  either  traumatic  or  idiopathic. 
In  the  former,  the  walls  are  sound,  the  force  severe,  and  the  rent  in  general  runs 
along  the  posterior  surface,  vertically  down  from  the  urachus,  for  one  or  two 
inches.     In  the  latter  it  takes  the  form  of  a  ragged  opening  with  thinned  and 


INJURIES  OF  THE  BLADDER.  1027 

sloughing  edges  ;  and  the  locahty  depends  upon  pre-existing  conditions.  There 
may,  for  example,  be  a  pouch  i)rotniding  from  between  the  muscular  fasciculi, 
formed  only  of  mucous  membrane  and  cellular  tissue,  and  ready  to  give  way  with 
the  least  pressure  ;  or  an  ulcer  caused  by  the  pressure  of  a  catheter,  or  by  syphilis, 
tubercle,  or  carcinoma.  In  other  ca.ses  a  calculus  has  been  known  to  cause  gradual 
thinning  at  one  spot,  until  the  wall  broke  down  almost  of  itself;  and  in  others, 
again,  the  tissues  are  so  weakened  from  long  continued  distention  and  fatty 
degeneration  as  to  yield  simply  t'rom  the  weight  of  the  contents. 

The  most  frequent  cause  is  a  blow  upon  the  lower  })art  of  the  alxlonien,  but 
it  may  be  produced  by  contraction  of  the  abdominal  muscles,  as  in  lifting  heavy 
weights  ;  and  perhaps,  for  the  same  reason,  by  violence  applied  to  the  back.  In 
one  or  two  instances,  in  which  it  has  been  due  to  a  fall  in  a  sitting  position,  it  was 
probably  the  result  of  the  sudden  impact  of  the  fluid  against  the  base.  The  blad- 
der must  be  distended,  or  it  cannot  be  torn  (though  it  maybe  punctured)  ;  and 
partly  for  this  reason,  partly  because  in  alcoholism  the  protecting  influence  of 
the  muscles  is  in  abeyance,  it  is  peculiarly  likely  to  occur  in  men  when  they  are 
drunk. 

The  rui)ture  maybe  either  intra-peritoneal  or  extra-peritoneal.  Occasionally 
it  extends  through  the  reflection  of  the  ]:)eritoneum  ;  and  a  few  instances  are  re- 
corded in  which  the  rent  has  been  really  subperitoneal,  involving  only  part  of  the 
thickness.  The  character  of  the  opening  depends  upon  the  condition  of  the  wall : 
if  this  is  healthy,  it  resembles  a  lacerated  wound,  and  the  blood  pours  out  freely 
into  the  peritoneal  cavity,  or  behind  the  pubes ;  when  the  rupture  is  due  to  ulcera- 
tion, the  opening  is  either  round  or  irregular,  with  everted  and  perhaps  sloughing 
edges,  and  the  bleeding  is  slight. 

Symptoms. — The  typical  symptoms  are  the  feeling  of  something  giving 
way  ;  collapse,  severe  pain,  inability  to  stand  upright  or  walk,  and  desire,  but  want 
of  power,  to  micturate.  Not  one  of  these,  however,  is  always  present,  and  the 
only  evidence  that  can  be  relied  upon  is  that  obtained  by  passing  a  catheter ;  the 
bladder  either  contains  only  blood  or  a  small  quantity  of  blood-stained  urine.  Col- 
lapse may  be  wanting  ;  patients  have  walked  to  hospital,  twenty-four  hours  after  the 
accident,  simply  from  anxiety  at  not  having  passed  any  urine.  Inability  to  mictu- 
rate cannot  be  relied  upon,  for  partial  and  even  complete  power  has  been  retained, 
especially  in  extra-peritoneal  cases.  Sometimes  there  is  no  pain  at  all ;  and  par- 
ticularly when  the  accident  has  occurred  during  drunkenness,  so  that  no  history 
can  be  obtained,  and  it  is  merely  a  matter  of  conjecture  whether  the  bladder  was 
full  at  the  time  or  not,  the  diagnosis  may  be  a  matter  of  the  greatest  difficulty, 
especially  during  the  period  when  treatment  is  most  valuable. 

Even  the  evidence  given  by  the  use  of  the  catheter  requires  consideration.  If 
it  was  known  that  the  bladder  was  full,  and  if  nothing  but  blood  or  a  few  drops 
of  urine  mixed  with  blood  come  away,  there  can  be  very  little  doubt ;  and  this 
little  may  be  removed  by  the  sensation  conveyed  by  the  instrument ;  it  is  clearly 
not  in  a  cavity  ;  it  cannot  be  rotated  or  depressed  ;  the  walls  everywhere  are  in 
contact  with  it,  and  cling  around  it.  The  instrument,  however,  may  slip  through 
the  rent  in  the  wall  and  enter  the  peritoneal  cavity,  or  there  may  be  only  a  punc- 
ture, or  simple  leakage,  such  as  is  produced  at  first  by  the  giving  way  of  an  ulcer. 

Occasionally  the  diagnosis  is  difficult  for  the  opposite  reason  ;  the  bladder 
has  been  bruised,  there  is  a  certain  amount  of  hemorrhage,  and  the  secretion  of 
urine  is  so  diminished  from  shock  that  the  cavity  remains  almost  empty  for  hours. 
It  has  been  suggested,  under  these  circumstances,  to  inject  the  bladder  with  a  warm 
antiseptic  solution,  to  ascertain  whether  it  can  rise  well  up  over  the  pulses. 

I.  Intraperito7ieal Rupture. — Immediately  after  the  accident  the  bladder  col- 
lapses, and  the  urine  enters  the  peritoneal  cavity,  collecting  at  first  at  the  lower 
part,  but  soon  becoming  diffused  by  the  movement  of  the  intestines.  Healthy 
urine  does  not  give  rise  to  peritonitis  immediately  ;  the  abdomen  has  been  opened 
on  several  occasions,  more  than  twenty-four  hours  after  extravasation,  without  there 
being  any  evidence  of  inflammation.     If,  however,  it  is  left,  or  if  the  urine  comes 


I028    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

from  a  bladder  already  inflamed,  as  when  the  wall  of  a  sacculous  slough,  or  a 
cancerous  ulcer  gives  way,  peritonitis  sets  in  within  a  very  few  hours,  and  becomes 
general,  the  abdomen  becoming  distended,  the  face  pinched  and  drawn,  and  the 
pulse  rapidly  failing. 

2.  Extraperitoneal  Rupture. — In  this  the  urine  is  poured  out  either  into  the 
loose  tissue  that  lies  in  front  of  the  neck  of  the  bladder,  or  behind,  between  the 
bladder  and  the  rectum,  or  the  uterus.  Sometimes  there  is  a  free  exit,  the  j>erineum, 
or  the  vagina,  or  rectum,  being  torn  as  well.  If  there  is  not,  the  ordinary  symp- 
toms of  extravasation  of  urine  set  in,  and  inflammation,  followed  by  sloughing  and 
septic  poison,  spreads  rapidly  into  the  iliac  fossae,  the  front  wall  of  the  abdomen, 
and  even  into  the  scrotum,  through  the  inguinal  canal.  Generally,  the  peritoneum 
becomes  involved  as  well  before  the  patient  dies. 

Prognosis. — Gunshot  injuries  are  not  so  fatal  as  might  have  been  expected  ; 
the  urine  escaji^s  through  the  wound,  and  retention  and  decomposition  are  pre- 
vented. The  same  occurs  when  the  bladder  is  wounded  by  foreign  Ixidies  pushed 
into  it  through  the  rectum  or  vagina,  or  when  it  sloughs  in  consequence  of  pressure 
during  parturition.  When  there  is  no  external  wound,  or  easy  exit  for  the  urine, 
it  accumulates,  decomposes,  and  acts  as  a  virulent  poison. 

Treatment. — The  first  indication  is  to  remove  the  urine  that  has  already 
escaped,  the  second  is  to  close  the  rent  in  the  bladder  so  as  to  prevent  further  ex- 
travasation. 

Until  within  the  last  few  years  there  was  no  certain  case  of  recovery  after  rup- 
ture of  the  bladder  into  the  peritoneum.  Various  methods  had  been  attempted  : 
the  abdomen  had  been  opened,  thoroughly  cleansed,  and  the  wound  in  the  bladder 
closed  :  but  either  leakage  had  taken  place  or  the  sutures  had  given  way.  The 
peritoneal  cavity  had  been  washed  out  through  the  rent.  The  bladder  had  been 
drained,  not  only  by  catheters,  but  by  median  and  lateral  cystotomy,  to  prevent  the 
exit  of  any  more,  hoping  that  the  peritoneum  would  be  able  to  deal  with  that 
already  present ;  but  all  without  avail.  It  was  not  until  Lembert's  fashion  of 
suturing  the  intestines  was  applied  to  the  bladder  that  there  was  any  success,  and 
then  MacCormac's,  Holmes's,  and  Walsham's  cases  followed  rapidly  one  after  the 
other.  Now  there  is  no  doubt  :  the  patient  is  placed  under  an  anaesthetic  ;  a  rub- 
ber bag  introduced  into  the  rectum  to  raise  and  fix  the  floor  of  the  bladder ;  and 
an  incision  made  in  the  middle  line,  ending  just  below  the  upjjer  border  of  the 
pubic  symphysis.  The  extra-peritoneal  portion  of  the  bladder  is  examined  first 
by  gently  pushing  the  folds  of  peritoneum  upward.  If  there  is  no  extravasation 
of  blood  there,  or  evidence  of  bruising,  the  peritoneal  cavity  itself  is  laid  open 
and  the  rest  of  the  bladder  carefully  felt.  If  there  is  a  rupture,  the  edges  are 
steadied  and  drawn  forward  by  hooking  up  the  nearer  end  with  a  blunt  and  rounded 
retractor  (a  suture  is  unnecessary  and  only  inflicts  further  injury),  and  then  a  series 
of  Lembert's  sutures  passed  close  together,  commencing  in  the  sound  tissue  beyond 
either  end  of  the  rent  and  carefully  avoiding  including  any  of  the  mucous  mem- 
brane. Greig  Smith  recommends  a  double  row,  one  to  transfix  the  cut  muscular 
surface,  the  other,  Lembert's,  outside  this  ;  and  that  all  should  be  passed  before 
being  tied.  The  intestines  are  held  back  out  of  the  way,  in  the  meantime,  with 
a  soft,  flat  sponge.  Then  the  abdominal  cavity  is  cleared  of  all  blood-clot  and 
urine  that  may  have  found  its  way  in,  and  irrigated  either  with  warm  water  (temp. 
ioo°  F.),  or  with  a  dilute  solution  of  some  non-poisonous  antiseptic.  The  wound 
should  be  closed  in  the  usual  way,  introducing  a  drainage-tube  only  when  there  is 
already  peritonitis.  If  there  is  any  doubt  as  to  the  security  of  the  sutures  in  the 
walls  of  the  bladder,  they  can  be  tested  first  by  distending  the  cavity  through  a 
catheter.  Silk  is  the  best  material,  and  the  sutures  should  not  be  more  than  one- 
eighth  of  an  inch  apart:  catgut,  even  if  it  were  so  certain,  is  difficult  to  knot 
securely  when  the  wound  lies  deep  in  the  cavity  of  the  pelvis.  In  one  or  twc 
cases  the  difficulty  has  been  so  great  that  it  was  necessary  to  make  a  short  trans- 
verse incision  through  the  peritoneum  on  either  side. 

After  the  operation  the  bag  in  the  rectum  is  emptied  and  withdrawn,  a  sup- 


ATONY  OF  THE  BLADDER.  1029 

positoryor  a  hypodermic  injection  of  morphia  given,  and  the  patient  kept  warm 
and  quiet  in  bed,  with  only  a  small  quantity  of  ice  to  suck  or  a  few  teaspoonfuls 
of  milk.  At  first  there  is  very  little  urine  secreted,  and  if  the  sutures  are  suffi- 
ciently close  there  is  no  need  to  pass  a  catheter,  much  less  to  tie  one  in,  or  jjerform 
cystotomy  ;   the  bladder  is  able  to  empty  itself  without  risk. 

Kxtra-i)eritoneal  rupture  must  be  treated  on  the  .same  jjrinciples.  If  the  rent 
can  be  secured  from  the  front,  an  ojiening  should  be  made  over  the  pubes,  and 
Lembert's  sutures  passed  as  before  ;  only,  as  it  is  impossible  to  remove  the  urine 
from  the  loose  cellular  tissue  around  the  bladder,  the  abdominal  opening  should  not 
be  closed  and  a  large  drainage  tube  should  be  inserted.  Wounds  involving  the 
rectum  or  vagina,  if  not  very  large,  may  be  left  for  a  time ;  very  frequently  they 
close  in  :  or,  if  not,  contract  so  that  the  resulting  fistula  is  much  smaller.  Wounds 
in  other  parts  are  usually  complicated  by  other  injuries. 


DISEASES  OF  THE  BLADDER. 

Atony. 

The  bladder  is  said  to  be  in  a  state  of  atony  when  the  muscular  power  is  im- 
paired, without  there  being  any  evidence  that  the  nervous  system  is  affected. 

Atony  may  occur  when  the  walls  are  healthy,  but  it  is  much  more  likely  if  the 
strength  of  the  muscles  is  enfeebled  by  old  age  or  inflammation.  In  such  cases, 
even  passing  a  catheter  or  drawing  off  residual  urine  may  abolish  the  small  amount 
of  power  that  still  remains. 

Atony  may  be  caused  by  a  single  act  of  retention  ;  the  bladder  becomes  over- 
distended  ;  the  muscular  fibres  over-stretched  ;  and  all  power  is  lost,  perhaps  for 
life.  This  may  happen  even  in  voluntary  cases,  although  it  is  more  likely  if  the 
obstruction  is  mechanical.  More  frequently  the  loss  of  power  is  gradual  and 
slowly  grows  worse  ;  the  bladder  is  imperfectly  emptied  ;  some  urine  always  re- 
mains behind  ;  the  amount  grows  larger  and  larger;  the  muscular  coat  becomes 
accustomed  to  it ;  and  at  length  the  bladder  remains  full,  the  urine  falling  out  of 
it,  drop  by  drop,  as  it  enters  from  the  ureters  (overflow). 

Obstruction  sometimes  causes  atony,  sometimes  hypertrophy.  The  difference 
depends,  to  some  extent,  upon  the  age  and  strength  of  the  patient ;  the  effect  of 
retention  is  different  naturally  in  an  old  man  of  feeble  health  and  in  a  younger  one 
of  vigorous  life  ;  but  the  chief  causes  are  the  rapidity  with  which  the  obstruction 
is  produced  and  the  amount  of  irritation  at  the  neck  of  the  bladder.  In  cystitis, 
for  example,  and  in  cases  of  enlarged  prostate  in  which  there  is  much  spasm, 
hypertrophy  usually  results.  When,  on  the  other  hand,  the  prostate  is  tender  and 
painful  as  the  bladder  contracts  and  presses  upon  it,  the  patient,  perhaps  uncon- 
sciously, tries  to  save  himself  and  quietly  stops  before  he  has  finished.  If  this 
happens  constantly,  the  bladder  at  length  loses  the  power  of  emptying  itself,  and 
atony  sets  in.  The  same  thing  happens  from  purely  mechanical  causes  in  enlarge- 
ment of  the  prostate  :  the  bladder  becomes  accustomed  to  retain  a  certain  amount 
of  urine,  and  after  a  time  is  unable  to  expel  it. 

The  immediate  result  of  atony  is  distention  and  dilatation,  owing  to  the 
pressure  of  the  urine  :  the  bladder  grows  thinner  ;  the  muscular  fibres  degenerate, 
and  at  length  the  ureters  and  the  pelvis  of  the  kidneys  become  affected.  Cystitis 
and  pyelonephritis  nearly  always  follow,  sooner  or  later  :  there  is  everything  to 
favor  their  occurrence  ;  and  if  the  urea  decomposes  the  walls  of  the  bladder  may 
slough. 

Symptoms. — Increased  frequency  of  micturition  is  the  most  prominent:  if 
the  bladder  is  over-full,  the  urine  flows  away  without  cessation  ;  if  there  is  less,  it 
escapes  on  coughing  or  laughing,  or  at  night,  giving  rise  to  extreme  annoyance  ; 
and  the  patient  either  complains  that  he  is  passing  too  much  water,  or  that  he  can- 
not retain  it.      In  some  cases  the  bladder  is  distended  nearly  up  to  the  umbilicus, 


I030    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

forming  a  rounded,  fluctuating  swelling  on  the  front  of  the  abdomen  ;  in  others, 
especially  where  chronic  cystitis  precedes  the  atony,  the  size  is  so  small  that  it  can 
scarcely  l)e  felt.  The  diagnosis  can  only  be  made  by  ]jassing  a  catheter,  after  the 
patient  has,  as  he  thinks,  emptied  his  bladder ;  if  there  is  atony  a  variable  amount 
flows  away  without  any  force,  the  stream  rising  and  falling  with  the  respiration. 
This  proceeding,  however,  is  not  unattended  with  danger ;  the  patient  must  be 
lying  down  ;  sudden  evacuation  of  a  bladder  in  a  state  of  passive  distention  has 
before  now  caused  fatal  syncope  ;  and  if  the  amount  of  urine  withdrawn  is  over  a 
few  ounces,  some  of  it  must  be  replaced  by  a  smaller  quantity  of  some  dilute  anti- 
septic, so  that  the  pressure  in  the  bladder  may  be  gradually  reduced.  Too  sudden 
relief  brings  on  passive  congestion  of  the  renal  vessels;  and  this,  if  the  kidneys 
are  in  the  least  diseased,  may  end  in  suppression. 

The  treatment  is  very  simple  :  in  the  first  place,  the  cause  of  the  retention,  if 
it  is  practicable,  must  be  removed  ;  then  the  bladder  must  be  carefully  emptied, 
at  least  four  times  in  the  twenty-four  hours,  so  that  there  may  be  no  further  strain 
upon  the  muscular  wall.  If  the  amount  of  residual  urine  was  large  it  may  be 
some  weeks  before  it  is  safe  to  remove  it  completely.  A  catheter  should  not  be 
tied  in,  the  danger  of  cystitis  and  urinary  fever  is  much  too  great.  Subcutaneous 
injections  of  strychnia  are  sometimes  of  benefit,  and  occasionally  the  walls  may 
be  stimulated  by  injecting  cold  water  after  the  bladder  is  emptied.  Galvanism, 
one  pole  in  the  rectum,  the  other  on  the  surface  of  the  body,  and  the  current 
slowly  interrupted  from  time  to  time,  may  effect  some  improvement  even  in  ad- 
vanced cases. 

Irritability  of    the  Bladder. 

Irritability  of  the  bladder  is  a  symptom,  not  a  disease.  It  is  present,  to  a 
greater  or  less  extent,  in  all  local  affections,  such  as  cystitis,  calculus,  tumor,  fissure 
at  the  neck,  atony,  etc.  ;  in  cases  in  which  the  urine  contains  an  excess  of  uric  acid 
or  other  irritating  substances  ;  and  sometimes  in  affections  of  other  organs  which 
apparently  have  nothing  to  do  with  the  bladder.  It  may  be  only  slight,  giving 
rise  to  a  certain  amount  of  annoyance,  or  it  may  be  so  intense  as  to  render  life 
almost  unendurable.  In  itself  it  is  a  matter  of  some  imjjortance,  as  a  constant 
contraction  of  the  bladder  leads  in  time  to  hypertrophy  of  its  walls  and  dilatation 
of  the  ureters  and  of  the  pelvis  of  the  kidneys. 

The  most  common  cause  is  some  affection  of  other  parts  of  the  urinary  sys- 
tem. In  many  of  these  the  neck  of  the  bladder  is  involved  directly.  In  con- 
gestion of  the  prostate,  for  example,  after  excessive  coitus  or  masturbation,  or  in 
that  form  of  slight  irritation  which  is  so  frequent  in  gouty  people  of  sedentary 
habits,  and  in  women  when  the  bladder  is  pressed  upon  or  dragged  out  of  its  place 
in  pregnancy,  it  is  reasonable  to  refer  the  irritability  to  the  congestion  and  in- 
creased sensibility  at  the  neck.  In  other  instances,  however,  it  is  probably  reflex. 
All  diseases  of  the  kidney,  for  example,  are  liable  to  be  attended  by  it  ;  in  tuber- 
culous pyelitis,  in  particular,  it  is  a  most  distressing  symptom,  as,  unlike  the  irri- 
tation of  tuberculous  cystitis,  it  cannot  be  relieved  by  median  cystotomy  and 
drainage  ;  and  it  may  be  caused  by  phimosis,  with  accumulation  of  the  secretion 
beneath  the  prepuce,  by  slight  strictures  near  the  orifice,  or  by  vascular  growths 
or  superficial  fissures  around  the  meatus  in  women.  Its  reflex  character  is  still 
more  plain  when  it  is  excited  by  affections  of  other  organs,  such  as  disease  of  the 
uterus,  fissure  of  the  rectum  and  anus,  piles,  prolapse,  intestinal  worms,  vari- 
cocele, etc.  ;  and  this  is  not  at  all  uncommon. 

Reflex  irritability  may  occur  even  in  the  strongest  and  most  healthy  ;  it  is 
much  more  frequent,  however,  and  more  obstinate  in  those  who  are  broken  down 
by  excesses  or  by  prolonged  residence  in  hot  climates,  or  who,  from  inheritance 
or  other  causes,  are  especially  prone  to  nervous  disorders.  In  some  instances, 
and  they  are  often  the  worst,  no  immediate  exciting  cause  can  be  found  ;  the  de- 
sire to  pass  water  is  constant,  or  it  invariably  comes  on  under  certain  particular 
circumstances,  and  the  patient  lives  in  a  state  of  continual  apprehension,  until, 


INCONTINENCE  OF  URINE.  1031 

from  constantly  dwelling  upon  it,  the  condition  becomes  permanent  and  almost 
incurable. 

The  prognosis  and  treatment  in  cases  such  as  these  must  be  guided  by  the 
cause.  Where  some  definite  source  of  irritation  can  be  found  and  removed,  the 
l^rognosis  is  good,  especially  in  the  early  stages  ;  after  it  has  lasted  some  length 
of  time  the  difficulty  becomes  greater,  partly  because  of  the  force  of  habit,  partly 
from  the  changes  that  are  induced  in  the  condition  of  the  bladder.  Where  nothing 
can  be  found,  the  chief  reliance  must  l>e  placed  upon  careful  dieting  and  restor- 
ing the  i)atient's  strength  and  confidence  in  himself,  paying  special  attention  to 
any  constitutional  tendency  that  is  present. 

In  some  cases  steel  sounds  may  be  used  with  benefit ;  at  first  they  should  be 
only  of  moderate  size  (No.  10  or  11  English)  and  withdrawn  at  once  ;  but  as  soon 
as  the  mucous  membrane  of  the  urethra  has  grown  accustomed  to  them,  larger  and 
larger  ones  may  be  passed,  and  left  in  position  until  they  are  no  longer  grasped. 
In  women  dilatation  of  the  urethra  with  the  finger  is  sometimes  attended  with  suc- 
cess. Tepid  douches  apjjlied  to  the  loins  and  the  hypogastric  region  for  ten  or  fif- 
teen minutes,  if  the  patient  can  stand  it,  may  answer  ;  and,  even  when  the  condition 
is  advanced,  relief  may  be  obtained  by  slowly  injecting  the  bladder  through  the 
urethra,  beginning  with  a  small  quantity,  two  or  three  ounces,  and  gradually  in- 
creasing it  day  by  day  as  the  patient  grows  more  accustomed  to  it.  When  all  other 
measures  fail,  median  cystotomy  and  drainage  sometimes  succeed.  It  is  probable 
that  in  some  instances  at  least  the  irritability  of  the  bladder,  whatever  may  have 
been  the  original  cause,  is  maintained  by  the  contracted  and  hy])ertrophied  condi- 
tion of  the  walls,  and  that  the  ])rolonged  rest  obtained  in  this  way  allows  time  for 
a  certain  amount  of  relaxation  and  even  wasting,  so  that  when  the  artificial  open- 
ing closes  the  bladder  becomes  more  tolerant. 


Inxontinen'ce  of  Urine. 

Nocturnal  Incontinence. — Closely  allied  to  irritability  is  a  condition,  very 
common  in  children,  especially  boys,  in  which  the  bladder  will  only  retain  a  certain 
amount  of  urine.  As  soon  as  it  becomes  filled  to  a  certain  point  it  contracts  and 
expels  its  contents,  without  any  j)ain,  and  without  the  child  being  able  to  prevent 
it.  This  is  known  as  nocturnal  incontinence  of  children,  owing  to  its  usually 
occurring  at  night.  The  least  stimulus  is  sufficient  to  excite  it  Tthere  may  be  a 
calculus,  but  generally,  when  there  is  one,  micturition  is  more  frequent  while  the 
child  is  running  about)  ;  contracted  prepuce  with  retained  secretion  ;  polypus  in 
the  rectum  ;  oxyurides ;  the  pressure  of  the  bedclothes  on  the  penis ;  excess  of 
uric  acid  in  the  urine  ;  any  slight  irritant,  in  fact,  is  sufficient.  The  most  common 
is  the  tension  upon  the  walls  and  the  pressure  upon  the  neck,  as  the  bladder 
becomes  fiill. 

The  real  reason  is  the  excitability  of  the  reflex  centres,  which  is  always  greater 
in  children  than  in  adults,  even  during  health,  and  which  sometimes,  as  at  the 
period  of  teething,  becomes  immensely  exaggerated  ;  and  it  occurs  more  frequently 
during  sleep,  because  then  the  influence  of  the  cerebrum  is  suspended,  and  the 
spinal  cord  is  free  to  act  for  itself.     Toward  puberty  it  nearly  always  disappears. 

Treatment. — In  most  cases  nocturnal  incontinence  may  be  cured  by  care 
and  attention.  All  sources  of  irritation  that  can  reasonably  be  suspected  must,  of 
course,  be  excluded,  but  unless  it  is  exceedingly  obstinate,  or  other  symptoms  are 
present,  it  is  rarely  advisable  to  explore  the  bladder  for  this  only.  Circumcision, 
however,  may  generally  be  performed  with  advantage.  Careful  attention  must  be 
paid  to  diet,  especially  if  the  urine  deposits  crystals  of  uric  acid  :  the  amount  of 
liquid  taken,  particularly  toward  evening,  must  be  restricted  ;  the  child  should  be 
taken  up  the  last  thing  at  night  ;  the  bed  should  be  firm,  the  clothing  light,  and  the 
patient  made  to  sleep  on  his  side,  not  his  back.  The  old-fashioned  plan  of  tying 
a  handkerchief  round  the  waist  so  that  the  knot  comes  over  the  vertebrge  answers 
exceedingly  well.     In  addition,  the  back  should  be  sponged  and  rubbed  well,  night 


I032     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

and  morning,  the  bowels  made  to  act  regularly,  and  qninine  and  tonics  given  in- 
ternally. If  anything  more  is  recjuired.  belladonna  rarely  fails  ;  either  the  tincture 
or  the  extract  may  be  given,  commencing  with  small  doses,  and  gradually  increas- 
ing them  until  the  drug  produces  some  physiological  effect,  such  as  dryness  of  the 
mouth  and  fauces  or  dilatation  of  the  pupil.  The  dose  should  then  be  diminished, 
and  kept  up  for  some  weeks,  leaving  it  off  gradually.  Nux  vomica  and  cantharides 
are  also  said  to  be  of  service. 

In  very  inveterate  cases  a  soft  bougie  may  be  passed,  or  a  dilute  solution  of 
nitrate  of  silver  (gr.  ij  ad  .^j)  (.12  ad  32  c.c.)  applied  to  the  neck  of  the  bladder. 
Galvanism,  one  pole  being  placed  in  the  rectum,  the  other  over  the  sacral  region, 
and  the  current  occasionally  reversed,  sometimes  succeeds  where  everything  else 
has  failed. 

True  incontinence  in  men  is  very  rare.  It  is  common  for  patients  to  comjjlain 
that  !hey  are  unable  to  hold  their  urine,  or  that  it  is  constantly  running  away  from 
them  ;  but  it  rarely  happens  that  this  is  incontinence  in  the  proper  sense  of  the 
term.  Either  the  bladder  is  over-distended,  as  sometimes  in  stricture  or  enlarged 
prostate,  and  a  drop  falls  out  for  every  one  that  enters,  leaving  it  as  full  as  ever 
\overflow)  ;  or  they  are  suffering  from  atony  and  partial  retention,  and  the  bladder 
is  irritable,  and  unable,  owing  to  the  presence  of  residual  urine,  to  hold  much 
more.  True  incontinence  has,  however,  been  known  to  occur  after  the  median 
operation  for  lithotomy,  even  when  the  calculus  was  not  of  unusual  size ;  and  it 
may  follow  belladonna  poisoning  and  injury  or  disease  of  the  lumbar  portion  of  the 
cord.  The  bladder  loses  its  power  altogether  ;  it  slowly  shrinks  and  becomes 
smaller,  merely  acting  as  a  mechanical  receptacle,  until  its  function  is  lost.  It  is 
also  stated  to  have  followed  impaction  of  a  calculus  in  the  neck  of  the  bladder, 
and  in  one  or  two  instances  to  have  been  occasioned  by  a  growth  from  the  prostate 
of  peculiar  shape,  projecting  forward  into  the  orifice  so  as  to  prevent  the  action  of 
the  sphincter. 

In  women  incontinence  of  urine  is  much  more  common  from  anatomical 
reasons.  Sometimes  it  comes  on  gradually  in  old  age,  the  sphincter  losing  its 
power,  until  urine  is  expelled  with  every  cough  ;  and  it  may  follow  dilatation  of 
the  urethra  for  the  extraction  of  calculi  (it  has  been  known  to  happen  even  when 
only  the  finger  was  used)  ;  but  the  most  common  cause  is  some  injury  to  the  urethra, 
either  from  the  prolonged  pressure  of  the  child's  head  in  parturition  or  the  use  of 
instruments.  If  the  condition  is  incurable,  the  patient  must  be  fitted  with  a 
suitable  form  of  urinal. 

Retention. 

Retention  of  urine  is  either  partial  or  complete.  In  the  former  a  certain 
amount  of  urine  is  never  expelled,  and  the  capacity  of  the  bladder  is  proportion- 
ately diminished  ;  in  the  latter  it  is  distended  until  it  can  hold  no  more. 

Causes. — Either  the  expulsive  power  of  the  bladder  is  defective,  or  there  is 
some  obstruction  to  the  exit  of  the  urine  ;  or  both  may  happen. 

1 .  The  former  may  arise  from  failure  of  the  muscular  power,  or  of  the  nervous 
stimuli,  or  of  both.  Atony  and  peritonitis,  spreading  to  the  muscular  coat,  are 
instances  of  the  former  ;  paralysis  from  disease  or  injury  of  the  spinal  cord  or  of 
the  sacral  nerves,  hysteria,  exhaustion  (as  in  fevers),  alcoholic  excesses,  shock, 
and,  perhaps,  belladonna  poisoning,  of  the  second.  Railway  accidents,  ojjerations 
about  the  rectum,  such  as  ligature  of  piles,  and  injuries  in  the  region  of  the  pelvis 
are  especially  likely  to  cause  it  ;  but  in  old  people,  and  those  in  whom  the  wall 
of  the  bladder  is  already  in  a  condition  of  partial  atony,  retention  may  follow  the 
slightest  accident,  even  a  fall  on  the  trochanter  or  the  passage  of  a  catheter. 

2.  Obstruction  to  the  flow  of  urine  may  be  situated  : — 

(a)  In  the  interior  of  the  canal :   impacted  calculus,  for  example. 
\F)  Outside  the  urethra  :   such  as  a  string  tied  around  the  penis  by  a  child  to 
check  nocturnal  incontinence  ;  or  the  pressure  of  the  gravid  or  displaced  uterus. 
(<:)  In  the  wall  itself.     This  is  by  far  the  most  common.     The  affection  may 


RETENTION  OF  URINE.  1033 

be  permanent,  as  stricture  or  enlar^'ed  prostate,  or  temporary,  as  congestion  and 
spasm.  In  most  cases  temporary  and  permanent  act  together.  .\n  imj)acted  cal- 
culus, for  instance,  may  occupy  only  a  small  part  of  the  interior,  but  the  spasmodic 
contraction  that  it  causes  prevents  the  i)assage  of  a  drop  of  urine  ;  a  stricture  may 
admit  a  No.  7  or  9  French  catheter  the  day  before,  and  suddenly  become  clo.sed 
in  the  same  way,  owing  to  alcoholic  excesses  or  exposure  to  cold  ;  and  enlarged 
prostate  may  have  existed  for  years  without  serious  inconvenience,  until  suddenly 
congestion  sets  in,  and  the  mucous  membrane  becomes  so  swollen  that  the 
weakened  muscular  fibre  finds  the  task  too  great. 

Consequences. — As  the  bladder  fills  it  rises  up  into  the  abdomen  and  j^ro- 
jects  above  the  pubes  as  a  rounded  tumor,  dull  on  ])ercussion,  and  most  prominent 
when  the  patient  is  standing.  Sometimes  the  outline  can  almost  be  seen  through 
the  abdominal  wall.  It  may  reach  the  umbilicus  or  even  the  ensiform  cartilage  in 
the  middle  line,  sloping  off  on  either  side,  so  that  the  iliac  fossae  are  resonant,  and, 
especially  when  the  walls  are  thin  and  soft,  it  has  more  than  once  been  mistaken 
for  ovarian  tumor.  In  old  cases  of  cystitis,  however,  in  which  there  has  been 
partial  retention  for  years,  and  the  walls  are  rigid  and  hypertrophied,  and  the  cavity 
contracted,  such  distention  is  impossible,  and  retention  with  urgent  symptoms  may 
occur  without  the  bladder  being  perceptible  from  the  exterior. 

The  effect  depends  upon  whether  the  obstruction  can  or  cannot  be  surmounted. 
In  the  former  case  the  overflow  commences  ;  the  spasm  and  congestion  give  way 
before  the  increasing  pressure,  and  the  bladder  remaining  full,  the  urine  flows  away 
drop  by  drop.  This  condition  the  patient  almost  invariably  describes  as  incontin- 
ence, exactly  the  opposite  of  what  is  correct.  In  the  latter  either  the  urethra 
gives  way  {extravasation  of  urine'),  or  the  pressure  in  the  renal  tubules  grows  higher 
and  higher,  until  the  secretion  is  stopped  {suppressio7i). 

Retention  of  urine  is  often  followed  by  atony ;  the  unstriped  muscular  fibre 
of  the  wall  is  stretched  until  it  loses  its  power  of  contracting ;  in  some  cases  this 
condition  is  permanent. 

Symptoms. — If  obstruction  is  complete,  so  that  no  urine  can  escape,  the 
symi)toms  are  very  serious.  The  pain  as  the  tension  increases  is  extreme,  espe- 
cially when  the  cavity  is  small,  and  the  walls  thickened  and  rigid,  as  in  old  cases 
of  enlarged  prostate  ;  the  patient  becomes  delirious  ;  the  tongue  dry  and  brown  ; 
the  pulse  small  and  frequent ;  and  typhoid  symptoms,  with  extreme  prostration, 
soon  set  in. 

When  there  is  a  means  of  escape,  as  in  most  cases  of  stricture,  the  urinary 
organs  gradually  adapt  themselves,  and  the  immediate  symptoms  are  not  so  urgent. 
It  is  not  uncommon  to  find  that  a  patient  suffering  from  stricture,  with  his  bladder 
distended  far  above  the  pubes,  complains  of  nothing  more  than  the  inconvenience 
caused  by  the  incessant  dribbling  of  urine.  In  this  case  there  is  no  sudden  check 
to  the  secretion,  but  the  ultimate  result  is  no  less  grave,  for  the  ureters  become 
dilated,  the  kidney  substance  is  absorbed,  and  chronic  pyelitis  and  nephritis 
inevitably  follow. 

Treatment. — This  depends  upon  the  cause,  but  in  all  cases  it  is  absolutely 
essential  to  relieve  the  bladder  as  soon  as  possible. 

1.  Diminished  Power  of  Expulsion. — A  soft  catheter  must  be  passed  as  often 
as  required,  with  the  utmost  gentleness.  If  the  condition  is  of  long  standing, 
and  the  bladder  in  a  state  of  chronic  distention,  the  amount  of  residual  urine 
must  be  diminished  gradually;  sudden  evacuation  may  cause  congestion  and  sup- 
pression. 

2.  Mechanical  Obstruction. — Any  cause  blocking  the  interior,  or  pressing 
on  the  outside,  must,  of  course,  be  removed  at  once.  Morbid  conditions  of  the 
neck  of  the  bladder,  or  the  wall  of  the  urethra,  require  further  consideration  ;  the 
most  important  are  acute  inflammation,  stricture,  and  enlargement  of  the  prostate. 

{a)  Acute  Inflammation  {such,  for  example,  as   Gonorrhceal  Prostatitis'). — 
The  symptoms  are  exceedingly  severe  ;  the  bladder  soon  becomes  distended,  and 
there  is  intense  desire  to  pass  water,  with  high  fever  and  urgent  distress.     In  many 
66 


I034     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

cases  a  catheter  must  be  passed  at  once;  if  the  ijaticnt  can  wait,  relief  can  some- 
times be  obtained  by  free  leeching  in  the  perineum  and  by  hot  baths,  the  tem- 
perature as  high  as  can  be  borne,  for  at  least  half  an  hour.  A  full  dose  of  opium 
should  be  given  at  the  same  time,  and  the  bowels  opened  freely.  Even  if  this  is 
not  successful  it  makes  it  easier  to  pass  a  catheter  afterward,  procures  sleep  and 
quiet,  and  tends  to  prevent  the  occurrence  of  rigors  and  other  secondary  troubles. 
Afterwards  the  patient  must  be  kept  in  bed,  on  milk  diet  without  any  stimulants, 
and  the  urine  rendered  as  unirritating  as  possible.  In  cases  of  gonorrhoja,  or 
when  there  is  a  prostatic  abscess,  this  may  have  to  be  repeated  night  and  morning 
for  several  successive  days. 

(J))  Stricture. — In  this  case  the  distention  may  be  so  gradual  that  the  bladder 
rises  as  high  as  the  umbilicus  before  the  patient  is  in  the  least  concerned  about  it. 
The  urine  flows  away  drop  by  drop,  and  this  generally  is  the  cause  of  complaint ; 
there  is  little  or  no  pain,  and  no  fever,  although  the  health  is  sure  to  fail,  from 
the  interference  with  the  action  of  the  kidneys  A  moderate-sized  catheter  should 
be  tried  first,  then  smaller  and  smaller  ones,  but  always  with  the  utmost  gentleness. 
The  more  soft  and  flexible  the  instrument,  especially  near  the  point,  the  more 
likely  it  is  to  be  guided  by  the  folds  of  the  mucous  membrane  into  the  orifice 
of  the  stricture.  Black  ones,  slightly  bulbous  at  the  tip,  with  a  flexible  neck,  are 
the  best ;  small  metal  ones  are  excessively  dangerous.  If  these  fail,  a  catgut  bougie 
will  sometimes  succeed,  and,  if  it  passes,  the  urine  will  find  its  way  readily  by  the 
side  ;  but,  in  the  majority  of  instances,  when  the  constriction  is  so  tight,  it  is  not 
advisable  to  persist.  Retention  is  seldom  due  solely  to  organic  stricture ;  the 
urethra  is  narrowed  by  this  at  one  point,  and  rendered  so  sensitive  that  the 
slightest  irritant  will  close  it  completely  by  the  spasm  and  congestion  it  excites. 
Prolonged  irritation  with  a  catheter  only  makes  this  worse.  Cocaine  is  of  very 
great  service ;  a  few  drops  of  the  ten  per  cent,  solution,  injected  on  to  the  face  of 
the  stricture,  will  frequently  turn  the  scale ;  but  it  is  better,  if  the  catheter  does 
not  pass  after  a  very  moderate  trial,  to  place  the  patient  at  once  in  a  hot  bath  and 
give  him  a  full  dose  of  opium.  This  nearly  always  succeeds  ;  and,  generally,  if 
he  is  kept  in  bed,  on  light  food,  without  stimulants,  if  the  bowels  are  kept  freely 
open,  and  hot  baths  given  night  and  morning,  in  a  few  days  the  spasm  and  con- 
gestion are  relieved  to  such  an  extent  that  a  catheter  can  be  passed  with  ease. 
The  only  alternative  is  to  give  an  annssthetic,  try  again,  and,  in  case  of  failure, 
puncture  the  bladder.  The  result,  so  far  as  the  stricture  is  concerned,  is  the  same, 
but  at  the  expense  of  an  operation.  [Median  perineal  cystotomy  is  always  prefer- 
able to  puncture.] 

{/)  Enlarged  Prostate. — This  may  cause  retention,  either  by  the  third  lobe 
falling  over  the  orifice,  like  a  valve  ;  or  by  sudden  congestion,  narrowing  the 
elongated  and  tortuous  passage  to  such  a  degree  that  the  already  enfeebled  mus- 
cular coat  is  unable  to  overcome  the  resistance.  The  symptoms  are  usually  very 
acute,  the  pain  is  exceedingly  severe,  and  delirium  and  extreme  prostration  set  in 
almost  at  once.  For  this,  opium  and  hot  baths  can  do  no  good,  and  often  they 
are  positively  dangerous.  A  catheter  must  be  passed  at  once,  either  a  silver  one 
with  a  long,  sweeping  curve  ;  a  gum  elastic,  provided  with  a  stilet,  so  that  the 
end  can  be  tilted  up  ;  or  a  black  one  with  the  point  bent  at  an  angle  {coiide),  so 
that  it  can  ride  over  the  obstruction.  Unless  a  stricture  is  jiresent  as  well,  the 
largest  catheter  that  will  pass  the  meatus  should  always  be  selected,  and,  owing  to 
the  growth  of  the  prostate,  it  should  be  of  extra  length.  Violence  is  never  jus- 
tifiable, but  it  is  often  necessary,  when  passing  a  catheter  under  these  conditions, 
to  make  use  of  steady  but  firm  pressure.  The  urine  is  nearly  always  blood-stained 
afterward,  perhaps  for  several  days,  owing  to  rui)ture  of  the  vessels  in  the  congested 
mucous  membrane  and  the  blood  finding  its  way  back  into  the  bladder. 

If  this  does  not  succeed,  the  choice  lies  between  forcibly  pushing  the  catheter 
through  the  substance  of  the  prostate  or  tapping  the  bladder. 


TAPPING  THE   BLADDER. 


1035 


'I'ai'I'INc    Tin;    l>i.Ai)iii;u. 

'I'his  ma\-  be  rctiuirecl,  either  as  a  teni])orary  measure,  to  give  relief  until  the 
natural  passage  can  he  reopened,  or  as  a  permanent  means  of  exit  in  impermeable 
stricture  or  enlargement  of  the  prostate.  It  may  be  performed  either  over  the 
pubic  symphysis,  through  the  perineum  (going  either  through  or  behind  the  pros- 
tate), or  through  the  rectum.  In  exceptional  instances,  where,  as  in  cases  of 
extravasation  of  urine  or  advanced  cystitis,  the  object  is  rather  to  drain  the  bladder 
than  to  relieve  retention,  the  prostatic  portion  of  the  urethra  may  be  opened  in 
the  middle  line,  at  the  apex  of  the  gland  {^la  boutonniere)  ;  and  sometimes  this  is 
done  in  case  of  stricture  (Cock's  operation). 


Suprapubic  Tapping. 

This  may  be  performed  either  with  an  aspirator  or  with  an  ordinary  but  rather 
curved  trocar  and  cannula.  When  the  bladder  is  distended  there  is  abundant 
room  ;  but  especially  in  old  cases  of 
cystitis,  the  posterior  surface  of  the 
symphysis  must  always  be  followed. 
If  the  relief  required  is  only  tempo- 
rary, the  aspirator  may  be  used,  a  small 
incision  being  made  in  the  skin  with  a 
scalpel,  and  the  trocar  pushed  through 
it  into  the  bladder,  downward  and 
backward.  No  extravasation  follows, 
as  the  mucous  membrane  glides  upon 
the  muscular  coat  when  the  bladder 
collapses,  and  the  orifice  becomes  val- 
vular. If  necessary  this  may  be  re- 
peated two  or  three  times  without 
much  danger,  and  I  have  known  it 
done  night  and  morning,  for  more 
than  a  week,  without  any  ill  result ; 

but,  if  it  is  continued,  there  is  always  a  risk,  either  of  leakage  taking  place 
through  the  wall  of  the  bladder,  or  without  there  being  any  direct  opening,  of  an 
abscess  forming  in  the  loose  cellular  tissue,  between  the  layers  of  the  transversalis 
fascia,  possibly  due  to  the  escape  of  irritating  material  from  the  end  of  the  cannula 
as  it  is  withdrawn. 

When  a  permanent  opening  is  required  a  large  trocar  (with  a  linear,  not  a 
triangular,  cutting  edge)  and  cannula  may  be  introduced  in  the  same  way.  On 
withdrawing  the  trocar,  a  soft  india-rubber  tube  is  passed  down  the  cannula  and 
left  when  this  is  removed.  The  other  end  of  the  tube  may  be  carried  under  the 
bed-clothes  to  a  receptacle.  After  a  few  days  the  tissues  become  consolidated 
and  form  a  short,  straight  canal,  which  can  be  fitted  with  a  rubber  tube  and  stop- 
cock. Owing  to  the  contraction  of  the  sinus  there  is  no  leakage,  and  I  have  known 
patients  to  go  about  with  this  arrangement,  in  perfect  comfort,  for  years. 

In  exceptional  cases,  after  suprapubic  cystotomy  for  enlargement  of  the  pros- 
tate or  tumor  of  the  bladder,  the  opening  has  been  allowed  to  contract  to  a  sinus 
and  the  same  arrangement  made  use  of. 


Fig.  431  — Tapping  the  Bladder,     (i)  Suprapubic; 
(2)  Perineal :  (3)  Rectal. 


2.   Pcritieal  Tapping. 

Post-prostatic  tapping  through  the  perineum  has  recently  been  advocated  by 
Howlett.  The  patient  is  placed  in  the  lithotomy  jwsition,  the  forefinger  of  the 
left  hand  passed  into  the  rectum  as  a  guide,  and  an  incision  made  in  the  perineum 
behind  the  bulb  ;  a  trocar  and  cannula  is  then  pushed  onward  between  the  prostate 
and  the  rectum,  until  the  bladder  is  entered.  This  is  known  by  the  cessation  of 
the  resistance.     A  tube  is  introduced  afterward,  and  worn  so  long  as  the  patient 


1036    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

is  in  bed  ;  but  it  is  only  of  service  as  a  temporary  measure,  and  the  bladder,  unless 
there  is  a  large  post-i)rostatic  pouch,  is  entered  at  an  unnecessary  dejJth. 

Harrison  (see  Enlargement  of  the  Prostate)  advocates  draining  the  bladder 
through  the  prostate,  but  this  is  different  from  simi)le  tapping. 

3.  Tapping  per  Rfction. 
An  enema  having  been  administered,  the  patient  is  placed  in  the  lithotomy 
position  and  brought  down  to  the  edge  of  the  bed.  The  forefinger  of  the  left 
hand  is  introduced  into  the  anus,  and  the  boundaries  of  the  prostate  examined. 
The  finger  should  reach  well  above  the  ui)per  border,  and  be  able  to  feel  the  wave 
of  fluctuation  when  the  abdomen  is  percussed  above  the  pubes.  The  bladder  has 
often  been  entered  through  the  prostate,  but  it  is  not  advisable.  A  long  curved 
trocar  and  cannula  is  taken,  and  the  point,  guarded  by  the  finger,  guided  to  the 
spot  where  fluctuation  is  felt,  exactly  in  the  middle  line.  This  corresi)onds  to  the 
trigone.  When  it  is  adjusted  the  handle  is  slightly  depressed  and  driven  smartly 
upward  and  forward,  as  if  for  the  umbilicus. 


'Jnihilte 


Fig.  432. — Operation  of  Tapping  the  liladder  through  the  Rectum. 

There  is  no  doubt  that  in  this  way  the  bladder  is  drained  more  efficiently 
than  by  the  other  methods,  but  it  is  not  suited  to  cases  of  enlarged  prostate  and  is 
impossible  for  a  permanency.  In  many  patients  there  is  great  difficulty  in  main- 
taining the  cannula  or  catheter  in  position,  even  for  twenty-four  hours,  owing  to 
the  irritability  of  the  rectum.  I  have  known  it  stitched  to  the  skin  at  the  margin 
of  the  anus  without  avail.  Sometimes,  it  is  true,  if  the  cannula  is  removed  the 
two  orifices  face  each  other  again  as  the  bladder  becomes  distended,  and  the  urine 
is  discharged  into  the  rectum  ;  but  this  cannot  be  relied  upon,  and  is  attended 
with  some  danger  of  urinary  infiltration.  The  space  available  is  so  small  that  if 
the  tapping  is  repeated  there  is  considerable  risk  of  inflammation  and  even  of 
sloughing. 

In  brief,  where  temporary  relief  is  recpiired,  the  choice  lies  between  supra- 
pubic aspiration  and  rectal  tapping  :  neither  may  be  repeated  more  than  two  or 
three  times  without  running  serious  risk  ;  but  the  former  has  a  slight  advantage  so 
far  as  this  is  concerned.  Where  the  opening  must  be  permanent  the  suprapubic 
operation  is  the  only  one ;  whether  it  should  be  done  with  a  trocar  and  cannula, 
or  whether  cystotomy  should  be  performed  first,  must  depend  upon  the  cause  of  the 
retention  and  the  condition  of  the  bladder. 


Cystitis. 
Inflammation  of  the    bladder  may  be  acute  or  chronic.      Nearly  always  it 
begins  on  the  mucous  surface   and  is  of  local  origin.     The  chronic  form  may 
commence  as  such,  or  be  the  result  of  the  acute. 


CYSTITIS. 


1037 


Causes. —  i.  Injury,  mechanical  or  chemical.  The  former  includes  wounds 
and  contusions  trom  calculi  or  instruments  ;  tension,  as  in  stricture  and  enlarged 
prostate  ;  antl  bruising  or  straining,  as  in  i)arturition  or  disjjlacement  of  the  uterus  ; 
the  latter,  irritating  conditions  of  the  urine,  due  to  uric  acid,  cantharides,  and,  more 
than  anything  else,  carbonate  of  ammonia  and  other  products  of  decom])osition. 

2.  Infective  organisms,  such  as  tubercle,  and  new  growths,  such  as  carcinoma. 
Even  non-malignant  tumors  of  the  bladder  are  always  attended  with  a  slight 
degree  of  cystitis. 

3.  Extension  from  surrounding  parts,  especially  in  the  case  of  gonorrhoea  and 
stricture.  It  may  occur  in  peritonitis,  and,  excei)tionally,  in  diseases  of  other 
neighboring  structures. 

Pathological  Appearances. — In  the  milder  forms  of  acute  cystitis,  such 
as  occur  in  gonorrhoea,  the  mucous  membrane  is  thickened  and  swollen,  the  epi- 
thelium detached,  leaving  the  surface  raw  and  bleeding,  or  covered  over  with  flakes 
of  lymph  and  reddened  in  patches,  owing  to  small  extravasations.  When  it  is 
more  severe  it  may  be  lined  with  a  slough,  which  can  be  peeled  off  like  a  diph- 
theritic membrane  ;  the  color  is  dark  crimson,  or,  if  it  is  some  time  after  dteath, 
even  black ;  the  mucous  membrane  is  sloughing  and  gangrenous  ;  the  submucous 
tissue  and  even  the  muscular  coat  infiltrated  with  pus ;  and  sometimes  the 
peritoneal  surface  involved  as  well,  either  covered  with  lymph  from  recent  peri- 
tonitis, or,  in  the  worst  cases,  perforated  from  ulceration. 

In  chronic  cystitis  the  bladder  is  either  thin-walled  and  distended,  or  small, 
hard,  and  inelastic,  so  that  it  can  neither  expand  nor  collapse.  In  the  former  case 
the  mucous  membrane  is  thinned  and  stretched  and  generally  slate-colored  or  dark 
from  old  hemorrhages,  the  submucous  coat  can  hardly  be  found,  and  the  muscular 
fibres  are  wasted  until  scarcely  a  trace  of  them  is  left.  In  the  latter  the  interior  is 
rough  and  uneven  ;  here  and  there  it  is  bright  red  from  extravasated  blood,  in 
other  parts  almost  black,  especially  along  the  veins.  The  mucous  membrane  is 
thickened  and  velvety,  or  studded  with  superficial  excoriations  and  even  ulcers ; 
and  it  is  smeared  all  over  with  a  grayish,  intensely  offensive,  tenacious  mass  of 
mucus  and  phosphates.  The  submucous  tissue  in  some  parts  is  hard  and  dense 
from  long-continued  inflammation,  in  others  riddled  with  abscesses.  The  muscu- 
lar coat  is  thickened  into  great  bands  which  extend  around  the  bladder,  dividing 
and  joining  again,  so  as  to  leave  between  them  lozenge-shaped  depressions.  In  old 
cases  these  grow  out  into  thin-walled  sacculi  or  pouches  with  very  narrow  necks, 
and  once  formed,  they  are 
permanent  (Fig.  433)  ; 
each  time  the  bladder  con- 
tracts more  fluid  is  driven 
into  them  ;  there  is  no  mus- 
cular coat,  so  they  cannot 
empty  themselves  ;  and  at 
length  they  become  half- 
filled  with  mucus.  Other 
pouches  are  sometimes  due 
to  the  gradual  yielding  of 
the  whole  thickness  of  the 
wall ;  but  these  seldom  oc- 
cur unless  there  is  a  calculus 
(Fig.  437)  or  a  great  devel- 
opment of  the  inter-uretral 
bar.  In  some  of  these  the 
wall  is  forced  down  behind 
the  prostate  until  it  is  possi- 
ble to  tap  the  bladder  direct- 
ly through  the  perineum. 

When  ammoniacal  de-    Kig.  433.— Hypenrophied  and  Fasciculated  Bladder  Consequent  on  Enlarge- 
rnmnncitinn     r^f    tli^      iiri"n>i  ment  of  the  Median  Lobe  of  the  Prostate.     A  large,  ihin-walled  sacculus 

COmpOSUlOn     01     ine      urine  with  a  very  small  orifice  has  been  forced  out  on  the  left  side. 


1038    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

occurs  in  a  blackler  already  the  seat  of  chronic  cystitis  the  changes  are  more  exten- 
sive still.  The  walls  are  constantly  bathed  with  an  intense  irritant  ;  the  sarculi 
are  filled  with  a  most  offensive  mixture  ;  ulceration  and  sloughing  follow  ;  the  jnis 
spreads  into  the  submucous  coat  and  between  the  muscular  fibres,  even  to  the  jjeri- 
toneum  ;  and  at  length  the  bladder  is  reduced  to  the  condition  of  a  sloughing 
abscess,  filled  with  putrid  fluid,  under  constantly  increasing  tension. 

When  ulceration  occurs  at  an  early  period  it  is  usually  due  to  injury  fsuch  as 
the  pressure  of  the  point  of  a  catheter  tied  in)  or  to  tubercle.  In  the  latter  case 
the  trigone  is  chiefly  affected,  and  the  ulcers  are  multiple,  slightly  raised  at  the 
margin,  circular  in  shape,  and  covered  over  with  a  yellow  granular  slough.  Tuber- 
cle bacilli  may  l)e  found  on  the  surface  and  sometimes  in  the  urine. 

In  cystitis  the  inflammation  never  remains  limited  to  the  bladder  for  long; 
very  soon  it  spreads  to  the  ureters  and  involves  the  pelvis  (pyelitis)  ;  thence  it  ex- 
tends into  the  substance  of  the  kidney  itself.  So  long  as  the  nephritis  is  not  very 
intense,  there  is  merely  an  increase  in  the  amount  of  connective  tissue,  with  some 
diminution  of  the  secreting  power ;  if,  however,  the  urine  decomposes,  and  the 
products  gain  the  pelvis,  suppuration  and  multiple  abscesses  occur  very  soon. 

Symptoms. — Pain. — When  the  inflammation  is  very  acute,  or  when  there  is 
ulceration,  this  is  described  as  agonizing,  radiating  to  the  groins,  down  the  thighs, 
and  all  over  the  lower  part  of  the  body,  with  unceasing  desire  to  pass  water  {stran- 
gury), and  such  an  amount  of  spasm  that  only  a  few  drops  of  blood-stained  fluid 
are  ejected  at  a  time.  In  the  gonorrhoeal  form  it  is  less  severe  ;  and  as  the  inflam- 
mation becomes  chronic  it  may  almost  disappear.  Generally,  however,  there  is  a 
dull  aching  over  the  pubes  and  in  the  perineum  when  the  bladder  is  distended  and 
as  it  begins  to  contract,  when,  that  is  to  say,  tension  falls  upon  the  inflamed  mucous 
membrane  ;  and  for  the  same  reason  there  is  tenderness  on  pressure  over  the  .same 
regions,  and  on  examination  per  rectum  or  with  a  catheter. 

Contrary  to  what  occurs  in  calculus,  the  pain  is  less  severe  after  the  bladder 
is  emptied. 

Increased  frequency  of  micturition  is  never  absent,  unless  there  is  some  insur- 
mountable obstacle.  If  the  cystitis  is  severe  the  urine  is  ejected  every  few  minutes 
with  violent  spa.sm  ;  in  milder  ca.ses  the  intervals  are  longer,  but  the  call  scarcely 
less  urgent. 

The  character  and  frequently  the  amou?it  of  urine  are  altered.  In  very  acute 
cases  the  quantity  is  greatly  diminished,  and  it  consists  of  little  more  than  blood, 
mixed  with  shreds  and  flakes  of  lymph  from  the  surface  of  the  mucous  membrane. 
In  gonorrhoeal  cystitis  it  is  cloudy  and  turbid  with  mucus  ;  blood  is  usually  present, 
especially  toward  the  end  of  the  micturition,  when  the  muscles  at  the  neck  of  the 
bladder  are  contracting  upon  the  congested  mucous  meml)rane  ;  but  the  amount  of 
urine  generally  remains  the  same.  As  the  inflammation  grows  chronic  the  ha^ma- 
turia  diminishes  and  may  even  disajjpear  ;  but  blood  corpuscles  can  generally  be 
found  in  the  sediment. 

In  chronic  cystitis,  so  long  as  the  urine  is  acid,  the  deposit  consists  only  of 
mucus  mixed  with  minute  organisms,  detached  epithelium,  a  few  blood-corpuscles, 
urates,  and  oxalate  of  lime.  When  decomposition  sets  in  the  smell  becomes  ammo- 
niacal  and  intensely  offensive,  and  the  deposit  is  largely  increased  ;  a  thick,  viscid, 
gelatinous  mass  gradually  sinks  down  to  the  bottom  whenever  the  urine  is  allowed 
to  collect,  and  clings  tenaciously  to  the  sides. 

The  constitutional  disturbance  in  chronic  cystitis  is  rarely  severe,  though  the 
health  always  suffers  from  the  irritation  and  want  of  rest  and  from  the  changes 
that  are  induced  in  the  kidneys.  Traumatic  inflammation,  if  the  bladder  was 
healthy  before  the  injury,  may  be  attended  with  a  certain  amount  of  fever,  some- 
times with  shivering  ;  but,  unless  the  cause  is  persistent,  it  soon  subsides.  In  gon- 
orrhreal  cystitis  the  temperature  occasionally  ranges  very  high,  and  there  is  for  a 
time  great  anxiety,  with  distress.  The  worst  cases  are  those  in  which,  owing  to 
injury  or  decomposition  of  the  urine,  an  acute  attack  suddenly  breaks  out  in  a 
bladder  which,  from  atony,  enlarged  prostate,  or  any  other  cause,  cannot  completely 


CYSTITIS.  1039 

em|)ty  itself.  The  urine  ra];idly  becomes  i)utrid  ;  the  tension  grows  higher  and 
higher;  the  poison  is  absorljed  through  the  inflamed  and  ulcerated  walls  ;  and 
owing  to  the  kidneys  being  nearly  always  involved  as  well,  there  is  very  grave 
danger  of  sujipression  of  urine.  The  tcmi)erature  does  not  rise  very  high  ;  but  the 
patient  becomes  delirious  ;  the  most  extreme  exhaustion  sets  in  ;  the  symptoms 
assume  a  typhoid  character,  and  death  may  ensue  in  the  course  of  a  few  days. 

Prognosis. — This  depends  upon  the  cause  and  the  condition  of  the  bladder, 
though  naturally  the  secreting  jjower  of  the  kidneys  is  especially  imj^ortant.  In- 
flammation, excited  in  a  healthy  bladder  by  a  transient  agent  that  can  be  removed 
at  once,  soon  gets  well.  On  the  other  hand,  if  the  irritant  is  persistent,  as  in  the 
case  of  tubercle  or  carcinoma,  or  if  the  bladder  is  rough  and  irregular,  with  rigid 
walls  that  cannot  collapse,  or  studded  with  pouches  that  cannot  be  emptied,  or  if 
there  is  any  obstacle  to  complete  evacuation,  the  attack  may  be  stoi)ped  for  a  time, 
but  it  is  always  ready  to  break  out  again. 

Treatment. —  i.  Acute  Cystitis. — The  first  thing  is  to  remove  the  cause  ;  the 
second,  to  give  the  bladder  rest.  If  it  was  previously  healthy  and  the  irritant  was 
a  transient  one  (lithotrity,  for  example),  active  local  measures  are  not  required. 
The  patient  should  be  confined  to  bed,  on  milk  diet,  the  bowels  thoroughly 
opened,  and  a  hot  bath  given  night  and  morning.  If  there  is  much  pain  or  throb- 
bing, leeches  may  be  applied  to  the  perineum  ;  and  if  the  bladder  is  very  irritable, 
morphia  and  belladonna  may  be  given,  either  in  the  form  of  a  suppository  or  as 
a  pessary  introduced  into  the  bladder  at  night.  Alkalies  are  not  of  much  service, 
but  if  the  urine  contains  an  excess  of  uric  acid,  ten-grain  doses  of  citrate  of  potash 
may  be  given  with  hyoscyamus.  Iced  barley-water  and  similar  drinks  may  be 
taken  freely  if  the  patient  is  hot  and  feverish  ;  but  buchu  and  triticum  repens  are 
of  little  use  at  this  stage.  If  retention  occurs  from  congestion  of  the  mucous 
membrane  at  the  neck,  a  soft  or  black  catheter  should  be  passed. 

2.  Chronic  Cystitis. — In  this  again  the  cause  must  be  ascertained,  and,  if 
possible,  removed.  Irritating  conditions  of  the  urine,  for  example,  such  as  occur 
in  gout  and  ill-fed  strumous  children,  must  be  treated  by  attention  to  the  digestive 
organs.  Stricture  must  be  dilated  or  divided  ;  calculi  removed  ;  vascular  growths 
about  the  urethra  excised  ;  and  displacement  of  the  uterus  rectified. 

{a)  Constitutional. — In  some  cases — tubercular  cystitis,  for  example — this  is 
almost  all  that  can  be  done  ;  in  all  it  is  very  important.  The  clothing  must  be 
warm  ;  exposure  to  cold  and  over-exertion  avoided  ;  diet  regulated  ;  stimulants, 
coffee,  etc.,  prohibited;  and  the  bowels  kept  gently  relaxed.  If  there  is  much 
mucus  (mucus  does  not  cause  fermentation  of  urea,  but  it  assists  it,  partly  by 
lessening  the  acidity,  partly  by  coating  the  urethra  with  a  stagnant  layer  of  alkaline 
fluid,  in  which  the  ferment  growls  with  ease),  quinine,  boracic  or  salicylic  acid 
may  be  given  internally.  Benzoate  of  ammonia  helps  to  keep  the  urine  acid  ; 
triticum  repens,  pareira,  and  buchu  check  the  catarrh,  but  the  two  last  often  dis- 
agree ;  and  copaiba,  sandal  oil,  and  other  resins  are  of  service  in  the  same  way, 
especially  in  chronic  cystitis  with  abundant  secretion.  In  most  cases,  however, 
when  the  stage  is  reached,  local  measures  are  required  as  well. 

(/')  Local. — Washing  the  bladder  is  exceedingly  useful  in  checking  the  for- 
mation of  mucus,  clearing  out  the  adherent  coating,  and  preventing  decomposition  ; 
but  it  must  be  distinctly  recognized  that,  unless  it  is  done  with  the  greatest  care, 
it  may  easily  do  more  harm  than  good.  The  utmost  gentleness  must  be  used, 
and,  unless  there  is  some  special  condition,  the  amount  injected  should  never  exceed 
four  ounces.  The  simplest  contrivance,  one  which  the  patient  can  easily  manage 
for  himself,  is  a  glass  funnel  attached  by  flexible  tubing  to  a  large-eyed  soft  catheter. 
As  the  funnel  is  raised,  the  fluid  pours  into  the  bladder  by  its  own  weight ;  as  it  is 
lowered,  it  falls  back  again  ;  and  if  it  is  turbid,  it  can  at  once  be  replaced  by  fresh. 
When  there  is  a  large  amount  of  phosphatic  debris,  or  of  thick,  tenacious  mucus,  a 
modification  of  Higginson's  syringe  with  a  double-way  tap  or  a  lithotrity  evacuator 
may  be  employed  ;  but  the  amount  of  force  must  be  accurately  gauged  with  the 
hand.     Bladders  with  softened  walls  are  easily  ruptured. 


I040    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

The  most  useful  solutions  are  corrosive  sublimate  (i  in  10,000,  with  a  drop 
of  hydrochloric  acid)  ;  iodoform,  gr.  x  ad  5J,  susjiended  in  mucilage,  especially 
for  tubercular  cystitis  ;  (juinine,  with  a  drop  of  sulphuric  acid  ;  boracic  acid,  gr. 
X  ad  5j.  ^^'ith  glycerine,  nitrate  of  silver,  and  acetate  of  lead.  Hut  hot  salt  and 
water,  dilute  nitric  acid  (especially  if  there  is  much  phosphatic  debris),  perman- 
ganate of  potash,  sulphate  of  zinc  or  copper,  and  many  others  may  be  emj^loyed. 
It  seems  of  some  advantage,  when  there  is  much  mucus,  not  to  continue  with  the 
same  one  too  long.      Carbolic  acid,  unless  very  weak,  is  too  irritating. 

Even  when  the  urea  has  decomposed  and  the  urine  is  ammoniacal,  so  that  a 
fresh  and  very  grave  source  of  irritation  is  added,  washing  out  the  bladder,  if  it  is 
done  carefully,  and  if  the  condition  of  the  walls  and  of  the  kidneys  is  not  too  far 
advanced,  is  very  successful.  The  germ  upon  which  the  fermentation  depends  is 
killed  ;  the  decomposition  stopped  ;  the  excess  of  mucus  washed  away ;  and  the 
inflammation  of  the  mucous  membrane  gradually  subdued. 

Exploration  and  Drainage. — If  this  fails,  the  interior  of  the  bladder  may  be 
explored  either  with  the  cystoscope  or  with  the  finger.  In  some  instances  a  piece 
of  soft  rubber  tubing  has  been  found,  of  course,  without  any  history  ;  in  others  a 
pouch  spreading  out  from  the  bladder  ;  or  a  new  growth  ;  or  sometimes,  especially 
in  young  subjects,  a  deposit  of  tubercle  breaking  down.  The  cystoscope  may  be 
used  at  an  early  period.  Digital  exploration  of  the  male  bladder  necessitates  an 
opening  in  the  perineum  ;  but  the  operation  is  an  exceeding  simple  one,  almost 
unattended  with  danger,  and  in  nearly  all  the  cases  in  which  it  is  required  for 
diagnosis  it  is  equally  valuable  for  drainage.  A  grooved  staff  is  passed  down  the 
urethra  into  the  bladder;  the  patient  is  jjlaced  in  the  lithotomy  position  ;  a  small 
incision  made  exactly  in  the  middle  line,  three-quarters  of  an  inch  in  front  of  the 
anus,  and  deepened  until  the  finger-nail  can  feel  the  groove.  Then  the  membranous 
portion  of  the  urethra  is  opened  above  the  bulb,  and  a  prol)e  or  gorget  jnished 
along  the  groove  into  the  bladder.  The  staff  is  now  withdrawn  and  the  forefinger 
gently  pressed  through  the  prostatic  portion,  dilating  it  as  it  goes. 

The  further  treatment  depends  upon  what  is  found.  If  there  is  tubercular 
cystitis,  and  the  disease  is  not  too  far  advanced,  iodoform  or  dilute  lactic  acid  may 
be  applied  ;  or  suprapubic  cystotomy  performed  and  the  ulcers  scraped,  though  the 
cases  in  which  such  a  proceeding  is  advisable  are  very  few  in  number.  If  there  is 
a  foreign  body  or  a  tumor,  it  may  be  removed  ;  a  sacculus  may  be  drained  ;  and 
other  conditions  dealt  with  according  to  circumstances. 

When  the  cause  is  irremediable,  as  in  advanced  tubercle  or  carcinoma,  simple 
drainage  through  a  perineal  opening  gives  more  relief  than  anything  else  :  the 
patient  is  freed  from  jiain  ;  he  is  able  to  obtain  a  certain  amount  of  rest  at  night, 
and,  for  a  time  at  least,  he  may  gain  a  certain  amount  of  strength.  Even  when  no 
cause  for  the  cystitis  is  found,  and  sometimes  it  will  persist  in  a  most  inexplicable 
manner,  draining  the  bladder  through  the  perineum — giving  it  j^erfect  rest  for  a 
month,  and  allowing  all  the  urine  to  flow  out  through  a  tube — has  in  many  in- 
stances effected  a  permanent  cure. 

This  oj^eration  is  imperatively  required  when  chronic  cystitis  that  has  lasted 
perhaps  for  years,  and  has  produced  serious  changes  in  the  kidneys  and  in  the  wall 
of  the  bladder,  suddenly  becomes  acute.  This  may  be  due  to  lithotrity,  especially 
if  the  fragments  are  not  thoroughly  cleared  away  ;  or  to  the  use  of  instruments,  or 
to  decomposition  of  the  urine  in  cases  of  atony  and  enlarged  prostate.  The 
symptoms  are  of  the  gravest  description  :  the  kidneys  are  already  in  a  state  of  in- 
terstitial, sometimes  of  suppurative,  inflammation  ;  there  is  i)artial  sui)i)ression  of 
urine  ;  the  bladder  is  unable  to  expel  its  contents  ;  the  walls  are  intensely  inflamed, 
perhaps  sloughing  ;  septic  absorption  is  rapidly  taking  place,  and  the  ])atient  is  in 
imminent  danger  of  sinking  into  a  state  resembling  typhoid.  Under  such  con- 
ditions there  is  no  alternative :  the  bladder  must  be  opened  at  once  and  allowed 
to  drain  just  like  any  other  offensive  abscess.  In  many  cases  the  patient  sinks 
from  exhaustion  ;  but  sometimes  the  mucous  membrane  clears  itself  with  surj^rising 
rapidity  ;  the  urine  loses  its  offensive  character  ;  the  amount  and  the  specific 
gravity  both  increase  ;  and  the  strength  and  health  are  gradually  regained. 


VESICAL   CALCULUS.  1041 

Vf.suai.  Calculus. 

Calculi  mav  be  rorinctl  from  any  of  the  sediments  that  occur  in  urine,  but  the 
tendency  is  much  greater  in  the  case  of  some,  uric  acitl  for  example,  than  in  the 
case  of  others,  such  as  phosphate  of  lime.  The  animal  matter  that  holds  the 
particles  together  is  derived  from  the  mucus  of  the  urinary  tract,  which  undergoes 
a  process  of  fermentation,  and  either  collects  layer  after  layer  of  uric  acid  or  leads 
to  the  formation  of  sparingly  soluble  oxalate  of  lime. 

Origin. — The  nucleus  of  a  calculus  may  be  hollow,  or  consist  of  dried  blood  ; 
in  most,  however,  it  is  formed  of  uric  acid  or  oxalate  of  lime,  held  together  by  a 
colloid  material.  These  are  of  renal  origin,  though  they  subsequently  increa.se  by 
the  deposit  of  laminae,  as  they  lie  in  the  pelvis  of  the  kidney  or  in  the  bladder. 
Those  formed  of  triple  phosphates  are  only  thrown  down  when  the  urine  becomes 
ammoniacal,  and  usually,  therefore,  originate  in  the  bladder,  though  they  are  not 
confined  to  it. 

Nuclei  of  uric  acid  are  most  common  in  early  childhood  and  in  late  adult  life, 
especially  if  there  is  a  tendency  to  gout.  The  starting-point  is  the  deposit  of 
crystals  in  the  secreting  tubules,  and  most  likely  in  the  actual  cells  ;  infarcts  of  uric 
acid  are  often  present  in  the  renal  tubules  of  infants  shortly  after  birth  ;  and  in 
gout  all  stages  can  be  traced,  from  crystals  in  the  cells  and  irregular  masses  in  the 
tubules  of  the  medullary  i)art,  to  minute  calculi  i)rojecting  from  the  orifices  on  the 
pyramids  or  lying  loose  in  the  cavity  of  the  pelvis.  The  cause  of  the  precipitation 
is  probably  some  impairment  in  power  of  the  cells,  whether  this  arises  from  weak- 
ness, from  exhausting  illness,  or  from  long-continued  overwork,  as  in  gout  ;  and 
it  is  assisted  by  everything  that  tends  to  check  the  flow  of  urine,  whether  it  is  the 
small  size  of  the  secreting  passages,  as  in  children,  or  an  actual  obstruction,  such 
as  enlarged  prostate.  When  once  the  pelvis  of  the  kidney  or  the  bladder  is 
reached,  the  nucleus  increases  by  acting  as  a  focus  around  which  are  deposited 
layers  that  differ  according  to  the  reaction  and  composition  of  the  urine. 

Very  little  is  known  with  regard  to  the  formation  of  renal  calculi,  with  the 
exception  of  those  composed  of  triple  phosphate,  which  may,  of  course,  be  formed 
round  anything  that  causes  decomposition  of  urea.  It  is  notorious  that  in  certain 
parts  of  England — the  eastern  counties,  for  example — they  are  much  more  com- 
mon than  elsewhere,  but  though  this  has  been  assigned  to  climatic  conditions,  the 
prevalence  of  cold  and  damp,  the  nature  of  the  soil,  and  the  hardness  of  the 
drinking  water,  it  is  not  conclusive,  though  the  last  mentioned  cause  is  certainly  of 
importance.  In  certain  countries — India,  for  example — the  proportion  of  oxalate 
of  lime  calculi  is  higher  than  in  England,  without  any  reason  being  known.  In 
children  of  the  poorer  classes  calculi  are  more  common  than  among  the  well-to-do, 
and  are  nearly  always  composed  of  uric  acid  ;  possibly  this  arises  from  a  deficient 
supply  of  milk  and  improper  diet.  Gravel,  too,  is  chiefly  found  among  those  who 
have  a  tendency  to  gout,  or  who  consume  large  quantities  of  animal  food,  or  are 
addicted  to  alcohol  ;  but  though  this  points  in  a  general  way  to  increase  in  the 
tissue-waste,  and  to  the  effect  of  indigestion,  acidity,  and  malassimilation,  in 
causing  the  precipitation  of  sediments  in  the  urine,  something  more  is  needed  to 
explain  the  formation  of  calculi.  There  must  be  some  condition  of  the  urinary 
organs  leading  to  the  production  of  the  colloid  material  necessary  to  cement  the 
particles  together. 

Calculus  is  more  common  in  the  male  than  the  female  ;  and  this  cannot  be 
altogether  explained  by  anatomy,  as  the  same  holds  good  with  regard  to  the 
kidneys,  though  to  a  less  extent.  Hereditary  influence  probably  does  exist,  even 
after  full  allowance  has  been  made  for  the  efi'ects  of  locality  and  for  similarity  of 
habit. 

Physical  Characters. — Calculi  vary  in  size  from  minute  bodies,  only 
larger  than  gravel,  to  masses  of  more  than  a  pound  in  weight.  The  smaller  ones 
are  frequently  numerous,  large  ones  single.  In  shape,  unless  they  are  formed  upon 
some  foreign  body,  such  as  the  end  of  a  bougie,  they  are  more  or  less  rounded  ; 


I042    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


but  sometimes  they  are  llattened,  and  occasionally  they  are  covered  with  facets 
from  mutual  friction.  In  rare  cases  where  the  bladtler  is  sacculated  and  the  calculus 
lies  ]jartly  inside  the  i)ouch,  it  is  moulded  into  the  shape  of  an  hour-glass.  The 
surface  varies  according  to  the  composition,  those  formed  of  oxalate  of  lime  being 
peculiarly  rough  and  characteristic. 

It  rarely  happens  that  a  calculus  is  homogeneous  throughout.  \Vith  the  excep- 
tion of  some  formed  of  cystin,  which  have  a  peculiar  radiated  appearance,  the 
surface  of  the  cut  section  is  made  up  of  concentric  layers,  varying  in  character  and 
structure  according  to  the  reaction  and  comi)osition  of  the  urine.  Laminae  of 
oxalate  of  lime,  more  or  less  pure,  alternate  with  those  of  uric  acid  ;  or  a  soft 
earthy  layer  of  urate  of  ammonia  may  be  interposed  between  others  of  mixed  com- 
position. Owing  to  the  roughness  of  their  surface  and  the  amount  of  irritation 
they  cause,  nuclei  of  oxalate  of  lime  are  generally  coated  over  with  phosphates. 
Calculi  sometimes  suddenly  undergo  spontaneous  disintegration,  and  break  up. 
Probably  the  immediate  cause  is  an  alteration  in  the  reaction  or  the  specific  gravity 
of  the  urine,  so  that  the  solubility  of  the  different  layers  is  no  longer  the  same ; 
and  sometimes,  after  this  has  happened,  the  irritation  arising  from  the  presence 
of  numerous  angular  fragments  brings  on  an  attack  of  cystitis,  and  the  isolated 
portions  become  welded  together  again  with  triple  i)hosphate. 

Position. — For  the  most  part  calculi  lie  at  the  back  of  the  bladder  behind 
the  prostate  ;  sometimes  they  are  caught  l)ehind  the  pubes  in  front ;  and  occasion- 
ally they  lie  in  cysts,  either  large  sacculi  with  very  small  openings,  which  are 
formed  as  hernial  i)rotrusions  of  the  mucous  membrane  between  the  fasciculi  of  the 
muscular  wall  in  hyi)ertroi)hied  bladders  (Fig.  433),  or  little  cavities  which  the 
calculi  work  out  for  themselves.  These  are  most  common  on  the  right  side  at  the 
base,  close  to  the  orifice  of  the  ureter,  and  they  fit  so  accurately  round  the  stone 
that  it  may  require  considerable  force  to  dislodge  it  (Fig.  437).  All  the  layers  of 
the  bladder  wall,  very  much  thinned  and  stretched,  enter  into  their  structure,  and 
when  the  calculus  lies  behind  the  prostate  the  orifice  of  the  sac  may  be  almost 

closed  during  life  by  the  muscular  bands 
contracting  and  pressing  the  stone  deep  into 
the  substance  of  the  gland.  Phosphatic  con- 
cretions are  occasionally  found  upon  growths 
i:)rojecting  into  the  bladder  ;  and  it  is  said 
tliat  calculi  are  sometimes  adherent  to  the 
mucous  surface. 

Chemical  Reactions  of  Calculi. — The 
calculus  should  be  finely  pounded  and 
divided  into  four  parts. 

T.  One  i)ortion  is  placed  on  platinum 
foil,  and  heated  before  a  blow-j^ipe. 

{a)  It  disap])ears,  or  nearly  so  :  uric 
acid  or  urate  of  ammonia. 

(J))  It  clears  to  some  extent :   ])robably 
oxalate  of  lime  ;  if  so,  the  residue  effervesces, 
and  dissolves  with  hydrochloric  acid. 
{/)  It  fuses  readily  into  a  porcelain-like  mass  :   triple  jihosphate,  mixed  with 
phosphate  of  lime. 

2.  The  second  is  moistened  with  hydrochloric  acid. 

(rt)  It  dissolves  :  oxalate  of  lime,  ])hosphate  of  lime,  or  ammonio-magnesian 
phosphate.  Carbonate  of  lime,  and  oxalate  that  has  been  heated,  effervesce  as 
well.     Xanthin  also  dissolves. 

{b)  It  remains  unaltered  :   uric  acid  ;  urates  ;  or  cystin. 

3.  The  third  is  Avarmed  with  liquor  potassae. 

{a)  It  dissolves  :  uric  acid  ;  urates  ;  cystin  ;  or  xanthin.  The  two  former 
give  the  murexide  reaction  ;  the  latter  do  not.  If  ammonia  is  present,  it  is  given 
off  when  the  solution  in  liquor  potassK  is  heated. 


Fig.  434. — Uric  Acid  Calculus,  with  Nucleus  of 
Oxalate  of  Lime. 


VESICAL   CALCULUS. 


1043 


<«  0 

I'i 

.-  rt 

i^c 

D." 

3 

>^   </) 

a; 

_.      4; 

'"03 
C   c     - 

t/i    o    '-■ 

u 


tJ.t 


<u  3 ' 


C^    O  -".  3 

u  ■     >  3  ~ 

'^    3    t/1  O  «J    C 

XL  O^  g  C  rt 
W 


U 


.  <u  c  rt    . 

(fl  to--  C.rt 

C  <«  <j  V 

^f    4J    U  5    <U 

u 


^  03 


-^5  :! 


pa 


o 


rC       3-2 

"in  <^ 


'-'  rt  <u  o 

^-33  el- 
's '=■■5-= 

O    :-    OJ  •- 
p    bo  <J  J3 


-d 
c 
n 

-2 
o 
o 

s 

CO 


3 

H 


•a 

c 

cS 

o 
o 

S 


I-    ■fi 

'^. "«  T. 


fc 


ID 

Q 
Z 

< 
X 
in 


p   rt   C 
O  w,    > 


13 

D    rt 

0 

C 

U  "^ 

3 

^ 

0 

in   0 

bo 
bo 

4) 

C  — 

--    4J 

m 

13 

> 

C 

>-e 


o  ;a 


0  ^ 

3 
(J 

.  -  I- 

"1 

■r.^ 

u 

■^ 

t3 

fcoii 

ci; 


c 

(D 

(U 

N 

u 

cn 

^ 

g 

c 

3 

13 

13 
0) 

0 

> 

s 

0 

a, 

tn 

O 


«  c 


a. 


2  ° 


u 


I044     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

(J))   It  remains  unaltered  :   oxalate,  i)hosphate,  or  carbonate  of  lime. 

4.  The  fourth  is  moistened  with  acetic  acid;  if  it  dissolves,  it  is  either  car- 
bonate or  i)hos])hate  of  lime. 

Besides  these,  concretions  have  been  found  in  the  urinary  bladder,  formed 
of  fatty  matter,  with  a  certain  amount  of  urates  or  phosphates  (urostealith)  ;  of 
fibrin,  blood,  and  even  of  indigo,  derived  from  the  indican  ;  but  they  are  all 
extraordinarily  rare. 

Symptoms. — The  cardinal  symptoms  of  stone  are  pain,  increased  frequency 
of  micturition,  ha^maturia,  and  sudden  stoppage  in  the  stream  of  urine.  They  are 
worse  with  small  calculi  than  with  large  ones,  because  the  latter  remain  stationary 
in  the  bladder,  and  do  not  roll  about  and  irritate  the  mucous  membrane  ;  they  are 
more  marked  when  the  bladder  is  empty,  because,  so  long  as  it  is  full,  the  calculus 
lies  in  a  fluid  of  higher  specific  gravity  than  water,  and,  though  it  does  not  actually 
float,  it  cannot  come  into  forcible  contact  with  the  walls  ;  they  are  worse  with 
oxalate  of  lime  calculi,  because  their  surface  is  so  rough  ;  and  most  severe  of  all 
when  the  mucous  membrane  is  inflamed. 


Fig.  435. — Calculus  composed  of  Oxalate  of  Lime  : 
Surface  and  Section. 


Fig.  436. — Calculus  com- 
posed of  Cystin. 


Fig.  437. — Hypcrtrophied  and  Fascicu- 
lated Bladder,  with  Enlargement  of 
Prostate.  A  calculus  was  buried  in 
a  deep  pouch  behind  the  gland,  and 
the  orifice  was  so  firmly  contracted 
around  it  that  at  the  post-mortem  \ 
there  was  some  difficulty  in  dislodg- 
ing it. 


1.  Pain. — This  is  of  two  kinds.  The  one  is  a  constant,  dull,  aching  sensa- 
tion across  the  loins,  in  the  groin,  and  running  down  the  thighs  ;  worse  on  move- 
ment, especially  riding,  driving,  or  jumping.  The  other,  which  is  more  character- 
istic, is  an  intense  cutting  or  shooting  pain,  felt  at  the  end  of  the  penis  as  the  fluid 
leaves  the  bladder,  and  the  sensitive  mucous  membrane  at  the  neck  is  crushed  down 
upon  the  rough  and  hard  surface  of  the  calculus.  Children,  toward  the  end  of  mic- 
turition, scream  with  pain,  and  pull  upon  the  penis,  until  the  prepuce  is  im- 
mensely elongated.  Violent  straining  often  occurs  at  the  same  time,  the  contents 
of  the  rectum  are  discharged  involuntarily,  and  the  mucous  membrane,  especially 
if  any  piles  are  present,  often  becomes  prolapsed. 

2.  Increased  Frequency  of  Micturition. — This  is  especially  marked  during 
the  daytime,  while  the  patient  is  moving  about ;  at  night,  contrary  to  what 
occurs  when  there  is  enlargement  of  the  prostate,  the  bladder  is  at  rest,  because 
the  stone  is  quiet.     When  cystitis  sets  in,  this  symptom  is  very  troublesome. 

3.  Hiematuria. — Blood  is  frequently  present  in  the  urine  after  exertion  ;  but 


VESICAL  CALCULUS.  1045 

it  is  only  characteristic  if  the  urine  itself  is  clear,  and  at  the  cw^X  of  micturition, 
when  the  pain  is  coming  on,  a  few  bright  red  drojw  follow. 

4.  Sui/Jcn  Stop/^agf  of  the  Stream  of  Urine. — This  is  not  so  common  ;  it 
may  occur,  however,  from  the  stone  falling  against  the  neck,  especially  in 
children,  and  setting  up  spasmodic  contraction  of  the  sphincter. 

Latent  Calculus. — The  symptoms  of  calculus  are  occasionally  masked  to 
such  an  extent  that  its  i)resence  is  never  even  suspected. 

This  may  occur  with  very  large,  smooth,  and  rounded  calculi.  They  remain 
perfectly  quiet ;  there  is  no  hoematuria,  pain,  or  spasm  ;  merely  increa.sed  frequency 
of  micturition,  owing  to  the  diminished  capacity  of  the  bladder.  Stones  of 
over  a  pound  in  weight  have  been  found  post-mortem,  \vithout  the  inconvenience 
ever  having  been  sufficiently  great  to  make  the  patient  apply  for  treatment. 

It  may  also  happen  if  the  prostate  is  much  enlarged,  without  there  being  any 
cystitis.  The  calculus  remains  behind  the  projection,  and  never  comes  into  con- 
tact with  the  neck  ;  the  symptoms  never  become  urgent.  Chronic  inflammation 
of  the  bladder  is  always  present  in  encysted  calculus. 

Consequences  of  Calculus. — Inflammation  always  breaks  out  sooner  or  later  ; 
at  first  the  mucous  membrane  only  is  involved,  but  very  soon  it  spreads  to  the 
submucous  and  muscular  coats ;  the  cavity  shrinks,  the  walls  become  rigid, 
inelastic,  and  irregularly  thickened  ;  sometimes  sacculi  develoj)  or  ulceration  sets 
in,  and  the  mucous  membrane  becomes  coated  with  an  intensely  offensive  layer 
of  putrid  pus  and  triple  phosphates.  Dilatation  of  the  ureter  and  of  the  pelvis  of 
the  kidney  always  follows  ;  the  cortex  is  absorbed  ;  the  connective  tissue  increases 
in  quantity  ;  the  secreting  power  is  diminished  ;  the  urine  becomes  ammoniacal, 
and  the  inflammation  rapidly  spreads  upward,  involving  the  pelvis  and  the  sub- 
stance of  the  kidney,  and  causing  suppurative  pyelonephritis. 


R.  A.  YARN'ALL  Co.,  Phila. 


Fig.  438. — Thompson's  Metallic  Sounder. 


Diagnosis. — The  presence  of  a  calculus  can  only  be  proved  by  exploring 
the  bladder  with  a  sound  or  a  cystoscope. 

Sounds  are  made  of  steel,  for  the  sake  of  the  polish.  The  handle  may  be 
cylindrical  or  flattened  and  rougher  on  one  surface  than  the  other,  so  that  there 
may  be  no  mistake  as  to  the  direction  of  the  beak.  The  shaft  is  round,  nine 
inches  in  length,  and  about  the  size  of  a  No.  7  English  catheter ;  the  beak  is  an 
inch  and  a  quarter  in  length,  slightly  bulbous  at  the  end,  and  is  bent  up  to  an 
angle  of  120°.  For  children,  of  course,  they  are  smaller.  Sometimes  it  is  of 
advantage  to  have  them  hollow,  so  that  the  amount  of  fluid  in  the  bladder  can  be 
varied.  With  children  it  is  always  advisable  to  give  an  anaesthetic;  in  an  adult 
an  injection  of  cocaine  does  a  great  deal  toward  diminishing  the  discomfort. 

The  same  precautions  should  be  taken  in  passing  a  sound  as  in  passing  a 
catheter.  Fatal  consequences  have  occurred  even  in  children  with  perfectly  healthy 
kidneys.  The  patient  should,  if  possible,  be  prepared  beforehand,  and  should  re- 
main quiet  afterward.  It  is  best  if  he  will  keep  his  room,  and,  if  there  is  the 
least  suspicion  with  regard  to  the  kidneys,  even  his  bed,  for  the  rest  of  the  day. 
A  large  cupful  of  hot  tea  with  five  grains  of  quinine  and  a  few  minims  of  lauda- 
num is  an  excellent  precaution.  If  there  is  any  retention  afterward  it  may  be 
relieved  by  a  full  dose  of  opium  (provided  the  kidneys  are  not  affected)  and  a  hot 
bath. 

For  choice,  the  bladder  should  contain  four  or  five  ounces  of  urine ;  if  there 
is  more  than  this,  a  small  calculus  may  easily  elude  the  sound  ;  if  less,  the  folds  of 
the  mucous  membrane  may  collapse  around  it  and  cover  it  in.  In  children  and 
young  adults,  in  whom  there  is  no  reason  to  suspect  chronic  retention,  it  is  suffi- 
cient if  the  bladder  contains  the  secretion  of  the  last  hour  or  two  ;  but  in  older 


I046    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

men,  with  possible  atony  antl  enlarged  prostate,  or  where  there  is  any  difficulty,  it 
is  better  to  pass  a  soft  catheter  first,  empty  the  l)ladder  thoroughly,  and  then  inject 
it  with  four  or  five  ounces  of  warm  boracic  solution. 

The  i)atient  should  be  lying  down,  with  the  head  comfortably  supported  upon 
a  i)illow,  the  pelvis  slightly  raised,  and  the  knees  and  hips  flexed  and  rotated  out- 
ward. The  sound,  of  course,  must  be  warmed  and  well  lubricated,  preferaljly  with 
Lund's  oil. 

In  sounding  a  bladder  a  definite  i)lan  should  be  followed.  The  upper  part  and 
the  sides  are  examined  first,  as  the  point  emerges  from  the  jjrostatic  portion  of  the 
urethra,  not  forgetting  that  a  calculus  is  sometimes  held  against  the  pubes,  even 
when  the  patient  is  lying  down  ;  then  the  handle  is  depressed,  the  beak  inverted, 
and  the  floor  and  the  pouch  that  exists  in  so  many  ca.ses  behind  the  prostate  care- 
fully felt  all  over.  Rapid  or  rough  movements  must  be  strictly  avoided  :  the  former 
give  rise  to  waves  which  may  drive  a  light  calculus  away  ;  the  latter  may  injure  the 
wall  of  the  bladder.  Digital  examination  of  the  rectum  at  the  same  time  should 
never  be  omitted,  i)articularly  with  children. 

The  contact  of  the  sound  with  the  stone  must  be  heard  as  well  as  felt,  and 
an  attempt  should  be  made  to  ascertain  further  details.  Sometimes  the  material  of 
which  the  stone  is  composed  may  be  conjectured  from  the  character  of  the  sound 
it  gives  when  struck.  If  it  is  oxalate  of  lime,  the  ring  is  clear,  as  against  metal  ; 
if  uric  acid,  it  is  more  dull,  like  stone;  if  the  outer  crust  is  composed  of  triple 
phosphates,  there  is  merely  a  rough,  grating  sound.  In  the  same  way  a  general  idea 
may  be  gathered  with  regard  to  the  size  and  number ;  but  to  obtain  definite  infor- 
mation, a  lithotrite  must  be  used,  and  even  then,  if,  for  example,  the  calculus  is  a 
very  flat  one,  it  is  not  always  possible  to  be  certain  ;  one  stone  must  be  grasped 
first,  its  measurement  taken,  if  possible,  in  more  than  one  diameter,  and  then  the 
instrument  used  as  a  sound  to  detect  the  presence  of  others.  Besides  this,  the  posi- 
tion and  mobility  of  the  stone,  whether  it  is  encysted  or  not ;  the  state  of  the 
bladder  as  regards  irritability,  softness  or  hardness  of  the  wall,  whether  it  is  smooth 
or  covered  over  with  xngx,  ;  the  size  and  prominence  of  the  prostate  ;  and  the 
condition  of  the  urethra,  should  all  be  noted.  Very  often  the  method  of  opera- 
tion is  determined  to  a  large  extent  by  some  detail  of  this  description. 

Errors  may  arise  in  various  ways.  Not  unfrequently  a  calculus  is  missed,  even 
after  repeated  examination.  There  is  too  much  fluid  in  the  bladder,  and  the  stone 
floats  away  before  the  sound  ;  or  too  little,  and  it  is  enveloped  in  folds  of  mucous 
membrane.  Sometimes  the  sound  never  reaches  the  bladder  at  all,  but  stops  in  the 
prostatic  portion  of  the  urethra  or  in  the  enlarged  and  dilated  prostatic  sinus. 
More  often  the  stone  is  missed  just  at  the  neck,  because  the  sound  is  not  rotated 
soon  enough  after  entering  the  bladder.  Calculi  lying  in  cysts  are  always  difficult, 
owing  to  the  very  small  size  of  the  opening  ;  and  after  lithotrity  minute  fragments 
covered  over  with  a  layer  of  coagulated  blood  may  easily  escape  notice. 

The  opposite  error,  imagining  that  a  calculus  is  present,  is  more  serious.  In 
children,  in  whom  the  wall  of  the  bladder  is  very  thin,  the  sacral  promontory  and 
the  spine  of  the  ischium,  if  struck  smartly  with  a  sound,  give  something  of  the 
same  sensation,  though  the  ring  is  not  clear.  A  rough  and  fasciculated  condition 
of  the  wall  of  the  bladder,  especially  if  the  rugoe  are  coated  over  with  i^hosj^hates, 
and  tumors  encrusted  in  the  same  manner,  sometimes  raise  a  momentary  doubt ; 
and  the  same  thing  may  occur  after  lithotrity,  when  the  bladder  is  being  washed 
out,  from  the  mucous  membrane  suddenly  flapping  with  an  audible  click  against 
the  orifice  of  a  large  and  straight  evacuator. 

The  other  methods  of  examining  the  bladder  can  only  be  regarded  as  acces- 
sories to  the  sound.  The  cysto.scope,  except  in  the  case  of  a  sacculated  bladder, 
gives  little  or  no  further  information. 

With  very  few  exce])tions,  calculi  must  be  removed  from  the  bladder  by  crush- 
ing or  cutting  ;  solution  is  rarely  worth  the  trial.  As  the  former  is  more  common, 
and  has  to  a  great  extent  superseded  the  latter,  it  will  be  taken  first. 


LITHOTRITY. 


1047 


LnnoiRirY. 

The  modern  operation  owes  its  position  to  Kigelow,  who,  in  i  Sy.S,  recognizing 
the  immense  ])Ower  of  dilatation  possessed  by  the  urethra,  and  the  ease  with  which 
the  fragments  of  a  calciihis  can  be  extracted  by  suction,  proved  that  a  stone  could 
be  crushed  and  removed,  once  for  all,  with  far  less  risk  than  when  the  o])eration 
was  repeated  many  times  successively,  and  the  bladder  in  the  meanwhile  left  full 


Full  Size. 


Fig.  439. — Bigelow's  Lithotrite. 


Fig.  440. — Thompson's  Lithotrite. 


of  sharp,  angular  fragments,  any  one  of  which  might   become   impacted  at  any 
moment. 

Lithotrites  for  large  calculi  must  be  cut  from  a  solid  bar  of  steel ;  those  for 
finishing  the  fragments  may  be  forged.  The  principle  is  the  same  in  all ;  a  male 
blade  gliding  on  a  female  one,  and  capable  of  being  screwed  down  into  it  with 
immense  force.     The  jaws  are  modified  according  to  the  kind  of  work  ;   in  the 


I048    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


larger  instruments  the  female  is  pierced  at  the  base,  so  that  it  cannot  become 
clogged  with  debris,  while  the  male  is  deeply  cut  into  sharp-edged  notches,  so 
that  the  calculus  may  not  slip ;  in  the  smaller  ones  both  are  solid  and  the  surfaces 
are  smoother.  The  male  is  narrower  than  the  female,  to  avoid  the  risk  of  catch- 
ing the  mucous  membrane.  In  one  of  the  latest  jjatterns  (Reli(|uet's)  the  teeth 
of  the  female  blade  are  directed  transversely  and  obli«iuely,  so  that  the  calculus 
cannot  slij)  toward  the  point  when  the  male  one  comes  clown  upon  it ;  and  the 
teeth  of  the  latter,  which  act  singly  upon  the  stone,  pass  through  the  fenestras  of 
the  female  so  as  even  to  project  beyond.  The  handle  varies  a  good  deal,  but  in 
all  it  is  so  contrived  that  while  the  male  blade  can  glide  up  and  down  freely  in 
the  female  for  the  purpose  of  seizing  the  calculus,  it  can  be  fixed  at  any  point  by 
simply  touching  a  catch,  and  then  can  only  be  moved  by  the  screw.  The  largest 
instruments,  the  end  of  which  is  prolonged  into  a  kind  of  beak,  are  about  the 
size  of  No.  28,  French  ;  the  smallest.  No.  15. 

The  other  instruments  required  are  a  set  of  steel  sounds,  highly  polished,  for 
the  purpose  of  dilating  the  urethra  ;  evacuators.  thin-walled  metal  tubes,  straight, 
or  curved  like  a  catheter,  varying  in  size  from  No.  15  or  18  to  32,  French,  each 
having  a  single  large  opening  at  or  near  the  end,  on  the  convexity  or  in  the  hollow 
of  the  bend,  so  as  to  suit  all  conditions,  and  an  india-rubber  aspirator  (Fig.  443) 
which  can  be  fitted  on  to  the  end  of  these  by  means  of  a  short  piece  of  flexible 
tubing.     Various  forms  have  been  devised  to  prevent  the  entry  of  air,  regulate  the 

flow  of  liquid,  and  trap  the  frag- 
ments as  they  are  sucked  out.  They 
are  all  filled  from  the  top  by  means 
of  a  funnel  closed  with  a  stop-cock  ; 
some  are  fitted  with  a  wire  valve, 
which,  however,  is  liable  to  become 
clogged  ;  in  others,  the  glass  receiver, 
which  should  always  be  below  the 
aspirator,  is  so  placed  that  the  frag- 
ments are  conducted  at  once  to  the 
bottom,  and  the  fluid  drawn  away 
from  the  top.  Perhaps  the  most 
convenient,  except  that  its  connec- 
tion with  the  tube  is  rigid,  is  the  one 
de.scribed  by  Bigelow  in  the  Lancet 
(January  6,  1883),  as  it  can  be  filled 
with  clean  water  without  discon- 
necting. 

The  rectum  should  be  emptied 
the  morning  of  the  operation  by 
means  of  an  enema,  and  the  patient 
placed  under  an  anaesthetic.  Cocaine  may  be  used  for  small  calculi  if  the  patient 
is  accustomed  to  the  use  of  instruments.  The  pelvis  should  be  slightly  raised, 
and  care  should  be  taken  that  the  chest  and  limbs  are  well  covered  u]),  as  the 
operation  may  last  a  considerable  time. 

A  steel  sound  is  passed  first  to  dilate  the  urethra  and  to  ascertain  its  size.  As 
a  rule,  an  evacuator  equal  to  No.  28  can  be  passed  without  diftnculty,  and  some- 
times even  No.  32,  though  it  may  be  necessary  to  slit  the  meatus  down  by  the 
side  of  the  fraenum. 

If  the  patient's  bladder  is  not  irritable  and  is  known  to  contain  a  certain 
amount  of  urine,  it  may  be  left :  but  in  most  cases  it  is  advisable  to  withdraw  the 
contents,  and  inject  four  or  five  ounces  of  a  warm  antiseptic  solution.  The 
choice  of  lithotrite  must  be  guided  by  the  size  and  composition  of  the  calculus. 
If  it  is  large  the  instrument  should  be  of  proportionate  strength  and  the  jaws 
deeply  cut,  the  female  being  fenestrated  ;  if  small  or  soft,  such  as  a  phosphatic 
concretion,  a  medium-sized  one  may  be  used  from   the  first.      If  a  sound  passes 


KiG.  441. — Operation  of  Lithotrity. 


LITJIOTRJIY. 


1049 


Fk;.  442. — Operation  of  Lithotrity. 


easily,    it   rarely  happens    that   there  is  any  difficulty   in    the    introduction  ;    tlie 

instrument  must  be  warmed  and  oilctl,  and  then  allowed  to  slip  tlown  by  its  own 

weight,  not  letting  it  pass  beyond 

the  perpendicular  until  the  beak  y 

has  glided  well  below  the  ])ul)es.  y 

There  are   two  methods   of 
seizing  the  calculus.     In  the  first 
the  closed   lithotrite   is  allowed 
to  rest  with  the  convexity  upon 
the  fundus  of  the  bladder,  and 
the  male  blade  withdrawn  (Fig. 
441)  ;  very  often,  on  |nishing  it 
down  again,  the  stone  is  grasped 
at  once,  or,  if  not,  is  felt  to  slip 
to  one  side  or  the  other,  so  that 
its   position  is  known.      In   the 
other,  the  handle  of  the  instru- 
ment is  depressed  until  the  beak 
occupies  the  centre  of  the  blad- 
der, the  blades  reversed,  and  the 
stone  picked  up  from  the  floor  (Fig.  442).     The  former  answers  for  the  first  crush- 
ing ;  the  other  is  the  better  when  the  prostate  is  enlarged,  and  when  fragments  have 
to  be  dealt  with.    The  instrument,  as  it  were, 
swings  on  a  pi\ot  formed  by  the  fixed   por- 
tion of  the  urethra  ;  if  it  is  steadily  held,  the 
fragments,  as  the  stone  is  crushed,  drop  ver- 
tically down,  and  can  be  picked  up  again 
one  by  one  with  the  minimum  of  manipu- 
lation. 

With  soft  phosphatic  concretions  the 
crushing  can  be  effected  by  the  hand  ;  in 
other  cases,  as  soon  as  the  stone  is  grasped, 
the  male  blade  is  fixed  with  the  catch,  the 
instrument  gently  brought  to  the  centre  of 
the  bladder  so  as  to  make  certain  that  the 
mucous  membrane  is  well  out  of  the  way, 
and  the  screw  driven  home  until  the  calculus 
yields.  If  the  fragments  are  large  they  may 
be  crushed  w'ith  the  same  lithotrite,  but  as 
soon  as  the  bigger  ones  are  disposed  of  a 
lighter  instrument  is  better.  Great  care 
must  be  taken  before  it  is  withdrawn,  that 
the  male  blade  is  well  home,  and  that  no 
debris  is  entangled  in  the  jaws.  Dragging 
out  fragments  of  the  calculus,  tearing  the 
mucous  membrane  of  the  urethra,  is  a  most  dangerous  proceeding.  A  smart  tap 
on  the  handle,  or  working  the  blade  backward  and  forward,  nearly  always  releases 
it.  If  possible,  before  the  second  lithotrite  is  removed,  the  calculus  should  be 
thoroughly  crushed,  so  as  to  reduce  the  number  of  occasions  on  w'hich  an  instru- 
ment is  passed  as  much  as  possible. 

The  evacuating  tube  should  be  the  largest  the  urethra  will  admit  without 
straining.  Curved  ones  pass  more  easily,  but  Bigelow  prefers  them  straight.  If 
the  fluid  from  the  bladder  does  not  at  once  rise  up  in  the  tube,  it  must  be  filled  with 
a  syringe,  so  that  no  air  can  enter ;  but  a  careful  record  must  be  kept  as  to  the 
quantity.  The  aspirator  introduces  from  one  to  three  ounces  more,  and  though 
the  total  wnll  not  nearly  fill  a  healthy  bladder,  it  is  quite  possible  to  tear  the  walls 
if  thev  are  thinned  and   softened   from  atrophy  or  fatty  degeneration.     On  the 

'  67 


Fig.  443. — Bigeluw's  Evacuator. 


I050    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

other  hand,  if  there  is  too  little  (and  occasionally  a  certain  amount  is  lost  when  the 
instruments  are  changed),  the  mucous  membrane  may  be  sucked  into  the  orifice 
of  the  tube  and  bruised.  The  injection  should  be  slow,  but  the  bulb  quickly 
released,  so  that  it  expands  rapidly,  and  the  end  of  the  tube  should  be  moved 
gently  about  the  fundus,  especially  if  there  is  a  posl-prostatic  pouch,  to  search  the 
fragments  out.  Sudden  stoppage  of  the  current  is  due  to  the  tube  being  accident- 
ally withdrawn  into  the  prostate,  to  the  bladder  becoming  empty,  or  to  the  im- 
paction of  a  large  fragment  in  the  eye.  This  can  be  recognized  by  the  sharp,  clear 
sound,  and  the  sensation  as  it  strikes  against  the  side  of  the  tube.  When  the  cal- 
culus is  large  it  is  often  necessary  to  withdraw  the  evacuator  after  some  has  been 
removed  and  re-introduce  the  lithotrite,  but  this  should  be  avoided  if  i)o.ssible. 

At  the  end  of  the  operation  the  bladder  should  be  washed  out  with  some  clear 
fluid  to  make  sure  that  no  fragment  is  left.  In  the  case  of  small  calculi  there  is 
no  bleeding,  but  with  large  ones  and  prolonged  manipulation,  esjjecially  where  the 
veins  are  much  dilated,  it  is  scarcely  possible  to  avoid  it  altogether.  It  is  espe- 
cially desirable  to  avoid  leaving  any  fragment  behind.  The  opprobrium  of  lithot- 
rity  is  that  the  relief  is  not  permanent — that  recurrence  takes  place  much  more 
frequently  than  after  lithotomy  ;  and  there  is  no  doubt  that  it  is  to  a  great  extent 
true.  Sometimes  the  reappearance  of  calculi,  as  in  the  case  of  phosphatic  con- 
cretions in  old  men  with  enlargement  of  the  i)rostate,  is  due  to  entirely  independ- 


Fk;.  444. — Evacuating  Tubes. 

ent  causes ;  but  it  must  be  admitted  that  occasionally  small  fragments  are  left 
(they  may  be  passed  subsequently  by  the  patient)  and  form  a  fresh  nucleus. 

After-treatment. — If  the  urine  is  acid  and  the  bladder  and  kidneys  sound, 
the  after-treatment  of  the  case  is  exceedingly  simple.  There  is  always  a  certain 
amount  of  irritation,  owing  to  the  prolonged  manipulation  ;  but,  as  the  cause  is 
removed,  this  soon  subsides.  The  patient  should  be  kept  in  bed  for  a  day  or 
two ;  a  hot  bath  may  be  given  at  night ;  the  diet  should  be  light  and  unstimulat- 
ing ;  and  if  there  is  much  pain  or  tenesmus,  or  if  retention  is  threatened,  a  few 
drops  of  a  solution  of  morphia  may  be  introduced  just  inside  the  neck  of  the 
bladder,  or  an  opium  suppository  placed  in  the  rectum.  Unfortunately,  when  the 
urine  is  alkaline  and  the  calculus  phosphatic,  and  still  more  when  the  kidneys  are 
diseased,  even  though  the  stone  is  softer  and  the  amount  of  manipulation  less, 
the  risk  of  complications  setting  in,  and  of  after-troubles,  is  very  much  increased. 

Serious  accidents  may  occur  during  the  performance  of  lithotrity,  without  its 
being  possible  to  allege  undue  violence.  Hemorrhage  is  rarely  of  consequence, 
but  in  a  few  cases  it  has  been  excessive,  probably  from  the  rupture  of  a  varicose 
vein  filling  the  bladder  with  clot,  and  placing  the  patient  in  danger  of  septic 
decomposition  and  cystitis.  The  male  blade  may  become  so  fixed  that  it  is  diffi- 
cult to  dislodge  the  fragment,  and  in  one  or  two  instances  it  has  been  necessary 
to  open  the  bladder  and  free  it  before  it  could  be  withdrawn.  Rupture  of  the 
bladder  into  the  peritoneal  cavity  has  occurred  ;  and  occasionally  the  urethra  and 
the  prostate  are  so  bruised  by  the  frequent  passage  and  manipulation  of  very  large 
instruments,  that  inflammation,  and  even  suppuration,  have  followed.     Impaction 


LITIIOTRITY. 


1051 


of  a  fragment  at  the  neck  of  the  bladder,  which  used  to  be  not  uncommon,  is 
scarcely  ever  met  with  under  the  present  system. 

Complications. — Lithotrity,  like  all  other  operations  on  the  urinary  organs, 
may  be  followed  by  consequences,  some  reflex,  others  inflammatory. 

(</)  Reflex. — The  s]iock  may  be  general  and  prove  fatal,  even  when  the  kid- 
neys are  sound  ;  or  it  may  affect  the  vasomotor  nerves  of  the  kidneys,  causing 
pariial  or  com/^lete  suppression  o{  urine  ;  or  the  muscular  wall  of  the  bladder  {afony). 
This  last  is  especially  fre([uent  in  the  case  of  old  men  with  enlargement  of  the 
prostate,  in  whom  a  certain  amount  of  difficulty  exists  already.  In  addition 
rigors  may  occur,  and  urethral  fever  may  set  in  acutely,  or,  more  often,  insidi- 
ously, associated  with  partial  suppression,  and  ending  in  prostration  and  delirium. 

(/')  Itiflammatory. — Cystitis  is  the  most  common.  In  many  cases  it  exists 
already,  but  if  it  is  recent,  and  the  stone  the  only  cause,  it  soon  subsides.  When 
the  walls  of  the  bladder  are  rough  and  irregular,  covered  with  sacculi,  and  lined 
with  a  thickened  or  ulcerated  mucous  membrane — such  a  condition  as  commonly 
occurs  in  old  cases  of  cystitis  associated  with  enlarged  prostate — the  risk  is  very 
different.  If  decomposition  of  the  urine  sets  in,  the  inflammation  at  once  be- 
comes intense  ;  the  mixture  of  mucus  and  blood  with  ammoniacal  urine,  kept  at 
the  temperature  of  the  body,  becomes  offensive  to  the  last  degree  ;  and  unless  free 
exit  is  given  at  once,  either  the  patient  dies  of  septic  absorption  from  the  putrid 
mass,  or  the  inflammation  spreads  to  the  ureters  and  ends  in  acute  pyelonephritis. 

Inflammation  may  also  occur  in  or  around  the  prostate  dsvdi  at  the  neck  of  the 
bladder,  especially  after  the  'use  of  large  tubes ;  epididyinitis  is  not  uncommon  ; 
peritonitis  may  be  caused  by  direct  extension  ;  and,  particularly  when  the  large 
plexuses  at  the  neck  are  bruised  and  injured,  phlebitis  may  occur,  and  lead  either 
to  the  thrombosis  of  the  veins  of  the  extremities  or  to  general /^'^^«/a. 

In  all  cases  of  chronic  cystitis  there  is  great  risk  of  recurrence  ;  possibly 
minute  fragments  of  the  original  calculus  are  left  embedded  in  the  mucus  ;  possibly 
fresh  concretions  are  formed  from  the  accumulation  of  phosphates  on  the  walls ; 
and  in  all  such  cases  crushing  often  has  to  be  repeated  at  intervals  of  a  i^w  years. 

There  are  certain  conditions  in  which  the  difficulty  of  performing  lithotrity 
is  so  great,  or  the  after-consequences  so  serious,  that  it  is  advisable  to  select  some 
other  method. 

1.  Age. — It  has  been  shown  by  Keegan  and  others  that  lithotrity  may  be  per- 
formed with  perfect  safety  in  children  only  three  and  four  years  old.  The  meatus 
is  almost  uniformly  too  small,  but  the  urethra  will  usually  admit  a  No.  13  French 
lithotrite  and  evacuating  tube,  and  with  this  it  is  possible  in  a  reasonable  time  to 
remove  a  uric  acid  or  oxalate  calculus  of  moderate  size.  In  other  respects,  the 
small  size  of  the  prostate,  for  example,  the  healthy  tone  and  condition  of  the  walls 
of  the  bladder,  and  the  state  of  the  kidneys,  children  form  exceptionally  good 
subjects. 

2.  Stricture. — In  ordinary  cases  this  can  be  dilated  or  incised  first ;  but  where 
there  is  a  large  amount  of  inflammatory  exudation,  forming  a  den.se  mass  in  the 
perineum,  suppuration  with  urinary  abscess  is  not  unlikely. 

3.  Enlargement  of  the  prostate,  without  atony  or  cystitis,  is  of  little  conse- 
quence ;  the  only  difficulty  is  that  of  picking  up  the  stone  and  the  fragments  from 
the  pouch  that  forms  behind  ;  sometimes  this  can  be  facilitated  by  moderate  dis- 
tention of  the  rectum. 

4.  Similarly,  atony  of  the  bladder,  without  cystitis,  does  not  preclude  crushing, 
so  long  as  the  condition  is  recognized.  The  danger  is  that  it  sometimes  occurs 
unexpectedly,  and  that  a  quantity  of  fluid  in  a  state  of  putrefaction  is  left  stagnant 
in  the  bladder. 

5.  Cystitis. — Where  it  is  slight,  caused  by  the  calculus  itself,  and  there  is  no 
permanent  change  in  the  wall,  cystitis  is  not  serious.  On  the  other  hand,  if  the 
urine  is  ammoniacal  and  deposits  large  quantities  of  ropy  mucus ;  if  the  walls  are 
fasciculated,  and  the  lining  membrane  softened  and  coated  over  with  a  mixture 
of  mucus  and  phosphates,  the  question  becomes  grave.    Such  a  condition  is.always 


1 052    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

associated  with  disease  of  the  kidneys,  and  if  serious  consequences  do  not  arise 
from  this,  the  inflammation  about  the  bladder  is  ahuost  sure  to  be  made  worse,  and 
perhaps  become  diffuse  ;  suppuration  may  occur  around  the  prostate  ;  or  peritonitis 
set  in,  especially  if  there  are  sacculi  ;  or  the  inflammation  may  extend  up  the 
ureters  and  cause  acute  septic  pyelonephritis. 

6.  The  Condition  of  the  Kidneys. — When  they  are  diseased,  any  operation 
about  the  urinary  tract  is  liable  to  be  followed  by  partial  or  complete  su]>pression 
of  urine,  urinary  fever,  or  diffuse  inflammation  and  even  sloughing  ;  and  there  is 
no  doubt  that  lithotrity  is  esjjecially  exposed  to  these  dangers  ;  the  only  j)oint  is 
whether,  in  this  respect,  it  is  in  any  degree  worse  than  lithotomy. 

7.  Lithotrity  may  be  impossible  owing  to  the  size  and  hardness  of  the  stone. 
Calculi  of  over  three  ounces  in  weight  have  been  removed  by  crushing,  the  sitting 
lasting  as  long  as  four  hours  ;  but,  as  a  rule,  if  composed  of  unmixed  oxalate  of 
lime,  it  is  very  difficult  to  crush  one  that  measures  an  inch  in  diameter.  The  same 
thing  may  happen  from  the  position  of  the  stone.  A  calculus  lying  in  a  sacculus, 
or  embedded  in  a  cavity  it  has  worked  out  for  itself,  often  cannot  be  crushed.  It 
is  true  that  no  operation  can  boast  of  much  success  under  such  conditions,  but 
lithotrity  is  especially  bad  ;  the  wall  of  the  cyst  is  exceedingly  thin  ;  as  the  cavity 
cannot  be  emptied,  it  is  left  full  of  the  debris  ;  septic  cystitis  is  almost  certain  to 
follow,  and  peritonitis  or  even  sloughing  of  the  wall  may  occur. 

When  the  calculus  is  tightly  grasped,  so  that  it  cannot  be  dislodged  without 
using  excessive  force,  if  the  patient  is  an  old  man  it  is  better  to  leave  it  alone. 

Lithotomy. 

The  bladder  may  be  approached  either  through  the  perineum  or  above  the 
pubes.  In  exceptional  cases  calculi  have  been  removed  through  the  vagina  and 
the  rectum.  The  patient  should  be  prepared  in  the  same  way  as  for  lithotrity — a 
purgative  given  the  day  before  and  an  enema  the  morning  of  the  operation. 


Perineal  Lithotomy. 

Lateral  Lithotomx. — The  deep  incision  carried  through  the  membranous  and 
prostatic  portions  of  the  urethra  into  the  left  lobe  of  the  prostate.  The  instru- 
ments required  are  a  sound  ;  a  grooved  staff,  either  straight  or  curved  ;  lithotomy 

tapes,  anklets,  or  Clover's  crutch 
for  fastening  up  the  jjatient ;  a 
lithotomy  knife,  or  broad-bladed, 
straight-backed  scalpel  ;  various 
kinds  of  forceps  and  a  scoop.  A 
catheter  and  a  syringe  for  inject- 
ing the  bladder,  or  washing  it  out 
after  the  operation  ;  a  blunt-pointed 
gorget,  when  the  perineum  is  too 
deep,  or  the  prostrate  too  large  for 
the  finger  to  enter  the  bladder  ; 
and  a  petticoated  tube,  or  india-rub- 
ber tampon,  in  case  of  deep  hemor- 
rhage, may  be  required  as  well. 
The  table  should  be  narrow  and  of  a  convenient  height,  so  that  the  operator 
has  not  to  raise  his  hands  too  much.  If  Clover's  crutch  is  used,  the  anklets  and 
the  strap  may  be  placed  in  position  while  the  anaesthetic  is  being  given.  It  con- 
sists of  a  metal  bar  tp  place  between  the  legs,  with  a  semicircular  padded  crutch 
at  either  end.  The  legs  are  flexed  upon  the  thighs  ;  the  bar.  which  is  provided  with 
a  sliding  rod  fixed  by  means  of  a  screw  at  any  required  length,  i)laced  between 
them  ;  and  the  anklets  fastened  round  the  limbs,  immediately  below  the  knee. 
The  thighs  are  bent  upon  the  abdomen  ;  a  soft  leather  strap  passed  behind  the 


Key's  Knife. 


Straight  Probe-pointed  Knife. 
Fig.  445. — Lithotomy  Knives. 


LITHOTOMY. 


'053 


shoulders,  and  the  free  ends  buckled  to  the  crutches,  so  that  when  it  is  tightened 
up  the  limbs  are  absolutely  fixed.  Then  the  knees  are  separated  to  any  extent  by 
the  sliding  rod.  If  bandages  or  tapes  are  used,  the  i)atient's  hands  must  be  made 
to  grasj)  the  soles  of  the  feet,  the  bandage  being  fixed  first  by  a  clove-hitch  round 
the  wrist,  and  carried  round 
hand  and  foot  together  in  a 
figure-of-eight. 

The  staff  may  be  intro- 
duced either  before  or  after 
the  patient  is  tied.  The  for- 
mer is  the  easier,  but  care 
must  be  taken  in  moving  the 
limbs  that  the  point  is  not 
driven  through  the  wall.  It 
is  absolutely  essential  that  the 
stone  should  be  felt  with  it 
before  the  operation  is  com- 
menced, and  it  is  a  wi.se  pre- 
caution for  one  of  the  assist- 
ants to  feel  it  as  well.  If  the 
patient  has  not  passed  water 
recently,  and  the  bladder 
appears  to  contain  sufficient, 
there  is  no  need  to  pass  a 
catheter  ;  but  when  there  is 
any  doubt  it  is  as  well  to 
empty  it. and  replace  the  urine 
by  six  or  eight  ounces  of  some 
warm  antiseptic  fluid. 


Fig.  446. — Clover's  Crutch. 


The  patient  is  brought  to  the  edge  of  the  table,  so  that  the  nates  project 
slightly  over  it,  the  limbs  fixed  in  position,  the  perineum  shaved,  and  the  staff  given 
to  a  third  assistant  to  hold.  If  it  is  a  curved  one,  it  should  at  first  be  slanted  a 
little  toward  the  abdomen,  and  gently  pressed  down  in  the  perineum,  to  bring  the 


lergusson's  Staff. 


Fig.  447- 

membranous  portion  of  the  urethra  toward  the  surface  ;  as  soon  as  the  groove  is 
felt,  it  should  be  raised  to  a  vertical  position,  and  pulled  well  up  under  the  pubes 
for  the  deep  incisions.  The  shaft  should  be  grasped  firmly  with  the  fingers,  and 
the  ball  of  the  thumb  pressed  against  the  flat  part  of  the  handle.  If  the  staff  is 
straight,  it  is  held  well  up  with  the  handle  pointing  slightly  toward  the  operator, 
until  he  takes  it  himself. 

Before  beginning,  the  forefinger  is  introduced  into  the  rectum  to  feel  the 


I054    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


prostate,  to  make  sure  the  rectum  is  empty  and  the  staff  in  its  proper  jjlace,  and 
stimulate  the  gut  to  contract  out  of  the  way.  Then,  steadying  the  skin  with  the 
left  hand,  an  incision  is  made  from  a  point  midway  between  the  scrotum  and  the 

anus,  commencing  close  to,  but  not  at, 
the  middle  line,  downward  and  out- 
ward for  about  three  inches  (in  an 
adult)  to  a  point  nearer  the  ischial  tub- 
erosity than  the  anus.  This  divides 
skin,  superficial  fascia,  subcutaneous 
fat,  external  hemorrhoidal  vessels 
(which  may  bleed  freely  for  a  moment), 
and  perhaps  the  superficial  {perineal 
vessels  and  nerves.  The  incision  is 
then  deepened  by  dividing  the  trans- 
versus  perinei  muscle,  with  the  artery 
upon  it  and  the  lower  border  of  the 
triangular  ligament,  the  forefinger 
guarding  the  rectum  in  the  wound. 
The  bulb  should  not  be  touched, 
though  the  fibres  of  the  accelerator 
urinae  may  be  exposed  and  even 
divided. 
The  finger  is  then  pressed  into  the  upper  angle  of  the  wound,  to  feel  for  the 
staff,  and  the  knife  passed  along  it  until  the  point  is  lodged  in  the  groove.  The 
staff  is  then  raised  to  the  vertical  position  and  hooked  well  uj)  ;  and  the  knife, 
with  the  edge  turned  toward  the  tuberosity,  is  carried  forward  in  the  groove  until 
it  is  stopped  at  the  end,  dividing  as  it  goes  the  compressor  urethrre  and  the  mem- 
branous portion  of  the  urethra,  the  deep  layer  of  the  triangular  ligament,  the  left 
lobe  of  the  prostate,  some  of  the  fibres  of  the  levator  prostatae,  and  the  ring  at  the 
neck   of  the  bladder  ;  the  incision,  of  course,  not  being  deej^er  than  the  blade. 


Fig.   448. — The  Incision  for  Lateral  Lithotomy. 


Fig.  449. — Lithotomy  with  the  Curved  Staff. 


It  is  then  withdrawn,  the  edge  still  i)ointing  toward  the  right,  so  that  it  faces  the 
longest  diameter  of  the  prostate,  and  as  it  comes,  being  gently  drawn  downward 
and  outward,  to  enlarge  the  incision  on  the  under  surface  of  the  gland.  The 
fibrous  ring  at  the  neck  of  the  bladder  is  notched  so  that  it  yields  readily  ;  in 
doing  this  the  plexus  of  veins  may  be  laid  open,  and  in  old  people  they  are  not 
unlikely  to  bleed  profusely ;  but,  if  the  cut  is  not  deeper  than  this,  there  is  no  fear 
of  infiltration  of  urine. 

If  the  incision  is  too  small,  the  tissues  are  so  bruised  in  the  process  of  extrac- 


LITHOTOMY. 


1055 


tion  that  diffuse  inflammation  is  very  likely  to  follow.  If  it  is  too  large,  passing 
through  the  jjlexus  into  the  recto-vesical  fascia  and  dividing  the  lateral  true  liga- 
ment of  the  l)ladder,  urine  is  almost  certain  to  be  extravasated  into  the  deep 
cellular  tissue.  The  staff  must  be  held  well  up  against  the  j^ubes,  the  ])oint  of  the 
knife  not  allowed  to  leave  the  groove,  and  the  blade  ke})t  in  a  line  with  the  staff, 
except  in  withdrawing  it  quite  at  the  end.      If  this  is  carried  out,  it  is  almost  im- 


FiG.  450. — Lateral  Lithotomv  with  Key's   Straight  Staff. 

possible  to  wound  the  floor  of  the  bladder,  and  the  incision  is  sufficiently  large  to 
admit  the  finger  with  a  little  gentle  pressure.  When  the  calculus  is  left,  if  it  is 
thought  that  there  is  not  sufficient  space,  it  is  easy  to  divide  anything  that  resists 
with  a  probe-pointed  bistoury. 

With  a  straight  staff  the  process  is  slightly  different  ;  the  preliminary  stejis  are 
the  same,  but  as  soon  as  the  point  of  the  knife  is  placed  well  in  the  groove,  the 


Fig.  451. — Blunt  Gorget. 


operator  takes  the  staff  himself  with  the  left  hand,  lowers  it  until  it  is  nearly  hori- 
zontal, holding  the  point  of  the  knife  meanwhile  quite  still,  and  then,  turning  staff 
and  knife  together  on  their  long  axis,  so  that  the  latter  is  in  the  proper  plane, 
pushes  it  on  until  the  resistance  of  the  prostate  is  no  longer  felt.  The  extent  to 
which  the  gland  is  divided  depends  upon  the  angle  formed  by  the  knife  with  the 
staff.      With  a  straight  instrument  used  in  this  wav  as  a  director,  it  is  much  more 


Fig.  452. — Lithotomy  Forceps. 

easy  to  keep  the  knife  in  the  groove  and  to  make  an  incision  sufficiently  free  with- 
out being  too  wide. 

As  soon  as  the  knife  is  withdrawn  the  finger  is  gently  worked  down  the  groove 
without  using  force,  dilating  the  tissues  until  it  enters  the  bladder  and  feels  the 
calculus.  Then,  and  as  a  rule  not  till  then,  the  staff  may  be  removed.  In  the 
case  of  very  deep  perineum  or  very  large  prostate,  where  the  finger  is  too  short  to 
reach  the  bladder,  a  blunt  gorget  may  be  passed  along  the  groove  to  open  up 


1056    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  route  for  the  forceps  ;  or  a  director  may  be  used  to  keep  the  line  of  the  urethra 
and  act  as  a  guide  after  the  staff  has  been  withdrawn.  As  soon  as  the  finger  feels 
the  stone,  a  suitable  pair  of  forcei)S,  warmed,  must  be  guided  through  the  wound 
into  the  bladder,  and  the  blades  gently  separated.  Withdrawing  the  finger  is 
followed  by  a  gush  of  urine  which  may  carry  the  calculus  at  once  into  the  grasp 
of  the  forceps,  or  a  slight  movement  of  the  blades  may  enable  it  to  be  seized  ;  but 
often  this  is  the  most  difficult  part  of  the  operation.  The  blades  should  be  oi>ened 
laterally,  and  the  lower  one  made  to  sweep  along  the  floor  ;  if  this  fails,  the  stone 
may  be  caught  behind  the  prostate  or  above  the  pubes,  and  the  forceps  mu.st  be 
withdrawn  to  the  neck,  and  the  handles  raised  or  lowered.  Sometimes  the  diffi- 
culty arises  from  the  size  of  the  calculus  or  from  its  sha|je,  and  it  may  be  neces- 
sary to  remove  the  forceps  and  introduce  a  larger  pair,  or  to  manipulate  the  stone 
with  the  finger  so  that  it  may  be  caught  in  another  diameter.  If  it  breaks  up,  it 
must  be  extracted  with  the  finger  and  a  scoop,  washing  the  bladder  out  afterward 
to  remove  the  debris.  Everything  must  be  done  .slowly,  gently,  and  methodi- 
cally ;  the  direction  of  the  forceps  must  be  in  the  axis  of  the  pelvis  ;  the  traction 
must  be  straight,  without  rotation  ;  if  there  is  much  resistance,  the  tissues  in  front 
of  the  stone  must  be  felt  with  the  finger ;  sometimes  they  can  be  gently  pushed 
off  it  ;  or  they  may  be  notched  with  a  scalpel  ;  or  if  the  obstruction  can  be  felt  all 
round,  and  it  is  clear  that  the  incision  is  too  small,  the  forceps  may  be  removed, 
the  stone  allowed  to  drop  back,  and  the  tissues  that  resist  divided,  as  far  as  is 
prudent,  with  a  probe-pointed  bistoury,  using  the  finger  as  a  guide.  By  this  means, 
in  an  adult,  a  stone  an  inch  and  a  half  in  diameter  maybe  removed  without  divid- 
ing the  lateral  ligaments  and  without  too  much  bruising;  one  two  inches  across 
may  possibly  be  extracted  by  drawing  it  well  down  and  carefully  dividing  the 
tissues  that  resist,  or  incising  the  other  side  of  the  prostate  ;  but  in  such  a  case  it 


K.  A.  YaRNALL  Co.,  Vhila. 
Fig.  453. — Liihotoiny  Scoop  and  Director. 


is  better  either  to  perform  the  suprapubic  of^eration,  or  to  crush  the  calculus  first 
and  then  extract  the  fragments.  Under  no  conditions  may  the  incision  be  made 
first,  and  then  the  stone  broken  up  by  instruments  introduced  through  the  wound. 
The  fracture  of  a  calculus,  even  when  held  in  the  forceps,  adds  mat-erially  to  the 
risk,  owing  to  the  necessity  of  washing  out  the  bladder  to  get  rid  of  the  fragments. 

The  last  step  in  the  operation  is  to  explore  the  bladder  with  the  finger,  to 
make  sure  there  is  no  other  calculus  present. 

Unless  hemorrhage  is  feared,  there  is  no  need  to  leave  a  tube  in  the  wound. 
If  the  bladder  and  kidneys  are  sound,  it  is  quite  possible,  especially  in  children, 
to  secure  union  by  the  first  intention,  which  this,  of  course,  would  prevent.  As 
a  rule,  the  urine  flows  away  through  the  opening  for  the  first  two  days,  and  then, 
owing  to  the  swelling  about  the  prostate,  some,  and  occasionally  all,  comes  by  the 
urethra.  If  suppuration  begins  it  pours  out  of  the  wound,  the  amount  gradually 
diminishing  as  healing  jjrogresses.  The  patient  should  be  jilaced  in  bed,  on  his 
back,  on  a  divided  mattre.ss  protected  by  a  waterproof.  The  hips  and  knees  should 
be  bent  and  the  legs  supported  by  pillows.  Dry  sponges  wrung  out  of  carbolic 
solution  and  frequently  changed,  or  wood-wool,  may  be  used  to  absorb  the  urine 
and  the  discharges  of  the  wound.  Every  endeavor  must  be  made  to  keep  the  skin 
dry  and  to  prevent  excoriations;  especially  in  old  people,  and  where  the  urine  is 
ammoniacal,  this  sometimes  gives  a  great  deal  of  trouble.  Occasionally  the  wound 
becomes  coated  over  with  phosphates,  and  it  may  recjuire  to  be  washed  out. 

The  diet  should  be  simple  but  good.  The  question  of  stimulants  must  be 
determined  by  the  habits  of  the  patient  and  the  condition  of  the  pulse.  The 
bowels  may  be  opened  on  the  third  or  fourth  day  by  a  gentle  aperient,  aided  by  an 
enema  ;  and  as  soon  as  the  wound  is  closing  and  there  is  no  further  risk  of  hem- 
orrhage, the  patient  should  be  allowed  to  sit  up. 


LITHOTOMY. 


1057 


ACCIDKNIS. 

1.  //(-/norr/mi^i-. —  The  transverse  perineal  and  external  hemorrhoidal  arteries 
are  rarely  of  consecinence  ;  if  they  continue  bleeding,  pressure  forceps  may  be 
placed  upon  them  until  the  end  of  the  operation.  The  artery  to  the  bulb  may  be 
wounded  either  from  its  taking  an  abnormal  course,  or  from  the  incision  being 
commenced  too  far  forward,  but  it  seldom  causes  any  difficulty.  Sometimes  the 
bulb  itself  is  injured  in  the  same  way.  Profuse  arterial  hemorrhage  occasionally 
comes  from  some  deep-seated  trunk,  possibly  the  internal  pudic,  though  this  is 
very  well  guarded  under  the  lip  of  the  tuberosity  ;  if  the  vessel  cannot  be  found 
and  tied,  forcipressure,  acupressure,  or  even  digital  compression  by  relays  of 
dressers,  must  be  kept  uj)  for  twenty-four  hours. 

Venous  hemorrhage  may  be  i)rofuse  at  the  time,  or  may  come  on  later,  and 
the  blood  may  collect  in  the  bladder  and  distend  it  before  the  occurrence  is 
known.  The  coagula  must  be  washed  out,  the  bleeding  checked  by  cold  and  ex- 
posure to  air  ;  and  if  this  does  not  succeed,  or  if  it  recurs  after  a  few  hours,  the 
wound  must  be  plugged.  The  best  instrument  for  this  purpose  is  Buckston 
Browne's  dilatable  tampon — a  central  tube,  so  that  the  urine  has  free  exit,  sur- 
rounded with  a  soft  india-rubber  sac  which  can  be  introduced  when  collapsed,  and 
distended  with  air  or  water.  A  fle.xible  tube  should  be  attached,  to  conduct  the 
urine  at  once  to  a  vessel  beneath  the  bed  ;  but  it  must  be  recollected  that  plugging 
the  wound  assists  absorption  from  the  surface  and  exerts  very  injurious  pressure 
upon  the  soft  tissues. 

2.  Wound  of  the  rectum  may 
occur,  especially  in  old  people,  in 
whom  the  lower  end  is  often  much 
dilated.  It  may  be  cut,  owing  to 
the  knife  not  being  sufficiently 
turned  to  one  side,  or  it  may 
slough  from  bruising.  Generally 
the  opening  closes  of  itself,  but  it 
may  leave  a  fistula. 

3.  The  postej'ior  tvall  of  the 
bladder  has  been  punctured  by  the 
staff  and  by  the  knife  leaving  the 
groove  and  being  carried  in  too 
far ;    and    the    urethra    has    been 

missed  altogether,  the  knife  passing  by  the  side  of  it  or  behind  it,  and  entering 
the  bladder  through  the  floor,  or  even  behind  the  prostate. 

4.  Tearing  the  urethra  across  may  occur  in  children.  It  arises  from  the 
deep  incision  being  too  small.  The  tissues  are  very  delicate  and  easily  give  way  ; 
the  bladder  lies  higher  and  is  less  flexed  than  it  is  later  in  life,  and  if  an  attempt 
is  made  to  force  the  finger  down  the  urethra,  it  is  very  easy  to  tear  it  across  and 
push  everything  onward  until  a  cavity  that  feels  like  the  bladder  is  formed  in  the 
tissues  at  the  neck.  In  some  of  these  cases  the  deception  has  been  increased  by 
the  stone  being  felt  through  the  wall.  If  the  accident  is  recognized  in  time,  the 
finger  should  be  withdrawn,  and  the  knife  carefully  pushed  along  the  groove  until 
the  bladder  is  really  opened  ;  but  if  the  bladder  is  pushed  off  the  staff  so  far  that 
it  cannot  be  brought  down  again,  either  the  operation  must  be  abandoned,  or,  as 
this  is  practically  fatal,  the  suprapubic  operation  must  be  performed,  the  stone  ex- 
tracted, and  a  catheter  passed  through  the  orifice  of  the  urethra  from  the  interior 
into  the  perineal  wound. 

To  avoid  this  Heath  recommends  that,  instead  of  trying  to  pass  the  finger 
along  the  staff,  a  director  should  be  introduced  into  the  bladder  first,  the  staff 
withdrawn,  and  the  finger  then  gently  worked  along  the  upper  surface  of  the 
director.  In  other  cases  a  pair  of  polypus  forceps  may  be  introduced  to  dilate  the 
urethra  ;  but  whatever  plan  is  adopted,  if  there  is  much  resistance,  it  is  wiser  to 
remove  the  finger  and  enlarge  the  incision. 


Fig.   454. — Buckston  Browne's  Dilatable  Tampon. 


1058     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


The  prognosis  in  lateral  lithotomy  depends  upon:  — 

1.  Ai^e. — In  children  it  is  wonderfully  successful,  a  series  of  seventy  and 
eighty  cases  without  a  death  having  been  published.  As  years  advance  it  becomes 
steadily  more  and  more  fatal. 

2.  The  Size  of  the  Calculus. — Up  to  an  inch  in  diameter  this  is  not  material  ; 
over  this,  the  mortality  increases  rapidly,  and  in  very  large  calculi  the  operation  is 
exceedingly  dangerous. 

3.  The  State  of  the  Kidneys. —  This  is  the  most  important  of  the  three.  Most 
of  the  fatal  cases  may  be  traced  to  urinary  fever  with  suppression,  or  to  diffuse 
inflammation  and  exliaustion,  consequent  on  renal  disease. 

Causes  of  Death. — i.  Septicemia. — All  the  structures  around  the  wound 
are  torn  and  crushed  ;  there  is  a  certain  amount  of  decomposing  urine,  and  the 
tissues,  if  the  kidneys  are  diseased,  break  down  and  slough  at  once.  It  generally 
begins  about  the  second  or  third  day  ;  there  may  be  a  rigor  with  high  fever,  acute 
cellulitis,  and  distention  of  the  abdomen  ;  or  the  beginning  may  be  insidious  with 
little  or  no  pain,  but  with  dryness  of  the  mouth  and  tongue,  hiccough,  and  extreme 
prostration.  It  is  nearly  always  fatal,  but  recovery  with  the  formation  of  pelvic 
abscesses  has  been  known. 

2.  Urinary  fever  may  be  acute  and  fatal  within  forty-eight  hours  from  sup- 
pression of  urine  ;  more  often  it  is  chronic,  and  a.ssociated  in  such  a  way  with 
septicaemia  that  it  is  impossible  to  assign  to  each  its  share.      It  rarely  occurs  when 

the  kidneys  are  sound,  but  it  is  a  common  cause  of 
death  where  they  are  only  just  able  to  hold  their 
own,  as  in  old  cases  of  calculous  disease  and  chronic 
cystitis.  Suppurative  pyelonephritis  sets  in  from 
extension  of  the  inflammation  up  the  ureters  ; 
multiple  abscesses  form  in  the  cortex;  the  secretion 
of  urine  becomes  still  further  diminished,  and  the 
patient  dies  with  symptoms  of  low  fever  and 
prostration. 

3.  Extravasation  of  urine  into  the  celhilar 
tissue  at  the  base  of  the  bladder,  owing  to  the  neck 
having  been  laid  open  and  the  recto-vesical  fascia 
divided.  Brodie  saved  one  case  in  which  this  had 
occurred  by  laying  the  whole  perineum  open  into 
the  rectum.  Usually  it  is  fatal  within  the  first  few 
days  from  acute  peritonitis. 

4.  Hemorrhage,  not  so  much  from  the  loss  of 
blood  at  the  time  as  from  the  weakened  state  in 
which  the  patient  is  left. 

5.  Phlebitis  and pyeemia. 

6.  Peritonitis  from  wound  of  the  posterior  wall 
of  the  bladder,  sloughing  of  a  sacculus,  or  extension 
from  the  cellular  tissue. 

7.  Shock  and  exhaustion. 
I)ifticulties    may   arise    in    lateral    lithotomy, 

either  from  anatomical  causes,  or  from  the  size, 
position,  and  shape  of  the  calculus.  The  former 
include  false  passages  in  the  urethra,  enlargement  of 
the  prostate,  unusual  depth  of  perineum,  contrac- 
tion of  the  pelvis  from  rickets,  and  such  occasional 
obstacles  as  tumors  growing  from  the  bones,  and 
ankylosis  of  the  hip  joint.  These  may  usually  be 
overcome  by  the  exercise  of  a  certain  amount  of 
ingenuity.  The  size  and  shai)e  of  the  stone  may, 
however,  be  such  as  to  render  the  operation  imprac- 
ticable. It  is  difficult  to  say  what  size  of  stone  has 
not  been  removed  through  a  lateral  incision  ;   but  at 


a 


LITHOTOMY.  1059 

the  present  time  no  one  would  willingly  attempt  the  extraction  of  one  two  inches 
in  diameter,  and  it  is  better  to  ado|)t  other  methods  for  all  over  an  inch.  The 
position  of  the  stone  is  scarcely  less  important.  When  it  is  deeply  imbedded  in  a 
sac  that  it  has  worn  for  itself,  it  may  be  dislodged  either  by  the  finger  in  the  rectum, 
or  by  inserting  the  nail  beneath  it,  and  gradually  working  it  out,  or  even  by  very 
carefully  notching  the  edges  of  the  sphincter-like  ring  that  holds  it  fixed  ;  and  this, 
it  must  be  admitted,  cannot  be  done  by  lithotrity  ;  but  when  the  stone  is  lying  in 
a  large  thin-walled  sacculus,  the  orifice  of  which  is  at  some  distance  from  the  neck, 
and  very  likely  is  only  sufficiently  large  to  admit  a  quill  pen,  it  cannot  be  removed. 
If  a  small  tube  can  be  introduced  through  the  perineal  wound,  some  relief  may 
be  obtained  by  draining  the  sacculus,  but  there  is  no  means  of  extracting  the 
stone. 

Median  Lithotomy. — In  this  the  deep  incision  extends  only  through  the  mem- 
branous portion  of  the  urethra  and  the  apex  of  the  i)rostate. 

The  patient  is  prepared  for  operation  in  the  same  way,  and  placed  in  the  same 
position,  but  the  staff  used  is  rectangular,  so  as  to  bring  the  apex  of  the  prostate 
as  near  the  surface  as  possible.  The  forefinger  of  the  left  hand  is  placed  in  the 
rectum,  and  either  an  incision  made  in  the  middle  line,  or  a  straight-backed  bis- 
toury, with  the  edge  toward  the  pubes,  pushed  at  once  through  the  perineum  to 
the  angle  of  the  staff.  Whichever  plan  is  adopted,  the  incision  must  be  exactly 
median,  commencing  below  the  bulb,  stopping  short  of  the  rectum,  and  laying 
open  the  membranous  part  of  the  urethra  and  the  commencement  of  the  prostatic. 
A  director  is  then  passed  along  the  groove  into  the  bladder,  the  staff  withdrawn, 
and  the  forefinger  insinuated  along  the  urethra,  following  the  upper  surface, 
because  the  roof  is  more  firmly  fixed  than  the  floor,  and  there  is  less  danger  of 
tearing  it  across.  In  this  way  the  prostate  is  gradually  dilated,  until  the  finger 
gains  the  interior  of  the  bladder.  There  is  a  certain  amount  of  bruising,  and  pos- 
sibly rupture  of  the  gland  tissue  and  muscular  fibre  beneath  the  mucous  membrane  ; 
but,  so  far  as  the  adult  is  concerned,  there  is  no  extensive  laceration  (a  similar 
operation  is  often  performed  merely  for  exploration),  and  rupture  of  the  capsule 
or  of  the  recto-vesical  fascia  is  impossible.  The  operation  is  then  completed  in 
the  ordinary  manner. 

Comparison  of  Lateral  and  Median  Lithotomy. 

The  chief  advantages  possessed  by  the  median  are — 

{a)  Less  risk  of  hemorrhage.  Abnormal  arteries  cannot  be  divided,  and  the 
prostatic  plexus  is  not  opened. 

{J})  It  is  impossible  to  injure  the  recto-vesical  fascia.  In  the  lateral  operation 
the  knife  runs  along  the  groove  of  the  staff,  cutting  the  prostate  and  the  neck  of  the 
bladder  ;  so  long  as  the  incision  is  only  the  depth  of  the  blade,  which  is  quite 
sufficient  to  allow  the  finger  to  pass  into  the  bladder  without  forcing  it  in  the  least, 
the  lateral  true  ligaments  and  the  pelvic  cellular  tissue  are  entirely  out  of  danger  ; 
but  if  the  knife  is  not  kept  parallel  to  the  staff,  especially  when  the  deepest  part  of 
the  incision  is  being  made,  or  if  the  surgeon  allows  his  hand  to  drop  too  much,  it 
is  very  easy  to  carry  the  incision  right  through  the  gland  and  the  prostatic  plexus. 
In  the  median  operation  this  is  impossible  ;  the  incision  goes  no  further  than  the 
apex  of  the  prostate,  and  the  finger  cannot  tear  the  fascia. 

{/)  After  the  operation  the  urine  very  soon  ceases  to  flow  out  of  the  wound, 
and  the  patient  is  saved  much  discomfort. 

The  disadvantages  are — 

{a)  Want  of  space,  not  only  for  the  superficial,  but  for  the  deep  incision  ;  so 
that  a  calculus  more  than  an  inch  in  diameter  cannot  be  extracted.  To  obviate 
this  Harrison  recommends  that  an  incision  should  be  made  with  a  probe-pointed 
bistoury  along  the  floor  of  the  prostatic  urethra,  from  within  outward  ;  and  that 
then  the  two  sides  of  the  prostate  should  be  torn  asunder  by  the  pressure  of  the 
index  finger. 


io6o    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

(J))   In  children  particularly  there  is  the  danger  of  tearing  the  urethra  across. 

(r)   The  bull)  and  the  rectum  are  both  more  likely  to  be  wounded. 

Median  lithotomy  can  only  be  performed  when  the  calculus  is  small,  and  is 
seldom  selected  unless  there  is  some  condition  which  either  precludes  crushing  or 
renders  it  inadvisable.     The  following  are  the  chief: — 

1.  Dense  cartilaginous  stricture,  involving  the  membranous  or  the  posterior 
portion  of  the  bulbous  portion  of  the  urethra.  Tliis  may  l)e  incised  at  the  same 
time. 

2.  iMilargement  of  the  prostate,  in  which  it  is  thought  that  either  a  ])ortion  of 
the  gland  mav  be  removed  with  advantage,  or  the  post-prostatic  jjouch  drained. 

3.  When  there  is  a  foreign  body  of  peculiar  sha])e. 

4.  When  there  is  a  number  of  calculi,  too  large  to  come  away  in  an  ordinary 
evacuating  tube,  and  too  many  to  be  crushed. 

5.  When  there  is  a  calculus  or  a  fragment  impacted  at  the  neck  of  the  bladder, 
or  in  the  prostate,  or  in  the  orifice  of  one  of  the  ureters,  endangering  the  safety  of 
the  kidney. 

6.  As  an  adjunct  to  lithotrity,  after  the  stone  has  been  crushed,  where  it  is 
desired  to  evacuate  the  fragments  at  once  or  to  drain  the  bladder. 

onK 
SupRAPumc  LiTHoxtoiv. 

In  this  the  bladder  is  opened  over  the  pubic  symphysis,  below  the  peritoneum. 

When  the  bladder  is  empty  the  fold  of  the  peritoneum  lies  below  the  upper 
border  of  the  pubic  symphysis  ;  in  moderate  distention  it  rises  to  the  same  level, 
and  in  some  people  it  may  be  half,  or  even  three-quarters  of  an  inch  above,  but  it 
is  only  in  cases  of  chronic  retention  that  the  space  is  of  any  size.  According  to 
(rarson  this  is  mainly  due  to  the  bladder  stretching  backward  into  the  hollow  of 
the  sacrum  and  compressing  the  rectum,  instead  of  rising  uj)  out  of  the  pelvis  ;  and 
if  this  is  prevented  by  filling  the  intestine  to  a  very  moderate  extent,  the  fold  of 
the  peritoneum  may  be  raised  (especially  in  fat  people)  sufficiently  for  all  surgical 
purposes.  There  is  no  strain  upon  the  wall  of  the  bladder  ;  its  anterior  surface  is 
well  exposed  ;  and  the  floor  is  raised  and  fixed,  so  that  it  is  much  more  easy  to 
introduce  sutures  if  they  are  required. 

In  children  the  fold  of  the  peritoneum  is  higher  ;  when  the  bladder  is  moder- 
ately full  it  is  nearly  always  well  above  the  level  of  the  bone ;  in  distention  there 
may  be  two  inches,  and  even  more. 

The  preparation  of  the  patient  is  the  same,  but  the  i)osition  is  the  ordinary 
recumbent  one,  with  the  hips  slightly  flexed.  A  very  thin  cylindrical  rubber  bag, 
made  without  seams,  and  capable  of  holding  twelve  ounces,  is  introduced  into  the 
rectum  well  above  the  sphincter,  and  connected  with  an  irrigating  can  filled  with 
warm  water.  Distention  in  this  way  is  more  equable  than  with  a  syringe,  and  the 
tube  can  be  clamped  or  undamped  at  any  lime.  Ten  ounces  are  usually  ample, 
even  in  an  old  person  ;  and  le.ss  than  this  is  advisable  for  a  young  adult ;  the  mucous 
membrane  of  the  rectum  has  been  severely  injured  on  several  occasions  by  bags  of 
unsuitable  shape  or  size.  A  soft  catheter  should  then  be  passed,  the  bladder 
washed  out  with  a  warm  antiseptic  solution,  and  the  end  of  the  catheter  connected 
by  a  flexible  tube  with  a  vessel  filled  with  the  same.  By  raising  or  lowering  this, 
as  occasion  requires,  the  bladder  may  be  filled  to  any  desired  extent,  or  emptied, 
without  the  necessity  of  tying  anything  round  the  penis.  This  method  of  disten- 
tion is  much  to  be  preferred,  both  in  the  case  of  the  rectum  and  bladder.  It  is 
gradual  and  perfectly  even  ;  it  can  be  regulated  to  a  nicety,  andean  be  relieved  at 
once  by  lowering  the  vessel. 

The  pubes  must  be  shaved,  and  an  incision  three  or  four  inches  in  length 
made  exactly  in  the  middle  line,  commencing  just  below  the  upi)er  margin  of  the 
symphysis.  The  sheath  of  the  rectus  is  exposed  first,  and  carefiilly  divided  upon 
a  director ;  then  the  layer  of  the  transversalis  fascia  that  bounds  the  prevesical 
space  in  front ;  the  posterior  one  should  prevent  the  peritoneum  being  seen,  but  if 


SUPRAPUBIC  LITHOTMtFY. 


1061 


it  comes  into  view  it  must  be  pushed  up  out  of  the  way  with  the  finger.  In  the 
case  of  very  large  calculi  it  may  be  necessary  to  divide  the  tendon  on  cither  side, 
but  this  should  be  done  as  little  as  i)ossible. 

If  the  vessel  connected  with  the  catheter  is  raised  a  little,  the  bladder  slowly 
presents  itself  covered  over  with  a  layer  of  soft,  delicate  fat  (sometimes  of  consider- 
able thickness),  containing  numerous  tortuous  veins.  It  is  essential  to  interfere 
with  this  as  little  as  possible  ;  the  handle  of  a  scalpel,  or  an  ivory  separator,  as 
Thompson  recommends,  may  be  used  to  push  it  to  one  side ;  one  of  the  chief  risks 
is  the  infiltration  of  urine,  and  this  is  almost  sure  to  follow  if  there  is  any  rough 
handling  or  hemorrhage.  In  most  cases  there  are  two  large  veins  running  down 
the  anterior  surface  of  the  bladder  in  a  vertical  direction  ;  and  the  greatest  care  is 
needed  to  avoid  not  only  these  but  the  smaller  ones  near  the  neck. 

One  way  of  securing  the  bladder,  so  that  it  does  not  collapse  when  opened,  is 
to  pass  two  sutures  through  the  muscular  coat,  one  on  either  side  ;  but  a  sharp 
hook  or  toothed  forceps  is  usually  ju'cferred.  The  opening  itself  should  be  made 
with  a  scalpel  (the  edge  pointing  toward  the  pubes)  in  the  middle  line  between 


Showing  the  Incision  through  the  Skin.     {Bardenheuer.)        a.   Plate   showing   the    Bladder    Stitched    to    the 

marginof  the  wound,   b.  Appearance  on  Section. 
Fig.  456. — Suprapubic  Lithotrity. 


the  veins,  and  it  should  be  large  enough  to  admit  the  finger.  The  calculus  must 
be  dealt  with  according  to  its  size  and  position.  Sometimes  it  can  be  extracted 
by  the  finger  and  a  scoop,  or  with  the  two  fore-fingers ;  in  other  cases  polypus 
forceps,  or  lithotomy  forceps,  may  be  used  to  lay  hold  of  it ;  even  small  mid- 
wifery forceps  have  been  employed  ;  and  in  one  instance  it  was  necessary  to  break 
up  the  calculus  with  chisel  and  mallet.  One  disadvantage  of  rectal  distention  is 
that  the  stone,  owing  to  the  way  in  which  the  centre  of  the  floor  of  the  bladder 
is  elevated,  is  apt  to  roll  down  to  the  sides.  This,  however,  is  of  little  importance, 
as  the  whole  interior  can  be  easily  explored. 

The  treatment  of  the  wound  must  be  guided  by  the  condition  of  the  urine 
and  of  the  walls  of  the  bladder.  In  children  and  young  adults,  if  the  kidneys  are 
sound,  and  the  muscular  coat  fairly  healthy  and  not  much  bruised,  an  attempt 
should  be  made  to  secure  union  by  the  first  intention.  Two  series  of  sutures  may 
be  used — one  through  the  muscular  coat  to  bring  the  edges  together  ;  the  other, 
Lembert's,  outside  this;  but  neither  should  touch  the  mucous  membrane,  and  the 
latter  should  extend  not  only  the  whole  length  of  the  wound,  but  for  a  little  dis- 
tance beyond  at  either  end.     Either  silk  or  chromic  catgut  may  be  used.     In  any 


io62    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

case  the  sutures  must  not  be  more  than  an  eiglith  of  an  inch  apart,  or  wlien  the 
bladder  becomes  distended  leakage  will  take  place  between  them.  Kven  if  they 
do  give  way  after  twenty-four  or  forty-eight  hours,  the  risk  of  urinary  extravasation 
is  by  that  time  much  diminished,  and  in  a  fair  proi)ortion  of  the  cases  the  wound 
has  healed  up  at  once.  If,  however,  the  walls  are  thinned  or  fasciculated,  if  they 
have  been  bruised,  if  the  urine  is  ammoniacal,  or  the  kidneys  diseased,  union  by 
the  first  intention  is  so  problematical  that  it  is  wiser  not  to  try.  The  wound  in 
the  bladder  should  be  left  entirely  open,  the  abdominal  one,  if  it  is  very  long, 
being  closed,  so  far  at  least  as  the  ujiper  extremity  is  concerned. 

If  the  wound  of  the  bladder  is  sutured,  morphia  is  usually  advisable.  Sup- 
positories may  be  used,  but  it  is  better  injected  directly  into  the  tissues  over  the 
pubes.  If  there  is  any  doubt  about  the  condition  of  the  sutures  a  catheter  may  be 
passed  as  often  as  required  ;  with  cocaine  there  is  rarely  any  objection,  but,  espe- 
cially in  the  case  of  children,  it  should  be  avoided  if  possible.  Tying  a  catheter 
in  it  is  not  merely  useless,  but  a  constant  source  of  irritation  ;  and  draining  through 
the  perineum,  though  it  may  be  sometimes  advisable  to  prevent  decomposition 
after  the  removal  of  tumors  of  the  bladder,  is  rarely  needed  in  lithotomy. 

If  the  wound  is  not  secured,  an  attempt  must  be  made  to  keep  the  bladder  as 
dry  as  possible.  In  his  earlier  cases  Thompson  recommended  that  the  patient 
should  simply  lie  on  his  side,  changing  from  one  to  the  other  every  six  hours  so 
as  to  prevent  excoriation.  Trendelenburg  tried  the  prone  position,  but  this  is 
scarcely  practicable  in  the  cases  which  recjuire  it  most.  The  simplest  plan  is  to 
introduce  a  full-sized  tube,  and  thread  it  with  loosely-packed  lampwick  for  about 
a  foot  of  its  length,  so  that  it  will  act  as  a  siphon.  If  this  fails,  an  apparatus  like 
a  Higginson's  syringe  may  be  attached  to  it  by  a  side  branch,  and  the  contents  as- 
pirated at  frequent  intervals  either  by  the  patient  or  the  nurse.  Greig  Smith  does 
not  consider  a  drainage  tube  necessary  if  absorbent  dressings  are  used  and  changed 
at  frequent  intervals  ;  the  bladder  is  kept  empty  by  the  pressure  of  the  viscera 
above  it. 

Compared  with  the  perineal  methods,  the  accidents  that  may  occur  in  the 
course  of  suprapubic  lithotomy  are  exceedingly  few  and  easily  avoided.  The  rec- 
tum and  bladder  have  been  ruptured  from  excessive  dilatation,  and  inflammation  of 
the  mucous  membrane  of  the  former  has  been  caused  by  the  pressure.  The  peri- 
toneum has  been  opened,  so  that  the  operation  had  to  be  delayed  :  and  free  hemor- 
rhage may  occur  from  the  prevesical  plexus.  This,  however,  is  important  rather 
from  the  facility  that  it  gives  to  subsequent  suppuration  and  extrava.sation  of  urine 
than  from  actual  loss  of  blood. 

Causes  of  Death. — In  children  this  operation  is  as  successful  as  lateral 
lithotomy.  In  adults  the  comparison  is  hardly  fair,  as  many  of  the  cases  were  such 
that  the  lateral  operation  was  impossible. 

Suppurative  pyelonephritis,  with  j^artial  suppression,  is  the  most  common.  It 
generally  proves  fatal  in  the  course  of  a  few  days,  with  low  muttering  delirium  and 
extreme  prostration. 

Pericystitis,  extending  into  the  cavity  of  the  pelvis  and  setting  up  pelvic 
cellulitis  and  peritonitis,  may  occur  from  injury  to  the  soft  tissues  around  the 
bladder  or  from  extravasation  of  urine.  Its  course  and  severity  depend  largely 
upon  the  condition  of  the  kidneys  ;  in  children,  for  instance,  it  very  rarely  occurs. 

Besides  these,  death  may  occur  from  shock,  exhaustion,  pycemia,  or  other 
secjuelie  common  to  all  operations  in  such  conditions. 

Choice  of  Method. 

Three  things  have  to  be  taken  into  consideration  in  selecting  a  method  :  the 
patient,  the  urinary  organs,  and  the  calculus. 

I.  The  Patient. — Under  six  years  of  age,  crushing  is  not  advisable.  It  has 
been  done  in  younger  patients,  and  occasionally  the  urethra  is  sufficiently  capa- 
cious ;  but  this  is  exceptional. 


LITJIOTRITY  AND    LirJIOl'OMY.  1063 

Between  six  and  puberty,  crushing  antl  cutting  (for  all  moderate-sized  stones) 
are  e<iually  successful.  I'nless  there  is  some  other  condition,  the  choice  is  per- 
fectly open.  After  puberty,  so  far  as  years  alone  are  concerned,  there  is  no 
question  that  the  former  is  to  be  preferred. 

2.  The  Urinary  Organs.  —  T/tc  Urethra. — The  presence  of  a  stricture  or  false 
passage  does  not  preclude  lithotrity,  but  it  is  an  objection  ;  if  there  is  much  in- 
tlammatory  exudation  around,  sujipuration  and  urinary  abscess  are  not  unlikely. 
Enlargement  of  the  prostate  in  the  same  way,  so  long  as  it  is  moderate,  does  not 
prevent  crushing,  though  it  renders  it  difficult ;  but  when  it  is  excessive,  or  very 
irregular,  with  a  deep  post-prostatic  pouch,  the  sujjrapulMc  method  is  better. 

The  State  of  the  Bhidder. — Atony  of  itself  does  not  prevent  lithotrity,  or 
make  the  oi)eration  difficult ;  the  trouble  comes  afterward  from  the  constant  wash- 
ing out  that  is  recjuired.  It  must  be  remembered  that  sometimes  it  is  advisable, 
on  account  of  the  atony,  to  make  an  oi)ening  in  the  bladder  and  drain  it 
thoroughly. 

The  same  may  be  said  of  cystitis.  If  it  is  slight  and  due  to  the  calculus,  it 
will  be  made  perhaps  a  little  more  severe  by  the  crushing,  but,  the  cause  being  re- 
moved, the  inflammation  soon  subsides.  When,  however,  the  cystitis  has  already 
lasted  some  time,  and  the  walls  are  irregular  or  the  urine  ammoniacal,  it  is  neces- 
sary to  take  other  things  into  consideration.  If  the  kidneys  are  sound  (which 
they  seldom  are)  and  the  urethra  tolerant,  the  calculus  may  be  crushed  and  the 
bladder  washed  out  periodically,  to  clear  away  the  decomposing  mucus  from  the 
walls  and  stop  the  fermentation  ;  but  in  many  of  these  cases  it  is  wiser  to  drain  the 
bladder  through  an  opening  in  the  perineum,  and,  if  this  is  done,  it  is  as  well  at 
the  same  time  to  extract  either  the  calculus  itself,  if  it  is  small,  or  the  fragments 
into  which  it  has  been  broken  by  a  few'  minutes'  crushing.  This  combination  of 
crushing  with  the  median  operation  is  exceedingly  useful ;  the  operation  is  not  a 
long  one,  the  shock  is  not  severe,  the  bladder  can  be  thoroughly  emptied,  and  it 
enjoys  perfect  rest  afterward,  the  urine  being  drained  off  directly  by  means  of  a 
flexible  tube  carried  outside  the  bed. 

If  the  presence  of  sacculi  can  be  diagnosed,  crushing  should  not  be  attempted. 
Most  of  the  cases  of  peritonitis  are  caused  in  this  way. 

The  State  of  the  Kidneys. — When  these  are  diseased  it  is  still  a  question 
whether  lithotomy  or  lithotrity  is  the  worse.  Much  depends  upon  the  calculus, 
but  probably  a  great  deal  more  upon  the  operator.  If  the  stone  is  only  of  moderate 
size  and  soft,  and  if  the  crushing  is  done  by  a  practiced  hand,  rapidly  and  gently, 
with  the  minimum  of  manipulation  and  without  any  bruising,  the  risk  is  very  much 
less  than  in  any  cutting  operation  ;  but,  on  the  other  hand,  if  the  stone  is  of 
unusual  size  or  hardness,  if  the  condition  of  the  bladder  is  such  that  fragments 
are  likely  to  remain  behind  in  the  mucus,  or  to  require  a  great  deal  of  manipula- 
tion, it  is  probable  that  the  suprapubic  or  the  combined  operation  is  the  better,  as 
inflicting  less  injury. 

3.  The  Calculus. — Calculi  have  been  crushed  up  to  four  ounces  in  weight, 
but  such  are  exceptional.  As  a  rule,  an  oxalate  of  lime  one  over  an  inch  in  dia- 
meter, or  one  of  uric  acid  over  an  inch  and  a  half,  is  nearly  as  much  as  can  be 
accomplished.  For  larger  ones  (unless  they  are  very  soft)  the  suprapubic  opera- 
tion alone  is  suitable.  Besides  the  size  of  the  calculus,  however,  its  position, 
especially  if  it  is  fixed,  and  its  shape,  are  of  importance  in  determining  the  method 
of  operation. 

Sometimes  there  are  other  considerations  present  w-hich  prevent  either  crush- 
ing or  cutting,  and  limit  the  choice,  as,  for  example,  deformity  of  the  pelvis, 
tumors  growing  from  the  pubic  bones,  or  from  the  prostate  and  bladder,  ankylosis 
of  the  hip  joint,  etc. 

Lithotrity,  therefore,  is  not  suited  to  children  under  six  years  of  age  ;  for 
calculi  over  a  certain  size  (depending  upon  their  composition),  encysted  stone,  or 
in  cases  of  dense  stricture.  Whether  it  should  be  preferred  to  other  methods  in 
cystitis,  atony,  great  enlargement  of  the  prostate  and  disease  of  the  kidneys  (all 


io64    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

of  which  freciuently  occur  together),  depends  chiefly  upon  the  operator.  The 
stigma  from  which  it  suffers  is  the  freiiuency  of  recurrence,  even  as  much  as  one 
in  seven  or  eight,  in  the  most  i)racticed  hands. 

As  regards  lithotomy,  the  suprapubic  method  is  probably  the  easiest  and  the 
least  dangerous  in  the  hands  of  most  operators,  but  it  must  still  be  regarded  as  to 
a  certain  extent  the  fashion  of  the  day,  and  therefore  upon  its  trial.  For  calculi 
over  an  inch  and  a  half  in  diameter  it  is  the  only  method,  unless  the  stone  is  first 
broken  into  a  few  fragments  and  extracted  by  the  median.  Recovery  is  more 
slow  after  it  than  after  the  lateral  or  the  median  (except  in  children)  ;  it  is  almost 
as  liable  to  be  followed  by  urinary  fistula  ;  and  drainage  is  certainly  a  difficulty, 
especially  if  there  is  cystitis  ;  but  there  is  no  important  structure  near  that  can  be 
injured  if  reasonable  care  is  used,  the  space  is  less  limited,  there  is  no  danger  of 
hemorrhage,  the  incisions  are  more  easy,  the  removal  of  the  calculus  is  not  at- 
tended with  such  difficulty,  and  the  interior  of  the  bladder  can  be  explored  more 
thoroughly.  Sometimes  other  conditions,  such  as  adhering  masses  of  phosphates, 
can  be  dealt  with  at  the  same  time. 

Calculus  in  the  Female. 

The  anatomical  conditions  of  the  female  bladder  are  such  that  calculus  is 
much  more  rare,  and  is  much  easier  of  extraction  than  in  the  male ;  moreover,  in 
them,  the  extreme  form  of  cystitis,  with  fasciculated  and  sacculated  walls,  which 
results  from  stricture  or  enlarged  prostate,  and  is  always  attended  by  disease  of  the 
kidneys,  is  i^ractically  unknown. 

In  adults  the  urethra  maybe  dilated  so  as  to  admit  the  forefinger  without  risk 
of  incontinence,  so  that  small  calculi  can  be  extracted  directly.  If  they  are  too 
large  for  this,  a  lithotrite  may  be  used  to  break  them  up  sufficiently  ;  if  larger  still 
— and  they  have  been  known  to  be  of  enormous  size — they  may  be  extracted 
either  through  the  vagina  or  by  the  suprapubic  method.  The  latter  is  perhaps  to 
be  preferred,  as  the  former,  even  when  the  incision  is  sewn  up  at  once,  exposes 
the  patient  to  the  risk  of  vesico-vaginal  fistula.  In  children,  in  whom  the  sexual 
organs  are  not  developed,  and  who  seem  not  to  suffer  from  infiltration  of  urine  to 
the  same  extent  as  adults,  the  suprapubic  is  certainly  the  better  method. 


TUMORS  OF  THE  BLADDER. 

Tumors  of  the  bladder  have  a  peculiar  tendency  to  assume  a  papillomatous 
character,  even  when  they  are  malignant.  There  are  no  papilla  in  the  mucous 
membrane,  but  it  must  be  remembered  that  the  bladder  and  allantois  are  developed 
in  connection  with  each  other,  and  that  the  foetal  villi  are  partially  dependent  upon 
the  latter.  There  is  a  very  close  resemblance  in  external  appearance,  and  even  in 
structure,  between  some  forms  of  vesical  papilloma  and  the  tufts  that  are  found  on 
the  placenta. 

Papilloma. 

In  many  cases  the  tumor  is  composed  of  nothing  but  these  villi.  When  the 
bladder  is  empty  there  is  a  rounded,  red,  vascular  mass  lying  on  the  mucous  mem- 
brane, springing  from  its  superficial  layers,  and  freely  movable  on  the  subjacent 
tissue.  As  soon  as  it  is  placed  in  water  a  number  of  delicate,  hair-like  processes 
float  out  from  it  in  all  directions,  like  the  tentacles  of  a  sea  anemone.  Each  con- 
tains a  loop  of  a  vessel,  and  outside  this  a  delicate  basement  membrane  upon 
which  rests  the  columnar  epithelium.  In  many  there  is  no  fibrous  tissue  at  all ; 
in  the  larger  there  may  be  a  few  threads  running  by  the  side  of  and  surrounding 
the  blood-vessels.  These  tumors  are  known  as  fimbriated  papillomata  ;  usually 
they  are  single  and  sessile,  growing  near  the  trigone,  but  they  may  be  multiple 
and  i)edunculated.  In  exceptional  cases  the  whole  interior  of  the  bladder  is  cov- 
ered over  with  a  shaggy  coat. 


TUMORS  OF   THE   BLADDER.  10O5 

Fll!K()-l'AI'IM,O.MA. 

In  these  there  is  a  greater  amount  of  fibrous  tissue;  they  are  denser  and 
firmer  than  the  former,  but  they  still  belong  mainly  to  the  mucous  membrane.  In 
external   appearance   they  are  very 

similar,    but    the    villi    are    usually 

shorter  and  less  characteristic. 


Fll!I«l.MA. 


Wm^tmmi^ 


Tumors    consisting    of   fibrous 
tissue  only  are  occasionally  found  in     ,•  ; 

connection  with  the  submucous  coat,    i  'i 

Usually    they    project   as    polypoid    r  "% 

growths,  with  the  unaltered  mucous    \.  "^■. 

membrane  stretched  over  them;  but,    ^, 

as  all  other  vesical  tumors,  they  are     »  *•        / 

occasionally  covered  with  villi.  In 
some  there  is  a  certain  amount  of 
unstriped    muscular   tissue,   so   that  ™..-,  ^.> 

they  are  really  fibro-myomata  :  and  "'■^'^^:~ 

pure  myoma  has  been  described.    In  ,    ^,  .    -.  ■ . 

others  (fibro-myxoma)  some  of  the 

fibrous  part  has  become  converted  ^^^-  457  — Fjbro-papiiioma  of  the  Bladder, 

into  mucous  tissue. 

Sarcomata  are  more  rare.  In  external  appearance  they  resemble  fibro-papil- 
lomata,  but  the  fibrous  tissue  in  the  interior  is  replaced  by  sarcomatous  elements, 
and  their  growth  is  much  more  rapid.  In  some  instances,  in  which  fibro-papillo- 
mata  have  recurred  after  removal,  the  secondary  growths  were  softer  and  sprang 
up  more  quickly  than  the  original,  as  if  the  fibrous  part  was  giving  way  to  a 
growth  of  less  perfect  type.  In  a  few  cases  round-celled,  spindle-celled,  and  even 
chondrifying  sarcomata  have  been  found. 

Mucous  Polypi. 

Outgrowths  from  the  mucous  membrane,  resembling  those  that  are  met  with  in 
the  nasal  passages  and  in  the  rectum,  are  not  uncommon,  especially  in  children. 
Often  they  are  multiple,  and  the  pedicles  occasionally  become  stretched  to  such 
an  extent  that  in  females  they  may  even  protrude  at  the  meatus. 

Carcinoma. 

Scirrhus  and  encephaloid  are  rare.  Epithelioma,  on  the  other  hand,  is  the 
most  common  of  all  tumors.  It  is  usually  found  after  middle  life,  and  it  may 
occur  at  any  part  of  the  bladder.  Nothing  is  known  with  regard  to  its  cause ; 
there  is  no  reason  to  connect  it  with  the  irritation  of  calculi,  catheters,  or  any- 
thing else.  In  general  the  tumor  is  single,  but  sometimes  there  is  more  than  one, 
and  occasionally  they  are  very  numerous.  In  a  few  instances,  in  which  the 
growths  have  been  on  opposite  sides,  it  would  seem  as  if  the  secondary  ones  had 
originated  by  a  process  of  infection  from  the  first.  When  there  is  a  perineal 
wound  it  is  not  uncommon  for  the  mass  to  protrude  and  fungate,  as  if  it  had 
spread  along  the  granulation  tissue  ;   but  this  may  admit  of  other  explanations. 

At  first  the  mucous  membrane  is  smooth  and  unaltered,  merely  raised  and 
vascular ;  but  ulceration  very  soon  sets  in,  and  the  tumor  being,  as  it  were,  ma- 
cerated in  the  urine,  the  surface  .soon  becomes  exceedingly  irregular  and  covered 
over  with  sloughing  shreds  of  tissue.  The  growth  itself  is  never  encapsuled  or 
freely  movable  on  the  deeper  strata  ;  it  infiltrates  the  submucous  and  muscular 
coats  with  great  rapidity,  and  spreads  from  them  to  the  surrounding  organs. 
68 


io66    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

Sometimes  the  converse  is  the  case,  and  the  bladder  becomes  secondarily  involved 
from  malij^nunt  disease  of  the  uterus  or  rectum. 

General  Symptoms  of  Tumors  of  the  Bladder. — Hemorrha^je  and 
irritability  of  the  bladder,  usually  amounting  to  cystitis,  are  the  most  prominent. 

The  former  varies  in  amount  and  frequency  according  to  the  nature  of  the 
growth.  In  i)ai)illomata  it  is  j)rofuse,  pouring  out  from  the  delicate  villi,  and 
very  irregular  in  occurrence.  Often  the  first  thing  noticed  is  a  sudden  gush  of 
bright  blood  following  micturition,  and  then  there  may  be  an  interval  of  months. 
In  carcinoma,  on  the  other  hand,  hemorrhage  is  usually  preceded  by  increa.sed 
frequency  of  micturition  and  dysuria,  and  the  amount  of  l)lood,  though  small,  is 
much  more  constant.  In  the  later  stages  the  difference  becomes  still  more 
marked  ;  with  })apillomata  there  is  discomfort,  sometimes  pain  ;  severe  cystitis 
may  occur  as  a  complication  ;  the  urine  may  even  become  ammoniacal  and  the 
timior  crusted  over  with  a  layer  of  phosphates  ;  but  this  is  as  nothing  compared 
with  the  severity  of  the  suffering  in  carcinoma,  especially  when  ulceration  sets  in. 
Decomposition  of  the  urine  nearly  always  occurs  :   the  pain  is  excruciating,  radiat- 


FiG.  458.— Epithelioma  of  the  Bladder.     Two  apparently  distinct  masses 
opposite  to  each  other. 

ing  all  over  the  body  ;  the  desire  to  pass  water  is  unceasing,  and  gives  no  relief; 
there  is  constant  burning  at  the  neck  of  the  bladder,  rest  or  sleep  is  impossible, 
and  the  strength  rapidly  gives  way.  .All  these  symptoms  are  intensely  aggravated 
when  the  growth  is  near  the  orifice  of  the  ureters,  so  that  renal  troubles  are  present 
in  addition. 

The  diagnosis  must  be  made  from  :  {a)  the  age  of  the  patient  (papillomata 
and  polypi  may  occur  at  any  time  of  life,  though  they  are  more  common  in  the 
young — carcinoma  probably  never  before  forty)  ;  (/')  the  character  and  order  of 
the  symptoms  ;  (r)  examination  of  the  urine  ;  and  (</)  exploration  of  the  bladder. 

Besides  the  blood  that  is  present  in  the  urine  and  the  increa.sed  amount  of 
mucus  caused  by  the  cystitis,  portions  of  these  growths  may  occasionally  be  found 
and  their  nature  identified  under  the  microscope.  Villi  are  unmistakable  ;  cancer- 
cells  when  isolated  cannot  be  distinguished  from  the  normal  epithelium  of  the 
bladder,  but  occasionally  there  are  cell-nests  or  small,  sloughing  fragments  of 
the  growth.  It  is  convenient  for  this  purjjose  to  allow  the  urine  to  settle  for  some 
hours  in  a  tall,  conical  glxss  which  can  be  tapi)ed  from  the  bottom  without  the  in- 
troduction of  a  pipette.      In  suspected  cases,  when  this  fails,  an  attemjjt  may  be 


TUMORS  OF  THE   BLADDER. 


1067 


made  to  obtain  some  of  the  fragments  l)y  wasliing  out  the  l)la{l(lcr  with  a  large- 
eyed  catheter,  the  edges  of  the  opening  being  rather  sliarp.  If  the  nrine  is  allowed 
to  discharge  itself  suddenly,  projecting  ])ortions  of  the  growth  can  sometimes  l)e 
entangleil  and  brought  away.  Sir  H.  Thompson  on  one  occasion  extracted  a 
fragment  with  a  small  lithotrite. 

Exact  information,  jiarticularly  as  to  site,  can  only  be  obtained  by  examina- 
tion of  the  bladder  itself.  The  sound  is  of  very  little  use  until  the  disease  is  very 
far  advanced  ;  a  soft,  papillomatous  growth  cannot  be  detected  by  the  touch,  and 
though  profu.se  hcematuria  following  a  carefully  conducted  examination  is  very 
suggestive,  it  is  nothing  more  unless  a  fragment  of  the  growth  is  found.  It  is 
probably  in  this  that  the  cystoscope  will  show  its  value  most  (Fig.  459).  It  con- 
sists of  a  hollow  .shaft,  of  as  large  a  calibre  as  the  urethra  will  take,  with  a  short 
beak  set  on  the  end  at  an  angle.  At  the  end  of  the  beak  is  a  miniature  incan- 
descent electric  lamp  ;  in  one  form  of  the  instrument  this  is  unprotected,  in 
another  it  is  covered  in  by  a  cap  of  metal  with  a  rock-crystal  window.  At  the 
junction  of  the  beak  and  the  shaft  is  a  second  window,  closed  by  a  prism,  so  that 
the  rays  of  light  entering  it  are  reflected  down  the  tube  toward  the  eye  of  the  ob- 
server.     In  the  tube  are  lenses  for  the  purpose  of  magnifying  the  image. 

For  the  anterior  surface  of  the  bladder  (when  the  beak  is  turned  up)  the  two 


Fig.  459. — Leiter's  Cystoscope  (Sch.ill's  Catalogue),  showing  two  ends,  lamp,  and  cap. 


windows  are  on  the  concavity  ;  for  the  trigone  and  base,  on  the  convexity  of  the 
curve.  The  current  is  turned  on  and  off  as  required  by  means  of  a  small  key  in 
the  circular  handle. 

Burnt  in  air  the  cap  of  the  instrument  becomes  exceedingly  hot,  in  water  (and 
urine)  it  remains  perfectly  cool,  and  so  long  as  it  is  prevented  touching  the  mucous 
membrane  it  causes  no  inconvenience.  For  this  reason  the  bladder  is  partly  filled 
with  clear  water,  and  the  current  is  not  turned  on  until  the  instrument  is  in  posi- 
tion.     For  women  a  larger  tube  may  be  employed. 

There  is  no  doubt  as  to  the  value  of  this  instrument  in  distinguishing  the  site 
from  which  a  tumor  grows  ;  but  it  must  be  recollected  that  it  only  allows  a  very 
minute  portion  of  the  bladder  wall  to  be  seen  at  one  time,  and  that  even  with  the 
naked  eye,  when  the  bladder  is  laid  open,  it  is  not  always  possible  to  be  certain  as 
to  the  clinical  features  of  a  minute  growth.  Natural  rugosities  of  the  bladder  wall, 
low  villous  growths  of  an  inflammatory  character,  such  as  are  not  unfrequently 
met  with  in  cases  of  calculi,  prolapse  of  the  ureter  (Fig.  470),  and  many  other 
conditions,  present  a  closely  similar  appearance. 

Examination /^r  rectum  ox  per  vui^ina/ii  rarely  reveals  much.  Sometimes,  in 
the  case  of  carcinoma,  a  certain  amount  of  induration  may  be  detected  ;  the  tissues 
seem  matted  together  when  pressure  is  made  upon  them  ;  but  for  this  to  occur  the 


io68    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

growth  must  be  so  far  advanced  as  to  preclude  all  hoi)e  of  removal.  In  women  the 
interior  of  the  bladder  may  be  exj)lored  with  the  finger  under  an  anaesthetic. 

Treatment. — This  must  be  guided  by  the  nature  of  the  growth.  Simple 
tumors  should  be  removed  as  soon  as  possible  ;  if  left,  the  patient  becomes  ex- 
hausted by  hemorrhage  and  cystitis.  If  the  growth  is  pedunculated  and  accessible, 
the  oj^eration  is  one  of  comparative  ease  ;  when  these  conditions  are  reversed  it 
may  be  excessively  difficult,  and  in  some  instances  it  has  been  impossible.  In 
malignant  disease  it  is  questionable  whether  it  should  be  attempted.  The  cysto- 
scope  may  reveal  the  existence  of  an  epithelial  growth  long  before  it  could  be  de- 
tected in  other  ways  ;  but  even  then  the  hope  is  very  slight,  although  portions  of 
the  bladder  wall  have  been  removed  on  several  occasions,  with  recovery  from  the 
effects  of  the  operation,  for  a  time  at  least. 

In  men  the  bladder  may  be  entered  either  above  the  pubes  or  through  the 
perineum.  The  latter  i«  the  simpler,  and  affords  much  better  drainage,  so  that 
there  is  less  risk  of  septic  decomposition  and  absorption.  In  young  subjects,  too, 
the  whole  of  the  interior  can  be  brought  within  reach  of  the  finger  by  pressure 
over  the  pubes.  If,  however,  the  prostate  is  enlarged,  or  the  pelvis  contracted,  or 
if  the  perineum  is  thick  and  rigid,  this  is  scarcely  practicable  ,;  and  pressure  on 
the  abdomen  has  the  grave  disadvantage  of  inverting  the  bladder,  so  that,  before 
now,  portions  of  the  wall  have  been  excised  by  mistake,  and  the  peritoneal  cavity 
opened.  On  the  other  hand,  with  a  suprapubic  opening,  the  whole  of  the  interior 
can  be  easily  reached  with  the  finger ;  and,  what  is  very  important  (for  the  cysto- 
scope  is  of  no  use  in  an  ojieration,  owing  to  hemorrhage),  a  great  deal  of  it  can  be 
seen. 

Suprapubic  Cystotomy. 

The  preliminary  steps  are  the  same  as  in  suprapubic  lithotomy.  The  bladder 
is  carefully  washed  out  with  an  antiseptic  ;  the  rectum  distended  with  a  rubber  bag 
connected  with  a  receiver  ;  and  a  second  receiver  attached  to  the  catheter  in  the 
bladder.  The  incision  is  the  same  ;  the  sheath  of  the  recti  opened  in  the  same 
way  ;  and  the  same  precautions  taken  in  dealing  with  the  loose  cellular  tissue  and 
the  large  veins  in  the  pre-vesical  space.  As  soon  as  they  come  into  view,  the  re- 
ceiver connected  with  the  bladder  is  slowly  raised,' so  that  it  can  unfold  itself  and 
roll  the  fold  of  peritoneum  up  out  of  the  way. 

A  hook,  or  two  sutures,  should  be  inserted  into  the  wall  of  the  bladder  to 
prevent  its  collapsing  when  the  opening  is  made.  This  is  best  done  with  a  sharp 
bistoury,  the  incision  being  of  sufficient  size  to  admit  the  forefinger  without 
stretching. 

Various  methods  may  be  employed  for  the  removal  of  the  growth,  according 
to  its  nature,  situation,  and  the  extent  of  its  attachment.  Small  vascular  excres- 
cences covering  a  large  portion  of  the  wall,  and  bleeding  at  the  slightest  touch, 
should  be  scraped  off  with  the  finger  nail,  or.  as  Bryant  has  suggested,  with  a  dry 
and  rather  rough  sponge.  Polypi  with  a  distinct  j^edicle  may  either  be  removed 
in  the  same  way  or  twisted  off  with  two  pairs  of  forceps,  care  being  taken  that  the 
neck  only  is  grasped,  and  that  only  torsion,  not  traction,  is  used  ;  or  with  a  snare. 
The  galvano-cautery  has  been  employed,  but  it  does  not  present  any  material 
advantage.  Soft,  papillomatous  growths  may  be  treated  in  the  same  fashion,  but 
Thompson's  bladder  forceps,  in  which  the  crushing  edge  is  protected  by  a  free 
margin  projecting  beyond,  so  that  when  the  neck  of  the  growth  is  caught  the  wall 
of  the  bladder  is  pushed  away,  are  more  safe.  In  one  or  two  instances  catgut 
ligatures  have  been  placed  round  the  base,  and  the  growth  removed  with  scissors. 
Whatever  method  is  employed,  the  whole  tumor  should  be  excised  as  far  as  it 
possibly  can  be  :  any  portion  that  is  left  behind  is  liable  to  bleed,  and,  from  the 
bruising  it  has  undergone,  to  slough  and  become  septic.  Hemorrhage  must  be 
stopped,  and  all  the  blood  cleared  away  by  washing  out  the  bladder  with  water 
of  the  temperature  of  120°  F.,  and  touching  any  points  that  keep  on  oozing  with 
some  styptic. 


ru.\roRS  OF  the  bladder. 


1069 


[The  sharp  spoon  or  curette  may  be  used  with  advantage  in  removal  of 
bladder  tumors  with  broad  bases.] 

The  treatment  of  the  bladder  depends  upon  the  condition  of  the  urine  and 
the  state  of  its  walls.  In  young  subjects,  in  whom  the  urine  is  healthy  and  the 
tissues  not  bruised,  the  opening,  which  contracts  at  once,  should  be  secured  by 
passing  sutures,  after  Lembert's  plan,  through  the  muscular  coat  only,  or  by  using 
a  double  series,  as  in  rupture  of  the  bladder,  in  the  hope  of  obtaining  union  by 
the  first  intention  ;  and  the  external  wound  should  be  treated  in  the  same  way,  a 
large  drainage  tube  being  placed  in  the  lower  angle  behind  the  pubes.  If,  how- 
ever, the  urine  is  se|jtic,  or  the  walls  of  the  bladder  thickened  from  chronic 
inflammation,  or  if  they  are  much  bruised  in  the  course  of  the  operation,  the 
wound  is  better  left  open,  with  a  drainage  tube  as  described  in  suprapubic  lith- 
otomy. A  few  sutures  may  be  placed  in  the  superficial  wound,  if  it  is  large, 
but  only  at  its  upper  end.  If  the  bladder  is  accurately  sutured,  it  may  not 
be  necessary  to  pa.ss  a  catheter  at  all ;  but  in  many  ca.ses  the  urine  requires  to  be 
drawn  off  with  a  soft  instrument  three  or  four  times  a  day.      With  cocaine,  the 


Fic;.  460. — Thompson's  Bladder  Forceps. 


process  is  almost  painless.  If  septic  decomposition  is  feared,  especially  if  the 
urine  was  alkaline  before  the  operation,  or  if  a  portion  of  the  growth  was  left 
behind,  or  if  the  bleeding  could  not  be  completely  stayed,  the  urethra  should  be 
opened  in  the  perineum,  and  the  bladder  drained  thoroughly.  The  increased 
risk  is  very  slight  in  comparison  with  the  comfort  and  security  against  septic  ab- 
sorption that  it  ensures. 

Perineal  Cystotomy. 

Even  when  the  conditions  already  mentioned  are  favorable,  this  is  only 
suitable  for  tumors  in  the  immediate  neighborhood  of  the  trigone,  and  for  soft, 
distinctly  pedunculated  growths  springing  from  other  parts.  The  incisions  are  the 
same  as  for  exploring  or  draining  the  bladder.  Everything  must  be  done  by  the 
sense  of  touch  ;  the  exact  position  and  direction  of  the  neck  must  be  made  out 
with  the  finger,  and  then  either  the  loop  of  a  snare  ])assed  over  it,  or  a  pair  of 
forceps  introduced  to  seize  it.  The  great  merit  of  this  operation  consists  in  the 
perfect  drainage  that  it  affords  afterward,  but  it  is  only  suitable  for  growths  that 
can  be  scraped  away  at  once  with  the  finger  nail,  or  those  that  are  so  placed  that 
they  can  be  pinched  or  twisted  off  with  forceps,  without  the  wall  of  the  bladder 
running  any  risk. 

In  women,  tumors  of  the  bladder  may  be  removed  either  supra  pubes  or 
through  the  urethra.  The  steps  of  the  former  operation  are  the  same  as  those 
described  already  ;  the  pressure  of  the  rectal  bag  upon  the  urethra  is  generally 
sufiicient  to  close  it,  so  that  a  sufficient  quantity  of  fluid  can  be  injected.  In  the 
latter  it  is  not  advisable  to  rely  merely  upon  dilatation  ;  incontinence  of  urine, 
partial  more  often  than  complete,  has  been  known  to  follow  exploration  of  the 
bladder  w-ith  the  finger  only  ;  and  the  repeated  introduction  of  instruments,  and 
their  manipulation  when  tightly  grasped,  would  almost  certainly  end  in  this.  It 
is  much  better  to  divide  the  outer  two-thirds  of  the  urethra  in  the  middle  line  with 
a  pair  of  scissors  and  stretch  the  internal  orifice.     After  the  operation  is  finished. 


I o 7 o     DISEASES  AND  INJURIES  OF  SPK CIA L  STR UCTURES. 


one  or  two  sutures  may  be  used  to  l)ring  the  cut  surfaces  together  again.      Care 

must  be  taken  not  to  mistake  inversion  of 
the  l)ladder  and  prolapse  through  the  urethra 
for  a  polypus. 

In  malignant  disease  of  the  bladder, 
and  in  cases  of  simple  growths  that  are  too 
extensive  to  admit  of  removal,  much  may  be 
done  to  relieve  the  patient's  sufferings.  If 
cystitis  sets  in,  the  bladder  should  be  care- 
fully washed  out  with  a  solution  of  corrosive 
sublimate  every  day,  to  hold  the  decompo- 
sition in  check  ;  and  if  there  is  very  much 
irritation,  a  solution  containing  half  a  grain 
of  morphia  may  be  left  in  afterward.  Mor- 
phia, too,  may  be  given  hypodermically,  but 
a  careful  watch  must  be  kept  upon  the  con- 
dition of  the  kidneys.  If  the  strangury 
becomes  severe,  the  bladder  may  be  drained 
tlirough  an  oj^ening  in  the  perineum.  In 
most  cases  this  gives  great  relief,  and  the 
progress  of  the  growth  is  less  rapid  for  a 
time  ;  but  sometimes,  especially  when  it  is 
situated  near  the  neck  of  the  bladder, 
the  wound  becomes  infected  and  fungating 
masses  project.  It  has  been  proposed  to 
divert  the  ureters,  and  so  relieve  the  blad- 
der of  its  function  altogether  ;  but  I  am  not 
aware  of  any  instance  in  which  this  has  been 
done  for  carcinoma,  and  patients  suffering 
from  this  are  rarely  in  a  fit  condition  for 
such  operations.  Finally,  if  a  communica- 
tion forms  between  the  bladder  and  the  rectum,  so  that  faeces  pass  into  the  urine, 


Fig.  461. — Dilator  for  Female  Urethra. 


Fig.  462. — Cystoscope  in  Position.    (Di</>lny  and  Keclus.) 


FOREIGN  BODIES   IN  THE    BLADDER. 


1071 


the  distress  is  so  great,  esjiecially  in   men,  and   the   risk  of  nephritis  so  much 
increased,  that  colotomy  should  be  performed. 

ICxcision  of  a  portion  of  the  wall  of  the  bladder  has  been  practiced  in  a  few 
instances.  In  Sonneburg's  case,  the  upper  two-thirds  were  removed  with  the 
peritoneum  over  it,  the  wound  being  closed  by  means  of  sutures,  and  the  patient 
lived  for  six  weeks.  In  Antal's  a  tumor  the  size  of  a  child's  fist,  with  that  part  of 
the  bladder  wall  from  which  it  sprang,  was  removed  by  a  suprapubic  incision,  the 
peritoneum  being  stripped  up  without  being  opened.  The  vesical  wound  was 
closed,  the  abdominal  one  drained,  and  the  patient  recovered,  and  was  able  to 
hold  his  water  for  three  or  four  hours. 


[FORKKiN     HoiMKS    IN    'JHF,    BlADIjF.R. 

I'nder  the  name  of  foreign  bodies  in  the  bladder  are  included  every  species 
of  solid  sul)Stance  introduced  into  the  l>ladder  from  without.  Renal  and  vesical 
calculi  are  not  included. 

They  are  more  common  than  at  first  glance  would  seem  possible.  Among  them 
are  included  :  i.  Various  surgical  instruments,  such  as  portions  of  catheters,  sounds, 
bougies,  or  portions  of  any  of  the  ordinary  instruments  used  in  operations  within 
the  bladder;  2,  substances  introduced  by 
onanism  or  perverted  sexual  instinct  into 
the  bladder  by  way  of  the  urethra  ; 
3,  projectiles  thrown  from  firearms  or 
cannon  ;  and,  4,  foreign  bodies  entering 
the  bladder  by  means  of  a  fistulous  open- 
ing from  adjacent  tissues  or  organs. 
Among  the  first-named  class,  the  editor 
remembers  a  case,  where  a  practitioner  in 
attempting  to  catheterize  a  female  patient 
allowed  a  short  metallic  catheter  to  slip 
entirely  within  the  bladder.  Among  the 
second  class  hair  pins  occupy  a  leading 
place,  although  the  variety  is  very  great. 
The  third  class  frequently  includes  por- 
tions of  clothing  with  gunshot  wounds, 
spicula^  of  bone  chipped  from  the  pelvic 
walls,  and  occasionally  the  projectile  itself. 
The  fourth  class  may  include  substances 
from  the  intestine,  debris  of  dermoid  cysts,  and  even  pessaries  have  been  reported 
to  have  penetrated  the  bladder  by  ulceration. 

These  foreign  substances  rarely  become  encysted,  but  usually  soon  become 
incrusted  with  the  urinary  salts,  and  thus  form  the  centre  of  a  vesical  calculus. 

The  symptoms  depend  somewhat  upon  the  mode  of  entrance,  but  if  external 
or  fistulous  wounds  are  closed,  they  in  no  particular  differ  from  those  of  ordinary 
calculus. 

The  diagnosis  is  greatly  facilitated  by  the  use  of  the  cystoscope,  but  their 
presence  may  be  detected  by  the  sound. 

The  treatment  necessarily  depends  on  the  manner  of  introduction  of  the 
foreign  body  and  the  sex  of  the  patient.  In  the  female  the  urethra  may  usually  be 
dilated  sufficiently  to  allow'  the  removal  of  the  foreign  body  through  the  natural 
channels.     In  the  male,  extraction  is  performed  as  in  case  of  vesical  calculus.]  * 


Fig.  463. — Small  Polyp  as  seen  by  Cystoscope. 
(After  Duplay  and  Rectus.) 


*  See  the  section  on  Wounds  of  the  Bladder,  for  method  of  treatment  in  case  of  projectiles. 


I072    DISEASES  AND  INJURIES  OF  SPECIAL  SI'RUCTURES. 


CHAPTER  XXII. 

DISEASES  Of  THE  PROSTATE. 

Atrophy  of  the  Prostate. 

This  has  been  described  both  in  old  age  and  in  young  adults  ;  probably  it  is 
rather  defective  development  at  puberty.      It  does  not  give  rise  to  any  symptoms. 

Hypertrophy  ok  thk  Prostate. 

The  prostate  is  liable  to  a  peculiar  form  of  enlargement  which  produces  very 
serious  effects  upon  the  other  urinary  organs.  It  is  rarely  met  with  in  men  under 
fifty-five,  for  there  are  no  symptoms  until  the  size  is  very  considerable  ;  but  it  begins 
long  before  that,  and  I  have  known  it  well  marked  as  early  as  forty-two.  Some  en- 
largement is  present  in  about  one-third  of  those  who  reach  middle  life,  but  it  is 
only  in  a  small  proportion  of  these  that  there  is  any  interference  with  the  working 
of  the  bladder. 

Pathology. — The  nature  of  the  growth  is  not  always  the  same.  In  some 
cases  it  is  a  true  hypertrophy,  all  the  tissues  of  the  gland  enlarging  ecpially,  and  the 
normal  shape  is  retained  ;  but  this  is  the  exception.  The  fibrous  and  muscular 
elements  generally  form  by  far  the  larger  portion  ;  the  acini  may  dilate  and  become 
cystic,  but  there  is  rarely  much  adenoid  growth.  Not  unfrequenily  tumors,  resem- 
bling the  fibro-myomata  of  the  uterus,  are  found  in  the  interior  ;  they  are  round 
and  hard,  formed  of  concentric  layers,  lighter  in  color  than  the  tissues  near  them, 
and  surrounded  by  a  kind  of  capsule,  so  that  they  can  often  be  shelled  out.  As  a 
nile,  they  consist  mainly  of  fibrous  tissue,  with  someunstriped  muscular  fibre  ;  occa- 
sionally acini  and  ducts  are  present  as  well,  and  in  a  few  instances  they  deserve  the 
name  of  adenoma.  They  may  be  single,  but  more  often  multiple  ;  in  some  cases 
they  are  as  large  as  a  walnut,  in  others  so  small  that  they  can  scarcely  be  seen,  and 
they  maybe  buried  in  the  substance  of  the  gland,  or  project  on  the  e.\terior  as  dis- 
tinct nodules.  The  size  the  prostate  may  attain  under  these  conditions  is  enor- 
mous, and  the  shape  most  irregular.  Sometimes  the  lateral  lobes  are  enlarged 
equally,  or  one  is  in  great  excess  over  the  other  ;  sometimes  the  median  grows  out 
and  projects  under  the  mucous  membrane  of  the  bladder,  until  it  hangs  over  the 
orifice  like  a  valve  ;  in  other  cases  again  the  enlargement  is  toward  the  rectum. 
The  effect  on  the  prostatic  urethra  is  e(iually  variable  ;  it  maybe  merely  stretched 
until  it  is  four  inches  in  length,  or  it  maybe  so  tortuous  and  displaced  that  an  in- 
strument can  hardly  pass  through  it.  In  a  few  very  rare  cases  it  has  been  held  open 
in  such  a  way  as  to  cause  true  incontinence,  the  urine  flowing  away  from  the  blad- 
der as  it  entered,  leaving  it  always  empty  ;  much  more  often  the  walls  are  firmly 
pressed  together,  so  that  on  transverse  section  it  takes  the  form  of  a  narrow  vertical 
slit  lying  between  the  dense  and  solid  lateral  lobes. 

Changes  in  the  Bladder. — i.  The  Neck. — Owing  to  the  ai>ex  of  the  prostate 
being  fixed  by  the  triangular  ligament,  the  orifice  of  the  bladder,  which  normally 
is  the  lowest  point  when  the  body  is  erect,  becomes  displaced.  If  the  elongation 
is  uniform  it  is  simply  raised,  so  that  the  bladder  drops  as  it  were  into  a  pouch  in 
front  and  behind  (Fig.  464).  More  frequently,  owing  to  the  greater  amount  of 
the  growth  behind,  it  is  not  only  raised,  but  tilted  forward  so  that  it  faces  toward 
the  pubes  (Fig.  465),  and  instead  of  the  mucous  surface  shelving  smoothly  down 
to  the  urethra,  the  margins  of  the  orifice  are  raised  up  into  irregular  lips  and 
bosses.  The  anterior  pouch  is  never  very  large,  unless  a  calculus  is  impacted  in  it ; 
the  posterior,  on  the  other  hand,  owing  to  the  comparative  thinness  of  the  mus- 
cular coat  above  the  inter-uretral  bar,  and  the  yielding  nature  of  the  tissues  outside. 


HYPERTROPHY  OF  TlIE   PROSTATE. 


1073 


may  be  expanded  by  the  forcing  of  the  urine  down  into  it  until  it  projects  behind 
the  prostate,  between  it  and  the  rectum,  and  sometimes  even  reaches  the 
perineum. 


■■=---a««aat«!?- 


FiG.  464. — Enlargement  of  the  Whole  Prostate,  with  the  Formation  of  Ante-  and 
Post-prostatic  Pouches. 


Fig.  465.— Enlargement  of  Median  Lobe  of  Prostate,  showing  its  Valve-like  Action. 


2.  The  Fundus. — The  alteration  in  the  shape  of  the  neck  soon  produces 
changes  in  the  rest.  For  mechanical  reasons,  the  difficulty  of  emptying  the  blad- 
der becomes  greater.  It  may  be  the  third  lobe  hanging  over  the  orifice  like  a  valve, 
or  the  increased  length  of  the  neck,  forcing  the  bladder  to  act  at  a  disadvantage, 


I074    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

and  increasing  the  resistance.  If  the  obstruction  is  suddenly  developed  the  muscu- 
lar coat  becomes  stretched  until  it  can  no  longer  contract,  and  the  bladder  dis- 
tended until  it  may  reach  as  hij^'h  as  the  umbilicus.  If,  on  the  other  hand,  it  is 
slow  and  gradual,  and  if  the  neck  of  the  bladder  becomes  irritaljle,  so  that  the 
calls  to  micturition  are  more  frequent  than  natural,  the  opposite  effect  is  produced  : 
the  muscular  coat,  under  the  combined  effect  of  increased  work  and  increased  fre- 
quency, becomes  hypertrophied  ;  the  capacity  diminishes,  the  walls  grow  thick  and 
hard,  and  the  bladder  can  neither  collaj^se  nor  expand  as  it  ought. 

So  long  as  the  whole  bladder  is  equally  affected  and  there  is  no  inflammation, 
the  effect  is  similar  to  that  produced  by  any  other  obstructing  cause  ;  the  uterus 
and  the  pelvis  of  the  kidney  become  dilated,  the  renal  substance  is  absorbed,  the 
interstitial  connective  tissue  increases,  the  muscular  coat  of  the  bladder  becomes 
fasciculated  ;  and,  in  advanced  cases,  hernial  protrusions  of  the  mucous  membrane 
make  their  way  between  the  bands  and  enlarge  into  sacculi. 

The  effect,  however,  is  very  seldom  uniform.  Partly  owing  to  the  natural 
weakness  of  the  posterior  wall,  partly  to  the  direction  of  the  pressure  when  the 
bladder  contracts,  the  urine  is  driven  down  into  the  space  behind  the  prostate,  the 
tissues  stretch  more  and  more,  and  the  post-prostatic  pouch  grows  until  it  becomes 
a  receptacle  for  urine,  which  is  known  as  "  residual,"  becau.se  it  cannot  be  exi)elled 
by  the  bladder. 

Unhappily,  this  is  not  all.  If  inflammation  appears  all  the  symptoms  are  in- 
tensely aggravated,  the  bladder  becomes  irritable,  micturition  is  more  frequent, 
the  lining  membrane  is  swollen  and  congested  and  pours  out  an  abundance  of 
mucus  which  collects  behind  the  prostate  ;  the  walls  grow  thicker,  and  the  irrita- 
tion spreads  up  the  ureters,  so  that  catarrhal  pyelitis  and  interstitial  nephritis  soon 
follow. 

If,  in  such  a  condition  as  this,  decomposition  of  urea  takes  place,  and  the 
urine  becomes  ammoniacal,  the  effect  is  infinitely  more  severe.  The  patient  is 
already  broken  down  by  suffering  and  want  of  rest  ;  the  tissues  are  badly  nourished  ; 
the  bladder  is  fasciculated,  perhaps  sacculated  ;  the  mucous  membrane  is  in  a  state 
of  chronic  inflammation  :  the  pelvis  of  the  kidney  is  enlarged  ;.  its  secreting  power 
is  diminished  ;  a  certain  amount  of  urine,  loaded  with  mucus,  is  constantly  re- 
tained in  the  post-prostatic  pouch,  and  though  some  of  this  maybe  changed  when 
the  bladder  becomes  full,  the  urine  in  the  sacculi  (if  there  is  any)  is  not  ;  if,  in 
such  a  condition  as  this,  decomposition  of  urea  once  sets  in,  every  drop  of  urine 
as  it  falls  from  the  ureters  becomes  changed  at  once,  and  the  bladder  in  its  already 
diseased  state  is  filled  with  a  most  intense  irritant  which  it  cannot  expel.  The 
result  is  not  difficult  to  imagine  ;  phosphatic  concretions  form  in  all  the  depres- 
sions :  the  walls  are  covered  with  decomposing  mucus  mixed  with  salts  of  lime  ; 
the  surface  is  eaten  out  by  ulceration  ;  the  pus  spreads  in  the  submucous  tissue, 
extending  between  the  fasciculi  of  the  muscular  coat  ;  the  membrane  that  lines  the 
ureters  and  pelvis  of  the  kidneys  is  almost  destroyed,  and  all  the  renal  substance 
that  the  absorption  and  interstitial  nephritis  have  left  is  riddled  with  abscesses. 

Etiology. — The  cause  of  the  hypertrophy  is  unknown,  though  it  may  be 
compared  with  the  formation  of  fibroid  tumors  in  the  uterus.  The  muscular  system 
of  the  prostate  is  a  continuation  of  that  of  the  bladder,  but  the  gland  itself  is  con- 
nected with  the  sexual  rather  than  the  urinary  organs.  It  scarcely  exists  in  infancy 
and  does  not  attain  any  size  until  puberty  ;  in  adult  life  its  muscular  coat  forms, 
as  it  were,  a  funnel-shaped  prolongation  of  the  neck  of  the  bladder  ;  a  line  of 
separation  can  be  seen  on  section,  but  there  is  nothing  on  the  mucous  surface  to 
point  to  it.  For  some  reason,  possibly  connected  with  the  condition  of  the  sexual 
organs,  it  begins  to  enlarge  as  they  begin  to  wane,  and  the  larger  and  more  com- 
plex it  becomes  the  more  it  acquires  the  appearance  of  a  distinct  and  independent 
structure. 

Harrison  considers  the  prostate  essentially  muscle,  and  holds  that  the  presence 
of  residual  urine  precedes,  and  is  indirectly  the  cause  of,  the  hypertrophy.  For 
various  reasons,  in  old  age  the  floor  of  the  bladder  has  a  tendency  to  sink,  so  that 


HYPERTROPHY  OF  THE  PROSTATE. 


'075 


there  is  difficulty  in  emptying  it  ;  the  continued  effort  causes  the  prostate  and  the 
muscular  band  that  passes  between  the  ureters  to  increase  until  they  coalesce  and 
form  a  sufficiently  powerful  floor.  The  irregularities  of  growth,  and  the  hyper- 
trophy of  the  non-muscular  tissues,  are  secondary  to  this.  The  effect,  if  this  is 
the  case,  is  most  unfortunate,  for  the  hypertrophy,  which  is  intended  to  jirocure 
the  expulsion  of  the  residunl  urine,  makes  matters  tenfold  worse  by  the  changes  it 
induces  in  the  shape  of  the  neck. 

\Vith  more  jirobability  it  has  been  argued  that  the  enlargement  is  the  result 
of  persistent  congestion.  It  is  well  known  that  old  men  with  enlarged  prostates 
are  subject  to  the  most  extraordinary  libidinous  desires,  and  it  is  usual  to  assign 
this  as  the  cause.  That  they  are  connected  is  almost  certain,  but  it  is  not  impos- 
sible that  the  cause  has  been  mistaken  for  the  effect,  and  that  the  latent  erotic 
desires  are  manife.sted  because  at  that  time  of  life  the  control  that  was  formerly 
exercised  over  them  has  become  feeble.  Chronic  congestion  is  certainly  present 
in  enlargement  of  the  prostate  in  a  degree  that  would  not  be  susi)ected  from  post- 
mortem examination  ;  and  though  this  disease  is  met  with  in  all  classes,  it  is  of 
some  significance  that  it  occurs  most  frequently  in  those  who  are  of  full  or  gouty 
habit,  especially  if  they  are  compelled  to  lead  sedentary  lives. 


\^^J^^,\i^ 


Fig.  466. — Section  of  Hypertrophied  Prostate.     (From  Duplay  and  Rectus.) 

U.  Urethra.     E.   Ejaculatory  ducts.     T.  Fibrous  trabeciilae.     C.   Prostatic  nodules.     Z.  Fibro-muscular  capsule. 
V.  Periprostatic  veins.     F.   F'ibro-glandular  tissue.     S.  Section  of  seminal  vesicles. 


The  relation  between  atony  of  the  bladder  and  enlargement  of  the  prostate  is 
another  question.  Harrison  regards  the  former  as  the  origin  of  the  latter  ;  the 
primary  cause  is  the  inability  of  the  bladder  to  empty  itself.  Others  consider  that 
the  two  occur  together  as  a  result  of  senile  degeneration  ;  while  others  believe 
the  atony  to  be  entirely  the  consequence  of  the  obstruction,  compensative  hyper- 
trophy failing  from  age.  Whatever  the  primary  cause  may  be,  there  is  no  doubt, 
so  far  as  the  later  stages  are  concerned,  the  last-mentioned  view  is  the  correct  one. 

Symptoms. — The  symptoms  directly  due  to  the  enlargement  are  so  indefi- 
nite and  gradual  that  in  most  cases  the  disease  is  already  advanced  before  the 
patient  thinks  of  applying  for  relief.  Exceptionally,  retention  occurs  at  an  early 
period. 

Frequency  of  micturition  is  one  of  the  first  symptoms  ;  different  positions  of 
the  body,  various  kinds  of  movement,  especially  rising  from  the  recumbent  posi- 
tion, excite  a  desire  to  micturate  at  once,  and  the  call  must  be  obeyed.  In  the 
daytime  it  may  not  be  severe,  or  perhaps  is  not  much  noticed  ;  but,  especially  if 
much  fluid  is  taken  late  in  the  evening,  the  patient  has  to  get  out  of  bed  several 
times  toward  morning,  or  while  dressing  finds  that  he  is  constantly  desiring  to  pass 


1076     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

water.  In  other  words,  the  muscular  coat  is  beginning  to  fail,  and  though  it  may 
still  be  capable  of  emptying  a  blatlder  thoroughly  when  not  too  full,  it  cannot 
deal  effectually  with  an  accumulation  ;  a  certain  amount  only  isexf)elled  before  it 
is  tired  out,  then  it  must  rest  for  a  time  ;  and  the  difficulty  becomes  greater  every 
day,  until  at  length  a  small  but  constantly  increasing  amount  is  left  permanently 
as  residual  urine. 

For  the  same  rea.son  the  stream  fails  in  strength  ;  it  is  slow  in  coming  and  has 
no  force — the  urine  flows  away  rather  than  is  driven  out  :  there  is  hesitation  at 
the  commencement,  and  the  last  few  drops  fall  without  control. 

Slight  hemorrhage  is  not  unfrecpient,  especially  when  the  call  is  urgent  ;  oc- 
casionally it  is  rather  profuse  ;  obscure  aches  and  pains  are  often  felt  in  the  loins 
or  down  the  thighs  ;  erections  of  the  penis  and  sexual  irritation  may  occur  and  be 
very  annoying.  The  rectum  becomes  affected  by  the  constant  straining  ;  prolapse 
or  hemorrhoids  may  follow  ;  there  is  a  teasing  sense  of  fullness  about  the  anus,  and 
in  advanced  cases  defecation  is  very  liable  to  take  place  simultaneously  with 
micturition. 

Retention  may  occur  at  any  time.  It  may  be  complete,  no  drop  escaping 
from  the  urethra  :  either  the  median  lobe  suddenly  blocks  the  orifice  like  a  valve, 
or  the  congestion  becomes  so  great  that  the  obstruction  is  too  much  for  the  weak- 
ened muscle.  More  often  it  is  gradual  ;  the  residual  urine  increases,  the  strength 
of  the  bladder  diminishes,  and  at  length  it  becomes  so  full  that  it  can  contain  no 
more — the  urine  flows  out  from  it  drop  by  drop  as  it  enters  from  the  ureters.  This 
is  overflow,  and  must  be  clearly  distinguished  from  incontinence,  in  which  the 
bladder  is  empty. 

The  other  symptoms  depend  not  so  much  upon  the  enlargement  as  upon  its 
complications — cystitis  and  pyelonephritis.  Even  when  the  inflammation  is  slight 
the  irritability  of  the  bladder  is  most  distressing  ;  micturition  is  no  sooner  ended 
than  the  burning  begins  again  ;  rest  at  night  is  impossible  ;  the  jiain  never  ceases  ; 
the  appetite  is  lost ;  the  bowels  are  disordered  ;  the  health  is  broken  down  com- 
pletely by  the  ceaseless  suffering,  and  the  patient  becomes  worn  out  and  emaciated. 
But  when  the  urine  becomes  amraoniacal  and  suppurative  pyelonephritis  is  added 
to  the  rest,  the  results  are  infinitely  more  severe.  The  urine  is  offensive,  it  is  loaded 
with  albumin  and  throws  down  a  gelatinous  deposit  of  pus  mixed  with  blood  and 
phosphates,  the  specific  gravity  is  lowered,  the  quantity  fails.  There  is  partial  sup- 
pression, and  partly  from  this,  partly  from  the  constant  suffering  and  the  septic 
absorption  from  the  ulcerated  mucous  membrane  of  the  bladder,  the  constitution 
becomes  utterly  broken  down.  The  temperature  may  not  rise,  sometimes  it  is  even 
subnormal,  but  the  tongue  becomes  dry  and  brown  ;  the  pulse  small  and  quick  ; 
low  muttering  delirium  sets  in  ;  the  restlessness  is  extreme,  the  patient  wants  inces- 
santly to  get  out  of  bed  ;  the  strength  fails  completely,  and  exhaustion  or  urasmia 
and  coma  speedily  follow. 

Diagnosis. — Enlargement  of  the  prostate  can  only  be  proved  by  an  e.xamina- 
tion  of  the  urethra  or  rectum,  or  the  two  together.  If  the  rectum  only  is 
examined,  the  patient  may  either  stand  with  the  feet  slightly  separated  and  stoop 
forward  over  the  end  of  a  sofa,  or,  more  comfortably,  lie  on  his  side  close  to  the 
edge  of  a  firm  couch  with  the  knees  drawn  well  up.  The  central  portion  of  a 
healthy  prostate  is  soft  and  yielding,  the  sides  are  more  firm,  but  shade  off  gradu- 
ally into  the  tissues  around  ;  when  it  is  enlarged  it  feels  dense  and  resistant,  or  the 
consistence  is  uneven,  and  the  outline  more  sharply  marked  and  irregular.  In 
extreme  cases  a  shapeless  mass  projects  into  the  rectum,  extending  far  beyond  the 
reach  of  the  finger,  both  above  and  on  either  side. 

The  degree  of  obstruction  can  only  be  ascertained  by  pa.ssing  a  catheter  ;  if 
the  growth  extends  toward  the  rectum,  the  power  of  the  bladder  may  not  be  much 
impaired  ;  on  the  other  hand,  a  very  slight  enlargement  of  the  middle  lobe  may 
cause  complete  retention.  A  sound  may  be  used,  but  as  instruments  are  always  an 
evil,  it  is  better  to  take  a  catheter,  and  to  direct  the  patient  to  empty  the  bladder 
first,  so  that  not  only  the  shape  of  the  gland  but  the  amount  of  the  residual  urine 


in  PERTROrJIY  01'    yj/K   J'/W state.  1077 

may  l>e  ascertained.  Tlic  lcnj,^th  of  the  enlargement  may  be  judged  by  the  distance 
the  catheter  passes  before  entering  the  bhidder  ;  the  height  to  which  the  middle 
lobe  rises  by  the  depth  to  which  tlie  handle  of  the  instrument  uuist  be  depressed 
between  the  patient's  legs.  'I'he  most  accurate  information  is  obtained  by  con- 
joined rectal  and  urethral  examination  ;  the  distance  between  the  catheter  and  the 
finger  can  be  estimated,  and  the  jiresence  of  irregular  nodules  or  uneven  enlarge- 
^ment  of  one  lobe  better  made  out. 

Enlargement  due  to  inflammation  is  distinguished  by  the  pain  and  the  sensa- 
tion of  heat  in  the  rectum,  but  it  must  not  be  forgotten  that  a  certain  amount  of 
chronic  intlammation  is  not  uncommon  in  enlargement  of  the  j^rostate,  even  when 
instruments  have  not  been  used.  How  far  the  increase  is  due  to  passive  congestion 
is  much  more  difficult  ;  but  if  the  mucous  meml^rane  bleeds  very  readily  when  a 
large  instrument  is  passed,  and  the  hemorrhoidal  veins  are  much  enlarged,  it  is 
probable  that  some  at  least  is  caused  by  this.  In  malignant  disea.se  of  the  prostate 
the  growth  is  more  rapid  and  the  i)ain  more  intense,  radiating  from  the  perineum 
down  the  thighs.  (Generally  the  prostate  is  softer  ;  and  profuse  hematuria,  toward 
the  end  of  micturition,  is  the  rule.   . 

It  is  not  sufficient,  however,  to  make  out  that  the  prostate  is  enlarged,  or  even 
that  the  median  lobe  has  grown  out  and  obstructs  the  flow  ;  the  condition  of  the 
bladder  must  be  ascertained  as  well,  how  far  it  is  already  in  a  state  of  atony,  and 
what  amount  of  residual  urine  is  left.  This  can  only  be  done  by  passing  a  catheter  ; 
but  as  this  is  a  proceeding  which  is  sometimes  followed  by  very  serious  consequences, 
especially  when  done  for  the  first  time,  or  when  there  is  residual  urine,  certain  pre- 
cautions should  always  be  adopted.  The  patient  should  be  directed  to  lie  down 
and  keep  warm  and  quiet  for  the  rest  of  the  day ;  it  is  best  for  him  to  remain  in 
bed,  but  at  any  rate  he  should  not  go  out  or  expose  himself  to  cold.  Before  the 
catheter  is  passed  the  bladder  should  be  emptied  as  thoroughly  as  possible  ;  the 
object  is  to  find  out  the  quantity  that  cannot  be  expelled  ;  not  unfrequently  this 
must  be  done  on  more  than  one  occasion  before  the  amount  can  be  definitely  fixed, 
as  from  nervousness  or  other  causes  it  often  happens  that  the  bladder  does  not  act 
so  well  as  usual.  The  best  instrument  is  a  soft  rubber  catheter  of  moderate  size ; 
or,  if  this  will  not  find  its  way  in,  a  black  one  wnth  the  i)oint  well  bent  up  {coude), 
or  a  gum-elastic  fitted  with  a  stylet,  so  that  if  its  progress  is  stopped  abruptly  the 
end  may  be  tilted  up.  If  a  large  amount  of  residual  urine  has  been  drawn  off  (more 
than  five  or  six  ounces)  a  smaller  quantity  of  a  warm  antiseptic  solution  should  be 
introduced  and  left ;  the  bladder  cannot  readily  accustom  itself  to  such  altered 
conditions,  and  must  be  gradually  educated,  the  quantity  being  reduced  every 
second  or  third  day.  In  all  such  cases  the  patient  should  be  cautioned  that  there 
is  almost  certain  to  be  some  slight  fever  after  the  operation,  and  that  rest  in 
bed  until  the  temperature  is  normal  and  the  bladder  has  grown  accustomed  to  its 
new  condition  is  absolutely  essential. 

Treatment. — 1.  Palliative. — (a)  General. — The  treatment  of  enlargement 
of  the  prostate  depends  upon  the  condition  of  the  bladder.  If  the  patient's  rest  is 
not  seriously  disturbed  at  night,  and  if  there  is  only  a  small  amount  of  residual 
urine,  every  effort  must  be  made  to  maintain  the  strength  of  the  muscular  coat  and 
prevent  it  being  strained.  The  bowels  must  be  opened  regularly  ;  micturition  per- 
formed at  stated  times  ;  a  regular  amount  of  fluid  taken,  anything  late  at  night 
especially  being  avoided  ;  and  wines  and  spirits  consumed  very  sparingly.  The 
clothing  should  be  warm,  so  that  there  is  no  sudden  chill  or  congestion  of  internal 
organs  ;  and,  especially  if  there  is  any  tendency  to  gout,  the  diet  should  be  light 
and  without  much  meat,  so  that  the  urine  may  be  as  little  irritating  as  possible. 

{b)  Catheters. — If,  however,  as  generally  happens,  the  atony  of  the  muscular 
coat  is  already  advanced,  and  if  two  or  three  ounces  of  residual  urine  are  found  in 
the  bladder  on  more  than  one  occasion,  showing  that  it  is  habitual,  means  must 
be  taken  to  remove  it  thoroughly,  at  least  once  in  the  twenty-four  hours.  It  is 
true  that  the  passage  of  a  catheter,  under  these  conditions,  is  liable  to  cause  urinary 
fever,  even  when  every  precaution  is  adopted  ;  and  that,  if  no  other  treatment  than 


I078     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

that  already  described  is  employed, the  patient  may  go  on  for  some  years, though  with 
great  inconvenience  ;  but,  all  that  time,  the  amount  of  residual  urine  is  increasing, 
the  muscular  coat  of  the  bladder  is  becoming  weaker,  its  recuperative  power  more 
feeble,  and  the  kidneys  more  and  more  diseased,  so  that,  when  at  length,  after 
years  of  suffering  and  ai)prehension,  the  catheter  becomes  absolutely  necessary, 
urinary  fever  of  the  worst  sort  is  almost  certain  to  follow.  There  is  abundance  of 
evidence  to  show  that  the  ill  results  which  are  occasionally  met  with  after  catheter- 
ism  in  cases  of  enlarged  prostate  not  complicated  by  cystitis,  are  proportionate  in 
their  severity  to  the  amount  of  residual  urine,  and  postponing  the  commencement 
of  catheter-life  until  it  cannot  be  avoided  merely  means  running  a  far  greater  risk 
of  urinary  fever,  without  having,  in  the  meantime,  increased  in  any  way  the 
patient's  comfort. 

The  instrument  should  be  the  softest  and  most  flexible  that  can  be  introduced  ; 
and  the  greatest  care  must  be  taken  that  it  is  thoroughly  cleansed  inside  as  well  as 
out,  before  as  well  as  after  using.  It  is  not  a  bad  plan  to  keep  it  in  a  solution  of 
carbolic,  frequently  changed,  though  the  catheter  itself  soon  becomes  spoiled.  The 
best  time  for  beginning  is  when  the  patient  is  warm  in  bed,  and,  if  he  is  not 
already  accustomed  to  the  use  of  instruments,  he  should  be  recommended  to  keep 
in  bed  for  a  couple  of  days,  and  to  remain  in  his  room  for  a  week,  even  if  all  goes 
well.  A  week  is  none  too  long  to  give  up  altogether  in  such  a  case.  The  bowels 
should  be  kept  open  ;  a  warm  hip  bath  taken  every  night ;  and,  if  the  kidneys  are 
sound,  and  the  urine  of  fair  specific  gravity,  a  small  dose  of  opium  may  be  given 
an  hour  or  two  before  the  catheter  is  passed.  The  temi)erature  should  be  watched, 
and,  if  there  is  the  least  shivering,  a  full  dose  of  quinine  given  in  a  cupful  of  hot 
tea.  Unfortunately,  the  form  of  urethral  fever  that  occurs  in  these  cases  is  not  that 
characterized  by  a  single  severe  rigor,  with  temporary  renal  congestion,  and  which, 
though  exceedingly  alarming,  is  rarely  followed  by  serious  results.  Much  more 
frequently  the  fever  is  continued  and  commences  insidiously,  the  temperature  not 
rising  for  some  hours,  and  then  rarely  reaching  102°  or  103°  F.  When  this  occurs 
the  most  prominent  feature  is  the  prostration  ;  the  pulse  becomes  quick  and  small  ; 
the  tongue  brown  and  furred,  and  the  eyes  sunken  ;  there  is  constant  delirium, 
especially. at  night  ;  the  patient  is  incessantly  trying  to  get  out  of  bed  ;  the  quantity 
of  urine  is  deficient  ;  its  specific  gravity  is  below  normal  and  it  always  contains 
mucus  and  generally  albumin.  Symptoms  of  this  kind  seldom  occur  unless  the 
kidneys  are  already  in  a  state  of  advanced  interstitial  nephritis — the  secreting  power 
is  already  diminished  ;  the  additional  irritation,  setting  up  congestion,  leads  to 
partial  suppression  ;  typhoid  symptoms  follow,  and  unless  there  is  a  rapid  change, 
uraemia  and  coma  are  inevitable. 

As  soon  as  the  bladder  has  become  accustomed  to  the  sensation  of  being  emp- 
tied, and  the  urethra  to  the  passage  of  a  catheter,  the  patient  may  be  taught  to  pass 
one  for  himself.  The  best  time  is  the  last  thing  at  night,  before  retiring  to  rest, 
so  that  some  hours'  sound  sleep  may  be  secured  ;  but  if  the  amount  of  residual 
urine  is  constantlv  above  three  ounces,  the  instrument  should  be  passed  night  and 
morning  ;  and  if  between  three  and  six,  three  times  a  day.  It  is  better  to  do  it 
too  often  than  too  seldom  ;  if  distention  is  avoided,  the  muscular  coat  may  regain 
some  of  its  power,  and  though  the  residual  urine  never  disappears  altogether,  it 
diminishes  considerably  in  quantity.  One  single  instance  of  over-distention,  how- 
ever, is  sufficient  to  undo  all  the  good.  When  once  the  commencement  of  cathe- 
ter-life has  been  pa.ssed,  there  is  no  reason  why,  if  only  reasonable  j^recautions  are 
taken,  especially  against  the  occurrence  of  cystitis,  the  patient  should  not  resume 
active  habits  of  life  again. 

When  there  is  cystitis,  more  active  measures  are  required.  It  may  be  due  to 
the  catheter,  or  to  an  irritating  condition  of  the  urine,  or  possibly  to  the  obstruc- 
tion cau-sed  by  the  projecting  masses  of  the  prostate  ;  whatever  the  cause,  if  left 
to  itself,  it  can  only  grow  worse  and  spread  to  the  ureters  and  kidneys.  The  blad- 
der is  unable  to  empty  itself,  the  irritability  of  the  mucous  membrane  is  so  intense 
that  the  contraction  never  ceases  ;   the  muscular  coat  becomes  hypertrophied  ;  the 


HYPERTROrilV  OF  THE  PROSTATE. 


1079 


alkaline  mucus  collects  in  the  post-prostatic  pouch,  from  which  it  cannot  be  evacu- 
ated ;  the  urine  becomes  peculiarly  offensive  ;  at  length  ammoniacal  decomposi- 
tion sets  in.  and  the  inflammation,  which  at  first  was  simply  catarrhal,  runs  on 
rapidly  to  ulceration  and  sloughing. 

As  soon  as  it  begins  the  bladder  must  be  thoroughly  washed  out,  so  that  the 
post-jjrostatic  pouch  may  be  completely  cleared.  If  there  is  a  j^rofuse  secretion  of 
mucus  (catarrh),  hot  salt  and  water  (a  teaspoonful  to  the  pint)  may  be  used  first, 
and  then  a  mild  astringent,  acetate  of  lead  (.06  ad  32  c.  c),  nitrate  of  silver,  or, 
better,  bichloride  of  mercury  (.03  ad  32  c.  c),  on  account  of  its  powerful  antiseptic 
qualities.  Permanganate  of  potash,  borax  with  glycerine,  quinine,  tannin,  and  many 
other  substances  have  also  been  used.  If  there  is  much  phosjjhatic  deposit,  dilute 
nitric  (gtt.  j  vel  ij  ad  32  c.  c),  or  phosjjhoric  (gtt.  iij  ad  32  c.  c.)  acid  is  of  ser- 
vice. Meantime  the  jjatient  should  be  kept  warm,  if  jjossible  in  bed,  on  light  or 
even  milk  diet  ;  baths  should  be  given  every  night,  the  bowels  kept  well  open,  and 
the  state  of  the  urine  carefully  watched.  Stimulants  do  no  good,  but  sometimes 
they  must  be  given.  If  the  irritability  is  very  great,  morphia  suppositories  may  be 
tried,  or  a  few  drops  of  tincture  of  opium  injected  into  the  bladder  after  it  has 
been  washed  out.  Quinine  appears  of  service  when  given  internally,  possibly  be- 
cause some  of  it  is  excreted  in  the  urine  ;  and,  if  it  does  not  upset  the  patient, 
benzoate  of  ammonia  helps  to  keep  the  urine  acid  ;  but  the  cause  and  the  treat- 
ment are  both  mainly  local. 

(r)  Drairiage. — Patients  with  enlargement  of  the  prostate  have  been  known 
to  live  for  thirty  years  in  comparative  comfort,  using  a  catheter  two  or  three  times 
a  day  ;  but  not  unfrequently,  as  age  advances,  the  bladder  becomes  more  irritable, 
and  the  necessity  for  passing  an  instrument  more  frequent,  until  at  length  it  has 
to  be  done  every  hour,  night  and  day,  rendering  existence  a  burden.  The  prostate 
is  swollen  and  tender ;  sometimes  there  is  ulceration  at  the  neck  of  the  bladder, 
causing  extreme  tenesmus  ;  or  there  are  pouches  which  cannot  be  drained  and 
\vhich  are  constantly  infecting  the  rest  of  the  urine  ;  or  the  bladder  has  become  so 
rigid  and  contracted  that  it  can  only  retain  a  few  ounces  ;  and  sometimes  there  are 
calculi.  At  length  the  suffering  becomes  extreme  ;  day  and  night  there  is  most 
agonizing  pain  ;  the  catheter  is  wanted  every  minute,  and  every  time  it  is  passed 
only  makes  the  condition  worse. 

Temporary  relief  in  these  cases  may  always  be  obtained  by  draining  the  blad- 
der. This  is  easily  done  by  the  operation  known  as  "  la  boutonniere."  The 
patient  is  anaesthetized,  placed  in  the  lithotomy  position,  and  a  grooved  staff  passed 
into  the  bladder.  The  left  forefinger  is  placed  in  the  rectum  to  fix  the  apex  of 
the  prostate,  and  an  incision  three-quarters  of  an  inch  in  length  made  exactly  in 
the  middle  line  of  the  perineum,  an  inch  in  front  of  the  anus.  This  is  deepened 
until  the  membranous  portion  of  the  urethra  is  opened  behind  the  bulb.  A  direc- 
tor is  then  passed  along  the  staff  into  the  bladder,  the  staff  withdrawn,  and  the  fore- 
finger of  the  right  hand  gently  pressed  through  the  prostatic  urethra,  dilating  it 
as  it  goes.  If  no  calculus  is  found,  and  there  is  nothing  about  the  shape  of  the 
prostate  or  in  the  cavity  of  the  bladder  to  account  for  the  persistence  of  the 
symptoms,  a  large  rubber  tube  is  passed  through  the  perineal  wound  into  the  blad- 
der, and  connected  with  a  receptacle  under  the  bed,  so  that  every  drop  of  urine 
flows  out  at  once.  The  effect  of  this  is  most  striking:  the  need  for  the  catheter 
ceases  entirely,  the  night's  rest  is  uninterrupted,  the  pain  disappears,  and  the  patient 
can  sit  up  comfortably  in  bed.  The  mucous  membrane,  being  no  longer  in  con- 
stant contact  with  foul,  decomposing  urine,  begins  to  throw  off  its  coating  of 
mucus  and  phosphates,  the  ulcers  heal,  the  absorption  of  septic  material  from  the 
bladder  ceases,  the  reaction  of  the  urine  becomes  acid  again,  the  blood  disappears, 
and  the  deposit  begins  to  diminish.  As  soon  as  the  condition  of  the  bladder  is 
thoroughly  restored,  the  tube  may  be  withdrawn  and  the  opening  allowed  to 
close. 

Harrison  adopts  a  simple  process.  A  straight  trocar  and  cannula  is  intro- 
duced in  the  middle  line  of  the  perineum  an  inch  in  front  of  the  anus  and  pushed 


loSo     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

through  the  substance  of  the  prostate  until  the  bladder  is  tapped  ;  then  the  trocar 
is  withdrawn,  a  self-retaining  catheter  introduced  in  its  place,  and  the  cannula  re- 
moved. As  soon  as  the  urine  begins  to  improve,  the  patient  is  allowed  to  get  up 
and  move  about ;  and,  if  it  is  thought  desirable,  the  apparatus  may  be  permanently 
retained,  the  catheter  being  connected  by  means  of  a  rubber  tube  with  a  urinal 
strap])ed  on  to  the  leg.  The  amount  of  leakage  by  the  side  is  very  slight.  In 
most  ca.ses,  after  a  few  weeks  the  urine  begins  to  come  through  the  urethra  again  ; 
and  this  may  be  taken  as  a  signal  that  the  drain  is  no  longer  needed.  Harrison 
has  noted  the  curious  fact  that  in  several  of  these  cases  the  prostate  has  shrunk  to 
such  an  extent  after  the  operation  that  the  enlargement  can  hardly  be  detected 
through  the  rectum,  and  the  patient  experiences  little  or  no  difficulty  with  his  urine 
afterward. 

In  extreme  ca.ses,  in  which,  owing  to  the  enormous  size  of  the  prostate  or  to 
other  special  complications,  a  permanent  opening  affords  a  better  chance  of  relief, 
sui)rapubic  puncture  may  be  i)erformed  ;  or  the  bladder  may  be  deliberately 
opened  in  the  same  region  and  cleared  of  all  adhering  mucus  and  phosphates,  a 
properly  arranged  tube  and  urinal  being  worn  afterward,  as  in  cases  of  im]>erme- 
able  stricture. 

Other  complications  that  occur  in  the  course  of  enlargement  of  the  i)rostate 
may  require  special  treatment.    Retention  of  urine  must  be  relieved  by  catheter  as 


Fig.  467. — Watson's  Cannula  in  Position. 


soon  as  possible.  The  muscular  coat  is  already  in  a  state  of  partial  atony,  and  a 
slight  degree  of  over-distention  is  sufficient  to  increase  it  until  the  power  of  con- 
traction is  permanently  lost.  If  the  catheter  cannot  be  passed,  hot  baths  and 
similar  remedies  are  useless  ;  an  opening  must  be  made  in  the  bladder  at  once,  but 
the  necessity  for  this  is  very  rare. 

Hemorrhage  is  seldom  serious  ;  sometimes  it  ai)pears  to  give  relief,  especially 
the  slight  amount  which  in  some  patients  is  so  constant  as  almost  to  deserve  to  be 
called  periodic.  When  it  follows  the  use  of  a  catheter  it  may  either  be  due  to 
rupture  of  the  engorged  veins,  or  to  the  effect  of  suddenly  relieving  the  pressure 
upon  the  wall  of  the  bladder.  In  either  ca.se  the  blood  and  the  urine  are  inti- 
mately mixed,  and  though  the  color  may  be  bright  red  just  at  first,  it  soon  becomes 
smoky  and  brown.  The  patient  should  be  kept  quiet  in  bed,  and  the  urine  drawn 
off  as  occasion  requires  with  a  soft  catheter;  special  treatment  is  seldom  needed. 
If  it  persists,  the  bladder  may  be  washed  out  with  an  iced  infusion  of  matico 
or  tincture  of  hamamelis,  and  opium  with  garlic  and  sulphuric  acids  given  in- 
ternally. Clots,  as  a  rule,  disintegrate  of  themselves,  but  they  may  require  an 
evacuator. 

If  there  is  extreme  jiain  at  the  neck  of  the  bladder  when  the  catheter  touches 
a  certain  spot,  and  ulceration  or  fissure  can  be  diagnosed  by  the  endosco])e,  a 
solution  of  nitrate  of  silver  (gr.  v  ad  3J)  may  be  brushed  over  it  with  a  properly 


HYPERrROPHY  OF  THE  PROSTATE.  1081 

arranged  injector.  Sacculi  in  the  walls  should  be  drained  and  washed  out  like  the 
rest  of  the  bladder,  but  the  openings  are  so  small  that  it  is  seldom  possible  to  find 
them  without  the  aid  of  a  cystoscope.  The  ordinary  method  of  washing  out  the 
bladder  merely  tends  to  make  them  larger,  as  it  fills  them  under  pressure  with  fluid 
which  they  cannot  expel  again.  On  the  other  hand,  there  are  .several  cases  on 
record  in  which  regular  drainage  has  led,  if  not  to  their  disappearance,  at  least  to 
their  causing  no  further  trouble.  They  may  sometimes  be  susjjected  from  the 
peculiar  character  of  the  urine,  or  from  the  way  in  which  a  catheter,  after  passing 
the  normal  distance  and  drawing  off  one  kind  of  urine,  suddenly  slips  in  further 
and  draws  off  something  different. 

Phosphatic  calculi  are  not  at  all  uncommon,  but  fortunately  they  are  so  soft 
that  they  can  be  crushed  and  washed  out  without  prolonged  instrumentation.  It 
is  always  advisable,  however,  not  to  allow  them  to  attain  too  large  a  size.  Recur- 
rence is  very  common,  as  the  same  conditions  persist. 

2.  Operative  Treatment. — In  i)erforniing  lateral  lithotomy  portions  of  the 
prostate  have  often  been  removed  without  ill  consequence  of  any  kind.  Some  of 
these  were  pedunculated  mas.ses  projecting  into  the  urethra  or  the  bladder,  so  that 
they  were  caught  (occasionally  by  accident)  in  the  blades  of  the  forceps  ;  others 
were  growths  in  the  substance  of  the  gland  itself,  which  shelled  out  from  the 
pressure  of  the  finger  as  soon  as  the  tissues  around  them  were  incised.  Moreover, 
the  gland  has  been  repeatedly  punctured  from  the  perineum,  and  by  means  of 
catheters  through  the  urethra.  Occasionally  there  has  been  hemorrhage,  and  sup- 
puration and  sloughing  have  been  known  to  follow,  though  rarely  ;  as  a  rule,  the 
wound  heals  without  difficulty,  sometimes  relieving  the  condition  of  the  bladder 
by  making  a  direct  channel  to  the  pouch  behind.  In  a  few  instances  it  has  been 
noticed  that  after  these  partial  operations  the  prostate  has  imdergone  a  kind  of 
subinvolution,  and  diminishes  to  an  extent  that  cannot  be  accounted  for  even 
when  allowance  is  made  for  the  cessation  of  the  congestion  and  for  cicatrization. 
Whether  in  this  there  is  a  further  analogy  to  the  fibromyomata  of  the  uterus 
remains  to  be  proved.  Unfortunately,  it  does  not  happen  with  sufficient  frequency 
to  enable  any  reliance  to  be  placed  upon  it. 

In  some  of  the  cases  in  which  the  residual  urine  has  been  drained  in  this 
way,  even  when  the  amount  was  large,  the  bladder  has  recovered  its  tone,  the 
irritability  has  subsided,  and  catheters  have  been  dispensed  with.  The  question, 
therefore,  arises  whether  it  is  not  possible,  without  running  too  much  risk,  to  pro- 
duce the  same  result  at  an  earlier  period,  before  the  bladder  and  the  kidneys  are 
irretrievably  ruined. 

There  are  three  ways  in  which  the  prostate  may  be  approached  :  through 
the  urethra,  through  the  perineum,  and,  after  suprapubic  cystotomy,  through  the 
bladder. 

{a)  Urethral  Operations. — Of  these  the  best  known  are  Mercier's  and  Bot- 
tini's.  In  the  former  an  instrument  shaped  like  a  short-beaked  lithotrite,  with 
tolerably  sharp  edges,  is  used  to  punch  out  portions  of  the  floor.  In  the  latter  a 
fresh  urethra  is  bored  through  the  sub.stance  of  the  gland  by  means  of  the  galvano- 
cautery. 

This  has  been  done  on  several  occasions  (once  on  a  medical  man  without 
an  anaesthetic)  with  very  distinct  benefit.  In  the  first  case  the  residual  urine 
amounted  to  thirteen  ounces,  and  the  dysuria  was  so  great  that  a  catheter  had  to 
be  passed  every  two  hours,  night  and  day ;  the  operation  only  lasted  forty-five 
seconds ;  there  was  no  fever  afterward,  and  the  bladder  regained  a  great  deal  of 
its  power.  In  others,  however,  there  has  been  severe  vesical  tenesmus  after  the 
operation,  and  sloughs  have  continued  to  come  away  through  the  urethra  for  up- 
ward of  three  weeks. 

(b)  Perineal  Operation. — In  this  an  incision  is  made  in  the  middle  line,  in 

front  of  the  anus,  and  the  membranous  portion  of  the  urethra  opened  as  in  the 

operation  for  draining  the  bladder.     The  finger  is  then  passed  into  the  prostatic 

portion  and  the  obstruction  dealt  with  according  to  its  shape  and  position.      A 

69 


ioS2     DISEASES  AND  INJURIES  OF  SPECIAI  STRUCTURES. 


median  outgrowth,  if  sufficiently  pedunculated,  may  be  excised  or  removed  by 
.means  of  a  snare  ;  if  it  is  sessile  it  may  be  punched  out  with  a  modification  of 
Mercier's  prostatome,  or  incised  with  a  straight  probe-pointed  knife,  and  then 
torn  with  the  finger  until  the  passage  into  the  jjouch  is  straight.  Sometimes  it 
answers  better  to  pass  a  curved  bistoury  through  the  substance  of  the  gland  into 
the  post-prostatir  pouch,  and  cut  into  the  urethras©  as  to  ensure  that  division  is 
complete.  Afterward  a  full-sized  drainage  tube  is  introduced  and  retained  until 
the  urine  begins  to  come  by  the  natural  route.  When  it  is  withdrawn  the  perineal 
wound  usually  closes  rapidly.      If  the  section  is  sufficiently  deep  a  catheter  is  not 

recjuired    afterward,   but  it  should  still   be 

^ i:)assed  occasionally  as  a  precaution. 

{/)  Sitprapiibic  Operation. — This  was 
first  performed  after  the  removal  of  calculi, 
and  sub.sequently  as  an  independent  opera- 
tion. The  rectum  must  be  distended,  as  in 
suprai)ubic  cystotomy,  and  the  incisions 
through  the  abdominal  wall  and  into  the 
bladder  made  with  the  usual  precautions. 
The  finger  is  then  introduced  to  ascertain 
the  size  and  shape  of  the  mass.  There  are, 
according  to  McGill,  three  chief  varieties 
admitting  of  surgical  relief:  in  the  first 
there  is  a  uniform  circular  projection  sur- 
rounding the  internal  orifice  of  the  urethra  ; 
in  the  second  a  se.ssile  enlargement  of  the 
median  lobe  situated  partly  in  the  prostatic 
urethra  and  partly  in  the  position  of  the 
uvula  vesicae ;  in  the  third  a  pedunculated 
outgrowth.  Of  these  the  last  can  be  re- 
moved easily  with  scissors,  and  the  second 
may  be  treated  in  the  same  way  by  dividing  the  mucous  membrane  over  it  freely 
and  tearing  it  with  forceps.  The  scissors  should  have  long  handles  with  short 
blades,  curved  in  various  directions.  The  collar  enlargement  is  more  difficult. 
McGill  divides  it  longitudinally,  first  in  front  and  then  behind,  by  inserting  one 
blade  of  the  scissors  into  the  urethra,  and  cutting  in  each  direction.  By  this  the 
projecting  part  is  divided  into  two  halves,  which  can  be  removed  by  enucleation 
with  the  finger.  The  whole  of  the  projecting  valve  must  be  excised,  and  after 
the  operation  the  forefinger  must  be  pa.ssed  down  the  urethra,  to  make  certain  that 
it  is  free.  Hemorrhage  is  checked  by  a  hot  antiseptic  solution  ;  and  the  bladder 
drained  with  a  tube  through  the  lower  angle  of  the  wound  for  forty-eight  hours. 

It  is  impossible  at  the  present  time  to  give  a  definite  opinion  as  to  the  relative 
or  absolute  merits  of  these  operations.  The  last  is  the  most  complete,  but  at  the 
same  time  by  far  the  most  serious.  Mercier's  is  certainly  insufficient,  and  shares 
with  Bottini's  the  grave  disadvantage  of  uncertainty.  It  is  scarcely  possible,  even 
with  the  aid  of  the  .sound  and  the  cystoscope  (when  this  can  be  used)  to  obtain 
sufficiently  definite  information  concerning  the  relations  of  the  prostate  and  the 
bladder  under  their  altered  conditions. 

The  choice  between  the  suprapubic  and  perineal  operations  rests  on  different 
grounds.  There  are  three  chief  factors  upon  which  the  selection  depends  ;  of  these 
two  can  be  a.scertained  before  anything  is  done  ;  the  third  cannot.  One  is  the 
distance  of  the  bladder  from  the  perineum  ;  if  this  is  more  than  three  inches  and 
a  half  the  finger  cannot  reach  it,  and  the  operation  becomes  exceedingly  difficult. 
Possibly  the  urethroscope  with  a  very  wide  tube,  used  through  the  perineal  opening, 
might  prove  of  assistance,  but  the  view  would  soon  be  obscured  by  the  bleeding. 
The  second  is  the  condition  of  the  bladder  ;  if  it  is  small,  rigid,  and  degenerate 
from  chronic  cystitis,  the  sujjrapubic  operation  is  out  of  the  question.  The  third 
is  the  shape  of  the  obtruding  mass.      In  a  small  ])roportion  of  cases  this  is  such  as 


Fig.  468. — Neck  of  the  Bladder  seen  from  within, 
in  a  case  of  Enlarged  Prostate.  The  orifice 
of  the  urethra  lies  in  the  angle  between  the 
two  projections. 


PA'OSTAT/r/S.  1083 

to  preclude  effectual  removal  through  a  perineal  opening,  but  this  can  only  be  as- 
certained by  actual  exploration. 

The  perineal  operation  is  the  more  simple  :  it  gives  much  jjetter  drainage,  and 
these  cases  nearly  always  retiuire  it,  owing  to  the  presence  of  cystitis,  and  perhaps 
ammoniacal  urine.  I  have  performed  prostatotomy  through  it  on  several  occasions 
with  very  great  benefit  ;  prostatectomy,  sufficient  to  remove  the  median  obstruc- 
tion and  relieve  the  bladder,  is  possible  in  a  large  ])roportion  of  cases  ;  and  finally, 
in  the  few  instances  in  which  jjrostatectomy  cannot  be  managed  in  this  way,  and 
is  possible  by  the  suprapubic  method,  the  j)erineal  opening  does  not  add  materially 
to  the  gravity  of  the  operation,  and  is  of  the  greatest  assistance  for  draining  the 
bladder  and  preventing  septic  absorption  afterward. 

Malignant  Disease  of  the  Prostatf.. 

Carcinoma  and  sarcoma  both  occur,  but  the  former  is  the  more  common.  It 
is  usually  of  the  glandular  or  spheroidal-celled  tyjje,  and  is  more  often  soft  than 
hard.      Colloid  carcinoma  has  also  been  described. 

Symptoms. — Carcinoma  is  generally  met  with  after  middle  life  ;  sarcoma 
may  occur  earlier.  The  symptoms  at  the  first  are  the  same  as  those  of  simple 
enlargement  or  chronic  inflammation,  but  they  soon  become  more  intense  and 
acute.  The  obstruction  to  the  flow  of  urine  comes  on  more  quickly  ;  the  uneasi- 
ness and  frequency  of  micturition  are  more  marked,  and  the  pain  is  more  severe, 
radiating  from  the  perineum  down  the  thigh  and  to  the  end  of  the  penis.  Later, 
as  the  disease  advances,  it  may  become  agonizing.  Hemorrhages  are  common, 
often  profuse,  occurring  with  or  without  micturition,  and  tending  greatly  to  reduce 
the  patient's  strength.  Cystitis  and  decomposition  of  the  urine  follow  ;  the  glands 
in  the  iliac  region  become  involved,  and  death  usually  occurs  in  a  comparatively 
short  time  from  exhaustion,  interference  with  the  urinary  secretion,  want  of  rest, 
and  pain. 

Operative  treatment  is  practically  out  of  the  question,  though  in  one  or  two 
instances  obstructing  portions  have  been  removed  with  a  certain  amount  of  benefit. 
Suprapubic  puncture  at  an  early  period  is  more  effectual,  though  this  cannot  relieve 
the  pain.  The  bowels  must  be  kept  gently  relaxed,  a  soft  catheter  used  when 
required,  the  interior  of  the  bladder  washed  out  with  weak  antiseptics,  and  the 
pain  controlled,  as  far  as  possible,  by  means  of  morphia. 

Prostatitis. 

Inflammation  of  the  prostate  may  be  either  follicular  or  parenchymatous.  In 
the  former,  the  mucous  membrane  and  the  follicles  opening  upon  it  are  chiefly 
concerned  ;  abscesses  may  form,  but  they  are  rarely  large,  and  they  always  burst 
into  the  urethra.  In  the  latter,  the  whole  substance  of  the  gland  is  involved  ; 
and,  if  suppuration  occurs,  the  pus  may  spread  into  the  tissues  around,  and  point 
in  the  perineum,  or  even  in  the  groin. 

I .   FoUicula)-  Prostatitis. 

This  may  be  either  acute  or  chronic.  The  former  is  usually  due  to  gonorrhoea, 
but  it  may  be  caused  by  injury  (impaction  of  calculi,  the  passage  of  large  instru- 
ments, or  the  use  of  caustics),  especially  if  the  gland  is  already  in  a  state  of  con- 
gestion from  excessive  sexual  excitement,  advanced  stricture,  or  other  causes, 
pjicycle  riding  is  said  to  produce  the  same  effect.  It  is  very  doubtful  if  simi)le 
irritation  by  the  urine  is  sufficient  to  bring  it  on,  though  it  may  prevent  its  getting 
well.  The  chronic  form  is  either  the  result  of  the  acute,  or  commences  as  such, 
from  similar  causes  acting  with  less  energy. 

{a)  Acute. — This  usually  occurs  during  the  acute  stage  of  gonorrhoea,  liut  it 
may  be  brought  on  later  by  the  use  of  injections  or  the  passage  of  instruments. 
There  is  intense  burning  at  the  neck  of  the  bladder ;  the  desire  to  pass  water 


io84    DISEASES  AND  INJURIES  OF  SPECIAL  S'IRUCTURES. 

never  ceases  ;  the  stream  from  the  first  is  small  ;  a  few  drops  only  are  ejected, 
without  the  least  relief,  and  even  this  may  be  im|)ossible.  There  is  violent  throb- 
bing in  the  perineum  ;  the  pain  extends  down  the  thighs  and  into  the  loins;  in 
the  rectum  there  is  a  constant  sense  of  fullness  and  tenesmus,  with  great  suffering 
as  soon  as  the  bowels  begin  to  act;  and,  if  the  finger  is  introduced,  the  prostate 
feels  swollen  and  burning  hot.  The  temperature  rises  from  the  first  ;  the  pulse 
becomes  full  and  quick  ;  the  distress  is  very  great,  and  not  unfrecjuently  there  is 
high  fever.     Suppuration  is  usually,  but  not  always,  indicated  by  a  chill. 

When  the  inflammation  is  due  to  other  causes  the  course  is  generally  less 
severe;  and  occasionally  large  chronic  abscesses  form  in  the  substance  of  the 
gland,  without  any  marked  symptoms  other  than  those  of  irritation  about  the  neck 
of  the  bladder  and  obstruction  to  the  jjassage  of  urine. 

If  the  treatment  is  active  and  early,  the  sym])toms  usually  subside.  Occasion- 
ally the  inflammation  becomes  chronic  ;  the  irritability  and  pain  persist,  though 
with  less  severity  ;  there  is  a  certain  amount  of  discharge  washed  down  by  the  first 
few  drops  of  urine  ;  and  whenever  there  is  the  least  indiscretion,  all  the  old  trouble 
threatens  to  return. 

Treatment. — The  patient  should  be  confined  to  bed  and  placed  upon  milk 
diet  ;  a  hip-bath,  as  hot  as  can  be  borne,  should  be  given  twice  a  day,  and  the 
bowels  should  be  freely  opened  once;  after  that  it  is  better  to  leave  them  alone, 
owing  to  the  pain  and  need  for  local  rest.  The  rectum  may  be  washed  out  with 
hot  enemata,  leeches  applied  to  the  perineum,  and  the  bleeding  encouraged  by 
fomentations.  The  pain  must  be  relieved  by  suppositories  or  hypodermic  injections 
of  morphia.  Sometimes  the  inflammation  can  be  cut  short  by  full  doses  of  vinum 
antimoniale  every  hour,  until  nausea  is  i)roduced.  If  retention  occurs,  the  urine 
must  be  drawn  off  with  a  catheter,  either  a  soft  rubber  one  of  medium  size  or  a 
black  one,  coude,  so  that  it  can  ride  easily  over  the  obstruction. 

If  suppuration  is  suspected,  and  there  is  any  redness  or  fullness  in  the  peri- 
neum, a  free  median  incision  should  be  made  :  if  pus  is  not  found,  the  hemorrhage 
will  give  relief;  but,  though  this  is  not  uncommon  when  the  suppuration  is  in 
connection  with  the  membranous  portion  of  the  urethra  or  Cowper's  glands,  it 
rarely  occurs  in  prostatitis.  Generally  the  abscess  bursts  into  the  urethra,  either 
of  itself  or  when  a  catheter  is  passed  :  there  is  a  profuse  discharge,  and  at  once  a 
sensation  of  intense  relief.  Owing  to  the  extreme  tension,  the  cavity  contracts 
immediately,  and,  so  long  as  the  abscess  is  acute,  fistula  and  extravasation  of  urine 
rarely  follow. 

(Ji)  Chronic  Follicular  Prostatitis. — This  may  be  the  relic  of  an  acute  attack, 
or  it  may  result  directly  from  gonorrhcea,  stricture,  or  prolonged  masturbation. 

The  symptoms  are  the  same,  but  of  less  severity  ;  and  the  affection  is  often 
mistaken  for  calculus.  There  is  increased  frecpiency  of  micturition  ;  the  stream 
flows  away,  especially  the  last  few  drops,  without  any  force  ;  almost  always  there 
is  pain  and  scalding  toward  the  end,  and  sometimes  a  few  drops  of  blood  escape 
at  the  same  time.  Shreds  of  mucus  and  casts  of  the  jjrostatic  follicles  accumulate 
in  the  urethra,  and  are  either  washed  down  with  the  first  few  drops,  or  exude  from 
the  meatus  during  defecation.  In  the  latter  case,  they  are  often  mistaken  for  the 
secretion  of  the  testes,  and  the  patients  are  convinced  that  they  are  suffering  from 
spermatorrha;a.  Oleet  is  not  present  unless  the  i)enile  portion  of  the  urethra  is 
involved  as  well. 

Kxamined  through  the  rectum,  the  gland  feels  enlarged  and  tender.  There 
is  constant  aching  in  the  jjerineum,  extending  down  the  thighs  and  across  the  loins, 
much  more  severe  during  defecation  and  micturition,  because  then  the  prostate  is 
compre.ssed.  The  constant  straining  usually  brings  on  hemorrhoids  as  well  ;  the 
irritation  spreads  to  the  bladder,  and  cystitis  follows  ;  at  first  it  may  be  slight, 
but  by  degrees  the  walls  become  hypertrophied  and  lose  their  flexibility  ;  and 
then,  often  it  is  not  properly  emi)tied,  even  though  the  patient  may  pass  water 
every  hour.  At  last  the  health  breaks  down  altogether,  and  mental  as  well  as 
bodily  vigor  is  seriously  impaired. 


INFLAMMATION  OI<   II/i:    PROSIAJK.  1085 

Treatment. — This  affection  is  generally  of  a  most  obstinate  character,  and 
requires  prolonged  anil  careful  attention.  Fresh  air  and  change  of  scene  are  often 
necessary  ;  the  food  must  be  good,  but  not  rich  ;  stimulants,  especially  beer,  sherry, 
and  champagne,  must  be  prohibited,  and  tonics,  iron,  nux  vomica,  cod-liver  oil, 
and  phosphoric  acid,  given  according  to  the  condition  of  the  i)atient.  The 
bowels  should  be  kept  slightly  relaxed,  so  that  there  may  be  no  straining  at  stool, 
and  excessive  exercise,  especially  on  horseback,  or  on  a  bicycle,  and  sexual 
indulgence  must  be  avoided. 

In  most  cases  local  treatment  is  e.ssential.  Lightly  blistering  the  perineum 
is  .sometimes  of  service  ;  small  patches  should  be  painted  over  with  blistering  fluid 
on  successive  days,  taking  care  to  avoid  the  skin  of  the  .scrotum,  and,  if  po.ssible, 
not  raising  actual  vesicles,  or  a  little  dry  mustard  may  be  rubbed  in.  Astringent 
injections  ai)|)lied  to  the  part  itself  are  of  great  advantage,  using  either  an  injector 
or  a  i)rostatic  syringe.  (Glycerine  and  tannic  acid,  or  five  minims  of  a  two  per 
cent,  solution  of  nitrate  of  silver,  or  nitrate  of  bismuth  may  be  applied  without 
fear  ;  stronger  applications  (even  twenty  grains  of  nitrate  of  silver  to  the  ounce) 
are  emjiloyed  by  some,  but  the  pain  they  cause  is  very  severe  (though  this  may  be 
prevented  by  cocaine),  and  their  use  is  often  followed  by  vesical  tenesmus  and  a 
blood-stained  discharge.  The  urethra  should  be  washed  out  with  hot  salt  and 
water  first,  to  clear  away  adherent  mucus,  and  the  i)atient  kept  in  the  recumbent 
l)osition  for  the  rest  of  the  day,  as  a  precaution  against  epididymitis.  If  these 
fail,  tannic  acid,  eucaly])tus  oil,  and  other  astringents,  made  into  bougies,  may  suc- 
ceed, but  they  must  be  introduced  with  a  proper  instrument,  as  they  are  too  soft 
to  pass  of  themselves.  They  soon  become  liquid,  and  the  mucous  membrane 
remains  for  some  time  bathed  with  the  products  of  their  solution. 

ParciicJiymatoiis  Prostatitis. 

Gout,  tubercle,  and  injury  are  the  chief  causes.  Occasionally  it  is  due  to 
syphilis,  and  it  is  said  that  sometimes  inflammation  arises  from  exposure. 

Gouty  prostatitis  is  not  uncommon  toward  middle  life  in  men  who  live  rather 
freely,  and  whose  urine  is  loaded  with  uric  acid.  The  commencement  is  tolerably 
acute,  and  is  often  assigned  to  cold  ;  the  fever  is  not  so  high  as  in  the  acute  follic- 
ular form ;  there  is  very  rarely  retention  of  urine,  and  probably  never  actual 
suppuration.  The  irritability  of  the  bladder  is  even  more  intense  ;  the  urine  is 
ejected  spasmodically,  almost  without  the  patient  having  any  control,  and  the  pain 
is  very  severe,  especially  at  night.  Per  rectum,  the  prostate  is  distinctly  enlarged, 
hardened,  and  exceedingly  tender.  Sometimes  there  is  oedema  of  the  prej)uce, 
or  partial  erection  from  obstruction  of  the  veins  of  the  penis.  (Generally  the 
attack  subsides  readily  under  colchicum  and  the  alkaline  carbonates  ;  the  bowels 
should  be  freely  opened  with  blue  pill,  the  diet  carefully  restricted,  and  a  regular 
amount  of  fluid  (hot  water  is  the  best)  taken  at  stated  times,  to  diminish  the 
acidity  of  the  urine  and  prevent  any  concentration.  Gouty  prostatitis  may  in 
some  cases  lead  to  the  accumulation  of  residual  urine;  the  gland  is  very  sensitive, 
and,  to  avoid  squeezing  it,  the  patient  never  thoroughly  empties  the  bladder  ; 
after  a  time  a  certain  amount  is  constantly  retained,  the  walls  become  atonied, 
and  the  power  of  complete  evacuation  is  lost. 

Tubercular  prostatitis  usually  occurs  in  young  adults,  in  association  with 
tubercular  disease  of  the  bladder  or  kidneys  ;  sometimes  it  appears  to  follow  an 
attack  of  gonorrhoea,  but  it  is  rarely  as  a  primary  affection.  In  the  earlier  stages 
the  symptoms  are  almost  the  same  as  those  of  calculus ;  micturition  is  much  too 
frequent,  the  patient  wanting  to  pass  water  every  hour  ;  haematuria  is  often  present, 
especially  as  the  neck  of  the  bladder  is  beginning  to  contract,  and,  at  the  same 
time,  there  is  a  sharp,  cutting  pain  at  the  end  of  the  penis.  Per  rectum,  the 
prostate  is  seldom  much  enlarged  ;  at  first  it  is  rather  harder  than  natural,  and 
perhaps  nodular,  but,  as  the  caseous  masses  break  down  and  disappear,  it  may 
become  abnormally  soft.     In  the  later  stages  the  urine  brings  away  with  it  pus 


io86    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

and  caseating  debris,  full  of  tubercle  bacilli,  the  gland  itself  is  completely  exca- 
vated, the  irritability  and  pain  become  unbearable,  and  the  patient  grows  weaker 
and  weaker.      Generally  speaking,  there  are  dejiosits  in  other  organs  as  well. 

The  diagnosis  in  the  early  stages,  when  there  is  some  hope  of  removing,  or 
at  least  arresting  the  disease,  can  only  be  made  with  the  endosco])e.     If  this  is  not 


£/a(7(/r, 


Prostate 
Fig.  469. — Prostato-vesical  Calculus. 


.used,  neighboring  organs,  such  as  the  bladder  or  vesicuhc  seniinales,  are  nearly 
sure  to  be  involved  before  there  is  any  definite  evidence.  Constitutional  treatment 
is  of  great  importance,  but  it  does  not  seem  to  have  the  same  influence  over  tuber- 
culosis of  the  genito-urinary  tract  as  when  it  occurs  in  other  parts — the  bones,  for 
example.      Locally,  iodoform,  applied  in  an  emulsion  or  as  a  pessary,  is  of  some 


<      f 


^**   ^^^ 


■■*"\. 


/ 


>.  f 


■^^S*; 


^"^V.A   '.'u-^^ 


'\7--''. 


KiG.  470. — Prostatic  Calculi  with  some  Enlargement,  causing  Prolapse  of  the  Ureter. 
(Section  a  little  to  the  left  of  the  middle  line  ) 


service  ;  but  i)ossibly,  if  the  diagnosis  were  confirmed  by  microscopic  examination, 
and  it  was  fairly  certain  that  the  other  organs  were  sound,  it  would  be  better,  if 
speedy  improvement  did  not  take  place  with  ordinary  measures,  to  open  the  pros- 
tatic urethra  from  the  perineum,  and  try  free  scraping  and  the  application  of  lactic 
acid.     In  the  later  stages  morphia  is  the  only  drug  that  relieves  the  pain.      If  the 


PROSTATIC  CAJ.CULI.  1087 

disease  is  limited  to  the  jjrostatc  tlic  bladder  may  be  drained  thrcjiigh  the  peri- 
neum ;  but,  unfortunately,  this  often  fails  to  give  relief,  owinj^to  the  other  organs 
being  involved  as  well. 

Suppurative  Prostatitis. — Suppuration  in  and  around  the  [)rostate  is  occa- 
sionally the  immediate  cause  of  death  after  lithotrity,  operations  about  the  neck 
of  the  bladder,  or  the  passage  of  very  large  instruments,  especially  when  there  is 
old-standing  disease  of  the  kidneys.  It  may  commence  in  the  prostate  itself,  the 
gland  being  destroyed,  the  capsule  giving  way  and  the  pus  spreading  in  the  loose 
tissue  around  the  neck  of  the  bladder,  until,  if  the  patient  live  sufficiently  long, 
it  points  in  the  iliac  fossa;  or  it  may  be  periprostatic  from  the  first,  originating 
in  tissues  that  have  been  saturated  with  septic  material  by  absorption  from  the 
bladder.  There  may  or  may  not  be  a  rigor  ;  as  a  rule,  the  symptoms  are  exceed- 
ingly vague,  being  masked  entirely  by  the  vesical  and  renal  trouble,  and  in  the 
majority  of  instances  the  diagnosis  is  not  made  until  the  patient  is  sinking  from 
septicaemia  and  suppression  of  urine. 


Prostatic  Calculi. 

Calculi  occasionally  leave  the  bladder  and  become  impacted  in  the  prostatic 
portion  of  the  urethra  :  under  these  circumstances  they  may  sink  into  the  sub- 
stance of  the  gland,  and  become,  as  it  were,  encysted,  with  a  portion  of  their 
surface  projecting.  True  prostatic  calculi,  however,  are  not  uncommon,  originat- 
ing in  the  follicles,  and  gradually  growing  larger  and  larger  until  the  intervening 
tissue  is  absorbed,  and  they  come  into  contact  with  each  other.  They  are  always 
multiple,  rarely  very  large,  and  usually  faceted  from  pressure;  as  a  rule  they  con- 
tain about  85  per  cent,  of  phosphate  of  lime  with  a  trace  of  carbonate,  and  about 
15  per  cent,  of  animal  matter,  but  the  proportion  of  the  latter  is  sometimes  higher 
toward  the  centre.  In  one  or  two  cases  they  have  coalesced  into  large  masses. 
So  long  as  they  are  small  they  do  not  give  rise  to  any  symptoms ;  as  they  grow 
larger  they  may  cause  inflammation  and  even  suppuration.  In  one  case  under  my 
care,  admitted  for  extravasation  of  urine  consequent  on  this,  there  was,  in  addition 
to  the  prostatic  calculi,  a  much  larger  one  in  the  bladder,  composed  of  bone  earth 
with  a  little  carbonate  of  lime. 


io88    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 


CHAPTER  XXIII. 
INJURIES  AND  DISEASES  OF  THE   URETHRA. 

Injuries  of  thk  Urethra. 

The  mucous  lining  of  the  urethra  may  be  torn  by  calculi,  or  perforated  with 
catheters,  or  bruised  from  blows  upon  the  i)erineum,  or  from  attempts  at  forcibly 
straightening  out  chordee  ;  but  serious  consequences  rarely  follow.  There  is  a 
small  amount  of  hemorrhage,  perhaps  sufficient  to  drip  from  the  orifice  ;  micturi- 
tion is  attended  with  scalding,  and  there  is  soreness  about  the  part  with  a  slight 
mucous  discharge,  but  extravasation  of  urine  seldom  follows  a  superficial  injury 
unless  there  is  an  obstruction  as  well. 

False  passages  escape  from  their  direction.  They  start  in  most  cases  from 
the  floor,  in  front  of  the  bulb,  very  often  on  the  left  side,  and  run  from  there 
between  the  bladder  and  the  rectum,  but  the  opening  lies  toward  the  meatus,  so 
that  urine  does  not  enter. 

Rupture  of  the  urethra  may  be  caused  by  a  kick  or  violent  blow  in  the  [peri- 
neum, or  by  fracture  of  the  pelvis.* 

In  the  former  case  the  urethra  is  torn  at  the  junction  of  the  membranous  and 
bulbous  parts,  the  anterior  layer  of  the  triangular  ligament  giving  way  as  well ; 
sometimes  the  whole  circumference  is  ruptured,  and  the  ends  are  widely  separated  ; 
sometimes  there  is  only  a  rent  on  the  floor,  the  roof  remaining  intact.  Hemor- 
rhage is  usually  profuse,  forming  a  swelling  in  the  perineum  and  scrotum,  and 
often  dripping  freely  from  the  meatus,  but  no  urine  is  extravasated  until  an  attempt 
is  made  to  relieve  the  bladder. 

In  the  latter,  when  the  rupture  is  the  result  of  fracture  of  the  pelvis  or  sepa- 
ration of  the  symphysis,  the  deeper  part  of  the  urethra  and  the  neck  of  the  bladder 
generally  suffer ;  blood  does  not  escape  externally  until  an  attempt  is  made  to 
pass  urine  ;  but  this,  from  the  moment  of  the  accident,  begins  to  leak  out  from 
the  bladder  and  infiltrate  the  tissues  around,  setting  up  the  most  intense  inflam- 
mation. 

The  symptoms  depend  upon  the  seat  of  injury.  If  the  rujiture  is  in  front  of 
the  triangular  ligament,  or  involves  the  anterior  layer  of  it,  a  swelling  rapidly 
forms  in  the  perineum  ;  blood  drips  slowly  from  the  meatus,  and  either  the  patient 
is  unable  to  pass  any  urine,  or,  if  he  makes  the  attempt,  it  pours  into  the  loose 
cellular  tissue  of  the  perineum,  causing  the  most  intense  burning.  If  an  attempt 
is  made  to  pa.ss  a  catheter,  either  it  stops  abruptly  at  the  seat  of  injury,  the  point 
rubbing  against  the  lacerated  tissues,  or  it  suddenly  slips  onward,  entering  the 
bladder  and  drawing  off  clear  urine.  This  accident  is  nearly  always  followed  by 
a  stricture,  the  severity  of  which  de])ends  upon  the  amount  of  suppuration.  If 
the  rupture  is  complete,  and  there  is  the  least  infiltration  of  urine,  the  cicatricial 
tissue  becomes  so  hard  and  dense  that  practically  the  urethra  is  closed  (unless 
steps  are  taken  to  jjrevent  it)  ;  if  the  mucous  membrane  is  partly  intact  and  there 
is  no  supjjuration,  there  may  be  some  obstruction,  but  the  tendency  to  contraction 
is  not  nearly  so  severe. 

On  the  other  hand,  when  the  deeper  i)art  of  the  urethra  is  torn,  external 
hemorrhage  and  swelling  are  rarely  present,  but  the  pain  and  the  shock  are  much 
more  severe,  and,  owing  to  the  urine  soaking  at  once  into  the  cellular  tissue, 
inflammation  and  fever  soon  set  in.  If  a  catheter  is  passed  there  is  no  difficulty 
until  it  begins  to  wind  under  the  pubic  symphysis;  then  it  either  stops  altogether, 


[*  The  editor  has  seen  a  case  of  rupture  of  the  membranous  portion  produced  by  a  fall  from 
the  fourth  story  of  a  building.     The  patient  bad  a  full  bladder  at  the  time  of  the  accident.] 


RL'P  I'i'RK   OF  /•///•:   URETHRA.  1089 

or  if  it  can  be  introcliRctl  into  the  bUicUlcr,  tlic  urine  that  it  draws  off  is  loaded 
with  blood.  This  injury  usually  proves  fatal  from  infiltration  of  urine  into  the 
cellular  tissue  of  the  pelvis,  in  the  same  way  as  extra-peritoneal  rujjture  of  the 
bladder. 

Treatment. — In  every  case  of  severe  injury  to  the  jjelvis  or  iierineum  a 
catheter  should  be  passed  as  a  matter  of  routine,  to  ascertain  if  there  is  any  injury 
to  the  bladder  or  urethra.  If  it  slips  in  at  once,  without  any  grating,  or  perhaps 
with  a  sensation  of  roughness  of  the  mucous  surface  just  at  one  spot,  it  may  be 
withdrawn  again  ;  there  is  merely  an  abrasion  or  contusion  of  the  mucous  mem- 
brane, and,  if  the  bladder  is  emptied  and  urine  is  not  passed  for  some  hours,  the 
surface  will  glaze  over.  If,  on  the  other  hand,  the  catheter  is  brought  to  a  sudden 
stoj),  or  if  the  i)roximal  orifice  of  the  torn  urethra  is  only  found  with  difficulty, 
and  perhaps  after  more  than  one  instrument  has  been  tried,  steps  must  be  taken 
to  prevent  infiltration. 

{a)  Rupture  of  the  Anterior  Part  of  the  Urethra. — If  there  is  the  least  diffi- 
culty in  passing  an  instrument  into  the  bladder,  or  if  it  is  clear  from  other  evidence 
that  the  urethra  is  badly  torn,  the  patient  should  be  placed  in  the  lithotomy  posi- 
tion, a  catheter  passed  down  to  the  rupture,  or  through  it,  and  a  median  incision 
made  of  sufficient  length  and  depth  to  allow  the  extravasated  blood  to  escape  and 
l^revent  infiltration  of  urine.  Tying  a  catheter  in  will  not  do  this  ;  urine  always 
trickles  by  the  side  of  it,  no  matter  how  large  it  is,  and  if  the  wall  of  the  urethra  is 
torn  at  any  point,  infiltration  and  urinary  abscess  are  sure  to  follow.  The  blood 
collecting  in  the  wound  and  in  the  cellular  tissue  around  seems  to  encourage  it,  by 
the  readiness  with  which  it  undergoes  decomposition  and  the  way  in  which  it  opens 
up  the  tissues  for  the  urine. 

Various  methods  have  been  tried  to  provide  additional  security  against  this. 
I  have  on  several  occasions  sutured  the  two  ends  together;  there  is  no  difficulty, 
especially  in  young  subjects,  in  whom  the  perineum  is  yielding.  The  finger  placed 
in  the  rectum,  forcing  the  tissues  out  through  the  wound,  brings  the  proximal  end 
of  the  torn  urethra  quite  to  the  surface,  so  that  sutures  can  be  readily  passed  ;  but 
I  have  never  succeeded  in  obtaining  union  by  the  first  intention,  and  it  has  seemed 
to  me  that  not  only  is  the  additional  bruising  which  this  entails  injurious,  but  that 
there  is  a  great  tendency  for  the  two  parts  of  the  urethra  to  unite  at  an  angle  with 
a  spur  between.  Tying  a  catheter  in  after  the  incision  has  been  made  might  pre- 
vent this,  but  in  many  cases  it  is  a  very  serious  irritant,  causing  grave  reflex  dis- 
turbance, and  of  itself  tends  to  prevent  union,  so  that  it  would  do  more  harm  than 
good.  There  is  no  difficulty,  four  or  five  days  after  the  injury,  in  finding  the 
proximal  end  and  guiding  into  it  a  catheter  passed  down  the  penis. 

Draining  the  bladder  directly  through  the  perineum  or  the  rectum,  so  that  no 
drop  can  flow  down  the  urethra  until  the  wound  is  healed,  has  been  recommended  ; 
but  in  the  slighter  cases  it  is  not  required,  and  in  the  more  severe  ones  the  extrava- 
sation of  blood  is  so  great  that  an  abscess  is  almost  sure  to  follow  at  the  seat  of 
injury. 

In  any  case,  a  soft  catheter  must  be  passed  every  second  day  at  least,  com- 
mencing not  later  than  the  end  of  the  week  ;  for  although  there  are  cases  on  record 
which  prove  that  rupture  of  the  urethra  treated  by  early  incision  does  not  of 
necessity  lead  to  traumatic  stricture,  there  is  no  doubt  that  it  is  liable  to.* 

{b)  Rupture  of  the  deeper  part  of  the  urethra  does  not  admit  of  this,  or  of 
suture.  All  that  can  be  done  is  to  drain  the  bladder  as  efficiently  as  possible 
through  the  perineum,  in  the  hope  that  if  urine  has  already  been  extravasated,  the 
suppuration  that  follows  may  be  kept  within  bounds.  Unhappily,  in  nearly  all 
these  cases  there  is  a  fracture  of  the  pelvis,  which,  in  this  way,  becomes  com- 
pounded into  an  ill-drained  suppurating  cavity. 


[*  In  three  cases  of  urethral  rupture  under  the  care  of  the  Editor,  the  first  was  treated  by  repeated 
aspiration  of  the  bladder,  until  the  rent  healed  ;  the  others  by  perineal  section  and  tubal  drainage. 
All  recovered  without  unfavorable  symptoms,] 


loyo    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

Calculus  in  the  U'rhihra. 

Calculi  are  occasionally  formed  in  the  urethra  in  the  dilated  and  fasciculated 
pouch  that  develops  behind  a  stricture  ;  but  nearly  always  the  nucleus  is  carried 
down  from  the  bladder.  The  symptoms  depend  upon  the  degree  of  obstruction  ; 
if  the  calculus  is  large  enough  to  block  the  urethra  of  itself,  or  so  sharp  and  angu- 
lar as  to  bring  about  the  same  result  by  the  spasm  that  it  excites,  retention  occurs  ; 
and  if  sj)eedy  relief  is  not  given,  ulceration  and  extravasation  follow.  If,  on  the 
other  hand,  it  is  small  and  lodged  in  a  diverticulum,  it  may  continue  to  increase 
from  the  deposit  of  phosphates  on  its  surface  and  wear  its  way  into  the  tissues,  until 
at  length  it  forms  an  enormous  mass,  lying  in  the  substance  of  the  penis,  alongside 
the  urethra,  almost  buried  under  the  mucous  membrane. 

Impacted  Calculus. — This  is  more  common  in  children  than  in  adults,  owing 
to  the  greater  frecpiency  of  stone  in  them  and  the  small  size  of  their  urinary  pas- 
sages ;  the  calculus  is  washed  down  from  the  bladder  during  the  act  of  micturition 
and  suddenly  arrested,  generally  in  the  membranous  part  or  at  the  meatus.  The 
stream  stops  suddenly,  there  is  a  sharp  cutting  pain  at  the  end  of  the  penis  with 
violent  straining,  and  i)erhai)S  a  few  drops  of  blood  exude  from  the  urethra, 
especially  if  the  calculus  is  sharp  and  angular.  For  a  time  the  straining  continues, 
the  bladder  becomes  more  and  more  distended,  and  then  either  sudden  extravasa- 
tion occurs,  or,  if  a  small  (juantity  of  urine  can  escape  by  the  side,  so  that  there  is 
not  such  immediate  tension,  inflammation  sets  in,  ending  in  urinary  abscess  and 
fistula. 

There  is  seldom  difficulty  in  the  diagnosis.  The  history  of  the  case,  the  way 
in  which  the  child  keeps  screaming  and  pulling  at  the  end  of  its  penis,  the  retention 
of  urine,  which  is  so  rare  in  children  from  any  other  cause,  and  the  few  drops  of 
blood  are  distinctive.  Very  often  the  calculus  can  be  felt  from  the  outside.  If 
this  cannot  be  done,  a  small  catheter  may  be  passed  down  the  urethra  ;  sometimes 
it  comes  to  an  abrupt  stop  against  the  stone,  sometimes  it  slips  by  the  side  of  it 
with  a  rough,  grating  sensation,  and,  entering  the  bladder,  gives  relief  for  the 
moment.  If  any  time  has  elapsed  since  the  accident,  the  bladder  may  be  distended 
up  to  the  pubes  ;  or  there  may  already  be  a  swelling  in  the  perineum  due  to  inflam- 
mation and  commencing  extravasation. 

.\  calculus  in  the  penile  part  can  generally  be  worked  forward  with  the  fingers 
until  it  reaches  the  orifice,  when  a  small  incision  may  be  necessary  to  extract  it. 
If  this  does  not  answer,  a  scoop  or  a  pair  of  urethral  ["  alligator  "]  forceps  may  be 
passed  down  the  urethra,  and  an  attempt  made  to  draw  it  forward  ;  but  this  may 
inflict  serious  injury  upon  the  mucous  membrane.  If  it  is  fixed  or  too  far  back  for 
this,  the  patient  should  be  placed  in  the  lithotomy  position,  the  skin  over  the  pro- 
jection stretched  with  the  finger  and  thumb  of  the  left  hand,  and  a  small  median 
incision  made  down  on  to  it.  Generally  the  calculus  springs  out  at  once,  and  the 
wound  can  be  left  to  granulate.  The  bulb  should,  if  possible,  not  be  incised.  If 
the  calculus  is  near  the  neck  of  the  bladder  it  should  either  be  removed  by  the 
median  operation,  or,  if  there  is  a  suitable  instrument  handy,  jjushed  fiirther  back 
and  crushed  with  a  lithotrite. 

Foreign  bodies  introduced  into  the  urethra  may  re(iuire  extraction.  Crethral 
forcejjs  should  be  avoided  as  far  as  possible  ;  sometimes,  by  placing  the  patient  in 
a  hot  bath,  giving  him  plenty  of  licjuid  to  drink,  and  directing  him  to  hold  his 
water,  sufficient  head  can  be  obtained  to  drive  out  such  an  obstruction,  for  example, 
as  the  end  of  a  catheter  broken  off  in  a  stricture  ;  but  this  should  not  be  tried  too 
long.  Hair-pins,  on  the  other  hand,  and  such  like  structures,  nearly  always  require 
incision. 

The  cases  in  which  the  obstruction  is  slight  and  the  stone  lies  out  of  the  way 
are  much  more  rare,  and  as  a  rule  are  only  met  with  in  elderly  men.  In  a  few 
instances  huge  cylindrical  calculi  have  been  found,  three  or  four  inches  in  length 
and  one  and  a  half  in  circumference.  These  generally  lie  in  the  tissues  by  the 
side  of  the  urethra,  occupying  a  cavity  which  they  have  worn  out  for  themselves, 


THE  PASSAGE  OF  CATHETERS. 


1 09 1 


ami  sometimes  are  so  invested  by  the  mucous  membrane  that  a  sound  passed  down 
the  uretlira  slips  by  them  without  any  of  the  characteristic  grating. 

TlIK     I'ASSAdK    OF    CArilF/l'KkS,     AND    Till;    (JkNKRAI.    lOl'FKC   I     Ol     (  )l'KRA  IIONS 

ri'ON   THK    Urk'ihka. 

Catheters  are  made  of  various  materials,  some  rigid,  others  flexible  in  various 
degrees.  Metal  ones  have  a  fixed  curve,  occupying  a  quarter  of  a  circle  of  a 
radius  of  three  and  a  half  inches.  (Prostatic  ones  should  be  fifteen  inches  long, 
and  the  radius  of  the  curve  barely  three.)  The  handle  should  be  bent  a  little 
downward,  so  that  if  the  jiatient  is  lying  down  the  urine  may  not  be  ejected  all 
over  the  bed  ;  the  other  end  should  be  solid,  with  a  smooth  eye  on  the  side  about 
a  ([uarter  of  an  inch  liack.  If  it  is  hollow  to  the  end  the  space  beyond  the  eye  is 
never  cleaned. 


a  b  c  d 

Fig.  471. — Various  Forms  of  Catheters  :  a.  coiide  :  h,  bi-coude  ;  t',"olivary  :  d,  prostatic. 

Gum-elastic  catheters  are  made  of  webbing  coated  with  copal  varnish.  Like 
the  former,  they  follow  the  roof,  but  their  flexibility  depends  upon  temperature, 
and  they  can  be  bent  to  any  shape.  In  cases  of  enlarged  prostate,  for  example, 
if  the  point  of  the  catheter  is  arrested  by  the  median  lobe,  it  can  be  tilted  over  it 
by  withdrawing  the  stylet. 

Black  catheters  are  much  more  flexible,  and  follow  the  floor.  The  shape  dif- 
fers according  to  the  requirements  of  the  case  ;  some  have  a  minute  bulb  at  the 
end,  mounted  on  a  slender  neck,  so  that  it  can  follow  the  most  devious  route; 
others  are  rigid  and  bent  upward  at  an  angle  {coudc),  so  as  to  ride  over  an  ob- 
struction ;   others,  again,  are  bent  up  twice  in  the  same  way  {l)i-coiide). 


log 2    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Vulcanized  india-rubber  catheters  are  mere  nibber  tubes,  closed  at  the  end 
and  provided  with  a  lateral  opening  ;  they  are  esi>ecially  useful  for  j)atients  who 
have  to  pass  instruments  for  themselves,  or  where,  as  in  cases  of  fracture  of  the 
spine,  the  urethra  is  absolutely  insensitive.  Celluloid  instruments  are  too  brittle 
to  be  of  general  use,  but  they  are  particularly  suited  for  tying  in  the  bladder,  as 
they  are  much  less  affected  by  urine  than  the  others. 

The  sizes  of  English  instruments  are  arbitrary  ;^^  the  smallest  (^)  is  about 
one-fifth  of  an  inch  in  circumference;  the  largest  (12),  nearly  seven-eighths. 
French  ones  are  accurately  graduated  from  one  millimetre  circumference  up  to 
forty. 

Flexible  instruments  should  always  be  preferred  to  metal  ones.  If  there  is  a 
very  tight  stricture,  and  it  is  impossible  to  introduce  a  soft  one,  a  small  metal  one 
may  be  tried,  but,  owing  to  the  fineness  of  their  points,  they  are  exceedingly 
dangerous.  An  exception  to  this  rule  may  be  made  in  the  case  of  an  enlarged  pros- 
tate of  many  years'  standing,  in  which,  after  perhaps  years  of  self-catheterization, 
retention  has  occurred  at  last.  A  full-sized,  silver,  prostatic  one,  with  a  very 
long  curve,  will,  as  a  rule,  ride  over  the  obstruction,  and  squeeze  its  way  between 
the  swollen  and  congested  walls  of  the  urethra  more  easily  than  any  other.  Great 
care  must  be  taken  with  the  smaller  black  ones,  as  the  varnish  soon  becomes 
cracked  at  the  eye,  and  then  the  bulb  is  very  likely  to  break  off  and  be  left  behind. 

Unless  the  state  of  the  urethra  is  known,  a  moderate-sized  instrument,  15 
mm.  to  17  mm.,  French,  should  be  used  to  commence  with.  A  larger  one  gives 
more  pain,  a  smaller  one  may  catch  in  a  fold  of  the  mucous  membrane. 

The  patient  should  be  in  a  recumbent  position,  with  the  umbilicus  exposed, 
and  the  thighs  slightly  flexed  and  abducted.  The  instrument  is  sterilized  and 
lubricated,  preferably  with  Lund's  oil  falmond  oil  c.c.  32,  castor  oil  c.c.  32,  and 
pure  carbolic  acid  c.c.  4)  ;  or,  if  there  is  a  stricture,  4  c.c.  of  oil  may  be  injected 
first.  The  operator  stands  on  the  left,  and,  holding  the  penis  with  his  left  hand, 
draws  it  well  over  the  point  of  the  instrument,  putting  the  mucous  membrane  on  the 
stretch,  so  as  to  obliterate  its  folds.  The  point  of  the  instrument  should  follow 
the  floor  of  the  urethra  for  the  first  inch,  to  avoid  a  diverticulum  occasionally  left 
during  development,  after  that  the  roof  for  the  rest  of  its  course. 

In  a  normal  urethra,  either  the  catheter  experiences  no  resistance  at  all,  but 
merely  sinks  down  of  its  own  weight,  or,  after  passing  two  or  three  inches,  is 
quietly  and  slowly  gripped,  and  held  by  the  unstriped  muscular  fibre  in  the  wall. 
There  is  no  sudden  stop  (so  that  there  is  no  resemblance  to  the  resistance  of  stric- 
ture), and  in  a  minute  or  two  the  instrument  becomes  free  again  ;  the  fibres  have 
tired  themselves  out. 

As  the  bulb  is  reached,  owing  to  the  dilatation  on  the  floor  and  the  softness 
of  the  mucous  membrane,  the  point  of  the  catheter  may  catch  against  the  lower 
edge  of  the  oj^ening  in  the  triangular  ligament.  Ver}'  little  force,  then,  at  the 
end  of  a  long  lever,  will  drive  it  through  the  mucous  membrane  and  make  a  false 
passage.  The  instrument  must  be  withdrawn  a  little,  and  the  handle  gently 
lowered.  If  there  is  the  least  difficulty,  the  forefinger  placed  in  the  rectum  will 
find  the  cause  at  once ;  but  the  utmost  gentleness  is  required,  or  the  point  may 
slip  over  the  edge  in  the  right  direction,  but  with  a  ])ainful  jerk.  Withdrawing 
the  stylet  in  a  gum-elastic  catheter  has  the  same  effect.  Well-made  black  ones, 
with  a  sufficiently  flexible  neck,  rarely  cause  this  trouble. 

The  last  obstacle  is  the  neck  of  the  bladder ;  very  often  the  point  catches  on 
the  floor  again,  even  when  the  median  lobe  of  the  prostate  is  not  enlarged,  and 
the  obstruction  must  be  surmounted  in  the  same  way. 

The  best  time  for  passing  a  catheter  is  in  the  morning,  an  hour  or  two  before 
the  patient  gets  up,  so  that  he  may  remain  warm.  If  this  is  not  practicable,  care 
at  least  should  be  taken  that  there  is  no  exposure  to  cold  afterward,  and  that  mic- 
turition is  not  performed  until  it  is  absolutely  necessary.      With  many  patients, 

[*  Little  used  in  America.] 


THE  PASSAGE  OF  CATHETERS.  1093 

especially  those  who  have  suffered  from  ague,  or  who  have  lived  in  the  tropics,  it 
is  advisable  to  give  quinine  for  several  days  previously,  and,  if  the  kidneys  are 
sound,  one  small  dose  of  oi)iuni  ;  but  care  should  be  taken  that  the  bowels  are  not 
confined.  A  sixth  of  a  grain  of  mori)hia,  hypodermically,  a  few  minutes  before 
the  operation,  diminishes  the  irritability  of  the  urethra,  especially  if  the  injection 
is  made  in  the  region  of  the  perineum.  In  all  cases,  excei)t,  of  course,  where  there 
is  urgency,  a  previous  examination  of  the  urine,  both  as  to  quantity  and  (piality, 
should  be  made. 

The  passage  of  a  catheter,  esi)ecially  for  the  first  time,  is  a  very  painful  pro- 
ceeding, and  may  be  followed  by  serious  consequences.  '^\\t  pain  is  always  worst 
as  the  instrument  is  passing  through  the  membranous  part ;  it  is  usually  described 
as  cutting  or  burning,  and  it  may  cause  syncope.  If  it  is  very  severe  before  this 
point  is  reached,  there  is  probably  some  morbid  condition  of  the  mucous  mem- 
brane. Fortunately,  it  can  be  prevented  by  injecting  a  few  drops  of  a  ten  per 
cent,  solution  of  cocaine  down  the  urethra. 

Other  consequences  arise  from  the  effect  upon  the  nerve-centres.  Thus  shock 
may  affect  the  wall  of  the  bladder,  causing  retention  (especially  if  atony  is  already 
present)  ;  it  may  paralyze  the  vasomotor  nerves  of  the  kidneys,  leading,  according 
to  its  severity,  to  hcematuria,  or  siippressio7i  of  urine  (particularly  in  cases  in  which 
the  kidneys  are  already  diseased)  ;  or  it  may  involve  the  central  nervous  system  ; 
for  syncope  (probably  from  dilatation  of  the  abdominal  vessels)  and  sudden  death 
have  been  known  to  follow. 

Others,  again,  of  which  urethral  fever  is  the  most  important,  are  of  more 
doubtful  origin.  There  are  two  chief  forms  of  this  :  in  the  one  there  is  intense 
shivering,  with  headache,  depression,  and  vomiting;  the  temperature  rises  rapidly 
to  104°  or  105°,  and  then  begins  to  fall  almost  as  tjuickly  as  it  rose,  while  the 
patient  lies  in  a  state  of  utter  prostration,  sweating  profusely  ;  in  the  other,  the 
temperature  falls  at  first,  then  rises  slowly  until  it  reaches  102°  or  103°  F. ,  some- 
times with  a  rigor,  but  rarely  a  severe  one,  and,  after  a  few  hours,  if  the  kidneys 
are  sound,  gradually  sinks  again. 

This  may  occur  after  the  operation,  or  more  frequently  after  the  first  subsequent 
act  of  micturition,  especially  if  it  takes  place  soon.  Those  who  have  suffered  from 
ague,  or  have  lived  in  malarial  districts,  are  particularly  liable  to  it ;  exposure  to 
cold  is  especially  likely  to  bring  it  on,  and  there  is  no  doubt  that,  though  it  does 
occur  in  those  whose  kidneys  are  perfectly  healthy,  it  is  more  likely  to  happen,  and 
much  more  likely  to  be  followed  by  serious  consequences,  when  they  are  diseased. 
In  fatal  cases  intense  renal  congestion  is  usually  found,  but  it  is  not  improbable 
that  this  is  a  coincidence  due  to  the  effect  upon  the  vasomotor  nerves,  and  that 
rigors  may  occur  independently  of  it. 

Opinions  differ  with  regard  to  its  etiology.  Harrison  considers  it  due  to  the 
absorption  from  the  urine  of  toxic  alkaloids,  which  undoubtedly  are  produced  in 
considerable  quantities  in  the  alimentary  canal,  and  are  excreted  by  the  kidneys  ; 
but,  on  this  theory,  it  is  difficult  to  explain  the  non-occurrence  of  rigors  after  lith- 
otomy and  other  operations.  More  probably  it  is  a  pathological  exaggeration  of 
the  normal  shiver  which  is  so  frequent  during  and  immediately  after  micturition, 
and  which  is  so  strongly  marked  in  infants,  female  as  well  as  male,  in  whom  it  may 
be  conjectured  the  spinal  cord  is,  relatively  to  the  brain,  more  active  than  it  is  in 
adults.  This  would  bring  it  into  the  class  of  neurotic  fevers;  audits  more  fre- 
quent occurrence,  and  its  greater  severity  when  a  catheter  is  passed  for  the  first 
time,  and  when  a  stricture  is  still  young  and  irritable,  would  admit  of  easy  expla- 
nation. [It  is  significant  of  the  origin  of  urethral  fever  that  it  seldom,  if  ever, 
follows  the  careful  introduction  of  jr/'<f;77/s(f^/ instruments.] 

Other  consequences  that  occur  later  are  due  either  to  mechanical  injury,  or  to 
the  products  of  septic  or  ammoniacal  decomposition. 

Hemorrhage,  for  example,  from  laceration  of  the  mucous  membrane,  is  not 
uncommon,  and  in  cases  of  granular  urethra  or  inflamed  prostate  is  very  difficult 
to  avoid.  In  stricture  especial  care  is  required,  as  not  unfrequently  the  mucous 
membrane  is  so  softened  from  congestion  that  it  gives  way  at  once.      If  this  occur 


1094    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  catheter  should  be  iiii mediately  withdrawn  ;  the  wound  only  makes  the  conges- 
tion worse,  and  diminishes  by  so  much  the  chance  of  finding  the  orifice. 

False  passages  are  caused  in  the  same  way;  they  nearly  always  start  either 
from  the  bulb  or  just  in  front  of  a  stricture  ;  there  is  a  sense  of  resistance  suddenly 
giving  way,  the  patient  complains  of  pain,  and  the  catheter  slips  a  little  distance 
further,  with  an  unmistakable  sensation  of  grating. 

Inflammatory  affections  of  the  urinary  tract  are  still  more  common.  All  cath- 
eters, before  using,  must  be  thoroughly  disinfected  ;  it  is  not  enough  to  dip  them 
in  carbolic  oil  of  any  strength.  No  part  is  exempt  ;  urethritis,  perineal  abscess, 
prostatitis,  and  epitlidymitis  may  all  occur,  but  by  far  the  most  common  is  cystitis. 
It  is  significant  that  ammoniacal  decomposition  of  the  urine  often  sets  in  for  the 
first  time  within  a  week  or  two  of  the  beginning  of  catheterization. 

In  a  few  instance  synovitis  has  been  known  to  follow  the  passage  of  a  catheter. 
Whether  it  is  to  be  regarded  as  pyiiimic  in  origin  or  as  the  result  of  reflex  nerve 
irritation  is  uncertain. 

Treatment. — Local  affections  must  be  dealt  with  by  themselves;  so  far  as 
other  complications  are  concerned,  preventive  treatment,  by  carefully  preparing 
the  patient  and  using  the  utmost  gentleness,  is  the  first  consideration.  Harrison 
speaks  very  highly  of  Fleming's  tincture  of  aconite,  in  two-minim  doses,  for  several 
days  beforehand, and  belladonna  has  been  recommended.  Sometimes, however,  they 
will  occur  in  spite  of  all  precautions,  and  they  cannot  be  prevented  by  anaesthetics. 
The  tendency  to  rigors  may  be  checked,  and  if  it  is  taken  in  time,  as  soon  as 
the  temperature  begins  to  rise,  actual  shivering  may  certainly  be  shortened.  A 
large  cuj^ful  of  hot  tea  should  be  given  with  .30  gramme  of  quinine,  twenty  minims 
of  laudanum  (if  the  kidneys  are  sound),  and  sixteen  c.c  of  brandy  ;  and  the 
patient  should  be  well  wrapped  up  and  made  to  lie  down  at  once  ;  but,  if  it  has 
once  commenced,  it  is  doubtful  if  it  can  be  stopped  altogether.  If  signs  of  acute 
renal  congestion  set  in,  the  patient  should  be  placed  in  a  hot  bath  for  a  few 
minutes,  and  then  well  wrapped  up  in  blankets  ;  the  bowels  should  be  ojjened  as 
soon  as  possible,  and  dry  cups  applied  to  the  loins.  If  there  is  a  catheter  tied  in, 
it  must,  of  course,  be  removed  at  once.  Digitalis  may  be  given  with  advantage,  a 
teaspoonful  of  the  infusion  every  hour,  until  there  is  some  effect  on  the  circulation, 
or  a  linseed  poultice  may  be  made  with  the  infusion,  and  applied,  as  hot  as  possible, 
to  the  skin  over  the  loins. 

When,  on  the  other  hand,  the  attack  is  insidious,  as  in  old  cases  of  stricture 
and  enlarged  prostate,  and  marked  chiefly  by  wandering  delirium  and  great  pros- 
tration, active  treatment  is  out  of  the  question  ;  the  kidneys  are  already  diseased  ; 
the  bladder  is  in  a  state  of  partial  atony,  and  has  not  been  able  to  empty  itself 
perhaps  for  years,  and  the  patient's  reserve  of  strength  is  almost  exhausted  already. 
Very  little  can  be  done  beyond  general  measures  ;  the  patient  must  be  kept  warm 
in  bed,  the  diet  must  be  light  and  unstimulating,  and  the  bowels  kept  slightl) 
relaxed.  Opium  is  positively  injurious  ;  stimulants,  especially  spirits,  should  be 
avoided  as  far  as  possible,  but  often  they  must  be  given,  and  sleej)  must  be 
obtained  by  means  of  chloral  and  bromide.  This  condition  may  last  for  a  week  or 
ten  days  and  gradually  pass  away,  or,  especially  when,  owing  to  the  state  of  the 
bladder,  the  catheter  must  be  used,  it  may  very  soon  terminate  fatally.  The  jjulse 
becomes  quicker  and  feebler,  the  tongue  is  dry  and  brown,  the  delirium  is  more 

marked,  the  amount  of  urine  secreted  becomes  less 
and  le-ss,  the  strength  fails  from  hour  to  hour,  and 
the  patient  sinks  into  a  condition  resembling  typhoid. 
A  catheter  occasionally  recpiires  to  be  tied  in  the 
urethra.  This  may  be  necessary  where  there  has  been 
great  difficulty  in  passing  a  stricture,  or  when,  owing 
to  the  presence  of  fistuKne  or  for  other  rea.sons,  it  is 
wished  to  drain  the  bladder  and  prevent  urine  passing 
along  the  urethra.  In  the  former  case  the  instrument 
should  be  secured   so  that  the   point  lies  just  outside 

Fig.  472. — Mode  of  Fasteninc  Catheter  ^v       i  i     j  j  •       ii        i    i..         ^i  j        r  ,       ..  1  ■ 

in  the  Bladder.  the  bladder  ;  in  the  latter,  the  end,  of  course,  must  he 


A  CUTE   L  7v'  li  'J  'II R 1 7  IS. 


1095 


in  it,  but  even  then  a  certain  aniount  of  urine  will  al\\a)'.s  find  its  way  by  the  side. 
The  eatheter  should,  if  possible,  be  a  flexible  one.  and  celluloid  instruments  are 
to  be  preferred  to  others,  as  the  urine  does  not  decompose  so  readily.  I'>en  with 
them,  the  instruments  should  never  be  left  longer  than  three  days  without  being 
changed.  Many  patients  cannot  stand  the  continued  irritation  ;  the  catheter  acts 
as  a  foreign  body,  inllannnation  soon  commences,  and  in  a  very  short  time  the 
urea  decomposes,  and  the  end  of  the  instrument  ])ecomes  coated  over  with  a  layer  of 
phosphates. 

The  simplest  method  is  to  pass  two  threads  through  the  metal  loops,  one  on 
either  side,  and  fix  them  to  the  skin  of  the  penis  by  a  piece  of  strap|)ing  woimd 
round  it  near  its  root.  Or,  as  this  plan  has  certain  objections,  and  is  not  too 
secure,  the  threads  (which  must  be  double)  may  be  knotted  on  either  side  about 
an  inch  and  a  half  from  the  catheter  ;  then,  taking  the  two  threads  of  one  side, 
the  one  is  carried  over,  the  other  under  the  |)enis,  and  knotted  together  on  the 
opposite  side  so  as  to  enclose  in  a  loop  ;  the 
ends  are  tied  to  the  pubic  hair.  The 
other  pair  is  then  to  be  treated  in  the  same 
way. 

A  better  plan  still  is  to  fasten  a  band- 
age arovmd  the  abdomen,  and  to  attach  a 
long  tape  to  it  on  either  side  ;  these  are 
to  loop  round  the  thigh.  The  end  of 
each  is  carried  across  the  abdomen,  round 
the  outer  side  of  the  opposite  limb,  and 
then  brought  up  by  the  side  of  the  scrotum, 
so  as  to  be  fastened  to  the  waist-belt  again. 
The  tapes  from  the  catheter  are  tied,  one 
on  each  side,  to  the  band  in  the  groin, 
just  opjiosite  the  root  of  the  penis,  so  that  it  can  assume  any  position  that  is  con- 
venient, without  allowing  the  unstriped  muscular  fibre  of  the  urethra  to  push  the 
catheter  out.      Arnold's  elastic  holder  is  simpler  and  ecpially  effective  (Fig.  473). 


Fig.  473. — Arnolil's  Elastic  Holder 


DISEASES  OF  THE    URETHRA. 


Inflammation. 

Acute  inflammation  of  the  mucous  membrane  of  the  urethra  is  not  common 
except  as  a  result  of  gonorrhoia  ;  mild  forms  of  it,  however,  may  be  produced  by 
other  causes.  Chronic  inflammation  may  commence  as  such  (as  in  the  case  of 
tubercular  urethritis)  ;  or  follow  an  acute  attack  which  is  prevented  from  subsiding 
by  some  constitutional  or  local  cause,  such  as  gout  or  stricture. 

Causes. — i.  Mrchanicalinjiiry  :  the  passage  of  sounds,  for  example,  or  the 
impaction  of  a  calculus. 

2.  Chemical  Irritants. — These  maybe  the  product  of  a  specific  germ  (gono- 
coccus)  ;  or  they  may  be  present  in  foul  septic  discharge  ;  or  they  may  be  excreted 
by  the  kidneys  in  the  urine — e.^^.,  cantharides  and  uric  acid. 

3.  Syphilis  and  tubercle. 

Acute  Urethritis. 

The  most  intense  form  is  gonorrhoea,  an  acute  suppurative  inflammation  of 
the  mucous  membrane  due  to  contagion,  and  probably  to  the  presence  of  a  specific 
germ.  It  always  begins  as  a  local  disease,  but  sometimes  the  constitution  becomes 
affected,  and  secondary  troubles,  peculiar  to  itself,  make  their  appearance  in 
distant  parts  of  the  body. 

GonorrJioea. — The  germ  (gonococcus)  is  [a  diplococcus]  found  upon  the 
surface  of  the  epithelial  cells   in   gonorrhcjeal   pus,  each    individual  coccus  being 


1096     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

placed  at  a  distance  equal  to  its  own  diameter  from  its  fellows.  It  is  stated  to  be 
always  present,  and  to  be  found  in  the  discharge  of  ophthalmia  neonatorum,  as 
well  as  in  the  fluid  of  gonorrhteal  arthritis  and  conjunctivitis.  Cultivations  of  it 
have  been  made  in  gelatine,  and  these  are  equally  active.  Vaginal  discharges 
[containing  other  pyogenic  organisms]  can  infect  the  urethra  and  even  the  con- 
junctiva, and  cause  inflammation. 

There  is  no  doubt  that  the  action  of  the  germ  is  greatly  favored  by  different 
conditions.  Certain  people  seem  to  enjoy  immunity,  or,  if  they  are  attacked,  the 
inflammation  is  of  the  most  transitory  character.  The  first  attack  is  usually  by 
far  the  worst  and,  so  far  at  least  as  out-patient  practice  is  concerned,  it  is  rare  to 
see  it  very  severe  in  any  one  over  five-and-twenty.  Intense  and  prolonged 
sexual  excitement,  too  frequent  intercourse,  and  irritating  conditions  of  the  urine, 
such,  for  example,  as  that  produced  by  the  free  use  of  alcohol,  of  themselves  some- 
times cause  a  muco-purulent  discharge,  and  certainly  they  render  the  mucous  mem- 
brane more  sensitive.  Asparagus  and  new  sherry  are  stated  to  have  a  peculiarly 
strong  influence  in  this  direction. 

Symptoms. — The  period  of  incubation  is  short,  from  four  days  to  a  week. 
The  first  sign  is  a  slight  redness  at  the  meatus  with  an  increased  secretion  of 
mucus,  a  sense  of  soreness  or  itching,  and  a  certain  amount  of  smarting  during 
micturition.  In  the  course  of  the  next  two  days  these  symptoms  become  more 
marked,  and  more  and  more  of  the  urethra  is  involved,  until  the  whole  mucous 
membrane  is  in  a  state  of  the  most  intense  inflammation.     The  meatus  is  swollen, 


IS 


e«6   ^   ^    *t 


Fig.  474. — Gonococcus.  (Bumra.)  a,  from  a  pure  culture,  b,  from  a  blennorrhceic  conjunctival  secretion  ;  an 
epithelial  cell  covered  with  cocci  :  a  pus  cell  completely  filled  with  cocci  ;  a  free  mass  of  cocci  in  close  proximity 
to  a  pus  cell  (Seibert).  Oc.  2.     c,  scheme  of  development  cf  gonococci.    (From  Senn.) 

red,  and  pouting,  the  prepuce  oederaatous,  the  glands  turgid  and  shining,  the  whole 
penis  enlarged  and  soft,  with  the  veins  congested  and  prominent.  Sometimes  red 
lines,  due  to  the  inflamed  lymphatics,  can  be  seen  in  the  skin,  and  the  glands  in 
the  groin,  especially  those  just  below  Poupart's  ligament  at  the  inner  end,  are 
swollen  and  tender.  At  the  same  time  the  discharge  increases  until  it  flows  away 
continuously,  and  its  character  changes  from  glairy  mucus  to  thick,  cream-colored, 
yellow,  and  even,  in  severe  cases,  greenish  pus. 

Increased  frequency  of  micturition  occurs  very  early  ;  at  first  it  is  probably 
reflex,  but  later  it  is  due  to  extension  of  the  inflammation  toward  the  neck  of  the 
bladder  ;  and  each  act  is  attended  by  a  scalding,  burning  i)ain,  partly  caused  by 
the  tension  on  the  mucous  membrane,  partly  by  the  irritation  of  the  acid  urine. 
Sometimes,  as  the  swelling  and  congestion  increase,  the  stream  is  obstructed,  and 
if  the  prostate  is  attacked,  retention  is  almost  sure  to  occur.  Malaise  and  fever 
are  usually  present  during  the  acute  stage,  and  at  night,  even  when  the  penile  part 
only  is  involved,  rest  may  be  disturbed  by  chordee.  As  the  patient  grows  warm 
in  his  bed  the  penis  is  liable  to  become  erect  ;  owing  to  the  infiltration  in  the 
corpus  spongiosum,  it  cannot  expand  evenly,  and  the  inflamed  and  tender  fibrous 
tissue  is  stretched  until  it  causes  the  most  intense  suffering.  If  the  inflammation 
extends  to  the  deeper  part  of  the  urethra,  where  it  is  fixed  and  surrounded  by 
fibrous  tissue,  the  pain  is  even  more  severe,  and  there  may  be  high  fever  ;  the 
perineum  throbs  and  burns  ;  there  is  a  sense  of  weight  in  the  pelvis,  and  a  constant 
aching  across  the  loins ;  and  the  skin  over  the  scrotum  and  testes  is  sometimes  so 
tender  that  the  patient  can  scarcely  endure  being  touched. 

The  acute  stage  lasts  a  week  or  ten  days.     As  it  begins  to  subside,  the  scald- 


ACUTE  URETHRITIS.  1097 

ing  becomes  less  intense  ;  the  throbbing  ceases  ;  the  frequency  of  micturition  dis- 
appears, and  the  discharge  diminishes  in  quantity,  loses  its  greenish  color,  and 
becomes  less  thick.  If  no  complication  is  present  it  may  cease  altogether  in  about 
six  weeks  ;  more  frequently  it  i)ersists  for  some  time,  not  more  than  a  few  drops  of 
glairy  mucus  in  the  twenty-four  hours,  or  perhaps  merely  sufficient  to  glue  the  sides 
of  the  meatus  together  in  the  morning  ;  but  with  every  indiscretion,  irregularity  of 
diet,  sexual  excitement,  undue  exercise,  or  alcoholic  indulgence,  returning  and 
becoming  muco-purulent  for  a  few  days. 

Sometimes  it  becomes  chronic.  The  mucous  membrane  becomes  rough  and 
granular,  covered  with  hypertrophied  papilla  ;  or  the  loose  and  vascular  tissue  that 
surrounds  it  becomes  dense  and  hard,  as  the  lymph  that  fills  its  meshes  is  organ- 
ized ;  in  either  ca.se  the  change,  slight  as  it  is,  is  sufficient  to  maintain  a  certain 
degree  of  irritation  ;  there  is  a  constant  discharge  of  thin  mucus  from  the  meatus 
(gleet),  and  more  and  more  lymph  is  poured  out  until  the  diameter  of  the  urethra 
is  narrowed,  and  a  stricture  is  formed  which,  itself  an  irritant,  keeps  up  the  inflam- 
mation, and  continues  to  get  firmer  and  firmer  the  longer  it  lasts. 

Complications. — {a)  Hemorrhage  is  not  uncommon,  owing  to  the  over- 
loaded condition  of  the  thin-walled  vessels  in  the  mucous  membrane,  but,  unless 
very  profuse,  it  need  not  excite  alarm  ;  the  green  color  of  the  pus  is*  due  to  haemo- 
globin.     Chordce  and  retention  have  been  already  mentioned. 

(J))  The  most  common  are  caused  by  extension  of  the  inflammation  to  struc- 
tures near.  Balanitis,  posthitis,  phimosis,  z.nA  paraphimosis  are  of  frequent  occur- 
rence ;  7iiarts  rarely  occur  until  the  irritation  has  lasted  some  length  of  time. 
Abscesses  are  not  so  often  met  with,  but  they  occasionally  originate  in  the  mucous 
follicles,  especially  those  of  the  fossa  navicularis  ;  or  they  may  occur  independ- 
ently of  the  mucous  membrane,  in  the  lymph  that  is  poured  out  around  it.  If 
the  suppuration  is  in  the  region  of  the  bulb,  or  on  one  side  of  it,  in  connection 
with  Cowper's  gland,  it  often  spreads  a  considerable  distance  before  coming  to  the 
surface.  Prostatitis,  with  complete  retention,  and  cystitis  often  follow  ;  occasion- 
ally even  the  pelvis  of  the  kidney  and  the  peritoneum  are  involved.  Epididy- 
mitis, from  extension  down  the  vas  deferens,  is  not  so  common  in  the  acute  stage 
as  later,  when  gleet  sets  in.  Bubo  and  inflammation  of  the  lymphatics  may  occur 
at  any  time,  especially  if  the  patient  will  not  rest  quiet ;  and  even  pyaemia  may 
break  out  and  prove  fatal,  starting,  in  all  probability,  from  some  ulceration  of  the 
mucous  membrane. 

(r)  Others  are  caused  by  direct  infection.  Of  these,  conjunctivitis  h  the  best 
known  and  the  most  serious  {gonon-hceal  ophthalmia  and  ophthalmia  ?ieonatorum~); 
and  the  mucous  membrane  of  the  nose  and  of  the  rectum  may  be  also  infected. 
[Rectal  gonorrhoea  is  very  common  in  women,  from  overflowing  gonorrheal  dis- 
charge from  the  vagina.] 

(d)  Another  variety  is  the  result  of  constitutional  infection,  and  does  not 
occur,  so  it  is  said,  in  simple  urethritis,  however  severe  it  may  be.  The  fibrous  tis- 
sues (particularly  the  joints)  are  the  parts  most  liable  to  be  attacked,  but  sometimes 
the  sclerotic,  the  plantar  fascia,  the  tunica  albuginea  of  the  testis,  and  the  sheets 
of  fibrous  tissue  in  the  loins  suffer  as  well.  Its  connection  with  gonorrhoea  is 
shown  by  the  fact  that  not  only  does  it  return  with  each  fresh  attack,  but  that,  if 
from  any  indiscretion  there  is  a  relapse  or  an  increase  in  the  amount  of  discharge, 
there  is  frequently  at  the  same  time  a  fresh  outbreak  of  the  secondary  inflammation. 
When  it  is  acute  and  attacks  several  joints,  it  maybe  distinguished  from  rheumatic 
fever  by  the  absence  of  the  sweating  and  the  thick,  white  furred  tongue,  and  by  the 
rarity  with  which  cardiac  complications  occur  ;  but  the  relation  that  it  bears  to 
gout,  particularly  to  the  chronic  rheumatic  form,  is  much  more  uncertain.  There 
is  no  doubt  that  it  is  more  likely  to  break  out  in  those  who  are  subject  to  this  com- 
plaint ;  or  in  whose  families  there  is  a  well-marked  history  of  it ;  and  I  have  seen 
several  cases  which  strongly  bear  out  Hutchinson's  contention  that,  in  patients  who 
are  distinctly  gouty  or  rheumatic,  any  urethral  discharge,  specific  or  not,  may  give 
rise  to  symptoms  similar  to  those  of  gonorrhoeal  rheumatism.  Suppuration  rarely 
70 


1098     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

occurs  ;  but,  if  it  does,  it  is  impossible  to  draw  a  definite  line  between  gonorrh(jeal 
arthritis  and  jiyasmia.  A  similar  affection  occurs  not  unfrequently  in  women  who 
are  suffering  from  chronic  leucorrhtjea  ;  and  ophthalmia  neonatorum,  according  to 
Lucas,  may  give  rise  to  something  of  the  same  character.  For  a  further  descrijj- 
tion  see  Diseases  of  Joints.  [Bacteriologists  are  now  generally  agreed  that  arth- 
ritis complicating  gonorrhoea  is  caused  by  metastatic  infection.] 

Acute  //;r///r///>,  of  a  similar  description,  but  much  less  intense,  mav  be  caused 
by  infection  from  leucorrhceal  or  menstrual  discharges.  When  due  to  mechanical 
irritation,  such  as  the  passage  of  a  catheter  or  the  impaction  of  a  calculus,  it  rarely 
lasts  more  than  a  day  or  two.  If  there  is  a  stricture  the  discharge  may  be  profuse 
at  first,  but  it  is  rarely  purulent ;  and  if  the  cause  is  removed,  the  symptoms  soon 
subside.  Occasionally,  however,  the  inflammation  extends,  and  epididymitis  and 
other  complications  occur,  as  in  gonorrhoea. 

Gouty  urethritis,  like  inflammation  of  the  bladder,  is  not  uncommon  when  the 
urine  is  loaded  with  uric  acid.  Usually  it  is  an  extension  of  the  inflammation  from 
the  neck  of  the  bladder,  and  the  discharge  is  preceded  for  some  days  by  irritability, 
increased  fre(iuency  of  micturition,  and  sharp,  cutting  pain  at  the  end  of  the  penis. 
It  is  most  common  in  stoutly-built,  middle-aged  men,  addicted  to  alcohol,  but  it 
is  met  with  in  women  also;  and  a  somewhat  similar  form,  dependent  upon  mal- 
assimilation,  and  attended  with  a  deposit  of  uric  acid  crystals,  is  not  uncommon 
among  poorly-fed  children,  and  often  gives  rise  to  the  suspicion  of  calculus.  Un- 
less it  is  the  residue  of  a  gonorrhcea  kept  up  by  the  condition  of  the  urine,  it  rarely 
happens  that  there  is  much  discharge,  or  that  it  is  purulent.  l>erkeley  Hill  has 
described  a  very  obstinate  form  analogous  to  this,  eczematous  urethritis,  occurring 
under  much  the  same  conditions,  but  associated  with  eczema  of  the  skin.  The 
surface  of  the  glans  is  reddened  and  tender,  and  the  anterior  part  of  the  urethra 
appears  to  be  affected  in  the  same  way  ;  the  mucous  membrane  is  bright  red  in 
color,  though  it  does  not  bleed  easily,  and  the  discharge  is  scanty  and  milk-white. 
Epididymitis,  prostatitis,  and  other  complications  may  occur  in  gouty  urethritis  as 
well  as  in  the  rest;  but,  in  addition,  inflammation  may  attack  the  joints,  the  eye, 
the  testis,  the  fibrous  tissue  of  the  back,  the  sheaths  of  nerves,  and  the  plantar 
fascia,  just  as  in  gonorrhcea  ;  and  unless  the  history,  the  condition  of  the  patient, 
and  the  state  of  the  urine  are  carefully  investigated,  it  is  very  difficult  to  distinguish 
one  from  the  other. 

Tubercular  uretliritis  is  generally  secondary  to  inflammation  of  the  bladder, 
and  the  urethral  symptoms  are  completely  overshadowed  by  the  intense  irritability 
and  the  fearful  burning  pain  at  the  neck  when  it  contracts.  The  discharge  is  gen- 
erally scanty  in  amount,  and  unless  the  anterior  part  of  the  urethra  is  involved,  is 
only  seen  when  the  urine  washes  it  down,  but  it  is  often  stained  with  blood  coming 
from  the  surface  of  the  ulcers  when  the  muscles  are  contracting.  The  sense  of 
smarting  during  micturition  is  sometimes  very  severe  ;  and,  owing  to  muscular 
spasm,  is  apt  to  continue  for  a  long  time  after  the  act  is  finished  ;  and  the  passage 
of  a  sound  or  catheter  gives  the  most  intense  pain  when  the  ulcers  are  reached. 
Cicatrization  sometimes  occurs,  and  gives  rise  to  stricture  ;  but,  as  a  rule,  the 
bladder  and  other  organs  are  involved,  and  the  patient  rarely  lives  long. 

Syphilitic  Urethritis. — A  scanty  discharge,  with  a  certain  amount  of  soreness 
along  the  urethra,  is  not  infrequent  in  early  secondary  syphilis,  caused,  in  all  prob- 
ability, by  the  eruption  of  a  few  roseolous  spots  upon  the  mucous  lining.  As  a 
rule  it  disappears  very  rapidly  under  specific  treatment. 

Treatment. — As  gonorrhfjea  commences  by  infection  at  the  meatus,  it  has 
often  been  proposed  to  cut  short  the  attack  as  soon  as  the  redness  first  makes  its 
appearance  by  the  use  of  a  strong  astringent,  limited  to  the  anterior  i)art  of  the 
urethra.  Tannin  or  nitrate  of  silver  (gramme  .30  ad  c.c.  32)  is  generally  re- 
commended ;  and  so  long  as  the  penis  is  carefiilly  compressed  immediately  behind 
they  may  be  used  without  danger,  but  it  is  doubtful  whether  they  are  of  much  ser- 
vice. 

I.    The  Acute  Stage. — Local  applications  are  better  avoided  so  long  as  the 


SVrmi.lTIC  URETHRIJIS.  ,099 

intense  hyperaMiiiu  with  iirol'use  punilciit  discharge  and  the  severe  i)ain  continue. 
The  patient  should,  if  possible,  be  kept  in  bed  ;  the  absolute  rest  obtained  in  this 
way  is  better  than  anything  else.  The  bowels  should  be  kept  freely  open,  the  diet 
carefully  regulated,  all  forms  of  highly  sea.soned  food  and  sauces,  pepper,  vinegar, 
tea,  coffee,  rhubarb,  and  asparagus  being  forbidden,  and  as  much  fluid  (barley  water, 
milk,  etc.)  allowed  as  the  patient  wishes  ;  but  no  alcohol.  Claret  and  very  weak 
gin  and  water  are  perhaps  the  least  injurious  ;  champagne,  sherry,  and  beer  will 
often  bring  back  a  temjjorary  gleet  months  after  its  last  ajjpearance.  If  the  urine 
is  acid  and  irritating,  alkalies  maybe  given  with  sedatives,  such  as  hyoscyamus  ; 
but  if  the  l)icarbonates  are  used  they  should  always  be  taken  during  digestion,  not 
while  the  stomach  is  empty.  The  dressing  of  the  i)enis  itself  should  be  light  and 
frequently  changed  ;  anything  that  prevents  evaporation,  or  that  absorbs  the  pus 
and  dries  upon  the  meatus  so  that  the  discharge  cannot  escape,  is  injurious.  A 
soft  linen  bag  in  which  it  can  hang  freely,  with  some  wood-wool  at  the  bottom  to 
soak  up  the  discharge,  is  as  convenient  as  anything.  Dressings  retained  under  the 
prepuce  are  liable  to  be  very  irritating  ;  if  the  glans  cannot  be  exposed  it  is  better 
to  introduce  a  soft  rubber  tube  by  the  side  of  it  as  far  as  it  will  go,  and  irrigate 
its  surface  thoroughly  several  times  a  day  with  lead  lotion.  The  antiseptic 
treatment  by  means  of  bougies,  though  it  promises  well,  is  not  so  successful  in 
practice. 

If  the  hyperaimia  is  so  great  as  to  threaten  retention  of  urine  it  may  some- 
times be  checked  by  free  leeching  in  the  perineum,  or  by  the  application  of 
Leiter's  coil,  with  ice-cold  water.  If  it  come  on  in  spite  of  this,  a  soft  rubber 
catheter  of  moderate  size  must  be  passed,  and,  if  necessary,  this  must  be  repeated 
three  times  a  day.  A  morphia  and  belladonna  suppository  the  last  thing  at  night, 
or  a  hypodermic  injection  in  the  perineum,  will  usually  stop  chordee.  Bromide 
of  potash  in  full  doses  is  also  very  useful,  and  camphor  is  said  to  be  of  value.  The' 
l)atient  should  be  directed  to  take  a  warm  (not  hot)  sponge  bath,  at  night,  to  avoid 
late  meals,  to  cause  the  bowels  to  act  freely  before  retiring  to  rest,  and  to  have 
only  the  lightest  clothing  on  while  in  bed.  Abscesses  around  or  in  connection 
with  the  urethra  should  be  opened  freely  and  as  soon  as  possible,  or  they  may  de- 
generate into  troublesome  sinuses.  They  are  most  common  near  the  meatus,  start- 
ing from  the  follicles  in  the  fossa  navicularis,  or  else  forming  by  the  side  of  the 
frsenum  ;  sometimes,  however,  they  occur  further  back  in  connection  with  Cowper's 
glands.  They  may  burst  into  the  urethra,  but  unless  there  is  a  stricture  present  it 
seldom  happens  that  the  fistulous  opening  persists. 

2.  The  Subacute  Stage. — When  the  active  hypertemia  and  scalding  have  sub- 
sided, or  if  the  inflammation  is  only  subacute  from  the  first,  more  active  measures 
may  be  adopted.  Copaiba  and  cubebs  may  now  be  given  with  advantage  ;  or  if 
they  do  not  agree  with  the  patient,  gurjun,  sandal-wood,  or  eucalyptus  oil.  These 
all  appear  to  act  locally,  the  resin  being  excreted  by  the  walls  of  the  urinary  pas- 
sages. Copaiba,  when  it  can  be  tolerated,  is  perhaps  the  most  efficacious  ;  2  c.c. 
doses  may  be  given,  rubbed  up  with  burnt  magnesia  in  the  form  of  a  bolus,  or 
with  sulphuric  acid,  or  better  still,  if  the  patient  will  take  it,  with  liquor  potassoe, 
with  which  it  forms  a  kind  of  soap.  Harrison  has  shown  that  it  is  much  more 
effectual  when  given  with  an  alkali  than  in  the  form  of  capsules.  Cubebs  are 
more  stimulating,  and  may  be  taken  with  it.  The  best  time  for  administration  is 
either  an  hour  before  meals  or  three  hours  after.  In  some  patients,  however, 
copaiba  produces  a  characteristic  roseolous  and  even  papular  eruption  upon  the 
skin  (copaiba  rash)  ;  in  others  it  disturbs  digestion  to  such  an  extent  that  it  can- 
not be  endured  ;  and  it  even  has  the  credit  of  causing  hematuria.  Few  can  stand 
it  for  any  length  of  time,  and  if  it  does  not  produce  a  definite  improvement  in  the 
course  of  a  fortnight,  it  is  better  to  stop  it  altogether.  Such  patients  are  often 
more  benefited  by  tonics. 

In  the  majority  of  instances,  gonorrhcea  will  cease  without  the  use  of  injec- 
tions ;  but  in  the  subacute  stage,  when  the  discharge  shows  no  signs  of  abating, 
and  still  more  when  a  chronic  gleet  has  set  in,  they  may  be  used  with  advantage. 


iioo     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

So  long  as  there  is  extreme  hyperaemia  they  are  positively  harmful.  The  ordinary 
glass  syringe  is  useless,  unless  the  mischief  is  confined  to  the  fossa  navicularis ; 
the  object  is  to  wash  out  the  discharge  from  off  the  mucous  membrane,  so  that  it 
may  not  remain  stagnant  in  its  folds  or  recesses,  and  to  ai)ply  a  very  mild  astrin- 
gent to  the  surface.  Durham's  tube,  which  can  be  introduced  as  far  as  the  bulb, 
and  which  is  provided  with  openings  so  that  there  shall  be  a  recurrent  stream,  is 
the  best,  but  in  its  absence  a  small  flexible  rubber  catheter  may  be  employed. 
This  should  be  introduced  as  far  as  necessary,  and  then  connected  with  a  Hig- 
ginson's  syringe.  Hot  water  may  be  used  first  to  wash  out  the  urethra  and  then 
a  very  mild  astringent.  There  is  no  fear  of  any  injection  penetrating  as  far  as 
the  bladder,  if  ordinary  precautions  are  taken,  and  it  should  never  be  sufficiently 
strong  to  do  any  harm  if  it  does.  Chloride  of  zinc  (.03  ad  32  c.c),  sulj)hate  of 
zinc  (.06  ad  32  c.c),  acetate  of  lead  (.12  ad  32  c.c),  tannin,  mercuric  chloride, 
subnitrate  of  bismuth  (not  suspended  in  mucilage),  and  many  others  are  of  use; 
and  very  often  it  is  of  advantage  to  change  from  one  to  the  other.  The  bulb  and 
the  fossa  navicularis  may  be  thoroughly  douched  in  this  way  every  night,  or,  if  no 
progress  is  made,  night  and  morning;  the  application  cau.ses  a  certain  amount  of 
smarting,  but  if  it  is  really  painful,  either  the  injection  is  too  strong  or  the  inflam- 
mation still  too  acute. 

In  tubercular  urethritis  everything  must  be  done  to  maintain  the  strength  of 
the  patient  and  assuage,  as  far  as  possible,  by  morphia  and  belladonna,  the  irrita- 
bility of  the  bladder.  If  the  urine  becomes  ammoniacal,  relief  may  be  obtained 
by  opening  the  bladder  in  the  perineum  and  draining  it.  Iodoform  seems  to  be 
the  best  local  application,  as  in  tubercular  cystitis.  Local  applications  are  rarely 
of  service  when  urethritis  is  due  to  gout ;  the  urine  must  be  rendered  as  unirri- 
tating  as  possible,  the  bowels  kept  open  with  mercurial  purges,  and  careful  atten- 
tion paid  to  diet  and  exercise.  When  the  urethritis  is  simply  caused  by  the 
irritation  of  the  urine  it  can  easily  be  cured  ;  but  if  there  is  gouty  inflammation  of 
the  corpus  spongiosum  or  of  the  prostate,  the  condition  is  exceedingly  obstinate, 
and  epididymitis  and  other  se(iuelse  are  not  unlikely. 

Chronic  Urethritis. 

Chronic  urethritis  rarely  occurs  unless  there  has  been  an  acute  attack  ;  the 
inflammation  subsides  up  to  a  certain  point,  and  then  from  some  cause,  local  or 
constitutional,  becomes  stationary,  the  discharge  persisting  as  a  gleet,  sometimes 
disappearing  for  a  few  days,  and  then  returning  again  almost  as  bad  as  ever. 
Even  in  healthy  persons,  the  mucous  membrane  of  the  urethra  is  always  peculiarly 
sensitive  after  an  acute  attack  ;  the  least  indiscretion  for  months  after  brings  back 
a  certain  amount  of  gleet ;  and  a  very  slight  cause  is  sufficient  to  keep  the  irritation 
up  permanently.  Chronic  inflammation  of  this  descrii)tion  is  the  main  cause  of 
stricture;  for  months,  and  even  years,  minute  quantities  of  lymph  are  constantly 
Vjeing  poured  out  into  the  mucous  and  submucous  tissues  ;  as  it  becomes  organized, 
it  gradually  renders  them  so  dense  and  hard  that  at  length  a  definite  organic 
obstruction  is  developed. 

The  reason  is  often  difficult  to  find.  Sometimes  it  appears  to  be  due  to 
general  debility  rather  than  anything  else  ;  the  patient's  health  gives  way ;  the 
mucous  membrane  remains  soft  and  relaxed,  without  any  great  local  change,  and 
the  catarrh  becomes  chronic,  as  it  occasionally  does  in  other  parts  of  the  body. 
In  other  cases  it  may  be  traced  to  errors  in  diet  or  to  faulty  modes  of  living. 
More  frequently  it  is  dependent  upon  some  local  affection,  very  slight,  perhaps, 
but  quite  sufficient  to  keep  up  irritation.  Small  warts,  similar  to  those  on  the 
prepuce  and  behind  the  glans,  gan  be  seen  sometimes  just  inside  the  meatus. 
Pouches  and  dilatations  of  the  mucous  membrane,  possibly  originating  from  in- 
flamed follicles,  are  found  occasionally,  especially  in  the  fossa  navicularis  and  in 
the  region  of  the  bulb.  These  serve  to  collect  a  small  quantity  of  urine,  which 
begins  to  decompose  and  act  as  an  irritant  before  it  is  washed  away.      Chronic 


CHRONIC  URETHRITIS.  iioi 

inflammation  of  Cowper's  glands  sometimes  occurs  in  the  same  way.  A  granular 
condition  of  the  surface  is  still  more  common,  es[jecially  in  the  region  of  the  bulb. 
It  closely  resembles  in  appearance  that  which  is  left  after  rejjeated  attacks  of  con- 
junctivitis ;  the  mucous  membrane  is  rough  and  tender  when  touched  ;  the  color 
is  bright  red  ;  and  it  is  covered  with  small  pai)ilh\i.  Slight  strictures,  again,  are 
occasionally  the  cause  ;  the  exudation  of  lymj)!!  is  not  sufficient  to  affect  the  stream, 
but  for  all  that  it  renders  the  mucous  membrane  hard  and  unyielding,  so  that  it 
cannot  unfold  itself  as  the  urine  is  i)assing.  Finally,  in  some  cases  the  whole  of 
the  urethra  in  front  of  the  triangular  ligament  continues  to  secrete  a  profuse  muco- 
purulent fluid,  without  its  being  possible  to  find  any  local  or  constitutional  cause 
to  account  for  it.  Harrison  has  described  several  such  in  which  the  passage  ap- 
pears to  have  degenerated  into  a  chronic  suppurating  sinus,  which  could  not  be 
drained,  and  which,  in  spite  of  injections,  and  in  one  case  of  internal  urethrotomy. 


Fig.  475 — Leiter's  Panelectroscope.     Z,  Lamp  ;  .S/.  Mirror;    ^',  Lens  for  correcting 
any  defect  in  the  observer's  vision. 


declined  to  improve  in  any  way.  At  last  they  were  cured  by  giving  the  urethra 
perfect  rest  for  a  month,  opening  it  behind  in  the  perineum,  and  draining  off  all 
the  urine  from  the  bladder,  so  that  no  drop  should  flow  along  it. 

An  absolute  diagnosis  in  such  cases  can  only  be  made  by  means  of  an  endo- 
scope. Leiter's  panelectroscope  is  perhaps  the  most  convenient ;  it  carries  a  small 
incandescent  lamp  in  the  vertical  portion,  so  arranged  that  its  rays  are  concen- 
trated by  a  mirror  and  reflected  down  the  tube,  while  the  observer's  eye  looks  over 
the  upper  edge.  It  is  an  additional  advantage  that,  with  this  instrument,  appli- 
cations may  be  made  to  any  part  of  the  urethra  that  requires  them,  without  with- 
drawing the  tube. 

Constitutional  treatment  should  be  thoroughly  tried.  If  the  patient  is  broken 
down  in  health  and  strength,  tonics  and  sea-air  often  prove  efficacious;  or,  if 
there  is  evidence  of  gout,  alkalies  may  be  given,  or  the  patient  may  be  sent  for  a 


II02    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

time  to  a  suitable  watering  place,  so  that  the  mode  of  life  may  undergo  a  complete 
change.  The  diet  should,  in  all  cases,  be  carefully  regulated,  especially  as  regards 
the  amount  of  alcohol ;  and,  according  to  some,  smoking  is  particularly  injurious. 
At  the  same  time,  the  deeper  part  of  the  urethra  should  be  thoroughly  washed  out 
with  some  mild  astringent,  as  in  chronic  gonorrhoia,  only  this  should  be  done, 
not  once  a  day,  but  after  each  act  of  micturition.  It  is  no  use  injecting  the 
meatus  unless  it  is  known  there  is  a  tender  spot  in  the  fossa  navicularis  ;  the  only 
method  is  to  pass  a  soft  rubber  tube  down  as  far  as  the  bulb,  and  with  Higginson's 
syringe  gently  douche  the  whole  length  from  behind,  varying  the  nature  of  the 
application  every  week  or  ten  days.  If  this  does  not  succeed,  a  full-sized  bulbous 
instrument  should  be  slowly  and  carefully  passed,  and  then,  after  the  spasm  has 
subsided,  withdrawn  again.  Sometimes  this  of  itself  is  sufficient:  the  muscular 
fibre  of  the  urethra  is  stretched  ;  the  spasm  ceases  for  a  time  ;  the  mucous  mem- 
brane gets  a  certain  amount  of  rest,  and  the  irritation  has  a  chance  of  subsiding. 
The  same  treatment  is  often  successful  in  obstinate  cases  of  neuralgia,  which  per- 
sist without  anything  being  found  to  account  for  them. 

Most  frequently,  however,  the  persistence  of  the  symptoms  is  due  to  some  local 
change  in  the  mucous  membrane  which  requires  special  treatment.  The  method, 
of  course,  must  vary  with  the  lesion  ;  small  warts  in  the  meatus  may  be  snipped  off 
or  touched  with  mild  caustics  ;  if  the  mucous  membrane  is  rough  and  granular,  a 
moderately  strong  astringent  may  be  applied  to  the  surface  by  means  of  a  syringe, 
as  in  chronic  prostatitis.  Glycerine  and  tannic  acid  I  have  found  very  useful  to 
commence  with  ;  if  this  fails,  nitrate  of  silver  (.30  ad  32  c.c.)  may  be  tried.  Sinuses 
should  be  distended  with  a  similar  injection,  after  each  act  of  micturition,  or,  if 
near  the  meatus,  they  may  sometimes  be  laid  open.  There  is  a  congenital  diver- 
ticulum occasionally  present  in  the  fossa  navicularis,  which  rarely  gets  well  until 
it  is  treated  in  this  way.  Its  existence  may  be  sus])ected  when  there  is  a  feeling 
of  pain  in  the  glans  at  the  commencement  of  micturition,  or  when  squeezing  the 
glans  suddenly  sometimes  causes  a  iew  drops  of  discharge  to  make  their  appear- 
ance ;  but,  as  its  opening  lies  toward  the  bladder,  it  can  only  be  detected  with  the 
endoscope,  or  with  a  probe,  the  point  of  which  is  bent  back  upon  itself.  Finally, 
if  there  is  any  resistance  to  the  passage  of  a  sound,  especially  as  it  is  being  with- 
drawn, suggesting  the  presence  of  a  commencing  stricture,  a  full-sized  instrument 
should  be  passed  once  a  week,  until  it  is  no  longer  grasped. 

Stricture. 

Stricture  of  the  urethra  may  be  congenital  or  acquired.  The  former  is  very 
rare  and  only  occurs  at  the  meatus,  or  within  a  short  distance  of  it ;  the  latter  is 
met  with  in  every  part  except  the  prostatic,  and  is  always  the  result  of  inflammation. 

Stricture,  in  the  true  sense  of  the  term,  must  be  a  structural  alteration  in  the 
wall  of  the  urethra;  there  may  be  only  a  certain  degree  of  roughness  and  uneven- 
ness,  so  that  the  mucous  membrane  does  not  unfold  itself  smoothly  when  urine  is 
passing  ;  or  thickening  and  exudation  in  the  submucous  tissue,  leaving  the  surface 
smooth  ;  but  in  every  case  there  is  a  definite  and  persisting  change.  S])asm  and 
congestion  are  always  present  in  addition,  owing  to  the  vascularity  of  the  part  and 
to  the  amount  of  unstriped  muscular  fibre,  es])ecially  in  the  region  of  the  bulb  ; 
and  in  certain  conditions  (such  as  congestion  of  the  prostate)  these  of  themselves 
are  sufificient  to  cause  obstruction  and  retention  ;  but  they  are  in  reality  symptoms, 
not  diseases,  and  it  is  better  to  reserve  the  term  stricture  for  an  organic  change. 

Causes. —  Gonorrha'a  is  by  far  the  most  common.  A  slight  attack  merely 
leaves  the  surface  tender  with  enlarged  hypertrophied  papillae  ;  when  it  is  more 
severe  and  long  continued,  a  large  amount  of  exudation  is  poured  out  into  the 
submucous  tissue  ;  and  gradually,  as  it  becomes  organized,  it  constricts  the  canal 
more  and  more.      Ulceration  of  the  surface  and  cicatrization  are  rare. 

Injury. — Rupture  of  the  urethra  may  cause  stricture  of  a  very  obstinate  char- 
acter if  suppuration  occurs,  owing  to  the  dense  mass  of  cicatricial  tissue  formed. 


STRICTURE  OF  THE  URETHRA.  1103 

Impaction  of  a  calculus,  median  lithotomy,  when  the  urethra  is  torn,  and  caustics, 
are  occasional  causes. 

Syphilis. — Primary  sores  not  unfrequently  cause  stricture  at  the  orifice  ;  and 
occasionally,  in  the  later  stages,  ulceration  of  the  mucous  membrane  or  gumma- 
tous exudation  into  the  corpus  spongiosum,  leads  to  the  same  result.  A  few  in- 
stances are  on  record  in  which  stricture  has  followed  tubercular  ulceration. 

Many  different  terms  are  used  to  describe  strictures,  according  to  the  prom- 
inence of  sjjecial  features.  If  there  is  a  band  of  lymph  stretching  across  the  canal 
from  side  to  side,  it  is  called  a  bridle  ;  when  there  is  a  thickening  round  the  whole 
circumference,  as  if  a  piece  of  string  were  tied  around  it,  it  is  annular ,-  and  if  the 
base  is  much  infiltrated,  indurated.  Sometimes,  especially  in  old  cases  where 
there  are  fistulre,  this  is  so  hard  and  extensive  that  the  stricture  is  said  to  be  car- 
tilaginous. Those  are  irritable  where  rigors  occur  whenever  a  catheter  is  passed  ; 
and  resilient  or  elastic  if  the  constriction  returns  at  once  after  dilatation.  Very 
often  they  are  tortuous  ;  and  sometimes,  l)ut  probably  only  when  the  wall  of  the 
urethra  has  sloughed,  they  are  impermeable. 

So  far  as  concerns  the  question  of  treatment,  the  most  important  distinctions 
are  the  locality  (whether  near  the  meatus  or  deep  down  in  the  bulbous  part;,  the 
length  of  time  the  stricture  has  been  there,  and  the  amount  of  induration.  If  re- 
cent, the  infdtration  is  slight,  and  the  lymph  to  a  great  extent  is  still  soft  and 
cellular  ;  in  older  cases,  those,  for  instance,  of  some  years'  duration,  an  inch  or 
more  of  the  wall  of  the  urethi:a  may  be  converted  into  a  dense  cicatricial  ma.ss,  ex- 
tending into  the  corpus  spongiosum,  and  feeling  from  the  outside  as  hard  and 
resistant  as  cartilage. 

Locality. — Stricture  never  occurs  in  the  prostatic  portion  of  the  urethra.  The 
most  common  situation  is  said  to  be  at  the  bulb,  though  in  a  very  large  number 
of  instances  it  is  really  in  front  of  this,  ^'arious  reasons  have  been  offered  in  ex- 
planation. Some  consider  it  due  to  this  portion  of  the  urethra  being  horizontal 
when  the  body  is  erect ;  the  discharge  does  not  flow  away,  and,  acting  as  an 
irritant  to  the  mucous  membrane,  causes  a  greater  amount  of  lymph  to  be  poured 
out  here  than  elsewhere.  Others  have  assigned  it  to  the  angle  that  the  penis  forms 
in  front  of  this  spot,  so  that  the  walls  are  pressed  closely  together.  Probably  the 
real  reason  is  the  unusual  amount  and  the  looseness  of  the  mucous  and  submucous 
tissues  allowing  a  larger  quantity  of  lymph  to  collect.  The  urethra  is  only  patent 
for  the  moment  that  the  urine  is  passing  along  it  ;  except  at  this  instant,  its  walls 
are  in  contact  and  thrown  into  longitudinal  or  spiral  folds.  If  it  becomes  in- 
flamed, these  are  thickened,  swollen,  and  pressed  together ;  and  if  the  lymph  that 
is  poured  out  is  allowed  to  become  organized,  the  canal  is  permanently  narrowed. 

When  traumatic,  the  seat  of  the  stricture  depends  naturally  upon  the  injury. 
Usually  the  urethra  is  torn  a  little  in  front  of  the  membranous  part  or  just  where 
this  joins  the  bulb.  Those  due  to  venereal  sores  are  nearly  always  at  or  close  to 
the  meatus. 

In  most  instances  stricture  is  single,  but  it  is  not  uncommon  to  find  two  or 
even  more,(^and  in  a  few  cases  as  many  as  six  distinct  ones  have  been  described  as 
existing  at  the  .same  time.?) 

Pathology. — Post-mortem  a  stricture  appears  as  a  contraction  of  part  of  the 
urethra.  Sometimes,  especially  when  near  the  meatus,  there  is  a  band  stretching 
across  from  one  wall  to  the  other,  or  a  distinct  cicatrix  on  the  sides  ;  more  fre- 
quently there  is  an  opaque  white  constriction,  extending  around  the  whole  cir- 
cumference, dense  and  indurated,  and  varying  in  thickness  in  different  parts,  so 
that  the  canal  is  narrowed,  tortuous,  and  irregular.  In  many  cases  the  mucous 
membrane  is  affected  ecpially  with  the  submucous  tissue,  its  elasticity  is  entirely 
gone,  and  it  is  fixed  firmly  ;  but  sometimes  it  can  be  dissected  off,  and  opened  out 
to  its  full  extent,  almost  unaltered.  On  the  other  hand,  in  old  cases,  especially  in 
the  region  of  the  bulb,  the  mucous  and  submucous  coats,  the  corpus  spongiosum, 
and  even  the  areolar  tissue  outside,  are  converted  into  a  gristly  cartilaginous  mass, 
in  which  scarcely  a  trace  of  any  of  the  original  structures  can  be  found. 


II04    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


In  front  of  the  stricture  the  mucous  membrane  is  swollen,  reddened,  and 
hypereemic,  ready  to  bleed  at  the  least  touch,  and  the  unstriped  muscular  fibre  is 
in  a  state  of  tonic  contraction,  but  this,  of  course,  disappears /(^j-Z-wc/Vf^w.  The 
surface,  however,  is  rough  and  irregular,  with  small  granulations  ;  usually  it  is  dis- 
colored from  old  hemorrhages,  or  it  is  excoriated  or  covered  over  with  mucus,  and 
the  normal  folds  of  the  urethra  are  confused  and  sometimes  altogether  lost. 

Behind,  the  effect  upon  the  other  organs  is  soon  apjxirent.  Owing  to  the 
increase  in  the  pressure  the  urethra  becomes  dilated,  the  orifices  of  the  small  ducts 
enlarge,  some  of  the  bands  of  muscular  fibre  increase  in  size,  leaving  between  them 
depressions  in  the  thinned  and  stretched  mucous  membrane,  similar  to  those  found 
in  the  bladder,  only  ori  a  much  smaller  scale,  and  at  length  the  interior  may 
become  reticulated  or  studded  with  little  pouches,  which  act  as  receptacles  for 
decomposing  urine.  Then  the  bladder  becomes  affected.  If  the  obstruction  is 
sudden  and  extreme  from  the  first,  too  great  for  the  muscular  coat  to  overcome,  it 
yields  and  becomes  atrophied,  the  cavity  enlarges,  and  the  walls  become  thin  and 
soft.  If,  on  the  other  hand,  the  resistance  is  of  slow  formation,  so  that  the  work 
increases  gradually,  and  if  there  is  any  irritation,  so  that  the  bladder  is  constantly 
contracting,  the  opposite  effect  is  produced — at  first,  at  any  rate;  the  walls  grow 
thick  and  rigid,  the  cavity  diminishes  in  size,  the  muscular  coat  hypertrophies,  and 

the  fasciculi  stand  out  under  the  mucous  mem- 
brane in  ridges,  like  the  musculi  pectinati  of  an 
auricle,  leaving  between  them  deep  depressions. 
As  time  passes,  these  changes  become  more  and 
more  marked  ;  each  time  the  bladder  contracts 
the  urine  is  driven  into  the  depression  between 
the  ridges,  until  they  become  deep  enough  to 
jiroject  on  the  outside  under  the  serous  covering, 
md  then  they  soon  enlarge  mto  ttinii  a  ry  her  nice 
r  sacculi.  There  is  no  muscular  filire  in  their 
\\  all  ;  they  cannot  resist  or  empty  themselves  ; 
with  each  contraction  the  urine  is  driven  into 
them,  distending  them  in  all  directions,  and  not 
unfrequently  they  become  almost  as  large  as  the 
bladder  itself,  with  which  they  communicate  by 
a  very  narrow  opening  (Fig.  433).  The  same 
influence  is  felt  by  the  ureters  and  the  pelvis  of 
the  kidneys  ;  there  is  no  regurgitation,  but.  owing 
to  the  great  increase  in  the  pressure,  they  be- 
come more  and  more  distended,  at  the  expense 
of  the  glandular  part,  until,  in  the  case  of  the 
kidneys,  the  secreting  power  is  seriously  im- 
paired. 

The  effect,  however,  is  rarely  limited  to 
mechanical  dilatation.  I  have  known  ca.ses  in 
which,  though  the  bladder  was  distended  to  the 
umbilicus,  and  though  it  had  been  in  that  con- 
dition for  months,  and  even  years,  the  urine  on 
being  drawn  off  was  normal  and  acid,  but  this 
is  the  exception.  Inflammation  nearly  always 
breaks  out  sooner  or  later,  probably  extending 
upward  from  the  stricture.  Ulceration  may 
cies;  Ulceration  above  the  Stricture,  and   f^gn  Set   in   behind,  in  the  dilated  i)art  of  the 

orifice  of  false  passage  below.  ,  ,     ,         ,  .  ^-  c  • 

urethra,  and    lead   to   extravasation    of   urine  ; 

an   abscess   may  form  in   the  substance  of  the  stricture  tissue  and  burst  in  the 

perineum,  leaving  behind  it  a  fistulous  opening;  suppuration  may  occur  around 

the  prostate,  or  the  inflammation  may  sj^read  down  the  vas  deferens  to  the  testes. 

The  bladder  is  usually  the  first  involved,  but  the  ureters  and  kidneys  follow 


Fig.  476. — Stricture  of  Urethra  showing  Fas- 
ciculated and  Contracted  Bladder ;  Dilated 
Prostatic  Urethra  with  Reticulations  conse- 
quent upon  Distention  of  the  Prostatic  Folli- 


STRICTURE  OF  THE  URETHRA.  1105 

suit  very  soon.  At  first  there  is  merely  catarrhal  cystitis  and  pyelitis,  but  when  the 
urine  becomes  more  irritating,  and  especially  when  it  decomposes,  the  effect  is 
much  more  marked.  'J'he  mucous  membrane  becomes  ulcerated  and  coated  with 
phosphatic  debris,  the  pus  spreads  along  the  connective  tissue  in  the  sul)stance  of 
the  kidney,  numbers  of  minute  abscesses  form  under  the  capsule  and  in  the  cortex, 
the  apices  of  the  pyramids  are  destroyed,  and  at  length  the  kidney  is  almost  dis- 
organized ;  it  is  reduced  in  size,  hard,  and  irregular  on  the  smface,  from  old  inter- 
stitial intlammation  ;  the  cai)sule  is  adherent;  wlien  it  is  stripped  off  there  are 
numbers  of  little  abscesses  beneath  ;  and  the  pelvis  is  enlarged,  irregular  in  shape, 
blackened  and  ulcerated  on  the  surface,  and  filled  with  a  mixture  of  stinking  j)us 
and  phosphatic  debris. 

Symptoms. — {a)  Those  Due  to  the  Obstruction. — Complete  retention  is 
sometimes  almost  the  first.  In  recent  strictures  the  urethra  is  often  peculiarly 
sensitive  ;  spasm  and  congestion  may  be  caused  by  the  slightest  irritants  and  close 
the  channels  altogether,  even  though  the  opening  is  still  fairly  wide.  More  fre- 
quently the  outflow  is  merely  impeded.  Simple  twisting  or  flattening  of  the 
stream  may  be  due  to  the  shape  of  the  meatus,  and  means  nothing,  but  if  it  is 
forked  or  much  reduced  in  size  or  force  it  is  very  suggestive.  In  old  cases,  when 
the  obstruction  becomes  very  great,  the  stream  may  fail  completely,  the  urine  only 
coming  in  drops.  Generally,  after  micturition  is  finished,  the  last  few  drops  flow 
away  of  themselves,  owing  to  the  action  of  the  urethral  muscles  being  interfered 
with  but  this  happens  also  in  enlargement  of  the  prostate,  and  even  after  exposure 
to  cold. 

{b)  Those  Due  to  Inflammation. — Usually  there  is  a  slight  muco-purulent  dis- 
charge (gleet),  especially  in  the  morning,  or  after  exercise.  In  general  it  is  only  a 
drop  or  two,  and  many  i)atients  are  unaware  of  its  existence,  but  it  may  cause 
great  annoyance.  Pain  is  seldom  felt,  unless  there  is  some  inflammatory  compli- 
cation or  the  urethra  is  forcibly  distended.  In  cases  of  long  standing  there  is 
usually  thickening  about  the  corpus  spongiosum  or  the  bulb.  Spasm  is  rarely  want- 
ing, and  often  leads,  especially  in  recent  strictures,  to  complete  retention.  As 
they  grow  old  and  cartilaginous,  either  the  muscle  loses  its  power  or  the  surface  its 
sensibility,  but  in  this  there  is  a  strong  personal  element,  and  the  urethra  is  much 
more  sensitive,  especially  when  inflamed,  in  some  than  in  others.  Any  slight  irri- 
tant, an  excess  of  uric  acid  for  example,  alcohol,  sexual  indulgence,  exposure  to 
cold  or  wet,  constipation,  or  even  an  inflamed  pile,  may  set  up  sufficient  spasm  to 
render  the  closure  complete. 

This  is  of  great  consequence  in  relieving  retention  due  to  stricture.  If  a 
catheter  cannot  be  passed  at  once,  teasing  the  stricture  only  makes  the  spasm  and 
congestion  worse,  while  relief  (for  a  time,  until  more  efficient  measures  can  be 
adopted)  can  almost  always  be  obtained  by  hot  baths  and  other  measures  that  pro- 
cure muscular  relaxation. 

The  course  of  stricture,  if  left  to  itself,  is  simi^ly  from  bad  to  worse.  Tem- 
perament and  the  position  of  the  stricture  are  of  some  influence  ;  deep  ones,  that 
is  to  say,  are  worse  than  those  near  the  meatus,  but  the  chief  element  in  prognosis 
is  the  condition  of  the  kidneys.  As  the  bladder  becomes  involved,  micturition 
becomes  more  frequent  and  the  straining  greater  ;  the  patient  has  to  rise  at  night ; 
retention  is  always  liable  to  occur  ;  at  first  it  may  be  relieved  with  an  instrument 
or  baths  and  purgatives,  but  each  time  it  leaves  a  permanent  change  for  the  worse  ; 
pain  becomes  a  more  prominent  feature;  there  is  a  constant,  dull,  aching  pain  in 
the  loins,  and  rupture,  hemorrhoids,  and  other  troubles  follow.  Then  the  kid- 
neys become  affected,  the  specific  gravity  of  the  urine  diminishes,  the  amount  of 
solids  is  lessened,  the  patient  grows  weak  and  anaemic,  digestion  fails,  chills  and 
feverish  attacks  are  of  common  occurrence,  the  skin  becomes  harsh  and  dry,  and 
the  health  breaks  down  completely.  Urinary  abscess  is  of  common  occurrence, 
extravasation  may  take  place,  calculi  may  form,  inflammatory  troubles  of  all  kinds 
may  follow,  or,  if  none  of  these  things  happen,  the  cpiantity  as  well  as  the  quality 
of  the  urine  diminishes,  the  albuminuria  becomes  more  pronounced,  and  death  is 


iio6    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

caused  either  by  urethral  fever  and  suppression,  or  more  frequently  by  some  inter- 
current disorder,  such  as  pneumonia  or  pleurisy. 

Diagnosis. — The  diagnosis  of  stricture  can  only  be  made  by  sight  or  touch. 
With  the  exception  of  those  at  the  meatus,  either  an  endoscope  or  a  sound  must  be 
emjjloyed.  Each  has  its  separate  uses  ;  one  cannot  replace  the  other.  As  most 
patients  do  not  apply  for  relief  until  the  narrowing  of  the  canal  is  advanced,  the 
sound  is  of  greater  service  ;  but  in  earlier  cases,  where  there  is  little  organic  change, 
and  where  the  symptoms  are  mainly  due  to  spasm  and  congestion,  the  endoscope 
tells  much  more.  With  the  one  it  is  only  possible  to  say  that  there  is  a  tender  spot 
in  the  wall  of  the  urethra,  giving  rise  to  spasm,  congestion,  and  pain  ;  with  the 
other,  the  size,  locality,  and  nature  of  the  lesion  can  be  accurately  determined,  in 
most  cases  with  the  greatest  ease. 

For  diagnosis,  metal  sounds  are  preferable  to  flexible  ones  :  the  information 
they  give  is  more  precise.  For  treatment  this  does  not  hold  good  ;  a  soft,  flexible 
instrument  can  often  find  its  way  along  the  folds  of  the  mucous  membrane  into  the 
orifice  of  a  stricture,  while  a  rigid  one  becomes  entangled  at  once.  The  best  are 
of  steel,  as  this  takes  a  higher  polish,  and  the  curve  should  be  sharp  and  abrupt. 
The  smaller  sizes  may  be  of  the  same  diameter  throughout,  but  in  the  case  of  the 
larger  ones  the  shaft  is  slender,  so  that  it  may  move  freely  in  the  urethra,  and  the 
end  expanded  like  a  bulb.  This  may  be  either  conical  or  ovoid  ;  the  former  are 
used  for  ascertaining  the  length  of  a  stricture,  in  conical  shape  passing  readily 
through  the  narrowed  part ;  on  being  withdrawn  the  shoulder  catches  at  once. 
Unfortunately,  English  sizes  are  so  arbitrary  that  it  is  scarcely  possible  to  be 
accurate  with  them  :   the  smallest  is  usually  about  one-fifth  of  an  inch  in  circum- 


FlG.  477. — OtU's  Urethrameter. 

ference,  the  largest  (No.  12)  nearly  an  inch.  The  French,  on  the  other  hand, 
are  graduated  accurately  from  one  millimetre  in  circumference  up  to  forty. 

The  Size  of  the  Urethra. — There  is  a  distinction  between  the  normal  diameter 
of  the  urethra  during  life,  and  the  size  to  which  it  can  be  stretched  without  injury. 
Even  when  urine  is  passing  in  full  stream  the  walls  are  contracted  and  maintain  a 
certain  degree  of  tonic  pressure  upon  it  so  as  to  ensure  its  ejection  ;  and  they  can 
be  stretched,  so  far  at  least  as  the  penile  part  is  concerned,  far  beyond  this.  If  a 
stricture  is  to  be  considered  cured,  it  must  be  dilated  until  its  width  is  as  great  as 
that  of  the  adjacent  part  of  the  urethra  when  distended  to  iis  utmost.  Clearly,  if 
it  contracts  again,  it  will  close  much  sooner  if  it  has  been  dilated  to  No.  21  F. 
than  if  it  had  been  dilated  to  No.  28  F.  But  this  is  not  all :  if  it  is  in  a  part 
which  can  be  distended  more  widely  (even  though  its  diameter  is  equal  to  that  of 
the  rest  when  urine  is  passing),  it  remains  an  obstruction  still ;  the  walls  are  hard 
and  rigid  instead  of  being  soft  and  flexible,  and  they  must  be  stretched  until  the 
induration  is  gone  and  the  lining  membrane  falls  into  its  natural  folds  again.  How 
wide  this  may  be  differs  in  each  part,  and  probably  in  each  person  ;  and  the  only 
way  to  ascertain  it  is,  either  by  carefully  exploring  with  bullet  sounds  of  different 
sizes  (enlarging  the  meatus  if  necessary  to  admit  them),  or  by  measuring  it  directly 
with  a  urethrameter.  The  most  convenient  form  of  this  instrument  is  that  invented 
by  Otis  ;  it  consists  of  a  straight  shaft,  carrying  at  its  end  a  small  expanding  bulb. 
The  size  of  this  can  be  increased  or  diminished  by  means  of  a  screw  near  the 
handle.     The  measurement  is  recorded  on  a  gauge. 

The  relation  described  by  Otis  between  the  size  of  the  penis  and  that  of 
the  urethra  only  holds  good  in  a  limited  number  of  cases  ;  and  a  stricture  dilated 
to  No.  21  may  be  cured  in  one  ix;rson,  while  in  another  No.  32  is  not  too  large. 


STRICTURE  OF  THE  URETHRA.  1107 

The  meatus  varies  from  a  mere  pinhole  to  the  size  of  No.  30  mm.  F.  ;  very 
often  it  is  the  narrowest  part,  and  it  never  dilates  readily.  The  fossa  navicularis, 
on  the  other  hand,  is  fairly  wide,  and  can  be  enlarged  without  difficulty.  After 
this  the  canal  is  narrow  again,  the  diameter  slowly  increasing  as  the  bulb  is 
approached  ;  but  the  mucous  membrane  is  so  abundant  and  the  tissues  around  so 
soft,  that  in  most  cases  No.  30  F.  and  even  No.  34  F.  will  pass  with  very  little 
pressure  and  without  any  hemorrhage.  At  the  membranous  part  again  there  is  a 
very  sudden  constriction  ;  but  here  the  structures  around  the  canal  are  so  rigid 
and  unyielding  that  it  can  rarely  be  dilated  beyond  No.  12,  or  at  the  utmost  No. 
13  E.  ;  and  very  often  instruments  of  this  size  only  pass  with  considerable  pain. 
After  this  in  the  prostatic  portion  the  distensibility  increases  to  such  an  extent 
that  the  forefinger  (if  an  opening  is  made  in  the  perineum)  can  be  passed  through 
it  without  difficulty,  and  without  lacerating  the  mucous  membrane. 

There  are  certain  consequences  which  not  uncommonly  follow  the  introduc- 
tion of  a  bougie  or  catheter  ;  and.  so  far  at  least  as  most  of  them  are  con- 
cerned, the  liability  to  their  occurrence  is  distinctly  greater  when  a  stricture  is 
present,  especially  if  it  is  recent  and  the  mucous  membrane  is  soft,  hyperaemic, 
and  over-sensitive.  In  old  cases,  or  where  a  catheter  ha.s  been  repeatedly  passed, 
it  may  be  conjectured  that  the  nerve-endings  have  to  a  great  extent  lost  their 
sensibility. 

Most  of  these  have  been  already  mentioned  ;  some  are  due  to  mechanical 
violence  (hemorrhages  and  false  passages,  for  example)  ;  others  to  inflammation, 
affecting  the  urethra,  bladder,' or  prostate  ;  and  others  again  to  the  influence  upon 
the  nerve-centres.  Of  these  the  most  important  are  atony  of  the  bladder  muscle, 
leading  to  retention ;    paralysis  of  the  vasomotor  nerves  of  the  kidney,  causing 


E.  A.  YAENALL  Co.,  Phila. 

Fig.  478.  — Bulbous  Sound  for  Diagnosis. 

hsematuria,  or  suppression,  syncope,  shock,  rigors  and  urethral  fever  in  its  various 
forms. 

The  same  precautions  should  be  used  in  exploring  the  urethra  with  a  sound  as 
in  passing  a  catheter.  The  patient  should  be  prepared  in  the  same  way  and  the 
same  method  adopted  ;  but  as  the  object  is  not  to  get  into  the  bladder  with  the 
least  friction,  but  to  ascertain  what  sources  of  friction  there  are  in  the  urethra, 
anaesthetics  and  cocaine  are  not  advisable. 

Method  of  Exploration. — As  a  rule  it  is  best  to  commence  with  a  sound  of 
moderate  size.  No.  15  or  17  F.  ;  if  this  passes  smoothly  and  easily  along  the 
mucous  membrane,  stretching  out  the  folds  without  meeting  with  any  resistance,  a 
larger  one.  No.  20  or  21  F.,  may  be  tried  ;  and  if  this  is  equally  successful,  it  may 
be  concluded  that  there  is  no  serious  degree  of  contraction. 

More  frequently  the  instrument  is  grasped  and  held  as  soon  as  the  point  passes 
the  fossa  navicularis.  The  unstriped  muscular  fibre  slowly  contracts  upon  it,  holds 
it  fast  for  a  minute  or  two,  and  then  gradually  tires  itself  out  and  releases  it  again. 
For  this  reason  bulbous  sounds  with  a  comparatively  slender  shaft  are  more  useful 
for  exploring  than  those  of  which  the  diameter  is  the  same  throughout ;  with  the 
former  the  enlargement  only  is  held,  and  the  degree  of  resistance  in  different  parts 
of  the  canal  can  be  appreciated  ;  with  the  latter  the  shaft  is  grasped  with  as  much 
tenacity  as  the  end,  and  the  delicacy  of  touch  is  to  a  great  extent  lost. 

This  occurs  even  when  the  urethrals  perfectly  healthy,  especiallv  if  a  catheter 
is  being  passed  for  the  first  time,  or  if  the  patient  suff"ers  from  gout  or  from  highly 
acid  urine  ;  the  instrument  is  firmly  grasped  the  whole  way  down.  Very  often  a 
second  sound  several  sizes  longer  can  be  passed  more  easily  than  the  first.  If 
however,  before  the  membranous  part  is  reached,  there  is  one  spot  more  sen.sitive 
than  the  rest,  or  if,  after  passing  easily  for  an  inch  or  two,  the  sound  is  suddenly 


iio8    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

arrested  and  held  for  a  time,  and  perhaps  is  stopped  again  a  little  further  on  (espe- 
cially at  the  bulb,  for  the  muscular  coat  is  thickest  there),  there  is  probably  some 
local  affection,  not  sufficient  of  itself  to  cause  distinct  narrowing  of  the  canal,  but 
quite  enough  to  render  it  tender  and  sensitive  when  touched,  and  to  make  the 
muscular  fibre  of  the  deeper  part  of  the  urethra  involuntarily  contract  upon  the 
offending  body  and  bar  its  further  progress.  In  the  bulbous  part  this  is  not 
unusual;  and  if  the  front  portion  of  the  urethra  is  not  examined  with  sufficient 
care  the  mistake  maybe  made  of  imagining  that  there  is  an  organic  stricture  deep 
down,  while  the  real  cause  is  some  superficial  lesion,  a  mass  of  granulations,  per- 
haps, or  a  little  inflammatory  thickening  near  the  orifice.  Examination  with  the 
endoscof>e  under  an  anaesthetic  usually  reveals  at  once  the  true  state  of  things  ; 
unlike  an  organic  or  true  stricture,  the  obstruction  disappears  comijletely  as  the 
mucous  membrane  becomes  insensitive,  even  with  cocaine  ;  the  largest  tube  then 
that  the  meatus  will  admit  can  be  inserted  without  the  least  pain,  and  an  accurate 
diagnosis  made,  both  as  to  the  seat  and  the  nature  of  the  lesion. 

When  there  is  a  definite  organic  stricture  the  sound  is  either  stopped  abruptly, 
or,  if  the  spasmodic  contraction  relapses  sufficiently  to  allow  it  to  pass,  the  surface 
feels  rough  and  irregular.  The  situation  of  the  stricture,  its  size  and  length,  and 
whether  it  is  the  only  one  present,  must  next  be  ascertained.  Smaller  sounds  must 
be  used  for  this,  until  one  will  pass  ;  but  now,  as  the  object  is  not  to  ascertain  the 
presence  of  a  stricture,  but  to  find  out  how  wide  it  is,  flexible  instruments,  which 
will  find  the  easiest  path  for  themselves,  are  better  than  rigid  ones.  The  length 
can  only  be  ascertained  by  passing  through  the  stricture  a  sound  with  the  shaft 
graduated  with  inches,  and  a  conical  bulb  at  the  end  ;  as  this  is  drawn  out,  the  base 
of  the  cone  catches  against  the  edge  of  the  stricture  and  makes  the  furthest  limit. 
Great  care,  however,  is  necessary  for  this.  Recent  strictures  are  easily  displaced, 
owing  to  the  looseness  of  the  submucous  tissue  ;  and  if  the  shaft  of  the  sound  is 
too  flexible,  or  if  it  is  not  held  in  the  axis  of  the  canal,  it  is  easy  to  manufacture 
a  stricture  at  any  point  ;  as  the  bulb  is  withdrawn,  it  throws  the  mucous  membrane 
of  the  urethra  into  little  transverse  wrinkles,  over  which  it  slips  with  almost  the 
same  sensation  as  over  a  definite  fibrous  ring.  Deeper  strictures,  of  course,  can 
only  be  found  out  when  they  are  narrower  than  the  superficial  ones. 

Treatment. — The  object  in  treating  stricture  is  not  merely  to  dilate  that 
portion  of  the  urethra  to  its  full  dimensions,  but  to  prevent  it  narrowing  again. 
The  first  is  usually  easy  ;  the  second  exceedingly  difficult,  as  the  lymph  thrown  out 
resembles  scar  tissue  in  its  tendency  to  contract ;  but  as  cicatrices  differ  in  this 
respect,  according  to  their  cause,  those  due  to  burns  being  the  worst,  so  it  is 
claimed  for  some  of  the  methods  used  that  they  either  insert  in  the  stricture,  as  it 
were,  a  splice  of  material  less  prone  to  contract,  or  even  cause  the  disappearance 
of  the  cicatricial  tissue  itself. 

General. — The  first  thing  in  all  cases  is  to  allay  as  far  as  possible  the  spasm 
and  congestion,  that  are  nearly  always  present.  In  cartilaginous  strictures,  it 
is  true,  they  are  not  of  so  much  importance  ;  but  in  recent  cases,  of  only  a  year  or 
two's  duration,  they  are  not  unfrequently  the  main  obstruction.  It  is  a  very  com- 
mon thing  to  find  that  a  stricture  which  at  first  aj^pears  almost  impassable,  after  a 
few  days'  rest  in  bed  under  proper  treatment,  allows  a  Xo.  9,  or  even  a  No.  10, 
to  slip  through  with  ease. 

When  the  attack  is  recent  and  acute,  accompanied  by  retention  of  urine,  this 
demands  the  first  consideration.  Either  a  catheter  must  be  passed  at  once,  or  the 
patient  must  be  placed  in  a  hot  bath,  the  bowels  opened  as  soon  as  possible,  and, 
if  the  condition  of  the  kidneys  is  such  as  to  allow  it,  a  full  dose  of  opium  given. 
Where  the  case  is  not  so  urgent,  a  great  deal  may  be  done  by  attention  to  general 
treatment :  the  diet  should  be  light  and  unstimulating  ;  the  bowels  kept  well  open  ; 
and  if  the  urine  is  very  acid,  or  if  there  is  a  large  amount  of  urates,  the  liver  should 
be  made  to  act  thoroughly.  Alkalies  and  hyoscyamus  are  of  the  greatest  use  ; 
opium,  if  required,  should  be  given  in  the  form  of  a  suppository.  No  stimulants 
should  be  allowed  ;  the  patient  should  have  a  warm  bath  every  night;  and,  if  he 


STRICTURE  OF  THE  URETHRA.  1109 

is  not  kept  in  l)ed  or  confinetl  to  his  room,  care  should  h^  taken  that  his  clothing 
is  warm,  and  that  he  is  not  in  any  way  exposed  to  .cold. 

Irritability  of  the  urethra  and  spasmodic  obstruction,  provided  there  is  no 
organic  change,  usually  disappear  in  a  very  short  time,  and  a  catheter  slips  in 
readily  and  without  pain.  If  the  spasm  persists,  the  urethra  may  be  stretched  every 
second  or  third  day  by  passing  a  fidl-sized  bougie  as  far  as  the  bulb,  and  leaving 
it  until  it  is  no  longer  grasped.  At  first  the  disturbance  is  often  a  little  increased, 
but,  provided  there  is  nothing  local  to  keep  up  the  spasm,  this  rarely  fails.  If  it 
does,  the  endoscoi^e  usually  reveals  some  cause,  such  as  a  small  mass  of  granula- 
tions, or  a  slight  roughness  of  the  mucous  membrane  in  the  anterior  part  of  the 
urethra,  which  will  not  get  well  without  local  treatment. 

Local. — There  are  five  chief  methods  of  treating  stricture — dilatation,  rup- 
ture, incision,  excision,  and  electrolysis.  Of  these,  the  first  three  are  the  most 
important,  and  each  of  them  is  capable  of  being  carried  out  in  various  different 
ways. 

I.  Dilatation. — This  may  be  either  interru])ted  or  continuous.  In  the  former 
instruments  are  passed  every  two  or  three  days,  but  are  not  left  in  ;  they  are  simply 
introduced  and  withdrawn  again  ;  three  or  four  sizes  may  be  passed  at  each  sitting, 
but  none  should  be  so  large  as  to  be  tightly  grasped  by  the  stricture  ;  and  each  time 
it  is  as  well  to  commence,  not  with  the  largest  used  on  the  previous  occasion,  but 
with  one  a  size  smaller.  In  the  latter  an  instrument  is  passed  and  left  in,  so  that 
the  end  only  lies  just  at  the. neck  of  the  bladder.  The  principle  in  the  two  is 
somewhat  different ;  the  former  relies  merely  on  mechanical  means  ;  in  the  latter 
the  instrument  sets  up  a  certain  amount  of  irritation,  which  must  have  some  effect 
upon  the  stricture  tissue,  for  the  dilatation  succeeds  as  well  with  a  small  sound  as 
with  a  large  one.  Indeed,  if  the  instrument  fits  the  stricture  tightly,  it  is  very 
likely  to  set  up  so  great  a  disturbance  as  to  require  the  treatment  to  be  stopped 
for  a  time. 

{a)  Interrupted  Dilatation. — The  instruments  used  for  this  purpose  may  be 
either  catheters  or  bougies  :  the  former  have  the  advantage  of  allowing  a  drop  of 
urine  to  flow  away,  and  of  showing  that  the  bladder  has  been  successfully  reached  ; 
but  against  this  there  is  the  serious  objection  that,  especially  in  the  case  of  the 
smaller  ones,  they  are  more  inclined  to  break,  owing  to  the  eye,  and  also  that  it  is 
not  so  easy  to  ensure  absolute  cleanliness.  Soft  ones  should  always  be  preferred 
to  rigid  :  if  the  stricture  is  of  wide  calibre,  they  pass  just  as  well  ;  if  it  is  small, 
ihey  find  their  way  ;  if  they  are  properly  made,  infinitely  better.  A  small  metal 
instrument  maybe  guided  by  the  hand  more  easily,  it  is  true  ;  but  the  point  is  as 
sharp  as  a  needle,  and  unless  it  is  held  with  the  lightest  touch,  it  is  sure  to  per- 
forate the  mucous  membrane,  and  either  make  a  false  passage  or  else  convert  an 
annular  stricture  into  a  bridle. 

The  bougies  in  common  use  are  of  various  kinds.  The  English  or  gum- 
elastic  are  made  of  woven  silk,  coated  with  copal  varnish,  so  that  they  retain,  to 
some  extent,  when  cold,  the  shape  given  them  when  heated.  These  are  of  the 
same  circumference  the  whole  way  down.  The  French  or  black  bougies  are  made 
of  the  same  material,  but  are  much  more  flexible  and  of  different  shape.  Some 
little  distance  from  the  point  the  instrument  tapers  gradually  until  it  becomes  ex- 
ceedingly pliant ;  the  point  itself  is  either  left  unguarded,  or,  in  the  olivary  bougies, 
is  expanded  into  a  small  bulb  supported  upon  a  slender  neck.  Genuine  French 
bougies  are  as  flexible  as  india-rubber  tubing,  and  if  the  bulb  touches  anything  the 
neck  bends  at  once.  English  black  ones  are  stiffer,  the  neck  especially  is  not  so 
pliant,  the  bulb  is  usually  too  large,  and,  as  soon  as  any  pressure  is  made  upon  it, 
instead  of  the  curve  being  limited  to  the  neck,  it  involves  a  fourth  of  the  length. 
The  smaller  sizes  must  be  carefully  examined  to.  see  that  the  varnish  is  not  cracked 
at  the  neck  ;  there  is  not  so  much  danger  as  in  the  case  of  catheters,  but  it  is  not 
uncommon  for  the  bulb  to  break  off  suddenly,  and  this  might  easily  happen  in  the 
urethra  with  very  serious  results.  Sometimes  the  shaft  is  made  rigid  by  weaving 
it  round  a  metal  stylet,  so  that  the  instrument  can  be  bent  to  any  shape.      For  very 


mo    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

narrow  strictures  bougies  are  made  of  whalebone,  catgut,  or  silkworm  gut.  The 
first-named  is  too  rigid,  even  when  softened  in  boiling  water,  to  be  of  much  ser- 
vice. Catgut  is  more  useful,  but  it  soon  grows  soft  in  the  urethra,  and  then  bends 
upon  itself.  Silk-worm  gut  is  employed  where  bougies  of  moderate  length  and 
great  tenuity  are  required.  Some  of  the.se  should  be  straight;  others  bent  or 
twisted  a  little  at  the  point,  so  that,  if  the  orifice  is  not  found  at  once,  the  whole 
face  of  the  stricture  may  be  explored  systematically,  one  part  after  the  other,  by 
merely  twisting  the  instrument  between  the  finger  and  thumb. 

Besides  these,  there  are  many  contrivances  for  si)ecial  occasions  or  for  very 
narrow  and  tortuous  strictures.  Harrison's  whip-like  bougies  are  about  two  feet 
long,  very  thin,  and  tapering  to  a  fine  ])oint  at  the  end.  If  this  slijjs  through  the 
stricture,  the  thicker  part  will  follow,  and  coil  up  in  the  bladder  out  of  the  way. 
Then  it  may  either  be  left  in  to  dilate  the  stricture,  the  urine  passing  by  the  side 
of  it,  or  it  may  be  used  as  a  guide  or  pilot  for  a  railroad  or  tunneled  catheter  {i.e., 
one  with  an  opening  at  the  end  instead  of  the  side),  or  for  the  hollow  staff  of  a 
Maisonneuve-Teevan  urethrotome.  Sometimes,  a  silver  tube,  open  at  both  ends, 
is  of  help  ;  it  should  be  about  six  inches  long,  and  as  large  as  the  meatus  will 
admit.  This  may  be  passed  down  to  the  face  of  the  stricture,  and  then  filled  with 
a  number  of  filiform  bougies  ;  if  these  are  tried,  one  after  the  other,  occasionally 
one  will  slip  in.  An  instrument,  known  as  a  pathfinder,  is  further  elaborated 
from  this  :  it  consists  of  a  straight  tube  (20  mm.  F.  in  diameter),  the  end  of  which 
is  closed  by  a  disc  which  can  be  made  to  revolve.  In  the  disc  is  a  small  perfora- 
tion, through  which  a  filiform  bougie  passes,  and,  as  the  disc  rotates,  this  is  car- 
ried successively  all  round  the  stricture,  until  at  length  the  orifice  is  found.  The 
endoscope  answers  better  still :  if  the  opening  of  the  stricture  can  once  be  seen, 
a  fine-pointed  bougie  can  often  be  guided  into  it  without  diflficulty. 

A  stricture  should  never  be  condemned  as  impermeable,  so  long  as  a  drop  of 
urine  comes  out  from  the  meatus ;  by  trying  one  kind  of  bougie  after  another,  by 
carefully  and  systematically  exploring  the  face  of  the  obstruction,  the  orifice  can 
be  found  in  nearly  every  case.  Cocaine  is  of  great  value  ;  a  few  drops  of  a  ten 
per  cent,  solution  injected  into  the  urethra  render  it  insensitive,  and  do  away  to  a 
great  extent  with  the  muscular  spasm  ;  but,  of  course,  care  must  be  taken  not  to  in- 
jure the  mucous  membrane.  An  anaesthetic  is  rarely  necessary.  Sometimes  4  c.c. 
of  oil  may  be  injected  into  the  urethra  with  benefit  ;  occasionally  the  little  granu- 
lation or  fold  of  mucous  membrane,  which  often  covers  in  the  orifice,  and  pre- 
vents the  bougie  entering,  can  be  floated  off  in  this  way  ;  and,  in  some  instances, 
where  nothing  else  succeeds,  a  bougie  can  be  passed  during  the  act  of  micturition. 
False  passages  give  most  trouble  ;  they  nearly  always  start  from  the  floor  of 
the  urethra,  and,  though  they  are  most  common  in  the  region  of  the  bulb,  they 
may  occur  in  any  part.  As  a  rule,  a  slight  check  is  felt  at  the  moment  the  point 
of  the  instrument  slips  to  one  side,  and,  if  this  is  carefully  noted,  it  may  be 
avoided  afterward.  The  patient  very  often  feels  it  as  well,  and  sometimes  is  able 
to  give  valuable  information.  When  there  are  several,  or  when  flexible  bougies 
persist  in  following  the  wrong  track,  metal  instruments  may  succeed,  the  point 
being  guided  by  the  finger  in  the  rectum.  Sometimes,  if  the  opening  in  the  mu- 
cous membrane  is  occupied  by  one  instrument,  a  second  may  be  passed  by  the 
side  of  it  in  the  right  direction,  but,  when  two  or  three  of  these  pa.ssages  start 
immediately  in  front  of  a  stricture,  the  difficulty  of  avoiding  them  all  is  very  great. 
If  there  has  been  great  difficulty  in  introducing  a  bougie,  it  may  be  tied  in 
for  a  time,  beginning  with  continuous  dilatation.  When  this  is  not  necessary,  the 
bougie  is  withdrawn,  being  left  only  so  long  as  the  spasm  continues,  and  a  larger 
one  is  passed  at  once  before  the  track  is  lost.  Two  or  three  sizes  may  be  passed  in 
this  way  every  second  or  third  day  with  the  minimum  of  inconvenience  ;  the  best 
time'is  in  the  morning,  an  hour  before  the  patient  is  allowed  to  get  up.  When 
the  stricture  admits  No.  15  to  17  mm.  F.,  the  intervals  may  be  i)rolonged,  but  the 
dilatation  should  be  continued  until  no  obstruction  can  be  felt  with  a  fiill-sized 
bullet-sound.     Even  after  this,  a  catheter   must  be  passed  occasionally — once  a 


STRICTURE  OF  THE  URETHRA.  iiii 

week  at  first,  then  once  a  month,  and  after  a  time  perhaps  at  longer  periods  still, 
to  ensure  that  there  is  no  recontraction.  Unless  the  stricture  is  a  very  recent  one, 
so  that  the  greater  part  of  the  infiltration  is  still  cellular,  permanent  cure  is  not  to 
be  expected. 

'Fhe  dilatation  can  be  effected  much  more  quickly  by  the  use  of  conical  or 
bellied  sounds.  The  best  are  Lister's,  made  of  plated  steel,  so  as  to  combine 
weight  with  i)erfect  smoothness  of  surface.  The  ends  are  enlarged  a  little  ;  behind 
the  neck  they  increase  gradually  in  thickness  until,  at  the  other  end  of  the  curve, 
they  are  about  three  sizes  (English)  larger  than  the  point.  With  these  the  stric- 
tured  tissue  may  be  rapidly  stretched  to  almost  any  size,  and  without  tearing  the 
mucous  membrane.  Many  i)atients,  however,  resent  the  tension  they  cause,  and 
there  is  the  disadvantage  that  the  point  of  the  sound  is  no  longer  the  only  part  of 
the  instrument  that  touches  the  mucous  membrane,  and  conveys  .sensations  to  the 
hand  of  the  operator. 

(/;)  Continuous  Dilatation. — In  this,  as  already  mentioned,  the  instrument  is 
left  lying  in  the  stricture  for  twenty-four  or  forty-eight  hours,  the  patient  being 
confined  to  bed,  or,  in  exceptional  cases,  allowed  to  move  about  a  little  in  his 
room.  A  longer  time  than  this,  without  changing  the  instrument,  is  not  advisable  : 
and,  owing  to  the  irritation  that  is  set  up,  it  is  usually  as  well  to  allow  an  interval 
of  two  or  three  days  before  the  next  is  introduced.  Even  then,  there  is  usually  a 
muco-purulent  discharge  from  the  urethra. 

The  instrument  should  never  be  so  large  as  to  fill  the  stricture  ;  a  small  one 
acts  just  as  well  as  a  large  onej  and  is  much  less  likely  to  cause  nervous  symptoms, 
and  it  should  be  tied  in  so  that  the  point  lies  just  in  front  of  the  neck  of  the  blad- 
der. Either  a  bougie  or  a  catheter  may  be  used  ;  if  the  former,  the  urine  comes 
by  the  side;  if  the  latter,  the  instrument  may  be  pushed  into  the  bladder  every 
now  and  then,  and  withdrawn  again.  In  this  way  a  stricture,  through  which  No. 
3  F.  can  scarcely  pass,  will  admit  a  No.  lo,  and  even  a  No.  ii  easily,  after  forty- 
eight  hours.  The  presence  of  the  foreign  body  sets  up  a  certain  degree  of  hyper- 
gemia ;  the  fibrous  tissues  become  soft  and  swollen  ;  all  the  meshes  are  filled  with 
fluid,  and  the  denseness  of  the  cicatrix  disappears  for  a  time.  Unhappily,  if  left 
to  itself,  without  instruments  being  passed  at  frequent  intervals,  contraction  sets 
in  even  sooner  than  when  the  stricture  is  treated  in  the  intermittent  manner. 

Merits  of  Dilatation. — This  method  is  most  useful  in  recent  strictures,  in 
which  the  effusion  of  lymph  is  still  more  or  less  cellular,  and  has  not  yet  spread 
beyond  the  mucous  and  submucous  layers,  or  involved  the  periurethral  tissues. 
Those  near  the  meatus,  and  those  in  which  a  band  of  lymph  passes  across  from 
wall  to  wall,  can  be  treated  much  more  satisfactorily  in  other  ways.  Dense,  old 
cartilaginous  strictures  frequently  will  not  dilate  at  all,  the  tissues  are  too  hard  ; 
or,  if  they  do,  it  is  only  up  to  a  certain  point.  No.  lo  or  ii  ;  then  they  stop  and 
seem  to  be  entirely  unaffected  by  anything  further.  Sometimes,  too,  strictures  re- 
contract  so  rapidly  that  incision  offers  a  better  prospect,  and,  occasionally, 
instances  are  met  with  in  which  patients  resent  the  passage  of  an  instrument  to 
such  an  extent  that  it  is  advisable  to  get  rid  of  the  structure  at  all  hazards  by  one 
operation.  It  is  not  uncommon  to  find  that  though,  so  long  as  a  stricture  per- 
sists, every  attempt  at  passing  a  catheter  is  followed  by  a  rigor,  almost  anything 
may  be  done,  and  with  impunity,  as  soon  as  the  constriction  is  divided. 

Continuous  dilatation  may  be  employed  where  there  is  a  very  small  stricture 
and  great  difficulty  in  finding  the  orifice,  but  it  is  distinctly  more  liable  to  be  fol- 
lowed by  suppression  of  urine,  acute  nephritis,  and  other  .serious  consequences, 
and  relapses  are  more  rapid.  Further,  it  practically  necessitates  confinement  to 
bed,  but  in  many  cases  it  is  almost  essential  as  a  first  step  toward  something  else. 

2.  Rupture. — Many  instruments  have  been  devised  for  rapidly  stretching  or 
tearing  through  stricture  tissue  without  dividing  the  mucous  membrane.  Thomp- 
son's is  composed  of  two  blades,  which  are  passed  into  the  urethra  closed,  and 
then  very  slowly  separated  to  any  required  extent  by  means  of  a  lever  worked  from 
the  handle  of  the  instrument.      Holt's  is  shaped  like  a  catheter  divided  into  par- 


1 1 1 2     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


allel  halves  except  at  the  tip  ;  between  these  there  is  a  fine,  central  guiding  rod 
(Fig.  479).  Dilatation  is  effected  by  passing  on  this  tubes  of  various  size,  so  that, 
when  they  are  forced  down  between  the  blades,  these  are  driven  asunder.  In 
Berkeley  Hill's,  a  wedge  on  the  end  of  a  slender  shaft  is  used  instead,  so  that 
there  is  much  less  friction,  and  the  dilatation  is  limited  to  one  i)art  at  a  time. 

I'he  tissue  of  which  a  stricture  is  formed  is  (]uite  inelastic,  and  it  is  claimed 
that  by  the  use  of  these  instruments  it  is  either  stretched  to  its  utmost,  or  actually 
ruptured,  without  the  mucous  membrane  being  torn,  though,  of  course,  it  is  badly 
bruised.     The  process  is  exceedingly  simple,  but  as  a  matter  of  fact  the  mucous 

membrane  is  always  torn  or  crushed,  and 
there  is  no  guarantee  that  the  force  is 
api)lied  to  the  right  place  :  the  weakest 
]jart,  wherever  it  is,  gives  way  first.  More- 
over, this  method  is  peculiarly  liable  to  be 
followed  by  the  more  severe  forms  of  con- 
stitutional disturbance  —  rigors,  urethral 
fever,  and  suppression  of  urine;  and  re- 
lapses occur  more  quickly  than  they  do 
after  gradual  dilatation.  Even  when  it  is 
essential,  for  some  reason,  that  the  stricture 
should  be  dilated  at  once,  some  form  of 
urethrotomy,  where  what  is  done  can  be 
felt  and  regulated  at  the  time,  is  to  be 
preferred. 

3.   Urethrotomy. — (a)  Internal,  incis- 
ing the  stricture   from   the  urethra.     This 
may  be  done  in  two  ways,  either  from  in 
front,  cutting  backward  toward  the  bladder, 
§■     or  from  behind.    In  either  place  something 
i      must  be  passed  through  the  stricture  first  : 
^      in  the  former  to  act  as  a  guide  for  the  blade 
5      of  the  urethrotome  ;   in  tlie  latter  to  dilate 
'i^      the  narrowed  part  sufficiently  to  allow  the 
o;     instrument    to    pass  through.      Whichever 
.7     plan    is   adopted,  it  is  essential    that  the 
Z     stricture  should  be  fixed  in  some  way,  and 
that  it  should  be  divided  through  its  whole 
length    and    depth.     Serious    hemorrhage 
does   not  occur  so  long  as  the  incision  is 
limited  to  the  proper  structures.      The  in- 
cision is  generally  made  along  the  floor  of 
the   urethra:     if    Civiale's    instrument    is 
used,  this  is  necessary,  as  the  main  guide 
as  to  the  depth  of  the  cut  is  the  .sensation 
conveyed  to  the  finger  placed  on  the  skin 
over  the  stricture  :    with   the  others  it  is 
not    essential,   and    the    incision    may  be 
made  at  the  sides  if  required.     Owing  to 
the  presence  of  large  veins,  the  roof  of  the 
urethra  is  better  avoided,  so  far  at  least  as 
the  penile  part  of  the  urethra  is  concerned. 
Division  from  behind  is  scarcely  pos- 
sible unless  the  stricture  will  admit  a  No. 
10,  or   at  least  a  No.    9  ;    so  that  if  this 
])lan  is  followed  it  must  in  a  large  number 
of  cases  be  preceded  by  dilatation.     There  are  two  methods  in  which  it  may  be 
accomplished.      In   Civiale's  instrument  the  end   of  the  shaft  is  dilated  into  a 


STRICTURE  OF  THE  URETHRA. 


11J3 


bulb,  concealing  a  fine  cutting  blade;  by  means  of  a  screw  in  the  handle  this 
can  be  protruded  to  the  extent  required  (Fig.  480).  The  bulb  is  passed  through 
the  stricture  with  the  blade  sheathed  :  the  penis  is  drawn  up  as  far  as  possible 
so  as  to  fix  the  part  that  is  to  be  divided,  and  the  screw  turned.  The  forefinger 
of  the  other  hand  is  pres.sed  firmly  on  the  skin  over  the  stricture,  and  the 
knife  is  drawn  through,  cutting  deei)er  and  deeper,  until  all  the  tough  fiI)rous 
bands  which  grate  like  so  much  tendon  against  the  edge  are  thoroughly  divided. 
Then  the  knife  is  sheathed  again  and  the  instrument  withdrawn.  In  Otis's,  on  the 
other  hand,  the  stricture  is  fixed  and  stretched  until  it  is  quite  tight  by  gradually 
separating  the  two  parallel  rods  ;  then  the  knife  is  protruded  as  far  as  is  thought 
advisable  and  drawn  quickly  across  the  tightened  bands  (Fig.  481).  If  the  divi- 
sion is  not  comiilete  the  side  rods  are  screwed  apart  again  and  a  fresh  incision 
made. 

In  the  anterior  part  of  the  urethra  these  succeed  equally  well ;  the  one  be- 


FiG.  480. — Civiale's  Urethrotome. 


cause  the  strictured  part  can  be  held  firmly  with  the  fingers,  and  every  fibre  felt  as 
it  is  divided  ;  the  other  because  the  touch  of  the  instrument  is  so  light  when  it  is 
but  a  short  way  down  the  canal.  In  the  deeper  part,  especially  near  the  bulb, 
Civiale's  is  the  most  convenient. 

A  stricture  that  is  too  small  to  admit  these  may  be  divided  from  in  front  by 
means  of  Maisonneuve's  urethrotome,  as  modified  by  Teevan  and  Berkeley  Hill 
(Fig.  482).  A  filiform  bougie  must  first  be  passed,  and  on  this  an  exceedingly  fine 
catheter,  so  as  to  make  sure  that  the  end  is  really  in  the  bladder,  not  coiled  up  in 
some  false  passage.  The  catheter  may  then  be  withdrawn  and  the  guide  that 
screws  on  to  the  end  of  the  urethrotome  passed  instead.  The  instrument  itself 
consists  of  two  parallel  rods,  together  only  equal  to  a  No.  7  F.,  joined  at  the  tip, 
but  allowing  a  wedge  on  the  end  of  the  shaft  to  slide  down  between  them  as  far 
as  the  curve.    The  knife  is  concealed  in  the  wedge,  and  is  not  protruded  until  this 


Fig.  481. — Otis's  Urethrotome. 


has  been  passed  as  far  as  it  will  go ;  in  this  way  the  wall  of  the  urethra  and  the 
stricture  are  firmly  held  ;  and  the  wedge  being  pushed  forward  bit  by  bit,  as  the 
tissue  is  divided  with  the  knife,  the  whole  length  may  be  cut  through  without  en- 
dangering anything  else. 

The  success  of  this  operation  depends  very  greatly  upon  the  after-treatment ; 
if  urine  becomes  infiltrated  into  the  wound,  suppuration  is  sure  to  occur,  leaving 
behind  it  a  cicatrix  which  reproduces  the  stricture  in  a  still  worse  form  ;  and  there 
is  very  great  danger  of  other  troubles — rigors,  urethral  fever,  abscesses,  and  even 
pyaemia.  A  full-sized  bullet-sound.  No.  24  or  26,  must  be  passed  to  make  sure 
that  the  stricture  is  thoroughly  divided  ;  the  urine  that  remains  in  the  bladder 
drawn  off ;  and  the  cavity  washed  out  with  boracic  acid  or  a  very  dilute  solution  of 
corrosive  sublimate.  No  catheter  should  be  tied  in  unless  there  is  profuse  and  con- 
tinuous hemorrhage.  A  morphia  suppository  (if  the  kidneys  are  fairly  sound)  may 
be  placed  in  the  rectum,  and  then  the  patient  must  be  removed  to  bed,  and  en- 
71 


1 1 14    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

joined  to  delay  micturition  as  long  as  possible,  in  order  that  the  surface  of  the 
wound  may  be  sealed  with  lymph  before  urine  is  allowed  to  flow  over  it.  When 
the  bladder  must  be  emptied,  which  is  often  not  for  si.\  or  seven  hours,  a  large  cup 
of  tea  should  be  given,  with  five  grains  of  cpiinine  and  half  an  ounce  of  brandy, 
and  the  patient  placed  in  a  hot  bath,  so  that  the  flow  of  urine  may  be  as  free  as 
l)OSsible,  and  without  any  straining.  If  this  plan  is  adojited  there  is  rarely  any 
fever  after  the  operation  ;  sometimes  a  rigor  occurs  after  micturition  :  within  a  few 
minutes  the  temperature  begins  to  rise,  the  patient  feels  chilly  and  begins  to  shiver, 
there  is  a  feeling  of  the  most  intense  distress  :  the  thermometer  reaches  104°  F.  and 
even  higher;  then  after  twenty  minutes  or  half  an  hour  it  begins  to  fall  and  pro- 
fuse sweating  sets  in  ;  but  this  is  seldom  of  any  imjiort.  In  any  case  the  patient's 
temi^erature  should  be  carefully  taken  after  micturition,  and  if  there  is  a  sensible 
rise  it  should  be  met  at  once  by  repeating  the  quinine.  No  instrument  should  be 
passed  for  at  least  a  week  ;  the  patient  must  be  kept  in  bed,  on  light  diet  and 
without  stimulants  ;  the  bowels  may  be  opened  on  the  third  day,  and  a  warm  bath 
taken  every  night.  At  the  end  of  a  week  a  No.  22  bullet  sound  may  be  carefully 
passed  down  the  urethra  and  withdrawn  again  ;  if  the  operation  has  been  success- 
ful, no  hitch  should  be  felt  anywhere  and  there  should  be  no  stain  of  blood. 
Three  days  later  another  may  be  passed,  and  then  the  patient  may  be  instructed 
how  to  make  use  of  one  for  himself. 

Internal  urethrotomy  is  employed  by  some  to  a  very  much  greater  extent  than 
by  others,  but  there  are  certain  cases  in  which  it  is  generally  preferred. 


'.  .',.  YAR'-!PLL    C3     PilLf- 


FlG.  482. — Teev.-in's  Urethrotome. 

1.  Strictures  near  the  meatus,  especially  those  at  the  orifice  itself;  these  may 
often  be  divided  with  an  ordinary  bistoury. 

2.  Strictures  which  re-contract  rapidly  after  dilatation. 

3.  Strictures  in  patients  who  suffer  severely  from  rigors  or  other  troubles 
whenever  a  catheter  is  passed.  In  such  cases  it  is  best  to  finish  the  operation  at 
a  single  sitting,  and  it  is  often  found  that  the  irritability  of  the  urethra  disappears 
altogether  as  soon  as  the  stricture  is  divided. 

4.  If  there  is  a  perineal  abscess  present,  and  the  stricture  is  divided  before 
the  mucous  membrane  has  given  way,  a  fistula  may  sometimes  be  avoided. 

Dense  cartilaginous  strictures  that  refuse  to  dilate  may  be  treated  in  this  way, 
but  they  fre(iuently  require  more  than  one  operation,  and  for  them  external  ure- 
throtomy is  certainly  to  be  preferred. 

In  recent  strictures,  or  where  there  is  advanced  disease  of  the  kidneys,  or 
where  the  urethra  is  inflamed,  a  cutting  operation  is  not  advisable.  In  advanced 
cases  of  cystitis,  where  the  urine  is  ammoniacal  and  loaded  with  mucus,  the  stric- 
ture may  be  divided  and  an  ojjening  made  in  the  perineum  to  drain  the  bladder 
and  to  prevent  decomposing  urine  flowing  over  the  surface  of  the  wound. 

Complications. — Internal  urethrotomy  is  liable  to  be  followed  by  the  same 
complications  as  simple  catheterism,  but  some  are  more  common  and  more  serious 
than  others.  Rigors  have  been  already  mentioned.  Hemorrhage  (either  at  the 
time  of  the  operation  or  later,  especially  at  night,  if  there  is  an  erection)  is  some- 


STRICTURE  OF  THE  URETHRA.  1115 

times  very  profuse.  In  the  penile  part  it  may  be  controlled  by  passing  a  large 
gum-elastic  catheter  down  the  urethra,  and  compressing  the  bleeding  point  against 
it  with  a  bandage,  until  a  coagulum  has  formed  ;  or  an  ice  bag  may  be  laid  upon 
it ;   when  it  is  at  the  bulb  a  well-padded  firm  crutch,  after  (Jtis's  plan,  answers  best. 

If  there  is  evidence  of  infiltration  of  urine  at  the  seat  of  operation,  a  staff 
should  be  passed  down  the  urethra  and  a  free  incision  made  from  the  outside. 
Abscesses  should  be  opened  as  soon  as  possible  ;  but  if  they  occur  in  connection 
with  the  prostate  they  usually  make  their  way  into  the  urethra.  Acute  epididy- 
mitis is  not  uncommon,  especially  if  the  urethra  is  explored  too  soon  and  too 
much  after  the  operation  ;  and,  particularly  if  the  kidneys  are  diseased,  partial  or 
complete  suppression  of  urine  may  occur,  though  the  liability  to  this  occurrence 
may  be  greatly  lessened  by  taking  proper  precautions. 

SubcKtancoiis  Urethrotomy . — In  the  penile  portion  of  the  urethra  short  stric- 
tures may  be  divided  from  the  outside  by  means  of  a  long,  narrow  tenotomy  knife. 
A  staff  is  passed  down  the  urethra,  the  stricture  fixed  with  the  fingers,  and  the 
knife  thrust  through  the  skin,  making  a  minute  puncture,  and  carried  along  the 
staff  until  all  the  resisting  portion  of  the  stricture  has  been  divided.  It  is  then 
withdrawn,  and  the  puncture  sealed.  The  after  treatment  should  be  the  same  as 
in  internal  urethrotomy. 

{F)  External  urethrotomy,  where  an  incision  is  made  from  the  outside  into 
the  urethra,  passing  through  the  whole  of  the  stricture  tissue. 

There  are  two  distinct  classes  of  cases  in  which  this  may  be  required.  In 
the  first  a  catheter  can  be  passed  through  the  stricture ;  in  the  second  it  cannot, 
either  because  the  urethra  has  been  destroyed  by  extensive  sloughing,  or  because 


S.A.y/'.RNALL  CO, 

Fig.  483. — Syme's  Staff. 

it  is  SO  tortuous  that,  though  urine  can  find  its  way  out,  it  is  impossible  to  worm 
a  bougie  through  it. 

Sytne' s  operation,  external  urethrotomy  in  the  strict  sense  of  the  term,  where 
an  instrument  can  be  passed  into  the  bladder.  Syme's  staff  consists  of  two  parts 
of  different  diameters ;  for  the  last  two  inches  and  a  half,  it  is  about  the  size  of 
No.  6,  and  this  is  grooved  on  the  convexity;  the  rest  of  the  instrument  is  equal 
to  a  No.  18  or  19.  The  junction  of  the  two  is  abrupt,  so  that  there  is  a  sharply 
marked  shoulder,  which  is  intended  to  rest  upon  the  face  of  the  stricture ;  the 
groove  is  continued  on  to  this,  but  no  further.  This  is  passed  into  the  bladder, 
the  finger  being  placed  in  the  rectum,  to  make  sure  that  it  has  not  entered  a  false 
passage,  and  given  to  an  assistant  to  hold.  The  patient  is  then  tied  up  in  the 
lithotomy  position,  and  the  assistant  directed  to  push  the  convexity  of  the  staff 
downward  toward  the  perineum.  The  left  forefinger  is  placed  in  the  rectum,  and 
an  incision  made  exactly  in  the  middle  line,  about  an  inch  in  front  of  the  anus, 
and  carefully  carried  down  until  the  groove  in  the  narrow  portion  of  the  staff  is 
reached ;  this  is  usually  behind  the  stricture.  The  knife  is  carried  forward,  cut- 
ting from  the  anus,  in  the  groove  of  the  staff,  right  through  the  stricture  as  far  as 
the  shoulder.  A  probe-pointed  narrow  gorget  is  introduced  through  the  wound 
into  the  groove,  and  pushed  on  until  it  enters  the  bladder  ;  the  staff  is  withdrawn, 
and  a  full-sized  catheter  passed  from  the  urethra  along  the  gorget,  using  it  as  a 
director.  Generally  the  catheter  is  tied  in  for  the  next  three  days,  and  then 
withdraw^n  ;  but  I  have  not  found  this  necessary.  If  the  stricture  is  divided  thor- 
oughly, the  wound  may  be  left  entirely  to  itself,  the  patient  being  kept  in  bed, 
and  treated  in  the  same  way  as  after  the  operation  of  internal  urethrotomy.  At 
the  end  of  a  week  a  full-sized  bullet  sound  may  be  passed,  follow-ing  the  roof  of 
the  urethra,  a  i&w  drops  of  a  ten  per  cent,  solution  of  cocaine  being  injected  into 


1 1 16    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  wound  to  ])revent  jiain  ;  and  this  may  be  repeated,  at  first  every  second  day, 
and  then  gradually  at  longer  and  longer  intervals. 

This  oi)eration  is  esjiecially  useful  in  dense  cartilaginous  strictures  compli- 
cated with  fistula,  where  internal  urethrotomy  has  no  chance  of  succeeding ;  and 
it  may  be  performed  with  very  great  benefit  in  advanced  stricture  deep  in  the 
urethra,  where  the  bladder  is  diseased,  the  urine  ammoniacal,  and  the  kidneys 
affected.  In  this  case,  however,  a  drainage  tube  should  be  passed  through  the 
wound  into  the  bladder,  and  connected  with  a  receiver  outside  the  bed.  Of  course, 
the  prognosis  in  such  cases  is  not  good,  but  it  relieves  the  bladder  at  once,  the 
urine  gradually  becomes  clear  and  acid,  the  amount  of  mucus  diminishes,  the  con- 


:^:^?^ 


'^ 


Fig.  484.— Wheelhouse's  Operation,  showing  the  Sides  of  the  Ureihra  held  apart  by  temporary  Sutures,  and  the 
Apex  of  the  Triangle  stretched  up  by  the  Button  6n  the  end  of  the  Staff. 

stant  desire  to  micturate  ceases,  the  patient  enjoys  such  rest  as  he  has  not  had  for 
years,  and  very  often  the  general  health  begins  to  improve  at  once. 

There  is  another  advantage  claimed  for  this  operation,  that  it  holds  out  a 
prospect  of  permanent  cure.  There  is  no  doubt  that  sometimes,  if  external  ure- 
throtomy is  performed  in  cases  of  rupture  of  the  urethra  before  extravasation  of 
urine  has  taken  place,  the  formation  of  a  stricture  can  be  prevented,  but  Harrison 
has  described  cases  in  which  a  dense  cartilaginous  stricture  has  apparently  com- 
pletely disappeared.  In  1867  Bickersteth  performed  Syme's  operation  for  trau- 
matic stricture  and  urinary  fistula  of  the  worst  type  ;  in  1869  the  man  was  known 


■^  ^.V:\T^N^\.v.rA.v\\\\.\. 
Fig.  485. — Grooved  Staff,  with  Bulton-like  End. 


to  be  quite  well,  though  no  precautions  appear  to  have  been  taken  by  the  i)atient. 
After  his  death,  in  1885,  the  urethra  was  removed  and  carefully  e.xamined,  and  no 
signs  of  the  stricture  could  be  found  ;  in  fact,  the  urethra  is  described  as  being  of 
larger  calibre  in  proportion  to  the  rest  of  the  canal,  opposite  the  line  of  section, 
as  if  the  cicatrix  had  yielded  to  the  pressure  of  the  urine.  I  have  myself  the 
notes  of  a  patient'  on  whom  external  urethrotomy  was  performed  eighteen  years 
before  he  came  under  my  care,  and  though  he  assures  me  that  he  has  not  taken 
the  slightest  precaution  since,  there  is  no  evidence  of  any  recontraction. 

When  a  catheter  cannot  be  introduced  into  the  bladder,  either  the  urethra 
should  be  laid  open  in  front  of  the  stricture,  so  that  the  face   of  it  may  be  seen 


STRICTURE  OF  THE  URETHRA. 


1117 


(Wheelhoiise's  operation),  or  an  incision  is  made  into  the  urethra  behind,  through 
the  perineum,  and  prolonged  forward  through  the  stricture  tissue  until  the  canal  is 
reached  again  in  front  (Guthrie's  perineal  section,  or  Cock's  operation). 

WJieelhouse' s  Operation. — The  patient  is  placed  in  the  lithotomy  position  and 
a  special  staff  passed  down  as  far  as  the  stricture.  This  instrument  is  straight, 
with  on  one  side  a  groove,  which  runs  down  until  within  half  an  inch  of  the  point, 
and  on  the  other,  at  the  point  itself,  a  projection  in  the  form  of  a  blunt  hook. 
An  incision  is  made  on  to  the  staff  so  as  to  open  the  urethra  a  quarter  of  an  inch 
in  front  of  the  stricture,  and  two  sutures  are  looped  through  the  edges  of  the 
mucous  membrane,  so  that  the  sides  can  be  held  apart  by  assistants.  The  staff  is 
withdrawn  until  the  end  appears  in  the  wound,  and  turned  round  so  that  the  i)ro- 


FiG.  486. — Teale's  Probe-gorget. 


jection  is  hooked  into  the  upper  angle  of  the  opening  in  the  urethra.  This  is 
stretched  in  this  way  into  the  shape  of  a  triangle,  the  base  of  which  is  formed  by 
the  front  of  the  stricture.  There  is  very  little  hemorrhage,  and  nearly  always  the 
orifice  can  be  seen  at  once.  A  probe  is  then  carefully  passed  through  the  stricture, 
and  the  whole  length  is  carefully  and  deliberately  divided  along  its  under  surface. 
The  subsequent  proceedings  and  the  after-treatment  are  the  same  as  in  Syme's 
operation,  a  probe-pointed  narrow  gorget  being  used  to  pass  into  the  bladder 
through  the  wound  and  act  as  a  guide  for  the  catheter. 

Perineal  Sectio7i. — The  patient  is  directed  to  hold  his  urine  if  possible  for 
some  hours  before  the  operation,  so  that  the  neck  of  the  bladder  and  the  proximal 
part  of  the  urethra  may  be  dis- 
tended. The  position  is  the  same, 
and  the  surgeon  begins  by  passing 
his  left  forefinger  into  the  rectum 
to  draw  it  back,  and  to  feel  the 
apex  of  the  prostate.  An  incision 
is  then  made  exactly  in  the  middle 
line  of  the  perineum  an  inch  and 
a  half  in  length  and  half  an  inch 
in  front  of  the  anus,  and  it  is 
gradually  deepened,  until,  if  the 
patient  strain  or  cough,  the  urethra 
bulges  into  the  wound.  If  this 
does  not  happen,  the  point  of  the 
knife,  guided  by  the  finger  in  the 
rectum,  must  be  pushed  forward 
so  as  to  hit  off  the  membranous 
portion  of  the  urethra  or  the  apex 

of  the  prostate.  If  urine  escapes  through  the  puncture,  difficulty  is  at  an  end. 
A  director  is  then  passed  into  the  bladder,  and  along  this  a  narrow  probe-pointed 
gorget.  The  stricture  may  either  be  dealt  with  at  once  (the  other  end  is  easily 
found  by  passing  an  instrument  down  the  urethra)  or  the  bladder  may  simply  be 
allowed  to  drain  itself  for  some  days.  It  is  not  uncommon  to  find  that  a  stricture 
which  obstinately  resists  all  attempts  before  the  operation  can  be  easily  passed 
afterward,  and  either  dilated  or  divided. 


Fig. 


487. — Cock's   Operation  for   Tapping  the   Urethra  at  the 
Apex  of  the  Prostate,  or  Perineal  Section. 


iii8    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

In  cases  in  which  a  large  ])ortion  of  the  urethra  has  been  destroyed  by  slough- 
ing, and  it  is  doubtful  whether  it  is  possible  to  establish  a  new  canal,  or  whether, 
if  it  is  established,  the  patient  will  take  the  trouble  to  maintain  its  patency,  an 
opening  may  be  made  into  the  bladder  over  the  jjubes,  and  fitted  with  an  india- 
rubber  tube  and  stoj^cock.  With  this  arrangement  patients  may  live  and  continue 
their  ordinary  occujiation,  not  only  with  perfect  safety,  but  almost  without  incon- 
venience. 

4.  Excision. — In  exceptional  cases  strictures  in  the  penile  portion  of  the  ure- 
thra have  been  excised,  and  the  edges  of  the  mucous  membrane  sutured  together, 
and  even  strips  of  mucous  membrane  from  other  parts  of  the  body  have  been  spliced 
in.  Such  operations,  however,  can  very  rarely  be  required,  as  most  strictures  so 
placed  are  amenable  to  simpler  treatment. 

5.  Electrolysis. — The  treatment  of  stricture  by  electrolysis  has  recently  been 
revived  by  Newman,  Bruce-Clarke,  Steavenson,  and  others.  The  negative  electrode 
is  passed  down  the  urethra,  and  allowed  to  remain  in  contact  with  the  face  of  the 
stricture  for  the  space  of  some  minutes  to  half  an  hour;  the  positive  is  applied  to 
some  other  part  of  the  patient's  body,  and  a  current  of  three  to  five  milliamperes 
used.  In  stricture  near  the  meatus  the  gradual  melting  away  of  the  cicatricial  tissue 
under  the  influence  of  the  caustic  set  free  on  the  surface  of  the  electrode,  can  be 
seen,  and  there  is  no  doubt  the  same  process  takes  place  when  the  stricture  is  deeper  ; 
but  in  many  patients  it  is  attended  with  quite  as  much  pain  as  gradual  dilatation. 
There  is  usually  a  considerable  degree  of  soreness  and  irritation  afterward,  and 
unless  the  same  precautions  are  taken,  there  is  no  greater  degree  of  immunity.  It 
is  true  that  in  some  instances  recontraction  does  not  occur  for  a  considerable  time  ; 
but  in  picked  cases  the  same  may  be  .said  of  nearly  every  other  method,  and  I  have 
known  it  take  place  within  six  months. 

Extravasation  of  Urine. 

Urine  may  escape  from  the  ureter  and  pelvis  of  the  kidney,  from  the  bladder 
(entering  the  peritoneal  cavity  of  the  cellular  tissue),  or  from  the  urethra.  The 
last  mentioned  is  by  far  the  most  common,  and  is  generally  understood  by  the  term 
extravasation. 

Causes. — The  urine  may  come  from  the  prostatic,  membranous,  or  penile 
portions  of  the  urethra.  In  the  first  case  the  causes  (and  the  symptoms)  are  prac- 
tically the  same  as  those  of  extra-peritoneal  rent  of  the  bladder.  It  rarely  occurs 
except  as  a  result  of  fracture  of  the  pelvis,  or  of  operations,  such  as  lateral  lithotomy, 
when  the  lobe  of  the  prostate  has  been  too  freely  incised.  In  children,  however, 
it  sometimes  happens  from  severe  compression  without  fracture,  owing  to  the 
elasticity  of  the  bones  of  the  pelvis.  'i1ie  urine  escapes  into  the  prevesical  space 
(that  which  is  bounded  by  the  two  lamellae  of  the  transversalis  fascia,  the  one  going 
to  the  pubes.  the  other  along  the  urachus  to  the  bladder),  above  the  deep  layer  of 
the  triangular  ligament,  or  else  directly  into  the  pelvic  cellular  tissue,  above  the 
recto-vesical  fascia. 

Extravasation  from  the  membranous  or  penile  portion  of  the  urethra  is  caused 
either  by  injury  (rupture,  impacted  calculus,  urethrotomy,  etc.),  or  by  stricture. 
The  latter  is  by  far  the  more  common.  It  may  be  either  sudden  or  gradual.  In 
the  former  case  the  urethra  becomes  thinned  and  dilated  behind  the  stricture,  owing 
to  the  constant  pressure  upon  it,  until,  some  day,  under  the  effort  of  micturition 
it  suddenly  gives  way,  and  the  urine  ])ours  out  into  the  tissues.  In  the  latter  a 
small  follicular  abscess  forms,  and  gradually  extends,  ulcerating  through  everything 
under  the  constant  pressure  of  the  septic  and  decomjjosing  urine,  until  at  length  it 
works  its  way  to  the  exterior,  and  the  urine  escapes  through  a  fistula  without  having 
been  widely  spread  in  the  cellular  tissue.  This  is  not  nearly  so  severe  a  form  as 
the  other,  at  any  rate  so  far  as  the  immediate  symptoms  are  concerned. 

When  the  extravasation  commences  between  the  two  layers  of  the  triangular 
ligament,  it  naturally  remains  limited  until  one  of  them,  usually  the  anterior,  gives 


EX  TRA  VASA  TION  OF  URINE.  1 1 1 9 

way.  If,  on  the  other  hand,  it  is  superficial  to  this,  under  the  deep  layers  of  the 
superficial  fascia,  it  spreads  at  once  until  it  may  actually  reach  the  ensiform 
cartilage.  Behind  its  progress  is  limited  by  the  attachment  of  the  fascia  to  the 
l)osterior  margin  of  the  triangular  ligament  ;  in  the  middle  line  it  cannot  extend 
further  back  than  the  centrum  tendineum  of  the  perineum  ;  under  cover  of  the 
rami  of  the  ischium,  it  can  reach  as  far  as  the  tuberosity,  but  it  never  enters  the 
ischio-rectal  fossa.  At  the  sides  the  fascia  joins  the  periosteum,  so  that  the  urine 
cannot  extentl  on  to  the  thighs.  Only  in  front  is  the  pa.ssage  free,  and  if  it  is  driven 
with  any  force  it  rushes  into  the  scrotum  under  the  dartos,  passes  over  the  pubes, 
and  covers  the  surfiice  of  the  abdomen,  as  low  as  Poupart's  ligament  at  the  sides, 
and  perhaps  as  high  as  the  ensiform  cartilage  in  the  middle. 

Consequences. — Wherever  urine  spreads  it  causes  inflammation  and  gan- 
grene. The  cellular  tissue  sloughs  wherever  it  comes  ;  the  skin  perishes,  and 
exposes  intensely  fcetid  masses  of  dark-colored  tissue,  sodden  with  urine  and 
pusl^  and  even  the  penis,  testes,  and  other  structures  may  be  destroyed  when  the 
planes  of  fascia  which  serve  at  first  to  limit  the  urine  in  certain  directions,  break 
down. 

Symptoms. — Sudden  extravasation  of  urine  is  unmistakable.  There  is  a 
history  of  obstruction,  of  some  difficulty  in  emptying  the  bladder,  for  weeks  or 
months  before,  if  due  to  stricture — for  the  first  time  if  the  urethra  has  been  rup- 
tured ;  then,  of  the  obstruction  having  suddenly  given  way,  and  of  the  bladder 
having  emptied  itself  with  a  feeling  of  intense  relief,  but  without  any  urine  being 
passed  externally.  In  a  few  minutes  a  smarting  sensation  is  felt  in  the  perineum 
and  scrotum  ;  soon  they  begin  to  burn  and  throb  ;  in  a  itw  hours  they  swell  to 
more  than  double  the  size  ;  the  patient  becomes  anxious  and  feverish,  and  a  con- 
dition of  extreme  prostration  sets  in. 

By  the  next  day,  especially  if  the  urine  was  already  septic,  the  sloughing  is 
well  advanced.  The  perineum  projects  under  the  scrotum,  reddened,  tense,  and 
hard  ;  the  scrotum  itself  is  swollen  out  to  an  enormous  size,  and  is  glazed  and  shin- 
ing, with  a  peculiar  translucent  appearance  from  the  amount  of  oedema  ;  and  the 
skin  over  the  abdomen  is  dusky,  pitting  on  pressure,  and  in  bad  cases  crackling 
from  incipient  putrefaction.  If  there  is  a  gangrenous  spot  on  the  penis,  the  prog- 
nosis, as  Brodie  first  showed,  is  almost  hopeless.  The  fever  may  be  high,  but  more 
frequently  the  temperature  is  only  moderately  raised  ;  the  patient  lies  in  a  state 
resembling  that  of  typhoid  ;  the  pulse  is  small  and  quick,  the  respiration  hurried 
and  shallow,  the  tongue  dry  and  brown  ;  often  there  is  muttering  delirium  ;  and 
the  eyes  are  sunken,  and  the  face  pinched,  with  a  look  upon  it  that  cannot  be 
mistaken. 

Treatment. — This  admits  of  no  delay  :  the  patient  must  at  once  be  placed 
in  the  lithotomy  position,  and  a  free  incision  made  deep  in  the  middle  line  of  the 
perineum,  until  the  main  source  is  tapped.  Then  other  incisions  must  be  made  all 
over  the  dusky  area  ;  in  the  penis  they  must  be  perfectly  straight  and  longitudinal, 
or  the  subsequent  cicatrization  may  lead  to  serious  trouble  ;  on  the  scrotum  one 
on  each  side  is  usually  sufficient,  but  it  should  extend  thoroughly  into  the  sodden 
cellular  tissue  ;  over  the  abdomen  their  direction  should  correspond  with  the 
vessels.  In  most  cases  it  is  sufficient  to  make  them  two  or  three  inches  long  ;  as 
soon  as  the  oedema  subsides  they  shrink  more  than  half;  sometimes  there  is  sharp 
hemorrhage  from  a  cutaneous  vessel,  but  this  may  always  be  stopped  by  pressure 
with  dried  lint.  Any  sloughs  that  are  loose  should  be  extracted  at  once,  and  as 
much  of  the  putrid  fluid  as  possible  squeezed  out  of  the  openings. 

The  treatment  of  the  bladder,  and  of  the  stricture  (if  there  is  one),  next 
requires  consideration.  It  is  distinctly  of  advantage  to  drain  the  former  thoroughly, 
not  only  because  it  prevents  more  urine  being  extravasated,  but  because  itself  is 
almost  sure  to  be  in  a  state  of  advanced  cystitis,  half  full  of  an  intensely  offensive 
putrid  fluid.  This  may  be  accomplished  either  by  dilating  the  prostatic  portion  of 
the  urethra  with  the  finger,  first  introducing  a  probe-pointed  gorget  into  the  blad- 
der as  a  guide,  or,  better,  by  passing  in  a  full-sized  soft  rubber  catheter,  and  con- 


II20    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

necting  it  with  a  receptacle  under  the  bed.  Whether  the  stricture  should  be 
touched  or  not  depends  upon  the  contiition  of  the  patient.  In  most  instances  it  is 
better  to  leave  it  alone  ;  if  the  patient  recovers,  a  catheter  can  often  be  pas.sed 
without  any  difficulty  ;  owing  to  the  prolonged  rest,  the  spasm  and  congestion 
entirely  disappear.  When,  however,  the  case  is  not  a  severe  one,  it  is  most  expe- 
ditious to  pass  a  staff  down  the  urethra,  and  at  once  lay  the  whole  stricture  open, 
as  in  external  urethrotomy. 

Great  care  must  be  taken  to  keep  the  patient  dry  ;  all  the  discharges  (and  they 
are  often  profuse),  must  be  soaked  up  with  freipiently  charged  pads  of  absorbent 
wool,  or  finely  picked  oakum.  Warm  hip-baths,  containing  small  quantities  of 
some  antiseptic,  are  of  great  service,  if  the  patient's  health  permits.  Sloughs  should 
be  removed  as  soon  as  possible,  and  the  strength  sustained  by  nourishing  diet, 
quinine,  and  stimulants.  The  temperature  requires  very  careful  watching,  as,  like 
all  oi)erations  about  the  urinary  organs,  extravasation  is  liable  to  be  followed  by 
pyxmia.  If  the  patient  does  not  die  from  this,  exhaustion  or  renal  disease,  the 
wounds  granulate  in  a  very  short  time,  and  the  cicatrices  left  are  always  surprisingly 
small. 

Urinary  Abscess. 

Peri-urethral  abscesses  are  not  uncommoii  in  the  glands  by  the  side  of  the 
frsenum  in  acute  gonorrhoea,  and  occasionally  they  are  met  with  in  other  parts  of 
the  corpus  si)ongiosum,  but  the  perineum  is  by  far  the  favorite  locality.  They 
may  be  divided  into  two  classes,  those  which  communicate  with  the  urethra  from 
the  first,  having  commenced  on  the  surface  of  the  mucous  membrane,  and  gradu- 
ally involved  deejjer  and  deeper  structures  ;  and  those  which  originate  independ- 
ently of  it,  and  if  they  do  communicate,  only  do  so  secondarily,  the  mucous 
membrane  covering  them  becoming  thinner  and  thinner  until  at  last  it  gives  way. 

Causes. — i.  Gonorrhoea. — Abscesses  occasionally  form  in  the  corpus  spon- 
giosum, but  (except  in  the  glands)  they  are  not  often  met  with  unless  there  is  an 
old  stricture,  or  unless  it  has  been  necessary  to  pass  a  catheter  frequently.  Some- 
times they  extend  down  from  the  mucous  follicles,  but  they  may  originate  inde- 
pendently, and,  if  the  pus  is  let  out  in  time,  they  may  never  communicate  with 
the  urethra  at  all. 

Cowper's  glands  are  sometimes  affected  in  this  way.  There  is  a  small,  hard, 
exceedingly  tender  spot,  not  quite  in  the  middle  line,  by  the  root  of  the  scrotum. 
After  a  time  it  works  its  way  through  the  triangular  ligament,  toward  the  skin,  or 
toward  the  rectum,  so  that  its  origin  is  often  not  recognized. 

2.  Injury. — Ru])ture  of  the  urethra,  impacted  calculus,  the  formation  of  a 
false  passage,  internal  urethrotomy,  and  forcible  splitting  of  strictures,  are  occa- 
sionally followed  by  perineal  abscesses.  Some  of  these  are  due  to  infiltration  of 
urine;  but  when,  for  exam  i)le,  a  stricture  is  ruptured  without  the  mucous  mem- 
brane being  torn,  or  when  suppuration  occurs  in  consequence  of  a  catheter  having 
been  tied  into  the  urethra,  it  is  probable  that  the  communication,  if  it  exists,  is 
secondary. 

3.  Stricture. — This  is  by  far  the  most  common. 

Usually  the  suppuration  commences  outside  the  urethra,  in  the  thickness  of 
the  stricture  tissue  ;  sometimes,  however,  it  spreads  from  the  interior — the  mucous 
membrane  is  thinned  and  driven  into  pouches,  which  often  contain  small  quanti- 
ties of  decomposing  urine  ;  ulceration  spreads  from  these  into  the  mass  of  inflam- 
matory exudation  around,  and  the  communication  exists  from  the  first. 

Abscesses  may,  of  course,  occur  in  the  perineum  from  other  causes,  the  ure- 
thra not  being  concerned  in  any  way.  Suppuration,  for  example,  may  occur  in 
connection  with  the  rectum  and  work  its  way  outward  in  front  of  the  anus,  and 
peri-prostatic  abscesses  sometimes  point  in  the  .same  situation. 

Symptoms, — Urinary  abscess,  except  when  it  is  the  result  of  gonorrhea,  is 
usuall\-  of  slow  formation.  If  it  occurs  in  the  glans,  there  is  a  small,  hard  mass 
on  one  or  both  sides  of  the  frrenum,  exceedingly  tender  to  the  touch,  and  rapidly 


URINAR  V  FISTULA.  1 1 2 1 

coming  to  the  surface.  In  the  perineum  it  depends  to  a  certain  extent  upon  the 
situation.  Usually  it  is  in  the  middle  line,  unless  it  originates  in  inflammation  of 
Cowper's  glands  ;  if  it  is  in  connection  with  the  bulb,  or  the  deeper  part  of  the 
corpus  spongiosum,  it  stands  out  to  a  certain  extent  from  the  fixed  tissues  beneath, 
and  often  runs  forward  with  a  hard,  spur-like  process  in  the  median  raphe  of  the 
scrotum.  When  it  begins  between  the  layers  of  the  triangular  ligament  there  is 
merely  a  hard,  but  exceedingly  tender  spot,  scarcely  raised  above  the  level  of  the 
rest.      Fluctuation  cannot  be  felt  unless  the  abscess  is  superficial. 

The  pain  at  the  first  is  dull  and  throbbing,  with  a  great  sense  of  weight ;  the 
stream  of  urine  (even  without  stricture)  is  reduced  in  size  and  force  ;  complete 
retention  may  occur,  especially  when  the  supjjuration  is  in  connection  with  the 
fixed  portion  of  the  urethra;  and  sitting  and  walking  are  attended  with  great 
discomfort.  Then,  as  the  pus  forms,  the  pain  becomes  more  intense,  and  shoots 
down  the  thighs  and  into  the  groin  ;  very  often  there  is  high  fever,  with  perhaps  a 
rigor  ;  and  constitutional  symptoms  of  great  severity  may  set  in.  If  the  abscess 
is  allowed  to  break  of  itself,  it  may  discharge  into  the  urethra  ;  there  is  a  sense 
of  inten.se  relief ;  a  certain  amount  of  pus  is  washed  down  with  the  urine,  and 
sometimes  the  cavity  contracts  and  heals  without  any  extravasation,  and  without 
an  external  opening.  More  often,  especially  if  there  is  a  stricture,  the  abscess 
bursts  externally  as  well  as  internally,  and  though  the  channel  contracts  as  soon  as 
the  tension  is  removed,  urine  escapes  through  the  opening,  and  a  fistula  is  formed. 

Treatment. — Urinary  abscess  should  be  opened  in  all  cases  as  soon  as  pos- 
sible. It  is  no  use  waiting  for  fluctuation,  the  sheets  of  fasciae  are  so  dense  that 
the  pus,  if  left  to  itself,  often  burrows  long  distances  before  it  reaches  the  surface, 
and  if  there  is  no  internal  opening,  a  timely  external  one  may  prevent  its  occur- 
rence. Buckston-Browne  has  pointed  out  that  in  cases  of  stricture  associated  with 
]:)erineal  abscess,  if  internal  urethrotomy  is  performed,  and  the  abscess  opened 
freely  from  the  outside,  a  fistula  may  often  be  prevented.  Care  must  be  taken 
that  the  incision,  if  the  abscess  is  in  the  perineum,  is  kept  absolutely  in  the 
middle  line. 

Urinary  Fistula. 

Fistulse  may  occur  in  connection  with  the  kidney,  ureter,  or  bladder,  after 
wounds  or  operations,  and  as  a  result  of  malignant  disease.  Sometimes  they  open 
directly  on  to  the  exterior  ;  sometimes  they  communicate  with  other  organs — the 
rectum,  vagina,  or  even  the  small  intestine.  Recent  ones,  in  which  there  has  been 
no  great  loss  of  tissue,  and  which  are  not  kept  open  by  a  permanent  irritant,  gener- 
ally close  of  themselves  if  the  natural  channel  is  patent.  Attention  to  drainage 
and  position  (the  patient,  for  example,  lying  prone  when  there  is  an  opening 
between  the  bladder  and  rectum),  the  free  use  of  antiseptics  and  a.stringents,  and 
the  occasional  application  of  caustics,  such  as  the  actual  cautery,  or  nitrate  of  silver 
melted  on  a  probe,  are  of  material  assistance.  If,  however,  they  are  old,  and  the 
walls  have  degenerated  into  dense  suppurating  sinuses,  the  surface  of  which  is  very 
likely  coated  over  with  a  layer  of  phosphates,  or  if  there  is  any  persistent  irritant 
(the  capsule,  for  example,  of  a  scrofulous  kidney  drained  through  the  loin),  further 
and  sometimes  extensive  operations  are  required.  These,  however,  and  vesico- 
vaginal fistuIcX  must  be  dealt  with  by  themselves. 

Urethral  Fistulce. — These  differ  in  severity,  and  may  be  divided  into  three 
classes  : — 

1.  Simple  straight  channels,  of  recent  formation,  opening  directly  on  to  the 
exterior,  without  much  induration  around. 

2.  Complicated  fistulae,  sometimes  very  numerous  (as  many  as  fifty  have 
been  described),  opening  in  all  directions,  over  the  penis,  in  the  groin,  in  the 
ischio-rectal  fossa — anywhere  near,  in  fact,  with  pouches  and  sinuses  in  which 
urine  collects  and  decomposes,  and  embedded  in  dense  cicatricial  tissue. 

3.  Fistulae,  very  often  in  the  penile  part,  in  which,  owing  to  extravasation  of 
urine,  phagedaena,  or  other  causes,  there  has  been  great  loss  of  tissue. 


1 122     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Urethral  fistula,  except  in  those  rare  cases  in  which  portions  of  the  penis  are 
removed  by  injury,  is  always  the  result  of  inflammation,  and  therefore  nearly 
always  of  stricture.  Abscesses,  however,  leaving  sinuses  behind  them,  do  occa- 
sionally occur  from  other  causes,  such  as  a  rupture  of  the  urethra,  impacted  calculus, 
or  urethrotomy.  It  is  not  material  whether  the  su[)puration  commences  on  the 
surface  of  the  mucous  membrane,  in  connection  with  an  inflamed  follicle  or  dilated 
pouch,  or  whether  it  originates  independently  of  this,  in  the  tissues  around  ;  in 
either  case  the  urine  finds  its  way  out  through  an  easier  channel,  and  a  fistula  is 
formed.  In  the  majority  of  instances  it  affords  little  or  no  relief  to  the  stricture. 
If  there  is  a  very  wide  opening,  or  if,  as  in  suprajjubic  puncture  of  the  bladder, 
the  sinus  is  fitted  with  a  suitable  instrument,  so  that  there  is  free  exit  for  the  urine, 
the  bladder,  being  relieved  from  all  tension,  may  recover  its  normal  condition — to 
a  certain  extent  at  least,  and  the  ill  effects  of  stricture  is  avoided  ;  but,  except  in 
such  cases  as  these,  the  orifice  of  the  fistula  soon  contracts  until  it  is  no  larger 
than  a  pinhole,  fresh  inflammation  takes  place  around  it,  more  abscesses  form, 
each  leaving  a  new  fistula,  and  at  length  the  whole  perineum  is  converted  into  a 
dense  mass  of  cicatricial  tissue,  riddled  with  openings  in  all  directions. 

Treatment. — The  treatment  of  urinary  fistula  depends  upon  the  cause.  The 
first  thing  is  to  remove  any  foreign  body  that  is  j)resent  (a  calculus,  for  example), 
and  to  see  that  the  natural  exit  for  the  urine  is  unimpeded  in  any  way. 

If  the  fistula  is  recent,  and  dependent,  as  it  usually  is,  upon  stricture,  it  will 
nearly  always  contract  aijd  heal  up  as  soon  as  the  stricture  is  healed.  Sometimes 
it  helps  to  stimulate  the  walls  by  injecting  tincture  of  iodine,  or  to  touch  uj)  the 
deeper  part  of  the  sinus  with  the  actual  cautery,  or  with  a  probe  upon  which  some 
nitrate  of  silver  has  been  fused.  If,  in  spite  of  this,  it  will  not  close,  means  must 
be  taken  to  prevent  any  urine  passing  through.  Occasionally  it  is  sufficient  to 
press  firmly  with  the  finger  upon  the  external  orifice  during  the  acfof  micturition. 
More  frequently  it  is  necessary  to  draw  the  urine  off  with  a  soft  catheter  as  often 
as  may  be  recjuired,  so  that  no  drop  shall  flow  along  the  urethra.  This  must, 
of  course,  be  done  before  each  act  of  defecation,  and  if,  in  spite  of  these  j^re- 
cautions,  the  least  drop  escapes,  the  urethra  must  at  once  be  thoroughly  washed 
out  with  a  weak  astringent.  It  is  no  use  tying  a  catheter  in  the  bladder  (unless 
it  is  connected  with  .some,  constantly  acting  exhausting  apparatus  to  suck  the 
urine  out),  some  will  always  pass  by  the  side,  no  matter  what  the  size  may  be  ; 
and  not  unfrequently  it  is  positively  injurious,  from  the  amount  of  irritation  it 
creates. 

If  this  does  not  succeed  and  the  stricture  is  fully  dilated,  it  is  possible 
that  the  irritation  is  kept  up  by  some  outlying  sinus  which  cannot  drain.  In 
such  a  case  it  is  best  to  perform  external  urethrotomy  at  once,  cutting  through 
the  whole  of  the  dense  tissue  in  which  the  fistula  lies.  If  there  are  many  open- 
ings, or  if  there  is  an  old  cartilaginous  stricture  to  deal  with,  this  is  almost  always 
nece.ssary. 

Where  a  considerable  portion  of  the  wall  has  been  destroyed  by  sloughing,  a 
plastic  operation  may  have  to  be  performed  in  order  to  close  the  oi)ening.  To 
secure  union  by  the  first  intention,  the  bladder  should  be  drained,  either  through 
the  rectum,  introducing  a  winged  soft  catheter,  or  through  an  opening  in  the  peri- 
neum, according  to  the  position  of  the  fistula.  Then  the  edges  may  be  pared 
and  brought  together,  or  a  flap  of  skin  may  be  raised  from  some  adjoining  part, 
and  sifted  so  as  to  cover  in  the  orifice. 

The  Female  Urethra. 

The  urethra  in  women  is  so  short,  and  the  extent  of  surface  so  small  in  com- 
parison with  that  of  the  male,  that  it  is  much  less  likely  to  become  inflamed,  and 
stricture  and  other  consequences  are  more  rare. 

Acute  inflammation,  commencing  with  great  severity,  and  attended  with 
scalding  and  purulent  discharge,  is  not  infrequent  as  a  result  of  gonorrhceal  in- 


THE  FEMALE  URETHRA.  1123 

fection  of  the  vulva.  Milder  forms  are  occasionally  met  with  as  a  consequence 
of  cystitis,  and  a  slight  but  very  troublesome  degree  of  irritation,  with  increased 
secretion  of  mucus,  is  not  uncommon  during  jjregnancy,  in  malposition  of  the 
uterus,  and  in  other  affections  of  the  generative  organs.  As  a  rule,  unless  the 
cause  is  a  persistent  one,  it  sul)sides  readily  under  the  use  of  astringent  injections, 
combined  with  hot  baths  and  purgatives.  Stricture,  as  a  result  of  inflammation, 
is  rare  ;  but  it  may  occur  from  chancres  or  other  sores  at  the  orifice,  and  from 
sloughing  of  part  of  the  anterior  wall  of  the  vagina.  It  may  be  treated  either 
by  dilatation  or  incision  ;  rigors  have  been  known  to  occur,  as  in  men,  but  very 
seldom. 

The  opposite  condition,  dilatation,  is  occasionally  met  with,  and  when  it  in- 
volves the  upper  third,  and  still  more  the  whole  length,  there  is  the  most  distress- 
ing incontinence.  It  may  result  from  long-continued  or  often-repeated  displace- 
ment, or  from  mechanical  stretching.  The  adult  urethra  admits  the  forefinger 
easily,  and,  as  a  rule,  if  the  dilatation  is  effected  rapidly,  no  ill  result  hajjpens  ; 
but  if  it  is  often  repeated,  or  if  it  is  carried  beyond  this,  as  in  extracting  a  calculus, 
it  may  become  permanent.  Sometimes  the  middle  portion  only  is  dilated  into  a 
pouch  (urethrocele)  felt  in  the  anterior  wall  of  the  vagina,  and  this,  acting  as  a 
receptacle  for  decomposing  urine,  keeps  up  the  irritation.  When  there  is  incon- 
tinence, due  to  impaired  power  at  the  neck  of  the  bladder,  galvanism,  tonics, 
strychnia,  cold,  and  other  measures  must  be  emi)loyed  to  restore  the  tone  of  the 
muscle. 

Urethral  caruncle,  a  small  vascular  growth  at  the  meatus,  occurring  more  fre- 
quently in  married  women  than  in  young  unmarried  girls,  may  give  rise  to  the 
greatest  distress.  It  bleeds  with  the  least  touch,  and  causes  the  most  intense  suffer- 
ing during  micturition  or  when  the  parts  are  moved  ;  at  the  same  time  there  is 
usually  great  irritability  of  the  bladder  and  a  profuse  discharge  of  mucus.  The 
symptoms  cease  at  once  on  its  removal. 

Fissure  at  the  neck  of  the  bladder  is  also  occasionally  met  with,  but  it  can 
only  be  diagnosed  with  the  endoscope.  There  is  a  small  superficial  erosion  of  the 
mucous  membrane,  circular  when  the  sphincter  is  stretched  but  appearing  like  a 
fissure  as  soon  as  it  contracts.  It  gives  rise  to  constant  tenesmus  and  staining,  with 
an  intense  burning  pain  at  the  end  of  micturition,  and  occasionally  a  few  drops  of 
blood.  It  may  readily  be  cured  by  means  of  a  light  application  of  caustic,  or  by 
mechanically  dilating  the  sphincter,  so  as  to  give  the  surface  rest.  The  former 
method  is  preferable,  as  it  is  not  always  possible  to  graduate  the  effects  of  the 
latter  sufficiently  in  individual  cases. 


1 1 24    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER    XXIV. 

INJURIES  AND  DISEASES  OF  THE  MALE  ORGANS. 

MALFORMATION  AND  DISEASES  OF  THE  PENIS. 

The  roof  may  be  defective  (epispadias)  ;  or  the  floor  (hypospadias)  ;  or  the 
invagination  that  forms  the  fossa  navicularis  may  fail  to  meet  the  part  behind  ;  if 
in  this  case  there  is  no  other  defect,  the  urethra  is  imperforate,  the  kidneys  become 
cystic,  and  the  child  dies  at  or  before  birth.  Usually,  however,  there  is  hypospa- 
dias, and  occasionally  the  two  channels  run  one  above  the  other  for  a  consider- 
able distance. 

Hypospadias. — The  orifice  is  usually  at  the  base  of  the  glans,  or  a  little  further 
back  ;  the  fraenum  is  wanting  ;  the  prepuce  forms  a  great  fold  on  the  dorsum  like 
a  cowl,  and  the  corpus  spongiosum  possesses  scarcely  any  erectile  tissue.  In  other 
cases  it  lies  at  the  end  of  the  membranous  urethra,  the  bulb  and  the  scrotum  fail- 
ing to  unite  in  the  middle  line,  and  forming  labia,  as  in  the  female.  When  the 
defect  is  slight,  the  fossa  navicularis  may  run  back  and  end  blindly  ;  in  other  cases 
the  penis  is  small,  and  the  corpus  spongiosum  (if  it  is  developed)  incapable  of 
erection. 

Epispadias. — The  complete  form  is  always  associated  with  ectopia  vesicae  ; 
occasionally  the  urethra  opens  behind  the  corona,  the  rest  of  the  penis  being  well 
developed. 

The  treatment  is  not  very  promising.  If  the  defect  is  slight,  and  micturi- 
tion not  impeded,  it  is  better  not  to  interfere.  The  orifice  should  be  dilated  to 
prevent  any  strain  upon  the  structures  behind  ;  and  if  the  urethra  fails  in  front,  so 
that  it  is  impossible  to  direct  the  stream,  an  attempt  should  be  made  to  carry  it 
forward  by  means  of  a  plastic  operation.  The  flap  must  be  double,  so  that  a 
cutaneous  surface  may  face  the  new  channel  ;  the  deeper  layer  is  taken  from  the 
side  of  the  penis  near,  and  twisted  round  upon  itself  ;  the  superficial  one  borrowed 
from  the  redundant  prepuce,  the  centre  of  the  cowl  being  dissected  up,  and  the 
glans  thrust  through  the  opening  so  that  the  dorsal  surface  becomes  inferior,  or 
vice  versa,  as  the  case  may  be. 

Phimosis  may  be  congenital  or  acquired,  following  balanitis,  soft  sores, 
chancre,  or  injury.  In  the  former  case  the  glans  is  often  adherent,  and  the  orifice 
may  be  reduced  to  the  size  of  a  i)inhole,  so  that  the  prepuce  swells  out  with  each 
act  of  micturition.  Circumcision  should  always  be  performed,  unless  the  corona 
can  be  thoroughly  and  easily  e.xposed  ;  the  secretion  collects  inside  ;  there  is  a 
constant  risk  of  balanitis  and  paraphimosis  ;  preputial  calculi  may  form  ;  and  the 
liability  to  syphilis  and  phagedasna  is  much  greater.  If  gonorrhoea  occurs,  it  is 
more  severe  ;  and  the  constant  irritacion  undoubtedly  favors  carcinoma. 

Circumcision. — The  prepuce  is  drawn  well  forward,  and  clipped  with  a  pair 
of  polypus  forceps  in  front  of  the  glans  ;  the  projecting  end  cut  off;  the  cutaneous 
sheath  allowed  to  retract ;  and  the  mucous  membrane  slit  up  along  the  dorsum  as 
far  as  its  attachment.  Each  half  is  then  cut  away,  following  the  line  of  the  corona, 
and  leaving  the  fr^enum  and  just  enough  to  hold  a  few  sutures.  If  catgut  is  used, 
and  the  wound  dried  and  covered  with  iodoform,  the  dressing  may  remain  on 
until  the  skin  has  united. 

Paraphimosis  is  the  condition  produced  by  forcing  the  glans  through  the  orifice 
of  the  prepuce  when  it  is  too  narrow  to  admit  it.  The  immediate  result  is  con- 
gestion and  inflammation,  ending,  if  left,  in  ulceration  and  sloughing.  The  glans 
becomes   swollen ;    the    prepuce   overhangs    it    like   an    oedematous  collar,   and 


DISEASES  OF  THE  SCROTUM. 

concealed  behind  thin  is  a  tight,  un- 
yielding ring  formed  by  the  orifice. 
In  early  cases  reduction  can  usually  be 
effected  by  oiling  the  parts  well,  and 
drawing  the  foreskin  forward  with  the 
index  and  middle  fingers  of  the  two 
hands,  while  the  thumbs  compress  the 
glans  ;  or  the  penis  may  be  wrajiped 
round  with  lint,  and  gently  squeezed 
in  the  hand  until  the  oedema  disap- 
pears ;  but  in  cases  that  have  already 
lasted  some  days,  it  is  often  necessary 
to  slip  the  end  of  a  director  under  the 

constricting     band      on     the     dorsum,  Fig.  488.— Mode  of  Dividing  Prepuce  in  Paraphimosis. 

and  divide  it  with  a  bistoury. 

Epitheijo.ma  of   the  Penis. 

Squamous  epithelioma  is  not  uncommon  after  middle  life,  commencing  on 
the  glans  or  the  inner  surface  of  the  prepuce,  especially  in  cases  of  phimosis.  It 
usually  begins  as  a  warty  nodule,  which  soon  breaks  down  into  an  ulcer,  with  in- 
tensely hard  base  and  edges.  If  left,  the  growth  spreads  rapidly,  owing  to  the 
constant  irritation  of  the  urine  ;  the  corpora  cavernosa  and  the  glans  are  quickly 
infiltrated  ;  the  lymphatics  in  the  groin  become  involved,  and  secondary  de- 
posits follow.  The  diagnosis  from  syphilis  rest  chiefly  on  the  character  of  the 
base,  which  is  covered  with  decaying  epithelium,  and  the  intense  induration 
beneath  and  around. 

Amputation  is  the  only  treatment.  Until  recently  this  wa.s  accomplished 
either  with  a  single  sweep  of  the  knife,  or  more  deliberately,  forming  a  flap  of  skin 
to  cover  the  surface  of  the  wound,  leaving  the  corpus  spongiosum  and  the  urethra 
longer  than  the  rest,  and  stitching  the  edge  of  the  mucous  membrane  to  that  of 
the  skin.  Recurrence,  however,  is  exceedingly  common  after  this  operation  ;  cica- 
tricial stricture  at  the  orifice  invariable  ;  and  all  power  of  directing  the  stream  of 
urine  lost.  To  avoid  this  Thiersch  recommends  an  oval  incision  round  the  root  of 
the  penis,  prolonged  a  little  backward  in  the  median  raphe  of  the  scrotum,  and 
then  dissecting  off  the  whole  of  the  corpora  cavernosa  from  the  rami  of  the  pubes 
and  the  triangular  ligament.  The  corpus  spongiosum  and  the  urethra  are  dealt 
with  separately,  through  an  incision  in  the  median  line  of  the  perineum  behind, 
as  much  being  removed  as  appears  desirable,  and  the  rest  sutured  to  the  skin  in 
front  of  the  anus.  Micturition  must,  of  course,  be  effected  in  the  sitting  posture, 
but  there  is  not  the  same  tendency  to  the  formation  of  stricture,  and  there  is  much 
further  freedom  from  return  of  the  growth. 

Wheelhouse  has  pointed  out  the  greatly  increased  comfort  the  patient  experi- 
ences when  the  testes  are  removed  as  well. 


DISEASES  OF  THE  SCROTUM. 

(Edema  may  occur  in  Bright' s  disease,  causing  enormous  swelling  ;  and  a 
similar  affection  (probably  inflammatory  in  origin)  is  occasionally  met  with  in 
infancy. 

Inflatnmation  is  very  common,  but  unless  the  cause  is  very  grave  (as  in  extrav- 
asation of  urine),  or  the  nutrition  much  enfeebled,  as  in  specific  fevers,  sloughing 
and  gangrene  rarely  occur.  It  may  arise  from  injury,  eczema,  the  irritation  of 
the  urine,  or  retained  perspiration,  or  it  may  start  from  the  interior,  or  spread 
from  other  tissues.  The  swelling  is  usually  immense,  but  the  other  signs,  pain, 
heat,  and  redness,  are  seldom  in  proportion. 


1 1 26    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Elephantiasis. — Enormous  hypertrophy  of  the  tissues  of  the  scrotum  may  be 
caused  by  lymphatic  obstruction,  or  by  repeated  attacks  of  inflammation,  as  in 
cases  of  urinary  fistula.  The  skin  and  subcutaneous  tissues  only  are  affected,  the 
cellular  elements  and  the  fibrous  tissue  l)eing  immensely  increased,  while  all  the 
interstices  are  filled  with  lymph,  or  in  rarer  cases  with  a  mixture  of  this  with  chyle. 
Hydrocele  is  usually  a.ssociated  with  it,  and  the  skin  of  the  penis  may  become  in- 
volved, but  the  testes  are  never  affected  (see  p.  291). 

Epithelioma  is  of  interest  from  the  fact  that  its  origin  can  nearly  always  be 
traced  to  local  irritation  caused  by  soot — whence  its  common  name,  chimney- 
sweep's cancer. 

It  begins  as  a  wart  or  nodule,  which  slowly  spreads  at  the  margin  as  it  decays 
and  ulcerates  in  the  centre.  Induration  is  its  chief  feature.  The  edges  are  raised, 
hard,  and  ill-defined  ;  the  base  is  covered  with  decaying  epidermis  and  florid 
granulations  which  discharge  a  thin,  off"ensive  fluid,  and  the  tissues  around  are 
swollen  and  oedematous.  At  first  it  can  be  pinched  up  from  the  structures  beneath, 
and  merely  feels  like  an  induration  in  the  skin  ;  soon  it  infects  the  lymphatic 
glands  in  the  groin,  spreads  to  the  rest  of  the  scrotum  and  the  jjenis,  and  involves 
the  testicles  as  well. 

Fortunately,  its  character  is  so  well  known  among  those  liable  to  it  (soot  may 
cause  it  in  other  parts  of  the  body,  and  there  is  reason  to  believe  that  tar  may  do 
the  same),  and  its  progress  (for  epithelioma)  is  so  slow,  that  removal  in  time  is 
usually  possible.  Even  if  the  inguinal  glancs  are  enlarged  and  broken  down,  the 
whole  of  the  disease  may  sometimes  be  successfully  scraped  out. 


EXAMINATION  OF  SCROTAL  SWELLINGS. 

Swellings  of  the  scrotum  are  divided  into  those  that  occupy  the  canal  as 
well  as  the  scrotum,  and  those  that  are  confined  to  the  latter  situation.  The 
distinction  is  made  by  feeling  the  cord  immediately  below  the  pubes,  whether  it 
is  the  natural  size,  with  all  its  components  distinct,  or  whether  it  is  thickened  or 
concealed  in  any  way. 

I.  Swellings  that  Occupy  the  Canal  as  well  as  the  Scrotum; 

OF    THESE,    SOME    ARE    REDUCIBLE,   OTHERS    ARE    NOT. 

{a)  Reducible. 

Bubonocele  and  scrotal  hernia  may  be  recognized  by  the  way  in  which  they 
disappear,  whether  they  consist  of  intestine  or  omentum. 

Varicocele,  by  its  characteristic  feel,  the  way  in  which  it  disappears  when  the 
patient  lies  down  and  the  scrotum  is  raised,  and  refills  in  spite  of  the  pressure  of 
the  finger  on  the  ring. 

Congenital  hydrocele,  by  its  translucency.  As  the  neck  of  the  canal  is  often 
long  and  narrow,  reduction  is  not  always  easy. 

{U)  Irreducible. 

Hernia,  either  because  it  is  strangulated  (in  which  case  there  is  no  impulse 
on  coughing),  or  because  it  is  irreducible,  i.  e.,  so  altered  in  shape,  or  so  tied 
down  by  adhesions,  that  it  cannot  pass  back.  In  strangulation,  constitutional 
symptoms  are  present  as  well. 

Infantile  Hydrocele. — The  neck  of  the  tunica  vaginalis  is  obliterated  only 
at  the  internal  abdominal  ring,  and  a  collection  of  fluid  extends  from  the  bottom 
of  the  scrotum  along  the  inguinal  canal.  The  slow  formation,  commencing 
below  and  extending  upward,  the  translucency  and  the  ab.sence  of  true  impulse 
(if  it  extends  really  into  the  canal  there  may  be  a  kind  of  shock  transmitted),  are 
distinctive. 

Inflammatory  Affections  of  the  Cord. — In  urethral  epididymitis  this  is  some- 


MALFORMATION  OF  THE  TESTES.  1127 

times  swollen  to  a  considerable  size  ;  in  tubercular  disease  the  vas  only  is  thickened, 
and  all  the  structures  of  the  cord  can  be  isolated. 

Growths  on  the  Cord. — The  most  common  X's,  encysted  hydrocele,  di  small, 
round,  and  tense  fluid  swelling,  due  to  incomplete  obliteration  of  the  funicular 
l)ortion  of  the  tunica  vaginalis.  It  is  movable  in  the  canal,  but  cannot  really  be 
reduced,  and  it  is  adherent  to  the  cord,  forming  i)art  of  it  and  moving  with  it. 

Lipoma,  sarcoma,  and  other  growths  may  occur,  but  they  are  very  rare.  Sec- 
ondary infiltration  is  always  present  in  malignant  disease  of  the  testis,  if  the  gland 
is  not  speedily  removed.     Hamatocele  of  the  cord  has  been  described. 

2.  Swellings  Confined  to  the  Scrotum. 
(a)    Those  Connected  with  the  Scrotum  Itself. 

(Edema. — In  Bright's  disease,  the  whole  scrotum  sometimes  becomes  enor- 
mously distended,  without  the  legs  being  much  affected.  A  moment's  consideration 
is  sufficient,  but  I  have  known  serious  mistakes  made. 

Elephantiasis. — In  the  tropical  variety  there  can  be  no  hesitation,  but  occa- 
sionally a  greatly  thickened  and  hardened  condition,  not  so  plainly  recognized,  is 
met  with  as  a  result  of  neglected  stricture. 

Lipoma,  epitliclioma,  and  other  varieties  of  new  growths  may  occur. 

(J))  Those  Connected  with  the ,  Testis  and  its  Coverings  :  these  may  be  solid  or  fluid. 

The  former  include  inflammatory  diseases  and  tumors  of  the  testis.  The  chief 
difficulty  occurs  with  hsematocele  and  old  hydrocele,  the  walls  of  which  may  be 
so  thick  that  they  are  practically  solid. 

The  latter  may  be  connected  with  the  tunica  vaginalis  (hydrocele  or  haema- 
tocele)  ;  the  testis  or  epididymis  (encysted  hydrocele)  ;  or  the  lower  end  of  the 
cord  (hydrocele  of  the  cord)  ;  or  they  may  be  independent  cysts — dermoid,  for 
example,  or  hydatid.  Some  difficulty  may  arise  from  what  is  known  as  hydro- 
sarcocele,  a  collection  of  fluid  in  the  tunica  vaginalis,  surrounding  and  concealing 
an  enlargement  of  the  testis,  and  the  diagnosis  may  remain  uncertain  until  the 
fluid  is  drawn  off. 

Malformation  of  the  Testes. 

The  full  development  of  the  testis  is  not  reached  until  sexual  maturity.  It 
may  fail :  (i)  either  in  its  original  formation  ;  (2)  in  its  evolution  (including  its 
descent  into  the  scrotum)  ;  or  in  both  together.  In  addition,  it  occasionally 
happens  that,  though  perfectly  developed,  it  becomes  displaced  (malposition). 

(i)  Defective  Formation. — The  testis  and  epididymis  are  developed  indepen- 
dently of  each  other,  although  they  are  in  close  connection  ;  sometimes  one  fails, 
sometimes  the  other.  If  the  former,  the  epididymis  and  the  vas  may  occupy  their 
normal  situation,  the  gland  itself  being  represented  only  by  a  nodule  ;  if  the  lat- 
ter, the  testis  may  be  well  developed  and  of  its  normal  size,  although  its  secretion 
fails  to  reach  the  urethra.  Sometimes  the  whole  of  the  epididymis  is  wanting  ; 
more  frequently  only  part,  and  the  vas  terminates  blindly.  If  both  testicles  are 
wanting,  sexual  development  at  puberty  does  not  take  place,  and  often  there  is 
malformation  of  the  other  organs. 

(2)  Defective  Evolution. — The  testis  may  fail  to  attain  the  normal  size,  or  its 
normal  jjosition,  or  both. 

{a)  Imperfect  Evolution  of  the  Testis  whe7i  in  its  Normal  Situation. — In  most 
instances  the  cause  is  unknown  ;  the  subject  of  it  when  the  affection  is  bilateral, 
has  an  effeminate  appearance ;  the  voice  does  not  break  ;  the  larynx  remains 
small ;  there  is  no  growth  of  hair,  and  the  limbs  are  smooth  and  rounded.  When 
it  is  unilateral,  it  is  often  associated  with  varicocele,  but  it  is  more  probable  that 
they  are  both  dependent  upon  the  same  cause,  whatever  that  may  be,  than  that 
one  is  the  consequence  of  the  other. 


1 1 28    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

(^b)  Non-descent. — Descent  of  the  testis  may  be  delayed,  or  may  fail  to  take 
place,  wholly  or  in  part.  In  the  former  case,  the  testis  is  usually  well  (leveloi)ed, 
and  the  descent  is  completed  at  puberty,  when  the  organ  becomes  sexually  mature. 
In  the  latter  it  is  usually  small  and  flabby. 

The  cause  is  very  uncertain,  except  in  those  cases  in  which  there  is  a  distinct 
mechanical  impediment,  such  as  fusion  of  the  two  glands.  Adhesions  to  neigh- 
boring structures  (especially  the  intestine)  are  often  present,  but  there  is  no  proof 
that  they  are  the  reason.  The  gland  may  remain  in  the  original  position,  or  be 
arrested  in  the  iliac  fossa,  or  in  the  inguinal  canal.  The  .sac  of  the  tunica  vagi- 
nalis nearly  always  remains  open  ;  hernia  is,  in  consequence,  very  often  present  as 
Avell,  and,  if  not,  is  always  liable  to  occur  ;  and,  not  infrequently,  owing  to  slight 
attacks  of  inflammation,  there  are  adhesions  between  the  intestine  and  the  gland. 

The  symptoms  and  treatment  depend  upon  its  position  and  mobility. 

If  it  lies  in  the  iliac  fossa,  it  is  well  out  of  the  way  of  injury,  and  nothing  is 
required  but  a  truss  to  prevent  the  development  of  hernia. 

If  it  lies  in  the  inguinal  canal  and  is  sufficiently  movable  to  pass  out  of  the 
external  ring,  the  same  treatment  may  be  adopted,  a  horseshoe-pad  being  used  to 
avoid  undue  pressure  upon  it. 

If  it  is  fixed  between  the  muscles  the  conditions  are  different.  In  most  cases 
a  truss  cannot  be  worn,  and  there  is  constant  danger  of  hernia.  The  gland  itself 
is  always  liable  to  injury  and  inflammation  ;  if  this  occurs,  satisfactory  evolution 
at  puberty  is  improbable  ;  and,  like  other  ill-developed  organs,  it  is  liable  to  become 
the  seat  of  malignant  disease.  Under  these  circumstances,  if  the  tendency  to 
hernia  cannot  be  prevented,  or  if  there  has  been  an  attack  of  inflammation,  the 
gland  is  better  removed.  It  is,  in  all  probability,  functionally  useless,  and  is  a 
constant  source  of  danger. 

In  cases  of  strangulated  hernia  the  treatment  of  the  gland  depends  upon  its 
condition.  If  it  appears  fairly  well  formed  and  not  too  much  tied  down  by  adhe- 
sions, and  if  the  vas  is  of  sufficient  length  and  the  scrotum  will  admit  it,  an  attempt 
may  be  made  to  transplant  it.     If  this  cannot  be  done  it  should  be  excised. 

3.  Malposition. — The  testis  may  be  in  its  normal  position,  but  inverted  ;  the 
epididymis  and  the  vas  deferens  lying  in  front  of  the  other  structures.  If  hydro- 
cele or  hematocele  occurs,  and  this  condition  is  not  recognized,  the  gland  is  liable 
to  be  punctured  instead  of  the  tunica  vaginalis* 

In  other  cases  the  testis  passes  out  through  the  inguinal  canal  into  the  peri- 
neum, or  misses  this  altogether  and  slips  into  the  crural  ring,  even  passing  out  on 
to  the  thigh.  The  treatment  consists  either  in  transplantation  (waiting  until  the 
child  is  two  or  three  years  old)  or  excision,  according  to  the  condition  of  the 
scrotum  and  the  gland  and  the  amount  of  inconvenience  it  is  likely  to  cause. 

Neuralgia  of  the  Testis. 

Pain  and  retraction  of  the  testis  are  of  frequent  occurrence  in  disease  of  the 
kidneys  and  affections  involving  branches  of  the  lumbar  plexus  ;  further,  after 
obliteration  of  the  vas,  sexual  intercourse,  or  even  excitement,  may  be  attended 
with  severe  pain  and  swelling  of  the  gland  ;  in  addition  to  this,  however,  the 
testes  in  certain  people  are  liable  to  attacks  of  intense  neuralgia,  coming  on  at 
regular  intervals  or  excited  by  the  most  trivial  irritant.  I'sually  one  only  is 
affected,  but  both  maybe  ;  the  gland  maybe  ajiparently  well  nourished,  or  it  may 
be  small  and  flabby  ;  it  may  be  exceedingly  irritable,  resenting  the  slightest  touch, 
or  there  may  be  nothing  noteworthy  about  it. 

In  many  cases  there  is  a  history  of  injury,  but  it  seldom  stands  cro.ss-exami- 
nation.  Gout,  malaria,  anaemia,  and  other  constitutional  ailments  are  sometimes 
present.  It  may  occur  in  the  most  continent  ;  and  though  in  many  there  is  a 
history  of  abuse,  it  is  difficult  to  connect  one  condition  directly  with  the  other. 
Sexual  hypochondriasis  may  be  associated  with  it,  and  often  the  family  history  is 
decidedly  neurotic. 


DISEASES  OF  THE  TESTES.  1129 

Treatment  is  very  unsatisfactory.  Any  local  or  constitutional  cause  that 
can  be  detected  must,  of  course,  receive  thorough  consideration  ;  a  suspender  must 
be  worn  ;  lead,  or  some  other  cooling  lotion  ai)i)lied  ;  and  the  thoughts  and  ideas 
as  far  as  possible  directed  into  other  channels.  Cupping  over  the  loins,  massage 
of  the  back,  and  the  free  (local)  use  of  anodynes  may  be  tried  as  well.  If  there 
is  a  large  varicocele,  operation  may  give  relief,  but  castration  is  u.sele.ss. 

Atrophy. 

Rupture  or  ligature  of  the  spermatic  artery  and  occasionally  acute  orchitis 
(especially  that  variety  which  is  associated  with  mumps)  are  the  chief  causes,  the 
testicle  shrinking  to  a  small  nodule.  I  have  known  the  same  thing  occur  after  a 
blow.  Rupture  or  ligature  of  the  vas  deferens,  chronic  epididymitis,  the  pressure 
of  ill-fitting  trusses,  and  abuse,  may  be  followed  by  the  same  effect  ;  but  the 
wasting  is  seldom  so  extreme.  Whether  it  is  ever  a  result  of  varicocele  is 
doubtful,  though  this  is  so  often  associated  with  a  soft  and  flabby  condition  of 
the  gland. 

The  opposite  result,  hypertrophy,  is  said  to  occur  as  compensation  in 
cases  of  unilateral  retention. 


ORCHITIS  AND  EPIDIDYMITIS. 

Inflammation  of  the  testis  may  be  caused  by  injury,  morbid  conditions  of  the 
blood,  as  in  gout  or  rheumatism,  extension  from  the  neighboring  structures,  or  the 
presence  of  specific  irritants,  such  as  those  of  tubercle  and  syphilis.  It  may  affect 
the  testis,  only  or  chiefly  (orchitis)  ;  or  the  epididymis  (epididymitis)  ;  and  it  may 
be  acute  or  chronic,  ending  in  resolution,  organization,  caseation,  or  suppuration, 
according  to  the  cause.  In  addition,  acute  orchitis  is  sometimes  due  to  "  meta.sta- 
sis  "  in  connection  with  mumps,  but  only  after  puberty,  and  not  apparently  with 
equal  frequency  in  all  epidemics. 

I.  Acute  Inflammation. 

(^a)  Acute  orchitis  may  be  caused  by  metastasis  (the  parotid  is  occasionally 
not  affected),  injury,  or  pyaemia  ;  or  it  may  be  due  to  extension  from  the  epididy- 
mis or  tunica  vaginalis.  Subacute  attacks  are  not  uncommon  in  gout  and 
syphilis. 

The  gland  is  swollen  and  exquisitely  tender,  but  owing  to  the  toughness  of 
the  tunica  albuginea  it  retains  its  shape,  and  is  not  so  large  as  in  epididymitis,  or 
flattened  on  the  side.  The  skin  is  red  and  oedematous ;  the  temperature  raised, 
the  veins  swollen,  and  the  cord  thickened  and  tender,  but  the  structures  composing 
it  are  not  matted  together,  and  the  vas  is  but  little  affected.  The  tunica  vaginalis 
is  filled  with  fluid  (acute  hydrocele)  and  sometimes  obscures  the  local  signs  alto- 
gether— there  is  merely  evidence  of  intense  inflammation  without  its  being  possible 
to  say  from  the  appearance  of  the  swelling  whether  it  is  confined  to  the  tunica 
vaginalis  or  involves  the  testis  inside.  Pain  is  always  severe  and  of  a  peculiarly 
sickening  character,  with  heavy  dragging  in  the  loins;  and  the  constitutional 
symptoms  are  often  very  grave,  delirium  sometimes  occurring  in  the  metastatic 
variety. 

Localized  peritonitis  with  spasmodic  contraction  of  the  abdominal  muscles  is 
not  unfrequent  when  a  retained  testis  is  inflamed,  and  it  has  been  known  to  prove 
fatal. 

(J))  Acute  epididymitis  is  nearly  always  due  to  extension  from  the  urethra, 
though  the  actual  outbreak  is  often  determined  by  local  injury.  It  may  be  caused 
by  any  irritation  affecting  the  prostatic  portion,  gonorrhcea  (not  the  acute  stage, 
72 


II30    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

but  later  when  the  gleet  is  chronic),  impacted  calculus,  injections,  lithotrity,  or 
even  the  jjassage  of  a  catheter.  Exceptionally  it  follows  injury  alone,  or  occurs 
in  the  course  of  pygemia.  Subacute  varieties  are  met  with  in  the  early  stage  of 
secondary  syphilis,  and  occasionally  as  a  result  of  stricture  and  chronic  urethritis. 
This  is  of  special  importance,  as  sometimes,  when  there  has  been  no  acute 
attack,  the  enlargement  closely  resembles  that  due  to  tubercle  before  caseation 
has  begun. 

The  general  symptoms  are  the  same  as  those  of  acute  orchitis,  but  the  two 
affections  can  nearly  always  be  distinguished.  The  shape  is  different  ;  instead  of 
being  rounded,  it  is  flattened  by  the  pressure  of  the  thigh  upon  the  outer  side  ; 
and  the  testes  can  be  felt,  soft  and  almost  painless  in  the  front.  The  skin  is  red 
and  oedematous,  especially  behind  and  below,  and  it  cannot  be  pinched  up  into  a 
fold  or  lifted  off  the  subjacent  structures.  The  pain  begins  in  the  loins  before 
there  is  local  tenderness,  and  in  the  same  way  the  groin  may  be  exquisitely  sensi- 
tive before  the  testis  is  affected.  But  the  most  important  point  of  all  is  the  con- 
dition of  the  cord  :  the  vas  deferens  is  enlarged  ;  the  cord  immensely  thickened  ; 
and  all  the  structures  in  it  matted  together  so  that  they  cannot  be  isolated.  Epi- 
didymitis is  rather  more  common  upon  the  left  side  than  the  right,  and  seldom 
involves  both  at  the  same  time,  though  the  second  is  frequently  attacked  as  the 
first  is  getting  well. 

The  urethral  discharge  ceases  so  long  as  the  inflammation  is  acute,  and  begins 
again  as  it  subsides. 

Termination. — Acute  inflammation,  whether  it  involves  the  testes  or  the 
epididymis  or  both  (for  it  not  unfrequently  extends  from  one  to  the  other),  usually 
ends  in  resolution,  but  not  always.  Partial  organization  may  occur,  affecting 
especially  the  exudation  in  and  around  the  globus  minor.  An  indurated  mass  is 
left,  painless,  gradually  sinking  into  a  small,  hard  nodule,  apparently  insignificant, 
but  often  leading  to  obstruction  or  stricture  of  the  vas.  If  it  occurs  on  both  sides 
and  does  not  undergo  speedy  resolution  the  subject  is  sterile.  Atrophy  may  occur, 
and  in  the  case  of  orchitis  be  complete.  Epididymitis,  even  when  the  vas  is 
obstructed,  seldom  leads  to  this;  sexual  intercourse  may  be  very  painful  and  be 
followed  by  the  swelling  of  the  gland,  but  unless  the  artery  is  obliterated  at  the 
same  time  the  testis  seldom  wastes  altogether.  A  curiously  irritable  condition 
sometimes  persists,  the  testis  and  even  the  skin  of  the  .scrotum  remaining  excjuis- 
itely  tender.  Suppuration  occasionally  follows ;  gangrene  of  the  scrotum  and 
sloughing  of  the  testis  have  been  known  ;  and  tubercular  disease  is  not  uncommon. 
Whether  epididymitis  has  any  connection  with  the  vaginal  hydrocele  that  so  fre- 
quently develops  in  later  life  is  uncertain.  The  acute  effusion  that  accompanies 
the  attack  subsides  with  it,  though  it  may  leave  permanent  adhesions,  and  some- 
times causes  obliteration. 

Treatment. — If  possible,  the  patient  should  be  confined  to  bed  with  the 
scrotum  raised  on  a  small  pillow  between  the  thighs.  In  other  cases  a  suspender 
must  be  used,  but  the  effect  is  not  nearly  so  good.  The  bowels  should  be  freely 
opened,  liquid  diet  only  allowed,  and  rest  ensured  by  means  of  morphia  or  chloral. 
In  young  plethoric  patients,  with  a  hard,  bounding  pulse,  full  doses  of  antimony 
may  be  given  at  frequent  intervals  until  there  is  a  distinct  feeling  of  nausea,  but 
this  is  of  no  good  after  the  first  twenty-four  hours,  and  only  when  the  fever  begins 
with  severity.  Smaller  doses  three  times  a  day  are  useful  later,  if  the  skin  con- 
tinues hot  and  dry,  or  the  headache  is  severe. 

In  urethral  epididymitis  cold  is  by  far  the  best  application,  especially  at  the 
beginning.  An  ice  bag  may  be  laid  upon  the  part,  or  Leiter's  coils  used,  lead 
lotion  being  substituted  after  twenty-four  hours.  If  the  patient  cannot  remain  in 
bed,  the  skin  of  the  scrotum  should  be  covered  over  with  extract  of  belladonna 
and  glycerine  ;  and  then,  the  other  testis  being  pushed  out  of  the  way,  surrounded 
with  many  layers  of  cotton-wool  and  subjected  to  gentle  compression  by  means 
of  a  laced-up  bag  suspender.     A  few  common  rubber  bands  may  be  placed  outside 


niSEASES  OF  THE  TESTES.  1131 

this  with  advantage.     The  application  should  he  renewed  at  least  twice  a  day,  the 

patient  fomenting  the  part  each  time  with  hot  water,  or,  better,  sitting  in  a  hot 

bath.     If  the  belladonna  causes  any  irritation, 

lead  may  be  substituted  for  it.      The  urethra 

should,  of  course,   be   left  alone,    not   only        ^^^lOnV'^v 

during    the    inflammation,    but   after   it   has        '^  ' 

subsided. 

If  the  effusion  into  the  tunica  vaginalis 
is  at  all  considerable,  a  few  punctures  may  be 
made  with  a  fine  tenotomy  knife,  or  an  ordi- 
nary trocar  and  cannula  may  be  introduced; 
and  if  the  veins  of  the  scrotum  are  distended,  Fig.  489.— Strapping  Testicle. 

they    may    be    pricked    and    encouraged    to 

bleed  ;  or  leeches  may  be  placed  upon  the  inguinal  canal ;  but,  although  it  is 
largely  practiced  by  some  surgeons,  and  apparently  with  impunity,  puncture  of 
the  testis  itself  is  not  advisable. 

Later,  when  the  acute  symptoms  are  beginning  to  subside,  the  testis  .should 
be  strapped.  The  affected  organ  is  separated  from  its  fellow,  and  isolated  by 
winding  round  above  it  a  long,  narrow  strip  of  soft  leather  covered  with  emplas- 
trum  plumbi.  The  end  that  is  applied  first  should  be  narrower  than  the  other,  so 
as  to  prevent  the  edge  cutting  into  the  skin.  Then  narrow  strips  of  ordinary 
plaster  are  arranged  so  as  to  cover  the  whole  organ  evenly,  beginning  from  the 
horizontal  piece  in  front,  passing  down  round  the  bottom  of  the  scrotum,  and 
ending  on  it  again  behind.  Afterward  a  circular  piece  is  placed  over  all  the 
ends  to  keep  them  secure.  If  a  small  nodule  obstinately  persists,  mercurial 
ointment  may  be  rubbed  in  over  it,  or  a  thick  layer  of  it  may  be  applied 
upon  lint  under  the  strapping,  but  care  must  be  taken  that  it  does  not  irritate 
the  skin. 

Traumatic  orchitis  may  be  treated  in  the  same  way.  When  due  to  metastasis 
warm  fomentations  are  better  from  the  first ;  and  if  there  is  much  infiltration  of 
the  scrotum,  so  that  the  condition  of  the  circulation  is  doubtful,  or  if  the  patient 
is  old  and  feeble,  cold  should  not  be  used,  for  fear  of  gangrene. 


2.  Chronic  Inflammation, 

This  may  begin  as  such  or  be  the  relic  of  an  acute  attack.  When  confined 
to  the  body  of  the  testis  it  is  nearly  always  due  to  syphilis ;  gout  and  malaria  are 
exceptional  causes.  If  the  epididymis  only  is  concerned,  it  is  probably  tubercular 
or  urethral,  and  in  the  latter  case  it  may  be  either  the  remains  of  an  acute 
attack  or  chronic  from  the  first.  Syphilis  occasionally  affects  the  epididymis 
only  (in  the  early  secondary  period),  and  not  unfrequently  both  epididymis 
and  testis. 

l"he  diagnosis  is  usually  straightforward  ;  but  sometimes,  when  it  com- 
mences insidiously,  without  any  obvious  degree  of  inflammation,  involving  the 
body  of  the  gland,  and  not  the  epididymis,  and  affecting  one  side  only,  it  is  diffi- 
cult to  distinguish  it  from  incipient  malignant  disease,  except  by  watching  the 
progress  of  the  case  and  the  effect  of  treatment. 

(a)  Syphilitic  Inflammation. 

Subacute  epididymitis  may  occur  in  the  early  secondary  stage,  a  painful 
irregular  swelling  making  its  appearance  at  the  back  of  the  testicle,  involving  the 
cord  to  a  slight  extent.  It  never  possesses  the  severity  of  urethral  epididymitis ; 
the  skin  may  be  reddened,  but  it  is  not  oedematous ;  and,  like  the  other  secondary 
symptoms  with  which  it  occurs,  it  subsides  rapidly  under  mercury. 

True  orchitis  appears  later,  either  during  the  intermediate  period  (when  both 


.M^m^'^^: 


1 132     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

glands  are  involved),  or  with  the  tertiary  symptoms,  when  one  is  often  attacked 

long  before  the  other.     As  a  rule,  it  does  not  affect 
Vj'-V;  .'■  1'%^  the  epididymis  or  the  cord,  and  is  very  chronic  in  its 

f*^^'Vj !?;«'  progress;  but  often,  in  neglected  cases,  after  the  first 

ll^'!^''^*.^^^:.,  testicle  has  been  enlarged  for  some  time,  the  second 

^./^Kj^^?v'^>>'^i^i>^  suddenly  becomes  actually  inflamed,  the  skin   grows 

hot  and  red,  the  tunica  vaginalis  distended,  the  epi- 
didymis affected  as  much  as  the  testis,  and  the  pain  so 
severe  that  the  patient  is  comi)elled  to  apjily  for  relief. 
Symptoms. — The    character    of    the   swelling 
"■''^f^'     depends  upon  the  distribution  of  the  syphilitic  exu- 
■  ,^  "     '3/       dation,    and   the   changes    it   undergoes.     In   some 

'•'K^  {*\      cases,   especially  the  earlier   ones,   there   is  uniform 

%'^''\  '-'  .'       enlargement  of  the  whole  gland,  so  that  it  remains 

'^.^^^^^^      '   v-"  ovoid,  smooth,  and  even,  and  merely  becomes  heavy 

"""-sit-iS-Tirr '•  and  intensely  hard  ;  in  others  the  surface  is  nodular 

Fig.  490.— Syphilitic  Disease  of  Testis;  and  uueveu  in  cousistence,  dense  indurated  patches 
a  Centra    iimma.  alternating  with  Others  that  are  soft  and  clastic.     The 

e.xudation,  in  other  words,  may  be  uniformly  distributed  throughout  the  whole 
of  the  fibrous  tissue  of  the  gland  ;  or  aggregated  either  into  one  central  gumma 
or  into  numerous  scattered  ones  of  various  sizes  ;  and,  according  to  the  success  of 
the  treatment,  it  may  be  completely  absorbed,  merely  leaving  a  slight  depression, 
or  become  organized  into  cicatricial  bands,  or  break  down  and  undergo  caseation 
and  liquefaction.  Occasionally  this  ends  in  suppuration  and  hernia  testis  ;  more 
frequently  partial  absorption  takes  place,  and  a  hard  irregular  mass  is  left,  some- 
times in  the  middle,  sometimes  at  one  side  of  the  testis,  composed  of  a  caseous  or 
even  calcareous  centre,  surrounded  by  an  immense  thickness  of  cicatricial  tissue — 
a  so-called  chronic  abscess. 

The  size  a  testicle  may  reach  under  these  conditions  is  something  enormous  ; 
usually  when  large  it  is  painless  and  devoid  of  testicular  sensation.  Heat,  redness, 
thickening  of  the  cord,  oedema  of  the  skin,  and  effusion  into  the  tunica  vaginalis 
are  signs  of  acute  inflammation,  and  are  only  present  when  the  testicle  is  first 
attacked,  or  when  a  fresh  gumma  suddenly  develops.  I  have  known  cases  of  this 
kind  to  last  for  ten  years,  with  occasional  subacute  attacks  compelling  the  patient 
to  apply  for  relief,  until  at  length  the  testicles  were  enormously  enlarged,  irregular 
in  shape,  hard,  painless,  and  absolutely  devoid  of  sensation. 

The  diagnosis  of  syphilitic  orchitis  is  rarely  difficult ;  the  only  form  that 
resembles  it  is  that  which  occurs  in  gout.  The  chief  features  are  the  essentially 
chronic  character  of  the  affection  (varied  from  time  to  time  by  more  acute  attacks)  ; 
the  smooth,  hard,  heavy  character  of  the  swelling  ;  the  disappearance  of  the  epi- 
didymis, which  in  many  instances  is  so  flattened  out  that  it  cannot  be  felt  (occa- 
sionally it  is  enlarged)  ;  the  absence  of  pain  (during  the  greater  part  of  the  time), 
and  of  testicular  sensation  ;  and  the  fact  that  both  testes  are  involved,  though 
rarely  equally. 

Treatment. — In  epididymitis  and  recent  orchitis,  mercury  may  be  given 
freely  with  a  view  of  causing  speedy  absorption  ;  later,  especially  if  the  disease  has 
relapsed,  more  benefit  is  derived  from  small  doses  of  bichloride,  continued  with 
occasional  breaks.  Iodide  of  potash  always  causes  a  rapid  diminution  in  size,  but 
absorption  of  the  syphilitic  exudation  is  rarely  complete  ;  it  progresses  up  to  a  cer- 
tain point,  continues  as  the  dose  is  increased,  and  then  comes  to  a  standstill,  leav- 
ing a  dense  mass,  over  which  nothing  appears  to  have  any  influence.  The  acute 
symptoms,  however,  are  quickly  relieved  by  it.  Occasionally  other  remedies  are 
of  service  :  mercury,  for  example,  rubbed  into  the  skin  on  the  inner  side  of  the 
thigh  (it  cannot  be  ai)i)lied  to  the  scrotum),  strapping,  or  the  removal  of  hydro- 
cele fluid.^  .  If  suppuration  occurs,  the  ab.scess  must  be  opened  ;  and  at  length,  if 
the  testis  becomes  useless,  and  is  a  constant  source  of  pain  and  suffering,  castration 
may  be  advisable. 


DISEASES  OF  THE  TESTES. 


^^Zl 


(J))    Tubercular  Disease. 

This  is  most  common  about  puberty  and  in  young  adult  life,  although  it  may 
develop  at  any  age,  and  it  may  be  either  primary,  and  followed  by  extension  to 
other  organs,  or  secondary,  sometimes  occurring  as  part  of  general  tul)erculosis. 
Except  in  this  case  (which  from  the  condition  of  the  patient  rarely  admits  of  diag- 
nosis during  life)  it  always  begins  in  the  epididymis  as  a  deposit  of  gray  miliary 
tubercle  in  the  lymphoid  intertubular  tissue.  From  this  it  may  spread  into  the 
body  of  the  gland,  working  its  way  through  the  mediastinum  testis,  and  infecting 
the  lymphoid  tissue  around  the  tubuli  seminiferi  ;  or  up  the  vas,  to  the  vesiculae 
seminales,  prostate,  and  bladder  ;  or  it  may,  under  happier  circumstances,  after 
attaining  a  certain  size,  gradually  cease  to  enlarge,  and  either  discharge  itself 
externally  as  a  mass  of  caseous  debris,  or  undergo  calcification  or  fibroid  degenera- 
tion. One  side  is  usually  attacked  first,  but  it  rarely  happens  that  the  other  remains 
exempt  for  long. 

Symptoms. — The  beginning  is  rarely  noticed  :  a'hard  nodule,  already  of 
some  size,  is  usually  discovered  accidentally  at  the  back  of  the  gland.  It  is  quite 
painless  ;  there  is  no  hydrocele,  and  scarcely  any  inflammation  ;  it  is  only  slightly 
tender  even  on  pressure,  and  testicular  sensation  is  not  impaired.  At  first  it  may  be 
rounded  or  irregular,  but  after  a  time  it  becomes  crescentic,  and  grows  out  above  and 
below  the  testis  as  well  as  behind.     The  gland  itself  is  rarely  affected  at  this  stage. 

Sometimes  this  diminishes  in  size,  and  becomes  harder  and  more  irregular, 
probably  undergoing  fibroid  degeneration.  More  frequently  it  continues  to 
increase  ;  one  part  becomes  softer  than  the  rest ;  the  skin  over  it  grows  red  and 
adherent ;  then  becomes  thinner  and  thinner  until  it  breaks,  and  gives  exit  to  a 
turbid  caseous  liquid  resembling  pus.  Occasionally  even  then  the  morbid  process 
ceases ;  more  frequently  other  deposits  break  down  ;  more  sinuses  form  ;  the  testis 
and  vas  become  involved  ;  and  at  length  secondary  deposits  make  their  appearance 
elsewhere.      Hernia  testis  may  occur,  although  it  is  not  so  common  as  in  syphilis. 

Diagnosis. — Urethral  epididymitis  is  usually  acute.  Sometimes  it  is  chronic 
from  the  first  ;  but  then  therfe  is  seldom  a  real  increase  in  size  ;  there  is  merely  a 
certain  degree  of  induration,  usually  limited  to  the  globus  minor.  The  secondary 
syphilitic  form  disappears  within  a  week  or  ten  days,  under  mercury.  Cysts  may 
cause  a  little  trouble,  but  when  they  occur  in  connection  with  tubercular  epididy- 
mitis they  are  never  very  large  or  distinct. 

Treatment. — Constitutional  measures  are  of  the  highest  importance  ;   in  the 
early  stage,  when  the  diagnosis  is  still  uncertain,  or  before  the  patient  will  allow  an 
operation,  they  may  succeed  in  arresting  the  disease ;   in  the  later,  when  there  is 
no  longer  any  hope  of  effecting  a  cure  by 
local  measures,  they  will  often  check  it  for 
a  time.      Perfect  rest,  especially  avoidance 
of  sexual  excitement,  is  most  important  ; 
sea-air,  often   a  long  sea-voyage,   answers 
better  than  anything ;   the  food    must  be 
nutritious  ;  a  moderate  supply  of  stimulants 
allowed  ;    and  tonics,  especially  cod-liver 
oil,  given  freely. 

The  local  treatment  depends  upon  the 
stage  the  disease  has  reached.  If  the 
globus  minor  is  merely  indurated,  without 
there  being  any  definite  increase  in  size,  as 
compared  with  the  other  one,  or  any  dis- 
tinct nodule,  the  condition  of  the  urethra 
should  be  carefully  examined,  and  the 
testis  strapped  over  iodide  of  lead  ointment. 
In  most  cases,  however,  this  stage  is  already 
past,  and  there  is  a  definite  nodule,  often  commencing  to  soften,  at  the  back  of 


Fig.  491. — Tuberculrir  Disease  of  the  Epididymis  with 
Miliary  Deposits  in  the  Testis. 


1 134     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  testis,  or  even  several  of  them.  If  the  rest  of  the  epididymis  is  free,  and  the 
vas  not  thickened,  an  attempt  may  be  made  to  arrest  the  progress  of  the  disease 
by  laying  it  open,  scraping  out  all  the  tubercular  tissue,  and  plugging  the  cavity 
with  iodoform.  Such  a  state  of  things,  however,  is  rare  ;  nearly  always  the  whole 
epididymis  is  affected,  and  the  vas  distinctly  enlarged  before  the  patient  applies 
for  treatment.  Under  these  conditions,  if  the  opposite  gland  is  sound,  and  no 
enlargement  of  the  vesiculae  seminales  can  be  detected,  the  diseased  organ  should 
be  removed  at  once,  the  vas  being  divided  as  high  up  as  possible.  When  the 
di.sease  is  more  advanced,  much  may  still  be  done  to  husband  the  patient's  strength  ; 
sinuses  may  be  scraped  out  and  filled  with  iodoform  ;  the  testicle  carefully  pro- 
tected :  the  inflammation  checked  by  lead  lotion  or  belladonna;  and  if  there  is 
any  serious  amount  of  discharge,  weakening  or  distressing  the  patient,  or  if  hernia 
testis  forms,  castration  may  be  performed. 

(r)    Gouty  Orchitis. 

This  is  much  more  rare  than  either  the  syphilitic  or  tubercular  variety,  and 
in  many  of  the  cases  in  which  it  is  assigned  as  the  cause  the  evidence  of  gout  is  not 
so  clear  as  might  be  wished.  Subacute  orchitis,  however,  is  not  uncommon  in 
men  past  middle  life,  especially  those  of  gouty  habit,  and  occasionally  is  distinctly 
associated  with  gout.  The  testis  itself  is  involved,  not  the  epididymis  ;  a  certain 
amount  of  hydrocele  is  usually  present ;  the  pain  and  inflammation  are  severe, 
though  not  to  the  same  extent  as  in  urethral  epididymitis ;  and  some  chronic 
induration  is  not  unfrequently  left. 

In  addition  to  this,  subacute  orchitis  may  occur  in  connection  with  urethral 
arthritis,  hereditary  syphilis,  and  possibly  other  disorders. 

3.  Suppuration. 
Acute  orchitis,  unless  it  is  due  to  pyaemia,  rarely  breaks  down  and  suppurates. 
In  urethral  epididymitis  this  termination  is  rarely  more  common,  but  the.abscess 
is  seldom  acute.  Most  cases  arise  in  connection  with  syphilis  or  tubercle,  sup- 
puration either  occurring  around  the  caseous  mass  before  it  breaks  the  skin  and 
makes  its  way  out,  or,  after  this  has  happened,  in  which  case  the  pyogenic  organ- 
isms may  gain  entrance  through  the  wound.  In  any  case  the  abscess  should  be 
of>ened  as  soon  as  possible  and  drained. 


HERNIA  TESTIS. 
Hernia  testis,  like  hernia  cerebri,  is  a  protrusion  of  the  substance  of  the  organ 

through  an  opening  in  its  unyielding  capsule,  due  to  inflammation.     Suppuration 

is  not  essential  to  its  production,  but  it  is  so  uniformly  present  that  it  is  usually 

regarded  as  the  cause  ;  the  opening  in  the 
capsule  might,  however,  be  produced  in  other 
ways,  and  the  increased  tension  in  the  in- 
terior and  softening  of  the  subjacent  layers 
might  arise  from  other  causes,  such  as  syphilis 
or  tubercle. 

Hernia  testis  must  be  distinguished  from 
"malignant  fungus  "  of  the  testis  or  "fun- 
gus hasmatodes  " — the  protrusion  of  a  malig- 
nant growth  through  the  coats ;  and  also 
from  what  has  been  called  "  false  hernia" — 
a  prolapse  of  the  testis,  covered  with  a  layer 
of  granulations,  through  an  opening  in  the 
tunica  vaginalis  and  scrotum. 

In  the  majority  of  cases  hernia  testis  is 

due  to  syphilis  :  a  gumma  forms  in  the  substance  of  the  organ  and  breaks  down  ; 

the  lavers  of  the  tunica  vaginalis  fuse  with  each  other  and  with  the  skin  :   this  grows 


:.!^ 


Fig.  492. — Hernia  of  the  Testicle  following  Tuber- 
cular Disease,  removed  from  infant,  act  2. 


TUMORS  OF  THE  TESTES. 


thinner  and  thinner,  until  at  last  it  gives  way,  exposing  a  cavity  filled  with  caseous 
or  sloughing  debris,  and  lined  by  a  still  growing  layer  of  syphilitic  exudation. 
The  external  pressure  is  removed  by  the  rupture  of  the  fibrous  wall,  and  if  the 
syphilitic  growth  or  the  suppuration  is  active,  a  mass,  sometimes  of  granulations, 
sometimes  of  the  tubuli  seminiferi  themselves,  is  forced  out  through  the  orifice  by 
the  vascular  tension.  The  same  thing  may  occur  with  tubercle  when  this  involves 
the  testis,  and  with  other  forms  of  suppurative  orchitis. 

The  appearance  is  characteristic.  A  soft,  red,  granular  mass,  occasionally 
covered  withsloughsor  caseous  debris,  projects  through  an  opening  in  the  scrotum, 
to  the  margins  of  which  it  is  closely  adherent.  In  some  instances  it  seems  as  if 
the  whole  testis  is  driven  out,  and  the  edges  of  the  opening  are  everted  and  con- 
cealed beneath  a  mushroom-shaped  mass  ;  in  others  there  is  merely  an  open  sore 
with  protuberant  granulations  at  the  bottom.  It  does  not  bleed  very  readily  (like 
the  malignant  form),  and,  as  there  is  now  no  tension,  is  not  very  painful;  but, 
particularly  in  the  tubercular  variety,  it  may  prove  a  serious  drain  upon  the  patient's 
strength. 

Treatment. — As  in  hernia  cerebri,  the  first  point  is  to  stop  the  inflamma- 
tion. If  this  can  be  done  the  protrusion  soon  subsides  spontaneously  ;  the  wound 
becomes  a  granulating  sore,  and  cicatrization  begins.  Occasionally,  if  the  surface 
is  perfectly  clean,  this  may  be  hastened  by  Syme's  operation — removing  the  nar- 
row edge  of  unhealthy  skin  around  it  by  means  of  two  elliptical  incisions,  one  on 
each  side,  and  drawing  together  the  margins  over  it,  but  it  often  fails.  In  tuber- 
cular cases,  in  which  the  testis  is  pracfically  destroyed  and  the  caseous  process 
will  not  cease,  castration  is  usually  advisable,  not  with  a  view  of  curing  the  patient 
so  much  as  of  relieving  him  of  a  source  of  infection  and  a  constant  drain  upon 
his  strength. 

TUMORS. 

Derinoid  and  hydatid  cysts  are  occasionally  met  with.  The  former  may  be 
recognized  by  their  congenital  origin  (though  they  often  do  not  attain  much 
prominence  until  late  in  life)  and  uneven  consistence  ;  but  no  certain  diagnosis 
can  be  made  without  puncture. 

Cystic  adenoma  is  more  common.  Like  parotid  glandular  tumor,  it  is  pecu- 
liar to  the  organ  from  w^hich  it  springs,  and  only  admits  of  a  somewhat  vague 
comparison  with  other  growths.  It  consists  of  cysts  of  all  sizes,  lined  with  cubical 
or  flattened  epithelium,  filled  with  a  clear  brownish  or  greenish  fluid,  and  devel- 
oped from  the  tubuli  seminiferi,  the 
epithelium  of  which  has  either  lost  or 
has  never  acquired  its  distinctive  charac- 
ters. In  between  is  a  variable  amount  of 
fibrous  tissue,  sometimes  undergoing 
myxomatous  degeneration,  and  occa- 
sionally mixed  with  cartilage.  Intracys- 
tic  growths  may  occur  as  well. 

Tumors  of  this  kind  may  occur  at 
any  age,  but  they  are  rarely  noticed  be- 
fore puberty.  Growth  is  slow  and  pain- 
less, the  patient  suffering  no  inconveni- 
ence other  than  that  due  to  the  weight. 
The  vas  is  never  affected,  and  secondary 
deposits  do  not  occur,  the  cases  in 
which  this  is  said  to  have  taken  place 
having  really  been  sarcomata,  with  an 
accidental  development  of  cysts. 

Fibroma  and  enchondroma  of  the 
testis  are  met  with  in  young  adult  life, 
but  they  are  both  very  rare.     The   chief  clinical  feature  is  the  slow  growth  of  a 


Fig.  493. — Cystic  Disease  of  the  Testicle. 


1 1 36    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

hard  and  heavy  painless  mass.  The  surface  is  usually  smooth,  but  it  may  be  nodu- 
lar and  suggest  the  [presence  of  cysts.  Growths  of  this  kind  do  not  extend  along 
the  cord,  invade  other  organs,  or  recur  ;  but  removal  is  always  advisable.  There 
is  no  means  of  distinguishing  one  from  the  other  but  by  section. 

Carcinoma  of  the  testis  is  nearly  always  encephaloid,  though  a  few  cases  of 
scirrhus  have  been  described.  It  is  stated  to  be  most  common  between  twenty 
and  forty  years  of  age.  The  beginning  is  usually  very  insidious  ;  the  testis  is 
enlarged,  smooth,  ovoid,  and  at  first  fairly  firm,  the  cord  is  not  thickened,  nor  are 
its  components  matted  together,  but  it  feels  fuller  than  the  other,  and  the  veins 
over  the  scrotum  are  distended.  There  is  little  or  no  pain  or  tenderness,  and 
testicular  sensation  is  soon  lost.  In  a  very  few  weeks  there  is  a  rajjid  increase  in  size  ; 
the  tumor  is  softer,  the  surface  uneven,  the  cord  distinctly  thickened,  the  shape 
becomes  globular,  and  the  epididymis  flattened  out  at  the  back.  If  left,  it  becomes 
so  soft  that  it  almost  seems  to  contain  fluid  ;  the  skin  becomes  adherent,  the 
veins  are  more  distended,  the  thickening  extends  higher  up  the  cord,  and,  j^erhaps, 
if  the  patient  is  thin,  an  ill-defined  sense  of  resistance  can  be  made  out  by  deep 
jiressure  at  the  back  of  the  abdomen.  Soon  the  skin  of  the  scrotum  gives  way, 
allowing  a  bleeding  mass  to  protrude,  the  glands  of  the  groin  enlarge,  secondary 
deposits  make  their  appearance  in  other  organs,  and  the  i)atient  sinks  rapidly  from 
exhaustion. 

Sarcovia  of  the  testis  presents  greater  variety  of  appearance  and  character. 
It  may  be  round-celled,  or  spindle-celled  ;  and  the  latter  especially  may  become 
more  or  less  converted  into  cartilage  (without,  however,  losing  one  atom  of  its 
malignant  sarcomatous  character)  ;  sometimes  there  are  only  nodules  here  and 
there,  sometimes  branching  outgrowths,  due,  perhaps,  to  the  spreading  of  the  disease 
inside  the  lymphatics,  and  occasionally  so  much  that  the  original  sarcomatous 
growth  is  hard  to  find.  In  addition,  both  of  these  forms  may  be  associated  with 
cysts,  due  either  to  softening  and  hemorrhages,  or  to  distention  of  the  seminiferous 
tubules,  with  proliferation  of  the  epithelium  lining  them,  and  occasionally  intra- 
cystic  growths,  so  that  they  may  present  a  close  resemblance  to  some  of  the  forms 
of  cystic  adenoma. 

Sarcoma  may  occur  at  any  age,  even  before  birth,  though  it  is  most  common 
under  ten  years  and  between  thirty  and  forty.  The  round-celled  variety,  unless  the 
patient  is  a  child,  or  both  testicles  are  attacked  at  once,  cannot  be  distinguished 
from  encephaloid  carcinoma ;  the  progress  is  as  rapid,  and  the  glands  of  the  lum- 
bar and  other  regions  are  involved  as  soon  ;  if  possible  it  is  even  more  fatal.  The 
other  variety  is  much  less  uniform  in  rate  of  growth  and  consistence  ;  it  may,  for 
example,  be  formed  almost  wholly  of  cartilage  or  fibrous  tissue  ;  cysts  are  less 
common  ;  and  it  does  not  appear  so  ready  to  fungate  ;  but  the  ultimate  results,  the 
infiltration  of  the  glands  with  growth  of  the  same  histological  character  as  the 
primary  one,  and  the  secondary  deposits  in  the  lungs  and  other  organs,  are  equally 
certain. 

Treatment. — Sarcoma  and  carcinoma  should  be  removed  as  .soon  as  the 
diagnosis  is  made,  the  cord  being  divided  as  high  up  as  possible.  The  i)rognosis 
is  very  unfavorable,  but  in  all  probability  this  is  due  in  some  measure  to  delay  ; 
there  is  evidence  to  show  that  if  castration  is  performed  in  time  recurrence  may  not 
take  place  for  many  years.  Even  if  the  skin  is  involved,  and  the  cord  thickened, 
the  operation  is  advisable  to  save  the  patient  from  the  formation  of  a  fungus,  if 
only  there  is  reasonable  prospect  of  securing  immediate  union  of  the  wound. 

Diagnosis  of  Tumors  of  the  Testes. 

Age. — A  tumor  that  api)ears  in  infancy  is  probably  hydrocele  ;  sarcoma,  syphi- 
litic and  tubercular  orchitis  do  occur,  but  they  are  very  rare  in  comparison. 

Etiology. — A  definite  history  of  accident  deserves  consideration,  though  it 
may  have  merely  drawn  attention  to  an  already  existing,  but  unsuspected,  enlarge- 
ment.    Sarcoma  may  follow  injury  as  well  as  hrematocele. 


CASTRATION.  1137 

Rapiditx  of  Groioth. — Hajmatocele  is  an  affair  of  minutes,  or  at  most  of  hours, 
malignant  disease  of  a  few  weel<s.  Acute  orcliitis  presents  no  difficulty  :  chronic 
inflammation,  on  the  other  hand,  if  only  one  side  is  involved,  if  there  is  no  evi- 
dence of  constitutional  complaint,  and  if  there  is  but  little  heat  or  pain,  and  no 
redness,  can  often  only  be  diagnosed  by  the  results  of  treatment.  Syphilitic  orchi- 
tis, for  example,  may,  so  far  as  a  single  examination  is  concerned,  be  indistinguish- 
able from  incipient  malignant  disease. 

Duration. — If  the  tumor  has  lasted  more  than  six  months,  without  the  doubt 
clearing  up,  it  is  not  malignant. 

Consistence,  whether  solid  or  fluid.  Hydrocele  and  heematocele  are  the  only 
fluid  tumors  at  all  common,  but  there  are  many  sources  of  fallacy.  A  hydrocele 
may  conceal  an  enlargement  of  the  testes  (hydro-sarcocele).  Old  hydroceles  and 
hematocele  may  have  walls  of  such  thickness  as  to  appear  solid  ;  and  rapidly  grow- 
ing malignant  tumors  may  be  as  soft  and  elastic  as  if  they  contained  fluid. 

Transliicency. — This  separates  off  at  once  thin -walled  hydroceles. 

Number. — Hydrocele  and  sarcoma  may  occur  on  both  sides,  but  nearly  always, 
when  both  testes  are  affected,  the  tumor  is  of  inflammatory  origin. 

Shape. — If  the  tumor  retains  the  shape  of  the  testis,  it  is  probably  either 
chronic  inflammation  or  incipient  malignant  disease.  Sarcoma  and  carcinoma 
when  more  advanced,  haematocele  and  encysted  hydrocele,  are  spherical ;  other 
tumors  are  very  irregular. 

Pain  and  Sensitiveness. — Haematocele  may  be  very  painful  at  first :  the  others 
(except  acute  inflammation)  are  rarely  attended  by  pain.  In  chronic  orchitis, 
malignant  disease,  and  haematocele  testicular  sensation  soon  disappears. 

The  Condition  of  the  Cord. — In  chronic  orchitis,  hydrocele,  and  haematocele 
the  cord  is  not  affected.  In  acute  inflammation  and  incipient  malignant  disease 
it  feels  full  because  of  the  increased  amount  of  blood.  In  acute  epididymitis  and 
advanced  sarcoma  and  carcinoma  it  is  thickened  and  all  its  component  structures 
welded  together.     The  vas  itself  is  enlarged  in  tubercular  epididymitis. 

The  skin  is  not  adherent  unless  there  is  acute  inflammation  or  advanced 
malignant  disease. 

Haematocele  can  only  be  distinguished  from  incipient  malignant  disease  by 
the  rapidity  of  its  development,  its  history,  or  the  result  of  puncture.  Even  this, 
however,  may  deceive  ;  on  one  occasion  I  tapped  a  blood-cyst  in  the  centre  of  a 
sarcoma. 

Chronic  orchitis  in  some  cases  can  only  be  diagno.sed  from  incipient  malig- 
nant disease  by  the  effects  of  treatment  ;  but  not  more  than  a  fortnight  should  be 
allowed. 

Castration. 

The  linear  incision  from  the  external  abdominal  ring  down  to  the  bottom  of 
the  scrotum  is  all  that  is  required,  unless,  as  in  the  case  of  a  malignant  growth,  or 
of  hernia  testis,  the  cutaneous  coverings  are  adherent  to  the  deeper  structures.  The 
skin  should  be  made  as  tense  as  possible  to  avoid  any  jagging,  and  the  cord  ex- 
posed at  once.  As  soon  as  this  is  isolated  the  testis  can  be  protruded  through  the 
wound.  In  the  case  of  malignant  disease  or  tubercular  infiltration,  the  inguinal 
canal  should  be  slit  up  on  a  director,  and  the  cord  drawn  down  as  far  as  possible 
before  securing  it. 

The  usual  method  is  either  to  pass  a  single  ligature  round  the  cord  (silk  should 
be  used)  or  to  tie  each  vessel  separately  as  it  is  divided,  leaving  the  vas  to  the  last. 
As,  however,  the  ligatures  may  slip  in  both  of  these,  causing  severe  and  deep  bleed- 
ing when  the  cord  retracts,  and  as  the  latter  is  very  tedious,  Jacobson  recommends 
that  a  double  ligature  should  be  passed  through  the  substance  of  the  cord,  the  loop 
cut,  and  the  two  halves  tied  separately.  Then  the  ends  of  the  one  are  cut  short, 
while  the  other  is  tied  again  round  the  whole  thickness.  If  possible  the  cord 
should  be  divided  well  above  the  disease.  No  drainage  tube  is  necessary  if  the 
dressing  is  carefully  arranged  around  the  wound. 


1 1 38     DISEASES  AND  IN/URIES  OF  SPECIAL  STRUCTURES. 

The  testis  should  always  l)e  examined  before  the  cord  is  tied,  in  case  of  a  mis- 
taken diagnosis,  and  the  cord  should  never  be  divided  until  it  is  certain  that  the 
ligature  is  secure. 

Varicocele. 

By  this  is  understood  a  varicose  condition  of  the  veins  of  the  spermatic  cord, 

often  associated  with  a  diminution  in  size  and  loss  of  tone  of  the  testis,  and  a 

peculiar  flabby  relaxed  condition  of  the  dartos.      It  is  very 

much  more  common  on  the  left  side  than  the  right,  and  if 

it  occurs  on  both  it  is  always  worse  on  the  left. 

Etiology. — It  is  rarely  or  never  noticed  before  the 
period  of  functional  activity  of  the  testis,  and  is  probably 
the  result  of  some  developmental  defect.  The  various 
causes  that  have  been  assigned,  the  length  and  direction  of 
the  veins,  their  imperfect  support,  and  the  vascular  changes 
that  attend  too  early  intercourse,  or  abuse,  act  on  both 
sides  alike  ;  and  the  reasons  given  for  the  predominant 
frequency  of  the  left — the  pressure  of  the  sigmoid  flexure, 
the  greater  length  of  the  veins  on  that  side,  and  the  open- 
ing into  the  renal — are  insufficient,  as  causes,  though  they 
may  make  the  condition  worse.  The  valves  in  the  veins 
are  thoroughly  competent. 

Symptoms. — These  bear  no  relation  to  the  size ;  a 
Fig  494.— Varicocele.  vcry  large  Varicocele  may  exist  without  the  patient  know- 
ing it.  Complaints  are  most  common  in  young  adult  life, 
or  much  later,  when  sexual  power  is  failing.  There  may  be  tenderness  and  irri- 
tability of  the  testis,  sometimes  amounting  to  severe  pain  ;  but  the  chief  feature 
is  a  constant  dragging  and  weight  in  the  loins,  made  worse  by  standing,  exercise, 
constipation,  or  sexual  intercourse — anything,  in  .short,  that  increases  the  conges- 
tion. With  this  there  is  frequently  associated  a  most  distressing  mental  condition  ; 
the  patient  is  subject  to  periods  of  intense  depression  ;  he  is  always  thinking  of 
himself;  often  he  believes  that  he  is  failing  in  power  from  some  old  indiscretion  ; 
and  not  unfrequently  he  becomes  a  confirmed  hypochondriac  at  last. 

The  skin  of  the  scrotum  is  so  lax  that  the  testicle  hangs  far  below  its  proper 
level  ;  the  cord  is  surrounded  by  a  soft,  irregular  mass  of  dilated  veins  (like  a  bag 
of  worms)  obscuring  the  gland  below,  and  ceasing  at  the  abdominal  ring  ;  and 
the  testis  itself  is  often  small,  soft,  and  flabby.  There  is  a  distinct  impulse  on 
coughing  ;  the  veins  empty  themselves  spontaneously  as  soon  as  the  patient  lies 
down  and  the  scrotum  is  raised  ;  and  if,  after  this,  he  stands  up  again  they  gradually 
refill  from  the  bottom  in  spite  of  firm  pressure  over  the  ring. 

Allusion  has  already  been  made  to  the  relation  between  the  testis  and  the 
varicocele  ;  the  morbid  condition  in  both  is  probably  dependent  upon  the  same 
cause.  Size  has  very  little  to  do  with  it  :  a  very  large  varicocele  may  coexist  with 
a  well-developed  testis  ;  but,  as  the  testis  is  frequently  ill-formed,  soft,  and  flabby, 
and  as  it  increases  in  size  and  firmness  after  operation,  it  is  clear  that  the  enlarge- 
ment of  the  veins  must  help  to  perpetuate  the  condition,  though  it  may  not  origi- 
nate it.  Where  one  testicle  only  is  affected,  there  is  no  means  of  judging  of  the 
effect  upon  the  seminal  secretion  ;  but  there  is  reason  to  believe  that  sometimes  at 
least,  when  both  are,  it  is  defective,  and  only  becomes  active  when  the  testes 
assume  their  normal  size  and  consistence. 

Treatment. — In  the  vast  majority,  radical  measures  are  entirely  out  of 
place  ;  varicocele  seldom  causes  inconvenience  after  early  manhood  is  past.  A 
suspender  should  be  worn,  one  that  is  not  too  hot  or  complicated  ;  the  parts 
should  be  bathed  with  cold  water  night  and  morning  ;  the  bowels  opened  regu- 
larly ;  a  fair  amount  of  e.xerci.se  taken,  and  stimulants,  sexual  excitement,  etc., 
avoided.  It  is  only  when  the  health  is  out  of  order  that  the  weight  of  the  part 
is  noticed.     Occasionally,  however,  this  is  not  sufficient ;  the  patient  may  wish  to 


HYDROCELE.  1139 

enter  one  of  the  Services ;  both  sides  may  be  involved  ;  tlie  varicocele  may  be 
serious  from  its  size,  the  rapidity  of  its  enlargement,  or  the  danger  of  rupture  or 
phlebitis  (which  is  not  uncommon  in  connection  with  gout)  ;  the  testis  may  be 
irritable  and  tender,  or  the  patient  very  much  trouliled  about  its  condition.  In 
those  cases  in  which  there  is  any  reason  to  fear  the  development  of  hypochon- 
driasis, every  endeavor  must  be  made  to  divert  the  patient's  attention  from  the 
subject ;  but  too  often  the  attempt  ends  in  complete  failure,  and,  though  the 
prospect  is  not  an  inviting  one,  there  is  no  alternative.  Pearce  Gould  considers 
operation  advisable  in  all  cases  in  which  varicocele  develops  before  puberty. 

Operation. — The  older  method,  in  which  a  ligature  was  passed  round  the 
veins  subcutuneously  in  one  or  more  places,  is  practically  abandoned  :  the  result 
is  uncertain,  and  there  is  great  risk  of  transfixing  a  vessel.  Even  the  addition  of 
subcutaneous  section  does  not  increase  the  security.  The  method  ordinarily 
adopted  is  to  expose  the  veins  freely,  so  that  the  structures  to  be  dealt  with  can 
be  seen  ;  isolate  the  vas  deferens  with  the  spermatic  artery,  ligature  the  vessels 
above  and  below,  and  excise  the  intermediate  portion.  Pearce  Gould,  however, 
considers  subcutaneous  section  with  the  cautery  preferable. 

The  patient  is  placed  under  an  anaesthetic,  the  parts  shaved  and  cleansed, 
and  an  incision  of  sufficient  length  made  along  the  cord,  exposing  the  fascia 
which  surrounds  the  veins.  The  vas  is  then  carefully  separated  at  the  back,  taking 
care  not  to  isolate  it,  but  to  leave  the  fascia  around  it  untouched  ;  a  catgut  liga- 
ture passed  round  the  rest  of  the  fascia  and  the  veins  above,  a  second  below,  and 
the  intervening  portion  excised.  Practically,  if  the  separation  is  commenced 
above,  all  the  veins  are  included  but  one  or  two  little  ones  with  the  vas.  The 
length  to  be  excised  depends,  as  Bennett  has  shown,  upon  the  height  to  which  it 
is  wished  to  raise  the  testicle,  and  after  excision  the  two  cut  ends  should  be 
sutured  together,  so  that  the  shortening  of  the  fascia  may  help  to  support  the 
gland.  No  drainage  tube  is  needed,  unless  there  has  been  much  handling.  The 
swelling  afterward  is  considerable,  and  the  testis  may  be  a  little  tender,  but  I 
have  never  known  orchitis  follow.  An  ice-bag  may  be  applied  for  forty-eight 
hours  as  a  precaution.  The  patient  should  remain  in  bed  for  ten  days  or  a  fort- 
night, by  which  time  the  induration  will  have  disappeared,  and  should  wear  a 
suspender  for  some  months. 

Hydrocele. 

Hydrocele  is  a  general  term  for  a  collection  of  serous  fluid  in  connection  with 
the  testis  or  its  coverings.  It  may  be  developed  from  the  tunica  vaginalis,  or  from 
the  testis  or  epididymis  ;  occasionally,  both  occur  together. 

I .  Hydrocele  Developed  from  the  Tunica  Vaginalis. 

Of  these  there  are  various  kinds,  according  to  the  part  in  which  the  fluid 
collects  ;  the  common  example  is  hydrocele  into  the  tunica  vaginalis  propria 
testis.      It  may  be  acute  or  chronic. 

Acute  hydrocele  is  usually  secondary  to  inflammation  of  the  testis  or  epididy- 
mis, but  it  may  be  caused  by  direct  irritation  of  the  tunica  vaginalis.  Its  symp- 
toms and  treatment  present  nothing  special :  it  may  subside,  leaving  the  sac  more 
or  less  obliterated,  or  become  chronic,  or  suppurate  and  form  an  abscess  in  front 
of  the  testis. 

Chronic  hydrocele,  too,  may  be  secondary  ;  and  occasionally  it  is  associated 
with  the  presence  of  a  pedunculated  growth  in  the  interior  of  the  sac,  or  with 
elephantiasis;  but  in  the  majority  there  is  very  little  evidence  of  irritation  or 
inflammation.  It  occurs  either  in  infancy  or  in  commencing  old  age,  when  the 
functional  activity  of  the  gland  is  on  the  decline.  In  the  former  case,  it  is  prob- 
ably originated  by  the  changes  that  attend  the  descent  of  the  testis,  and  kept  up 
by  the  tension  ;  the  cause,  at  any  rate,  is  not  persistent,  for  the  hydrocele,  once 
emptied,  seldom  returns  ;  in  the  latter,  it  is  more  likely  that  there  is  some  slight 


II40    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

irritant,  possibly  constitutional,  for  the  fluid  nearly  always  collects  again  if  it  is 
removed,  and  both  sides  are  often  affected.  At  other  times  of  life,  hydrocele,  for 
such  a  common  affection,  is  decidedly  rare. 

Symptoms. — Chronic  vaginal  hydrocele  forms  a  smooth,  ovoid,  or  pear- 
shaped  swelling,  more  or  less  tense,  comi)letely  concealing  the  testicle.  There  is 
no  impulse  on  coughing,  the  cord  above  it  is  distinct,  and  the  inguinal  canal  free. 
It  begins  below,  slowly  e.xtends  upward,  and  may  reach  an  enormous  size ;  fluc- 
tuation is  distinct  (unless  it  is  too  tense),  and  in  the  vast  majority  of  cases  the 
swelling  is  translucent.  There  is  no  pain  or  tenderness,  merely  a  sense  of  dragging 
on  the  loins,  owing  to  its  weight  ;  but  if  firm  pressure  is  made  behind,  on  the 
lower  part,  testicular  sensation  is  usually  felt.  It  is  absolutely  essential  to  make 
out  the  position  of  the  testis  (it  may  have  been  inverted  in  its  descent,  so  that  it 
lies  in  front,  or  dragged  in  various  directions  by  old  adhesions),  but  this  may  be 
done  with  much  less  discomfort  to  the  i)atient  by  e.xamining  the  swelling  with 
transmitted  light.  The  patient  should  stand  upright,  with  a  light  held  on  the 
side  on  which  the  hydrocele  is  ;  the  back  part  of  the  scrotum  and  the  other  tes- 
ticle should  be  grasped  with  the  left  hand  and  drawn  down,  so  as  to  make  the 
skin  as  tense  as  possible,  and  the  light  shaded  off  with  the  right,  which  at  the 
same  time  keeps  the  penis  out  of  the  way.  The  red  glare  can  be  recognized  at 
once,  the  testis  appearing  as  a  dark  shadow.  If  there  is  any  difficulty,  a  roll  of 
paper  may  be  used  as  a  tube  to  keep  off  outer  rays. 

Variations  are  not  uncommon.  Hernia  or  encysted  hydrocele  may  be  pres- 
ent. The  shape  may  be  complicated,  owing  to  adhesions  or  sacculi  ;  the  fluid 
may  have  accumulated  rapidly,  with  severe  pain  ;  translucency  may  be  lost,  owing 
to  the  addition  of  blood,  and  the  walls  may  have  become  thickened  from  chronic 
inflammation.  Old  hydroceles  are  especially  deceptive;  they  are  often  perfectly 
globular,  like  a  haematocele,  or  malignant  tumor  of  the  testis ;  the  walls  are  half 
an  inch  or  more  in  thickness,  with  calcareous  plates  inside  them,  and  the  contents 
are  milky  and  semi-solid  with  fatty  matter  and  cholesterin  ;  they  are  perfectly 
opaque  ;  there  is  no  sense  of  fluctuation,  and,  even  if  they  are  tapped,  it  is  diffi- 
cult to  get  a  sufficient  amount  of  fluid  out  of  them  for  purposes  of  diagnosis. 
Practically,  they  can  only  be  distinguished  by  their  history,  or  by  exploration. 

Diagnosis. — Hernia. — Unless  it  is  strangulated,  there  is  always  an  impulse 
on  coughing  ;  a  hernia  is  never  translucent,  and  the  swelling  always  extends 
through  the  abdominal  ring.  An  irreducible  epiplocele  associated  with  hydrocele 
may  cause  some  difficulty,  but,  if  the  swelling  is  grasped  between  the  finger  and 
thumb  while  the  patient  coughs,  the  impulse  can  be  felt  in  one  part  and  not  in 
the  other. 

Hcematocele  and  tumors  of  the  testis  are  never  translucent.  Old  hydroceles 
are,  it  is  true,  not  translucent  either,  but  in  all  of  these  exjjloration  is  essential. 

Inflammatory  Affections  of  the  Testis. — Acute  inflammation  cannot  easily  be 
mistaken  ;  chronic  orchitis,  on  the  other  hand,  attended  with  hydrocele  (hydro- 
sarcocele)  may  be  very  difficult :  the  fluid  invests  the  testis  completely,  and  the 
state  of  the  gland  cannot  be  ascertained  until  this  is  withdrawn. 

The  other  forms  of  hydrocele  into  the  tunica  vaginalis  are  associated  with 
congenital  defects. 

{a)  In  congenital  hydrocele,  the  tunica  vaginalis  still  communicates  with  the 
abdominal  cavity.  This  is  more  common  on  the  right  side  than  the  left,  and 
usually  occurs  in  children,  although  it  may  be  met  with  at  any  age.  It  is  distin- 
guished by  the  swelling  disapjjearing  when  the  patient  lies  down  and  the  sac  is  gently 
manipulated  (some  care  is  recpiired,  as  the  neck  is  usually  long  and  tortuous)  ;  by 
an  impulse  on  coughing  (when  the  communication  is  sufficiently  free)  ;  and  by  the 
variations  in  its  size.  It  may  or  may  not  be  associated  with  congenital  inguinal 
hernia  ;  the  pressure  of  a  truss  is  usually  sufficient  to  jirocure  obliteration  of  the  neck. 

(/^)  In  infantile  hydrocele,  the  communication  is  shut  off  in  the  inguinal  canal, 
but  nowhere  else,  so  that  when  the  sac  is  distended  it  forms  a  pear-shaped  swelling, 
the  smaller  end  of  which  extends  up  to  and  sometimes  into  the  external  abdominal 


HYDROCELE. 


1 141 


ring.  Old  hydroceles  of  the  tunica  vaginalis  testis  occasionally  irritate  this,  owing 
to  the  yielding  of  the  up])er  part  of  the  sac.  It  occurs  in  infants,  but  is  by  no 
means  confined  to  them,  and  requires  the  same  treatment  as  the  ordinary  form. 

{/)  In  encysted  hydrocele  of  the  cord  the  communication  is  shut  off  in  the 
normal  manner  above  and  below,  but  the  intermediate  (funicular)  part  of  the  serous 
sac  is  not  obliterated.  It  may  form  a  sausage-shaped  swelling  in  the  cord  in  front 
of  the  vas  ;  or  a  chain  of  separate  rounded  cysts,  or  a  single  one  \  and  it  may  be 
immediately  above  the  testis,  so  as  almost  to  seem  i)art  of  it,  or  in  the  inguinal 
canal,  simulating  a  bubonocele.  It  is  always  translucent  (when  large  enough) 
and  tense,  and  it  is  distinguished  at  once  by  its  moving  with  the  cord. 


2.   Hxdrocele  Developed  in  Connection  with  the  Testis  or  Epididymis. 

Encysted  Hydrocele  of  the  Testis. — Small  cysts  may  be  formed  in  the  tunica 
albuginea,  or  late  in  life  in  the  epididymis,  but  these  are  of  no  surgical  importance  ; 
the  former  are  very  rare,  the  latter  scarcely  admit  of  recognition.  A  different  kind 
is  occasionally  found  attached  to  the  epididymis,  developed  in  all  j^robability  from 
a  rudiment  of  the  non-sexual  part  of  the  Wolffian  body,  and  corresponding,  there- 
fore, to  the  parovarian  cysts  in  the  female.  Usually  it  is  single,  and  of  no  great 
size  ;  but  it  may  be  multiple,  or  it  may  reach  along  the  cord  and  simulate  encysted 


Fig.  495.— Encysted  Hydrocele  of  the  Cord. 


Fig.  496. — Spermatocele. 


hydrocele  developed  from  the  tunica  vaginalis.  When  small  its  contents  are  clear 
and  albuminous,  effervescing  with  acetic  acid,  from  the  presence  of  alkaline  car- 
bonates. As  it  grows  larger,  and  presses  upon  the  neighboring  tubules,  these  not 
unfrequently  rupture  into  it,  so  that  it  becomes  filled  with  spermatozoa.  Some- 
times these  are  still  living  when  the  cyst  is  tapped  ;  more  frequently  they  are  dead 
and  motionless,  but  their  presence  is  almost  certain  when  the  contents  on  their 
exit  are  milky  white  and  opaque  {spermatocele^.  Occasionally  cysts  of  this  kind 
are  associated  with  the  common  form,  and  sometimes  the  partition  wall  becomes 
so  thin  that  a  communication  forms  at  last. 

Treatment. — Congenital  hydrocele,  whenever  it  appears,  is  a  prolongation 
of  the  peritoneal  cavity,  and  must  be  treated  as  such  ;  a  truss  may  be  applied,  and 
if  this  does  not  succeed  the  neck  may  be  ligatured. 

Hydrocele  (other  than  congenital),  occurring  in  infancy,  usually  gets  well  of 
itself.  If  it  does  not,  lead  lotion  may  be  applied  ;  or  the  swelling  may  be  pricked 
(acupuncture)  or  tapped.     Very  few  require  anything  more. 

Later  in  life,  if  the  tumor  is  of  any  size,  it  should  be  tapped.  Occasionally  it 
does  not  refill :  much  more  frequently  the  fluid  collects  again,  and  if  it  is  tapped 
a  second  time  comes  back  more  quickly  than  before.  Whether  the  patient  should 
rest  content  with  temporary  relief  of  this  character,  or  undergo  what  is  known  as 
the  "  radical  cure,"  must  depend  upon  his  age,  the  state  of  his  health,  his  occu- 


1 142    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

pation,  and   the  amount  of  inconvenience  he   suffers.      The  operation   is  not    a 
serious  one  in  itself;   but  it  may  not  l)e  worth  his  while. 

Tapping. — An  ordinary  trocar  and  cannula  of  small  calibre  is  used,  taking  care 
that  it  is  thoroughly  clean  and  well  oiled.  The  patient  should  be  seated  on  the  edge 
of  a  chair,  with  the  knees  separated,  and  the  position  of  the  testicle  ascertained. 
The  scrotum  is  grasped  from  behind  with  the  left  hand,  so  as  to  stretch  the  skin 
tensely  over  the  swelling,  and  a  spot  selected  on  the  front  (in  all  ordinary  cases), 
between  some  of  the  large  scrotal  veins.     The  trocar  is  held  in   the  right,  the 


Fig.  497. — Tapping  a  Hydrocele. 

thumb  or  forefinger  being  placed  on  it  about  half  an  inch  from  the  point,  so  as  to 
limit  the  amount  of  penetration,  and  entrance  effected  with  a  quick  and  firm  thrust. 
As  soon  as  the  point  of  the  instrument  is  in  the  cavity,  the  hand  should  be  dropped 
so  as  to  direct  it  upward  away  from  the  testicle.  The  whole  of  the  fluid  should  be 
removed  and  the  little  puncture  covered  with  some  dry  lint.  The  patient  should 
wear  a  suspender  afterward  until  the  dartos  has  recovered. 

Aciipitnctiire,  piercing  the  sac  with  a  harelip-needle,  and  freely  scarifying  the 
interior,  is  chiefly  suited  to  encysted  hydrocele  and  the  forms  that  occur  in  infancy. 


■  \ 


■"-K. 


Fig.  498. — Obliteration  of  the  Tunica  Vaginalis 
after  injection  with  tincture  of  iodine. 


Fig.  499. — Tapping  the  Hydrocele.    {After  v.l'olkmann.) 


Injection. — Tincture  of  iodine  (,^ss,  pure,  or  with  an  equal  quantity  of  water) 
is  commonly  used.  The  sac  is  emptied  thoroughly,  the  fluid  injected  through  a 
glass  syringe  (taking  care  that  none  enters  the  cellular  tissue),  and  then,  after  being 
manipulated  so  as  to  bring  it  into  contact  with  every  part  of  the  interior,  allowed 
to  escape  again.  Subacute  inflammation  at  once  sets  in,  with  in  many  cases  very 
severe  pain,  confining  the  patient  to  bed  for  some  days.  The  skin  becomes  red  ; 
the  sac  refills ;  and  even  the  testis  may  be  affected.     At  the  end  of  a  week  this 


H^MA  TO  CEL  E.  1 1 43 

should  begin  to  subside,  and  in  a  fortnight  the  whole  should  have  disappeared,  and 
the  sac  should  have  resumed  its  normal  size,  merely  leaving  a  little  thickening  at 
the  back  of  the  testis.  Occasionally,  even  when  cure  is  permanent,  no  visible 
change  is  produced  in  the  sac  ;  more  often  a  few  adhesions  form  ;  and  sometimes 
the  sac  is  completely  obliterated  (I'ig-  498).      Failure  occurs  in  at  least  one-third. 

Carbolic  acid  (n\^  xx,  with  glycerine),  corrosive  sublimate  (.001),  and  iodo- 
form may  be  used  instead  of  iodine.  The  pain  is  less  severe  ;  if  the  sac  is  a  small 
one,  it  is  not  necessary  to  confine  the  patient  to  bed,  and  the  results  are  as  good. 

This  method  is  chiefly  suited  to  small  hydroceles  of  the  tunica  vaginalis  that 
have  not  been  tapped  many  times  :  it  should  not  be  employed  if  there  is  any 
reason  to  suspect  chronic  orchitis  ;  if  the  walls  of  the  sac  are  thick  ;  if  the  size  is 
large  ;  or  if  the  patient  is  old  and  broken  down  in  health. 

Incision. — The  tunica  vaginalis  is  laid  open  ;  the  edges  sutured  to  the  skin; 
and  a  drainage  tube  passed  down  to  the  bottom.  This  plan  (using  Lister's  dress- 
ings) was  introduced  by  Volkmann  with  the  view  of  procuring  direct  union  ;  but 
it  is  uncertain  ;  it  necessitates  confinement  to  bed  ;  and  sometimes  it  leaves  a  per- 
sistent sinus. 

Partial  incision,  removing  the  parietal  portion  of  the  sac,  is  much  more  sat- 
isfactory. A  free  incision  is  made  down  to  the  tunica  vaginalis,  the  sac  emptied, 
and  as  much  as  is  thought  desirable  cut  away  with  scissors,  avoiding  large  veins 
and  leaving  the  covering  of  the  epididymis  and  cord.  No  vessels  require  liga- 
ture ;  the  wound  is  sewn  up  ;a  drain  is  inserted  ;  and  the  dressings  arranged  so  as 
to  obliterate  the  cavity  and  ensure  primary  union.  If  enough  is  removed  the  sac 
cannot  refill  ;  there  is  no  pain  afterward,  and  one  change  of  dressings  is  usually 
sufficient.  ^ 

In  old  hydroceles  with  thickened  walls  this  is  the  only  method  ;  but  in  many 
of  these  the  patients  are  already  aged  and  broken  down  ;  the  tissues  are  badly 
nourished  and  prone  to  slough  ;  the  testis  can  hardly  be  isolated  without  bruising  ; 
and  it  is  a  question  whether  castration  is  not  preferable.  The  risk  is  certainly 
less. 

HiEMATOCELE. 

By  this  is  understood  an  effusion  of  blood  into  the  tunica  vaginalis  or  a  cyst 
of  the  epididymis  or  testis.  In  addition,  a  form  of  diffuse  hsematoma  has  been 
described  in  connection  with  the  spermatic  cord. 

{a)  Haimatocele  into  the  tunica  vaginalis  propria  testis  is  the  usual  form  ;  all 
others  are  very  rare.  It  is  always  the  result  of  injury — blows,  strains,  the  sudden 
emptying  of  a  hydrocele  sac  reducing  the  pressure  upon  the  vessels,  or  the"  punc- 
ture of  a  vein  in  tapping  a  hydrocele  ;  but,  for  various  reasons,  it  is  very  much 
more  likely  to  occur  when  there  is  a  pre-existing  hydrocele  than  when  the  struc- 
tures are  sound  and  healthy.  Its  contents  may  be  pure  blood,  or  a  mixture  of 
blood  and  serum  ;  coagulation  usually  follows,  and  after  a  time  the  clot  breaks 
down,  forming  a  turbid,  chocolate-colored  fluid,  which  becomes  lighter  and  redder 
when  exposed  to  the  air.  At  first  the  sac  itself  is  but  little  changed,  but  as 
time  passes  the  walls  become  thickened,  partly  from  the  deposit  of  lymph  around, 
partly  from  the  deposit  of  fibrin  mixed  with  ordinary  coagula  (almost  as  in  an 
aneurysm)  in  the  interior,  until  at  length  the  testis  is  completely  buried,  and  all 
sense  of  fluctuation  is  lost. 

Haematocele  developed  suddenly  in  a  previously  healthy  sac  is  usually  globu- 
lar ;  when  it  follows  a  hydrocele  the  shape  depends  on  this.  In  either  case  it 
forms  a  smooth,  tense,  and  elastic  swelling  perfectly  opaque,  concealing  the 
testicle  and  not  involving  the  cord.  Fluctuation  is  rarely  distinct ;  at  first  the  sac 
is  too  tense  ;  later,  the  blood  coagulates  and  the  walls  become  thickened.  Signs 
of  bruising  and  extravasation  may  be  present  for  a  time  ;  and  inflammation  may 
follow,  and  even  run  on  to  suppuration  ;  but  the  chief  distinguishing  feature  is  the 
rapidity  of  its  formation. 

The  diagnosis  must  be  made  from  tumors  of  the  testis  and  old  cases  of  hy- 


1 144     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

drocele  with  thickened  walls.  In  the  absence  of  history  that  can  be  relied  upon, 
exploratory  incision  is  necessary. 

(J))  Heematocele  into  the  funicular  portion  of  the  tunica  vaginalis  is  very  rare, 
and  can  only  be  diagnosed  from  encysted  hydrocele  of  the  cord  by  the  history  and 
the  opacity  of  the  swelling. 

(<-)  Hematocele  of  the  testis  or  epididymis  must  be  distinguished  from  the 
corresponding  form  of  hydrocele  in  the  same  way. 

Treatment. — If  the  case  is  seen  at  once,  an  attempt  must  be  made  to  limit 
the  extravasation  by  means  of  cold,  rest,  and  pressure.  Afterward,  when  there  is 
no  fear  of  further  hemorrhage,  the  size  of  the  swelling  should  be  reduced  by  tap- 
ping, and  strapping  aj^plied,  in  the  hope  of  causing  absorption  of  the  more  solid 
portion.  If  this  fails,  or  if  the  case  is  not  seen  until  it  has  already  lasted  some 
time,  an  exploratory  incision  should  be  carefully  made  into  the  front  of  the  swell- 
ing (the  position  of  the  vas  deferens  will  usually  give  a  clue  to  the  relation  the 
sac  bears  to  the  testis),  the  contents  turned  out,  and  all  the  fibrin  dissected  off. 
As  this  operation  is  a  very  tedious  one,  likely  to  be  followed  by  extensive  slough- 
ing (the  vitality  of  the  sac  and  of  the  layers  that  line  it  is  very  low)  and  exposes 
the  testis  to  considerable  danger,  the  question  arises,  as  in  the  case  of  old  hydro- 
celes, whether  castration  is  not  better  for  the  patient. 


INFLAMMATION  OF  THE   FALLOPIAN  TUBES. 


1 145 


CHAPTER  XXV. 

DISEASES   OF   THE  FEMALE    GENERATIVE  ORGANS. 
By  J.  A.  Manseli,  Moullin,  m.  b.,  m.  r.  c.  p. 

Inflammation  of  the  Ovaries  and  Fallopian  Tubes. 

Inflammation  of  the  Fallopian  tubes  may  be  acute  or  chronic.  It  rarely 
occurs  as  a  primary  affection  ;  nearly  always  it  is  due  to  extension  from  the  lining 
membrane  of  the  uterus,  sometimes  from  the  ovaries. 

Causes. — Gonorrhoea,  inflammation  after  labor  or  mi.scarriage,  the  applica- 
tion of  caustics  to  the  interior  of  the  uterus,  anything,  in  short,  that  is  liable  to 
set  up  endometritis  may  cause  it.  The  chronic  form  is  usually  associated  with 
degenerative  changes,  cystic  or  cirrhotic,  of  the  ovaries  ;  but  it  is  uncertain  what 
relation  these  affections  bear  to  each  other. 

Pathological  Appearances. — In  acute  cases  the  tube  is  swollen,  softened 
and  engorged  with  blood,  its  inner  surface  covered  with  a  flocculent  muco-purulent 
fluid.     Being  loosely  attached  to  the  upper  border  of  the  broad  ligament,  it  tends. 


Fig.  500. —  Inflammation  of  the  Fallopian  Tubes  ;  saccular  dilatation  laid  open. 

by  its  weight,  to  sink  lower  in  the  pelvis,  partially  covering  over  the  ovary.  The 
surrounding  peritoneum  becomes  inflamed  and  covered  with  lymph,  glueing  adja- 
cent organs  together. 

In  long-standing  cases,  especially  those  in  which  the  acute  attacks  have 
recurred,  the  parts  become  utterly  disorganized  and  indistinguishable.  At  an  early 
stage  the  fimbriae  become  glued,  by  adhesive  peritonitis,  to  each  other,  or  to  the 
ovary,  or  to  some  neighboring  part,  and  the  outer  oj^ening  is  thus  sealed.  The 
secretion  may  find  an  exit  through  the  urine  opening,  but  in  many  instances  this 
also  becomes  occluded,  either  by  some  valvular  fold  or  the  contraction  of  the 
inflammatory  deposit  in  its  walls.  The  tube  thus  becomes  enormously  distended 
by  the  retained  secretion,  forming  a  cyst  containing  several  ounces,  and  presenting 
a  more  or  less  convoluted  and  pyriform  shape.  According  to  the  character 
of  the  fluid  distending  the  tube,  it  is  known  by  the  names  of  hydro-,  pyo-,  or 
h(e}?iato- salpinx. 

Symptoms,  in  recent  cases,  are  those  of  peritonitis.  In  the  chronic  form, 
which  comes  more  frequently  before  our  notice,  the  symptoms,  apart  from  the 
history,  are  exceedingly  vague.  Pain  is  always  present,  a  constant  dull  aching  in 
73 


1 1 46    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  inguinal  regions,  extending  to  the  sacrum  and  down  the  thighs.  It  is  much 
aggravated  by  locomotion,  and  only  partially  relieved  by  rest,  the  patient  waking 
with  it  in  the  morning.  Menorrhagia  is  very  constant,  and  the  pain  which  has 
been  present  all  along  is  much  intensified  at  the  time  of  the  catamenia.  Dyspa- 
reunia  and  pain  on  defecation  are  almost  always  present.  Sterility  is  the  natural 
result  of  the  tubes  on  both  sides  being  simultaneously  affected.  A  most  character- 
istic symptom  is  the  recurrence  of  local  jjeritonitis,  time  after  time,  without  a 
definite  reason.  In  recent  ca.ses,  while  the  jiain  is  severe,  all  that  can  be  made  out 
is  a  certain  degree  of  fullness  in  the  broad  ligament,  with  extreme  tenderness  and 
fixation  of  the  uterus.  Later,  as  the  attack  subsides,  bimanual  examination  may 
reveal  a  fullness  in  the  region  of  the  tube  ;  sometimes  it  forms  a  distinct  rounded 
tumor  with  a  clear  sense  of  fluctuation  ;  sometimes,  according  as  distention  is 
present  or  not,  a  rounded  band  like  an  adhesion.  The  distended  tubes  are  often 
prolapsed  into  Douglas's  pouch.  Whether  clear  serous  fluid  or  pus  is  present  can 
only  be  conjectured. 

The  Prognosis  is  very  grave.  Even  if  nothing  worse  hapjjens,  the  patient 
is  reduced  bv  constant  suff"ering  to  the  condition  of  a  chronic  invalid.  General 
peritonitis  may  supervene  at  any  time,  from  extension  of  the  inflammation  or  rup- 
ture of  the  tube.  Pelvic  abscess  may  occur,  and  if  by  chance  concejjtion  should 
take  place,  the  puerperal  state  will  be  accompanied  by  the  gravest  dangers. 

Treatment. — Acute  inflammation  must  be  treated  as  acute  local  peritonitis  ; 
it  may  subside,  resolution  and  absorption  taking  place,  or  become  chronic.  In 
the  latter  case,  if  the  pain  continues  or  the  attacks  recur  with  severe  local  symp- 
toms, the  uterine  appendages  with  the  ovaries  should  be  removed. 

Oophorectomy.  Removal  of  Uterine  Appendages. — The  preparation  of  the 
patient  is  the  same  as  for  ovariotomy,  and  the  incision  in  thelinea  all)amade  in  a 
similar  manner.  It  should  begin  three  inches  below  the  umbilicus  and  run  down- 
ward for  two  inches  and  a  half.  The  fundus  of  the  uterus  is  felt  for  first  and  the 
broad  ligament  followed  until  the  ovary  is  discovered.  As  soon  as  this  is  found 
and  freed  from  adhesions,  it  is  drawn  up  and  the  pedicle  transfixed  with  a  double 
ligature  and  tied.  The  ovary  and  tube  are  then  cut  away  and  the  opposite  side 
explored  and  treated  according  to  circumstances. 

If  there  are  no  adhesions,  or  merely  recent  ones,  there  is  little  difficulty,  but 
in  long-standing  cases,  when  all  the  tissues  around  are  matted  together  by  adhe- 
sions, it  may  be  impossible  to  distinguish  one  structure  from  another,  or  to  free 
the  ovary  and  tube  sufficiently  to  bring  them  to  the  surface.  The  tubes  should  be 
ligatured  as  close  to  the  cornu  of  the  uterus  as  possible.  The  remaining  steps  of 
the  operation  are  dealt  with  according  to  ordinary  principles. 

Ectopic  Gestatiox. 

Ectopic  gestation  signifies  the  development  of  a  foetus  elsewhere  than  in  its 
normal  situation  in  the  cavity  of  the  uterus.  There  are  many  varieties  of  this 
displacement,  but  probably  they  all  arise  in  the  first  instance  from  arrest  of  the 
ovum  in  its  passage  along  the  Fallopian  tube.  Nothing  is  known  as  to  its  causa- 
tion. A  plausible  explanation  suggests  that  the  normal  ciliated  e|)ithelium  lining 
the  tube  having  been  destroyed  by  antecedent  inflammation  there  is  nothing  to 
prevent  the  entrance  of  spermatozoa  into  the  tube,  or  check  the  natural  tendency 
of  the  fertilized  ovum  to  adhere  to  the  first  surface  it  meets. 

It  forms  at  first  a  spherical  or  ovoid  swelling  by  the  side  of  the  uterus,  which 
undergoes  sympathetic  hypertrophy  and  forms  a  decidua,  as  in  normal  pregnancy. 
About  the  eighth  or  tenth  week  of  fcetal  life  the  walls  of  the  tube  rupture  at  the 
site  of  the  placental  attachment. 

It  must  be  remembered  that  the  Fallopian  tube  is  held  in  place  by  a  fold  of 
peritoneum  which,  after  passing  round  it,  is  united  loosely  to  it.self  by  cellular 
tissue,  forming  a  meso-salpinx.  There  is  thus  a  narrow  strip  of  tube  running  in  an 
axial  direction  along  the  line  where  the  two  layers  meet  without  any  covering  of 


ECTOPIC  GESTATION.  1147 

peritoneum.  As  the  tul)e  becomes  distended  by  the  growing  ovum,  these  layers 
tend  to  separate,  and  this  uncovered  surface  to  increase  in  width. 

The  site  of  the  rupture,  according  to  Tait,  is  the  leading  feature,  not  only  of  the 
future  pathological  changes,  but  of  the  clinical  progress  and  treatment  of  the  case. 
If  the  rupture  occurs  in  the  part  covered  by  peritoneum,  as  it  usually  does,  the 
patient  is  almost  certain  to  die  from  hemorrhage  unless  prompt  surgical  assistance 
is  at  hand.  If  rupture  occurs  into  the  broad  ligament,  in  many  instances  the  ovum 
does  not  die,  and  the  hemorrhage  is  controlled  by  the  fact  that  the  blood  pours 
into  a  mass  of  cellular  tissue.  The  development  of  the  ovum  may  go  on  to  full 
term  in  its  new  situation  between  the  layers  of  the  broad  ligament,  and  be  extra- 
peritoneal. 

When  the  ovum  is  arrested  in  that  jiart  of  the  tube  which  opens  into  the 
uterus,  the  period  of  rupture  is  usually  delayed.  This  variety  of  gestation  has  been 
termed  "interstitial." 

Symptoms  and  Diagnosis. — i.  Prior  to  Rupture. — Usually  there  is  a  his- 
tory of  previous  sterility  of  longer  or  shorter  duration.  Then,  about  four  weeks 
after  jjregnancy  has  commenced,  the  patient  begins  to  complain  of  constant  pain 
in  the  lower  abdomen,  with,  at  frequent  intervals,  violent  exacerbations,  causing 
intense  prostration.  At  the  .same  time  there  is  great  tenderness  all  over  the  iliac 
and  hypogastric  regions.  On  examination,  a  small  rounded  tumor,  exceedingly 
tender  on  pressure,  is  found  by  the  side  of  the  uterus.  This  indicates  nothing 
more  than  distention  of  the  tube,  but  if,  in  the  course  of  a  week,  it  enlarges  con- 
siderably, the  symptoms  become  of  great  significance.  No  ordinary  pelvic  tumor 
grows  with  such  rapidity. 

As  time  passes,  the  ordinary  signs  of  pregnancy  make  their  appearance,  with, 
in  addition,  irregular  uterine  hemorrhage,  the  decidua  coming  away  sometimes 
in  shreds,  sometimes  whole,  so  as  to  simulate  miscarriage.  The  uterus  enlarges, 
but  remains  empty  ;  the  os  is  soft  and  patulous  and  the  body  displaced  to  one 
side. 

2.  Rupture. — This  usually  occurs  during  some  slight  effort.  All  of  a  sudden 
the  patient  is  seized  with  the  most  intense  pain  ;  there  is  a  sensation  of  some- 
thing giving  way  inside,  and  collapse  follows  at  once.  Death  may  be  almost 
immediate,  or  the  patient  may  rally  and  peritonitis  set  in.  In  the  latter  case  a 
second  rupture,  to  which  the  patient  generally  succumbs,  may  be  anticipated  before 
very  long. 

3.  If  rupture  does  not  take  place,  or  does  not  prove  fatal,  the  signs  of 
pregnancy  become  more  marked  ;  a  tumor  develops  in  the  abdomen,  lying  to 
the  one  side,  with  perhaps  the  uterus  in  front  ;  the  pain  and  colic  become  less 
severe  ;  the  foetal  heart  can  be  heard  and  movements  felt.  If  the  case  progresses 
to  full  term,  labor  pains  set  in,  sometimes  more  than  once,  with  a  blood-stained 
discharge  from  the  uterus,  and  the  child  dies,  very  often  after  a  violent  attack  of 
convulsions. 

After  the  death  of  the  foetus  the  tumor  ceases  to  increase.  Generally  decom- 
position and  suppuration  set  in,  and,  if  the  patient  does  not  die  from  septic 
absorption  or  pyosmia,  the  debris  generally  makes  its  way  out  through  the  abdomi- 
nal wall,  or  the  intestine,  vagina,  or  bladder.  Sometimes  the  dead  foetus  remains 
quiescent  for  years,  and  occasionally  it  becomes  converted  into  a  calcareous  mass 
or  into  adipocere. 

Treatment. — i.  Before  rupture,  attempts  have  been  made  to  arrest  the 
development  of  the  ovum  by  various  means,  including  the  electric  current.  One 
electrode  is  applied  as  near  the  cyst  as  possible  in  the  vagina,  the  other  to  the 
abdominal  wall,  and  an  interrupted  current  passed  through  as  strong  as  the  patient 
can  endure.  Great  success  has  been  claimed  for  this  proceeding,  but  it  must  be 
remembered  that  cases  of  mistaken  diagnosis  are  not  uncommon  at  this  early  stage, 
that  the  muscular  contraction  induced  by  the  current  may  itself  cause  rupture,  and 
that  even  when  the  ovum  is  killed  all  danger  is  by  no  means  over.  In  comparison 
with  this,  abdominal  section  offers  manifold  advantages. 


1 148    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

2.  At  time  of  rupture,  the  symptoms  pointing  to  internal  hemorrhage, 
the  i)roper  course  to  pursue  is  to  open  the  abdomen,  secure  the  broad  ligament 
at  once,  to  control  the  bleeding,  remove  the  cyst,  clear  out  the  debris  as 
thoroughly  as  possible,  and  drain  the  i)eritoneum.  If  the  sac  cannot  be  removed, 
it  should  be  laid  open,  the  ftju-tus  extracted,  and  the  walls  stitched  to  the  parietal 
peritoneum. 

Interstitial  gestation,  unless  the  rupture  takes  place  into  the  uterus,  can  only  be 
treated  by  supra-vaginal  hysterectomy. 

3.  If  the  fcetus  survives  the  period  of  rupture,  the  question  arises  whether 
operation  should  be  performed  at  once,  or  whether  it  should  be  postponed  with 
the  view  of  extracting  a  living  child.  It  depends  upon  the  risk  the  mother  runs 
before  and  during  the  operation.  Tait  holds  that  it  is  not  materially  increased  by 
delaying  operation  ;   but  this  view  is  not  shared  by  others. 

The  patient  is  prepared  in  the  same  way  as  for  ovariotomy,  and  the  same  in- 
cision is  made.  The  fuetus  may  be  found  either  free  in  the  abdominal  cavity,  or 
enclosed  within  a  sac.  If  the  latter,  the  sac  must  be  laid  open,  avoiding,  if  pos- 
sible, the  placental  attachment,  and  the  fcetus  extracted.  The  sac  itself  is  then 
removed,  or,  if  this  is  impossible,  the  edges  secured  by-suture  to  the  parietal  peri- 
toneum and  skin.  The  chief  difficulty  which  presents  itself  to  the  surgeon  is  the 
management  of  the  placenta.  Opinions  are  divided  as  to  whether  it  should  be 
allowed  to  remain  in  situ,  or  an  attempt  made  to  remove  it.  It  must  be  remem- 
bered that  it  is  attached  to  the  interior  of  a  morbidly  vascular  cyst,  and  covers  a 
large  surface.  An  attempt  to  remove  it  may  be  followed  by  severe  hemorrhage, 
and  no  contraction  of  the  cyst  can  be  expected  to  follow  its  expulsion,  as  is  the 
case  in  normal  pregnancy.  The  advantages  of  removing  it  are,  however,  so  obvi- 
ous that  it  should  be  extracted  if  possible.  There  may  be  no  difficulty,  and  if  the 
hemorrhage  is  very  great  it  can  generally  be  controlled  with  perchloride  of 
iron.  If  it  is  impossible,  the  cord  must  be  left  hanging  out  of  the  abdominal 
incision,  and  a  drainage  tube  passed  into  the  cavity  to  keep  it  dry.  It  may  be 
necessary  to  syringe  out  the  cavity  with  some  antiseptic,  and  in  the  event  of  any 
large  portion  of  the  placenta  sloughing,  to  enlarge  the  opening  to  facilitate  its 
removal. 

Extraction  through  the  vagina  may  possess  certain  advantages  over  the 
abdominal  oi)eration,  if  the  foetus  can  be  felt  presenting  by  the  head  or  feet, 
and  if  the  thinness  of  the  structures  separating  the  presenting  part  from  the 
vaginal  canal  renders  it  certain  that  the  placenta  is  not  situated  in  that  part  of  the 
sac. 

In  cases  in  which  the  foetus  is  already  dead  no  rules  can  be  laid  down.  We 
must  be  guided  by  the  general  principles  which  direct  the  treatment  of  all  abdomi- 
nal tumors.  If  it  is  sujipurating,  an  attempt  must  be  made  to  open  the  abscess, 
evacuate  the  contents  and  drain  the  cavity  with  as  little  delay  as  possible. 

Tumors  of  the  Ovary  and  Broad  Ligament. 

Tumors  of  the  ovary  may  be  divided  broadly  into  two  classes,  cystic  and  solid. 
Solid  tumors  are  represented  by  fibroma  or  fibromyoma,  sarcoma  and  car- 
cinoma. 

1.  Fibroma  or  fibromyoma  of  the  ovary  is  not  very  common,  and  is  indistin- 
guishable from  fibroma  of  the  uterus.  Its  growth  is  usually  slow,  but  it  sometimes 
attains  a  large  size.  Both  organs  are  frequently  affected  at  the  same  time.  The 
tumors  are  hard,  smooth  externally,  and  on  section  present  a  perfectly  homoge- 
neous appearance.  Under  the  microscope  they  are  found  to  consist  of  fibrous 
tissue  with  a  variable  amount  of  non-striated  muscular  fibre. 

2.  Sarcoma  is  more  frequently  met  with.  It  occurs  as  a  i)rimary  affection  and 
is  often  symmetrical.  It  grows  with  great  rapidity,  and  is  generally  attended  with 
ascites.  Both  the  sarcomata  and  fibromata,  occurring  as  they  do  in  the  free  por- 
tion of  the  ovary,  are  generally  i)edunculated. 


TUMORS  OF  THE  OVARY. 


1 149 


3.  Carcinoma  is  alnK)st  invariably  secondary  to  cystic  disease  of  a  non-malig- 
nant type.  In  all  its  forms  it  grows  rapidly,  and  tends  to  invade  the  neighboring 
organs,  which  soon  become  matted  together  in  an  imnnnable  and  indistinguish- 
able mass.  Pain  and  a.scites  are  invariably  present,  and  the  general  condition  ot 
the  patient  fails  very  rapidly. 

Cystic  tumors  occur  with  much  greater  frecpiency  than  the  preceiling.  They 
present  an  infinite  number  of  varieties,  which  may  be  grouped  under  three  heads  : 
"  multilocular,"  "  dermoid,"  and  "  papillary." 


Fig.  50t.— Mullilocul.ir  Ovarian  Cyst. 

I.  J//.////.;.-///<r;- ///;//.'/-.- have  their  origin  in  the  Graafian  follicles  situated  in 
the  outer  or  free  portion  of  the  ovary— the  oophoron.  On  cutting  into  such  a 
tumor,  a  mass  of  thin,  but  opaque-walled,  secondary  cysts,  mixed  with  more  or 
less  solid  growth,  is  seen  projecting  into  the  main  cavity,  and  from  the  cysts  when 
opened  there  escapes  a  glairy  mucoid  fluid,  in  some  cases  as  tenacious  as  treacle 

The  small  cysts  are  lined   with  columnar  epithelium  of  large  size.      In  the 
larger  ones  it  is  more  flattened  or  tessellated, 
in  many  parts  dipping   down  to   form   mu- 
cous glands. 

The  more  solid  portions  consist  of 
young  or  embryonic  connective  tissue, 
crowded  with  spaces  filled  with  mucus. 
These  secondary  cysts  are  indistinguishable 
from  the  retention  cysts  formed  in  mucous 
membranes,  and,  indeed,  the  solid  ma.sses 
are  really  adenomata  on  the  type  of  mucous 
glands. 

One  cyst  often  predominates  to  such  an 
extent  that  the  tumor  api)ears  to  be  unilocu- 
lar, but  examination  seldom  fails  to  reveal 
secondary  cysts  projecting  under  the  lining 
membrane,  generally  toward  the  site  of  at- 
tachment of  the  pedicle. 

As  multilocular  cysts  originate  in  the 
free  part  of  the  ovary,  the  paroophoron  or 
tissue  of  the  hilum,  as  it  is  termed,  remains 
unaffected,  and  such  tumors  are  invariably 
pedunculated. 

The  Graafian  follicles  are  liable  to  other 
degenerative  changes  than  those  just  de- 
scribed. In  some  instances  they  undergo 
simple  dropsical  distention,  the  cysts  thus 
formed  varying  in  size  from  a  cherry  to  that 
of  the  foetal  head.     The  walls  are  thin,  membranous,  and  translucent,  identical  in 


■') 


Fig.  502.— Dermoid  Cyst  of  the   Ov.-»ry,  showing 
Hair,  Teeth,  and  Nipple. 


II50     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES.      ' 

structure  with  those  of  the  follicle.  The  contents  are  a  clear,  limpid  fluid,  with 
an  ovum  sometimes  floating  freely,  sometimes  attached  to  the  epithelial  lining, 
which  is  smooth  and  without  projecting  septa.  Rokitansky  first  described  this 
condition. 

2.  Dermoid  cysts  oi  the  ovary,  according  to  Sutton,  are  simply  a  highly  or- 
ganized form  of  the  common  multilocular,  glandular  cyst,  and  like  it  have  their 
origin  in  the  Graafian  tbllicles. 

The  walls  of  a  dermoid  cyst  resemble  in  every  respect  true  skin.  The  inner 
surface  is  lined  with  thick  layers  of  .squamous  cells,  becoming  more  rounded  in  the 
deeper  strata.  Beneath  this  is  a  layer  corresponding  to  the  cutis,  and  frequently 
presenting  papillae ;  deeper  still  are  areolar  tissue  and  fat  containing  hair  follicles, 
sebaceous  and  sweat  glands.  Teeth,  either  perfect  or  rudimentary,  are  often  pre- 
sent in  large  numbers,  springing  either  from  the  cyst  wall  or  from  well-formed 
alveoli  in  bony  plates.  Sometimes  even  a  mammary  gland  is  found,  presenting  a 
nip]jle  and  capable  of  secreting  a  fluid.  The  contents  of  the  cyst-consist,  in  many 
instances,  of  a  bright  yellow  liquid,  composed  of  fat,  cast-off  epithelium,  and  cho- 
lesterin.    At  the  temperature  of  the  body  it  remains  liquid,  but  very  soon  solidifies 


^?<l^^:-i 


Fig.  503. — Papillary  Cyst  of  the  Ovary. 

on  cooling.  In  other  cases  the  contents  are  of  much  the  same  color  and  appear- 
ance as  gruel  or  putty.  Mixed  with  this  are  often  large  masses  of  loose  hair,  gen- 
erally of  a  pale  color,  and  loose  teeth. 

At  first  sight  nothing  can  present  a  greater  contrast  than  a  dermoid  and  a  mul- 
tilocular, glandular  tumor.  They,  however,  both  take  their  origin  in  the  same  part 
of  the  ovary — the  oophoron — and  they  are  frequently  found  associated.  Careful 
examination  of  a  multilocular  tumor  often  discloses  a  small  patch  of  dermoid  tissue, 
and  the  presence  of  a  few  hairs.  The  great  frecpiency  with  which  dermoid  tumors 
occur  in  the  ovary  would  seem  to  prove  a  close  connection  with  the  production  of 
Graafian  follicles  ;  and  if  the  membrana  granulosa  of  the  follicle  is  capable  of 
forming  mucous  membrane  and  complex  mucous  glands,  there  is  no  reason  why  it 
should  not  form  skin,  which  is  practically  identical  with  mucous  membrane  and  its 
accompanying  teeth  and  hair.  All  these  transitional  stages  have  been  traced  by 
Sutton. 

3.  Papillary  cysts  of  the  ovary  have  a  totally  different  origin,  and  arise  in  the 
paroophoron  or  tissue  of  the  hilum.  Multilocular  tumors,  arising  in  the  free  part 
of  the  ovary,  are  usually  pedunculated  ;  papillary  cysts,  on  the  other  hand,  arising 
in  the  hilum,  are  more  usually  sessile  and  tend  to  burrow  between  the  layers  of  the 


TUMORS  OF  THE   OVARY.  1151 

broad  ligament,  while  the  ovary  more  or  less  retains  its  shape  or  is  flattened  out 
upon  the  surface  of  the  cyst. 

The  paroophoron  or  tissue  of  the  hilum  is  composed  largely  of  foutal  elements. 
The  vertical  tubes  of  the  parovarium  converge  toward  its  attached  border,  and 
can  be  traced  through  its  substance  sometimes  even  into  the  oophoron.  These 
tubes,  in  the  perfect  condition,  are  lined  with  ciliated  epithelium.  They  have  a 
tendency  to  morbid  changes  and  to  become  cystic,  the  chief  peculiarity  of  the 
cysts  being  the  development  of  solid  papillary  or  cauliflower  growths  from  their 
inner  surface.  These  growths  are  covered  on  the  free  surface  with  a  layer  of  cylin- 
drical epithelium,  occasionally  ciliated  and  bleeding  readily  when  handled  during 
operation.  They  have  a  tendency  to  burst  through  their  cyst  walls  and  then  spread 
over  and  infect  the  neighboring  organs.  The  secondary  deposits  often  exhibit  the 
same  character,  and  the  pelvis  has  been  found  filled  with  masses  of  thin-walled 
cysts  studded  with  numbers  of  outgrowths.  Cysts  of  this  kind  invariably  contain 
a  thin  fluid,  quite  different  from  the  mucous  contents  of  the  multilocular  tumors, 
and  often  stained  with  blood. 

The  occurrence  of  mixed  multilocular  and  papillary  tumors  is  readily  explained 
by  the  fact  that  the  foetal  elements  are  often  found  extending  into  the  oophoron. 
The  papillary  growths  have  a  further  tendency  to  become  malignant  in  char- 
acter, but  under  what  conditions  is  uncertain.  The  removal  of  a  papillary  tumor 
which  has  already  infected  the  neighboring  peritoneum  has  been  followed  by  per- 
manent cure,  and  the  secondary  growths  have  been  ascertained  by  subsequent 
operation  to  have  completely  disappeared. 

Cysts  of  the  broad  ligaments  are  either  "■  simple  "  or  "  papillary." 
Simple  cysts  may  take  their  origin  in  any  part  of  the  broad  ligament,  and 
when  of  minute  size  are  sometimes  present  in  considerable  numbers.  Occasionally 
they  are  pedunculated,  but  more  frequently  they  stand  out  from  the  surface  with- 
out possessing  a  distinct  pedicle.  They  are  invariably  unilocular,  with  thin  walls 
lined  with  flattened  epithelium,  and  contain  a  clear  limpid  fluid,  with  but  little 
albumin.  Their  growth  is  very  gradual,  and  they  cause  but  slight  peritoneal  irri- 
tation, so  that  adhesions  are  rarely  present.  When  pedunculated  they  cannot  be 
distinguished  from  thin-walled  ovarian  cysts.  When  sessile,  the  tumor  usually 
causes  great  lateral  displacement  of  the  uterus. 

Papillary  cysts  are  developed  from  the  vertical  tubes  of  the  parovarium,  and 
are  identical  in  every  respect  with  those  formed  from  similar  structures  in  the 
hilum  of  the  ovary.  They  may  increase  in  size  with  great  rapidity,  and  should 
rupture  occur,  the  papillary  masses  have  the  same  tendency  to  sprout  into  the  peri- 
toneal cavity,  and  extend  over  the  surface  of  the  uterus  and  neighboring  organs. 
Compared  with  the  simple  variety,  these  latter  are  not  of  very  common  occurrence. 
Papillary  cysts  are  always  sessile,  and  cannot,  even  when  of  large  size,  acquire  a 
central  position  in  the  abdomen,  like  an  ovarian  cystoma.  Per  z<aginam,  the 
uterus  is  always  found  displaced  to  one  side,  and  the  sense  of  immobility  is  very 
plainly  marked,  but  a  certain  diagnosis  is  impossible. 

Symptoms. — i.  The  Early  Stages  while  the  Tumor  still  Occupies  the  Pel- 
vis.— The  symptoms  in  many  cases  are  so  slight  that  they  escape  notice  altogether  ; 
in  others  there  is  a  history  of  long-continued  pelvic  trouble  and  lain  in  the  ovarian 
region.  Menstruation  is  not  necessarily  affected,  but  as  the  disease  advances  there 
is  a  tendency  for  it  to  become  more  and  more  scanty.  Conception  may  occur, 
even  though  both  ovaries  are  more  or  less  cystic.  If  the  tumor  falls  into  Douglas's 
pouch,  it  may  give  rise  to  symptoms  of  pressure  upon  neighboring  organs. 

On  bi-manual  examination  a  smooth,  rounded,  tense  body  can  be  felt,  stretch- 
ing the  roof  the  vagina  on  one  side  of  the  cervix,  or  a  little  behind.  If  there  is  a 
distinct  groove  or  furrow  between  it  and  the  uterus,  and  if  it  is  movable,  so  that 
it  can  be  easily  lifted  out  of  the  pelvis,  it  is  tolerably  certain  to  be  a  small  cyst  of 
the  ovary.  The  chief  difficulty  in  diagnosis  occurs  in  connection  with  dropsy  of 
the  Fallopian  tube.      The  latter  condition  may  usually  be  distinguished  by  the 


1 152     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

fact  that  it  is  in  many  cases  symmetrical,  and  by  the  history,  for  it  is  usually  jjre- 
ceded  by  prolonged  pelvic  trouble.  Sometimes  a  small  cyst  suppurates  (a  frequent 
complication  with  dermoid  tumors),  and  forms  a  swelling  that,  on  vaginal  ex- 
amination, is  i)ainful,  tense,  fluctuating,  and  indistinguishable  from  a  pelvic 
abscess. 

2.  After  the  Early  Stage  is  past,  when  the  Tumor  rises  up  into  the  Abdomen. — 
(i)  Obesity  may  give  rise  to  the  suspicion  of  ovarian  tumor,  especially  if  it  is  asso- 
csated  with  loss  of  tone  in  the  intestinal  wall,  so  that  the  abdomen  becomes 
immensely  distended  with  flatus  and  freces.  The  indications  of  general  obesity  ; 
the  soft  flaccid  condition  of  the  abdominal  wall  when  the  i)atient  lies  down  ;  the 
absence  of  any  tumor  on  palpation  ;  and  the  sinking  of  the  two  recti  below  the 
general  level,  when  the  patient  endeavors  to  rai.se  herself,  are  sufficient  to  dispel 
any  doubt. 

(2)  Pregnancy,  lohen  the  Uterus  has  begun  to  rise  out  of  the  Pelvis. — Ordin- 
arily speaking,  the  diagnosis  can  be  made  at  once  from  the  mammary  changes,  the 
placental  bruit,  fcetal  cardiac  sounds,  foetal  movements,  ballottement,  softening  of 
the  cervix,  blueness  of  the  vagina,  etc.  ;  but  in  exceptional  cases,  there  may  be 
some  difficulty.  The  two,  for  example,  may  occur  together.  This  may  be  sus- 
pected when,  with  a  history  of  pregnancy,  vaginal  examination  shows  the  uterus  to 
be  elevated,  with  the  cervix  high  above  the  pubic  symphysis,  and  an  ob.scurely  fluc- 
tuating mass  lying  behind  it  ;  or  when  the  abdominal  distention  is  greater  than 
the  period  of  gestation  would  account  for.  At  a  later  period,  the  abdomen  may 
be  distended  laterally  and  asymmetrically,  with  a  sulcus  separating  the  two 
tumors. 

(3)  Hydrajnnios. — This  may  easily  be  mistaken,  as  the  distention  is  out  of  all 
proportion  to  the  period  of  pregnancy  ;  and  the  walls  of  the  uterus  are  so  thin  that 
fluctuation  can  be  felt,  just  as  in  an  ovarian  cyst.  The  cervix,  however,  is  soft,  as 
in  pregnancy,  and  it  is  spread  over  and  evidently  continuous  with  the  tumor.  The 
sound  may  be  used  to  decide  the  question. 

(4)  Abdominal  Pregnancy. — The  symptoms  of  pregnancy  are  present,  but  the 
position  of  the  tumor  corresponds  more  nearly  with  that  of  an  ovarian  cyst.  If 
the  outline  of  the  child  can  be  felt,  or  its  movements  seen,  while  the  uterus  remains 
soft  and  empty,  there  is  no  difficulty  ;  but,  in  old-standing  cases,  unless  the  history 
is  very  clear,  a  positive  diagnosis  may  be  out  of  the  question. 

(5)  Ascites,  especially  with  Thin-walled  Unilocular  Cysts. — The  most  impor- 
tant diagnostic  sign  is  the  relative  position  of  the  intestines  and  the  tumors.  In 
ascites  there  is  resonance  in  front  and  dullness  in  the  flanks,  and  this  varies  with 
the  position  of  the  patient ;  again,  in  the  recumbent  position,  the  flanks  bulge  out 
and  the  belly  becomes  flatter.  In  ovarian  disease  this  is  reversed.  In  the  erect 
position,  the  upper  limit  of  the  area  of  dullness  is  concave  in  ascites,  convex  if 
there  is  an  ovarian  tumor. 


OVARIAN  CYST.  v.  ASCITES. 

History. 

General  health  good  before  discovery         Health   fails  before  the   swelling   ap- 
of  enlargement,  failing  gradually  pears, 

since. 
Often  dysmenorrhoea.  Nothing  characteristic. 

No  organic  disease.  Disease  of  heart,  liver,  kidneys,  or  peri- 

toneum. 
Tumor,  lateral  at  first,  central  later.  Bulging  at  lower  part  of  abdomen  when 

standing. 
CEdema  of  extremities  late.  OEdema  early. 


TUMORS  OF  THE  OVARY.  1,53 

OVARIAN  CYST.  v.  ASCITES. 

Inspection. 

Abdomen   prominent,  often  irregular.  Abdomen  flat  in  front,  bulging  at  the 

Umbilicus    never    prominent    or  sides  and  evenly.   Umbilicus  often 

thinned.  prominent  and  thinned. 

Greatest  circumference  below  umbili-  Greatest  at  umbilicus, 
cus. 

Facies  ovariana  not  marked  until  late.  Often  cachectic  from  the  first. 

Palpation. 

Abdominal  wall  tense,  and  resists  pres-         Soft  and  lax,  unless  amount  of    fluid 
sure.  very  great. 

Fluctuation  most  distinct  superficially         Most  distinct  in  flanks, 
in  front. 

Aortic  pulsation  may  be  felt.  Never  transmitted  to  the  front. 

Per  vaginam,  the  cyst   may  be   felt  at         No  cyst,  a  sense  of  bulging  only, 
the  roof  or  in  the  cavity  of  the  pel- 
vis, partially  displacing  the  uterus. 

Percussion. 

Dullness  in  front ;   flanks  resonant.  Resonant  in  front,  flanks  dull. 

In  erect  position,  line  of  dullness  con-         In  erect  position,  concave. 

vex. 
Dullness  not  altered  by  change  of  posi-         Varies  according  to  position. 

tion. 

Character  of  Fluid. 

Fluid    viscid,    sticky,   sp.    gr.    1018-         Limpid,  sp.  gr.  1010-1015. 

1024. 
Varies  in  color.  Light  straw-yellow. 

Difficulties  may  arise  from  : — 

{a)  The  absence  of  mesocolon,  so  that  the  flanks  are  resonant. 

{b)  The  small  intestine  being  tied  down  by  adhesions,  so  that  the  front  of 
the  abdomen  is  dull. 

{c)  The  fluid  being  encysted,  as  in  old  tubercular  peritonitis. 

{d')  Carcinoma  of  the  peritoneum,  but  usually  rough  nodules  can  be  felt. 

{/)  Both  may  be  present,  and  then  the  cyst  may  be  felt  sometimes  by  sud- 
denly depressing  the  front  wall  with  the  fingers. 

(6)  Hydatids  of  the  Liver  or  Omentum. — The  enlargement  usually  takes  place 
from  above.  The  pelvis  is  free  ;  the  uterus  and  ovaries  normal,  and  there  is  a 
line  of  resonance  between  the  tumor  and  the  pubes.  If  the  aspirator  is  used,  the 
fluid  is  colorless,  of  low  specific  gravity,  with  no  albumin,  but  some  chloride  of 
sodium. 

(7)  Hydronephrosis. — There  is  no  difficulty  when  the  tumor  is  small  or  varies 
in  size  concurrently  with  the  passage  of  large  quantities  of  urine.  As  the  tumor 
enlarges  and  grows  toward  the  centre  and  down  into  the  pelvis,  the  diagnosis  may 
be  almost  impossible.  The  relation  of  the  intestine  to  the  tumor  (the  colon  lying 
on  it,  either  as  a  band  which  rolls  under  the  finger,  or  as  a  line  of  resonance, 
according  to  the  distention),  and  the  dullness  reaching  round  in  the  flank  quite 
to  the  spine,  are  the  most  important  diagnostic  points. 

(8)  Uterine  Tumors  and  Fibrocysts. — These  may  usually  be  distinguished  by 
the  slowness  of  their  growth,  by  their  solidity,  and  by  the  fact  that,  apart  from 


T154     DISEASES  AND  INJURES  OF  SPECIAL  STRUCTURES. 

menorrhagia,  they  do  not  impair  the  general  health.  The  i)elvis  is  more  or  less 
filled  up  by  the  uterine  growth  ;  the  cervix  is  drawn  up  behind  the  symphysis,  or 
otherwise  displaced  ;  bi-manual  examination  shows  that  it  is  continuous  with  the 
tumor  ;  the  length  of  the  uterine  cavity  measured  by  the  sound  is  greatly  increased, 
and  abdominal  movement  of  the  tumor  is  distinctly  communicated  to  the  sound 
in  iitcro. 

OVARIAN  CYSTIC  DISEASE,     v.     UTERINE  FIBROCYSTIC  DISEASE. 

May  occur  at  any  age.  Rare  before  thirty. 

General  health  suffers  soon.  Good,  unless  there  is  menorrhagia. 

Emaciation.  None. 

Complexion  pale,  face  pinched,  "  facies  Often  florid,  at  other  times  the  face  is 

ovariana."  dull,  dejected,  and  muddy. 

Tumor  lateral  at  first.  Tumor  generally  central. 

Growth  rapid.  Slow. 

Surface,  uniform,  fluctuation  distinct.  Often   lobulated  ;  elastic,    but  fluctua- 
tion obscure.      Cyst  wall  thick. 

Uterine  souffle  never  heard.  Often  present,  resembling  the  placental 

bruit. 

Uterus  not  enlarged.  Elongated,  and  canal  tortuous. 

Tumor  may  be  raised   from  the  pelvis,  Tumor    continuous    with    uterus,  and 

or  uterus  can  be  moved  indepen-  moves  with  it. 

dently  of  the  tumor. 

Fluid  viscid,  albuminous,  clear  or  dark,  Fluid    clear   and    limpid,  not  viscid; 

not  spontaneously  coagulable.  little  albumin  ;  yellow  or  muddy  ; 

coagulates  spontaneously. 

Menstruation  not  necessarily  affected  ;  Profuse  menorrhagia,  unless  tumor  is 

may  be  dysmenorrhoea  at  first,  and  subperitoneal. 

then  su])pression,  but   no  menor- 
rhagia. 

In  spite  of  these  diff'erences,  it  may  be  impossible  (without  an  exploratory 
incision)  to  distinguish  an  ovarian  cyst  from  a  soft,  rapidly  growing  myoma,  or 
from  a  fibrocyst  connected  w-ith  the  uterus  by  a  slender  pedicle.  A  dermoid 
closely  connected  with  the  uterus  much  resembles  a  fibroid. 

Complications. — Adhesions. — Adhesions  are  found  not  to  interfere  with 
recovery,  unless  they  are  so  extensive  as  to  prevent  removal.  Their  absence  may 
be  presumed  if  there  has  been  no  peritonitis,  and  if  the  tumor  and  the  uterus  are 
both  freely  movable.  Extensive  adhesions,  however,  may  connect  it  to  the  liver 
above,  the  intestines  behind,  and  the  pelvis  below,  without  its  being  possible  to 
determine  beforehand  their  extent,  or  even  their  presence. 

Rupture  of  the  Cyst. — In  the  majority  of  instances  this  is  mere  leakage,  and 
the  fluid  is  absorbed  at  once  with  but  slight  discomfort.  Traumatic  rupture,  how- 
ever, may  be  followed  by  fatal  hemorrhage  or  peritonitis. 

It  may  be  caused  by  simple  thinning  ;  or  by  degeneration  from  thrombosis; 
or  by  the  formation  of  secondary  cysts  in  the  substance  of  the  main  wall,  weaken- 
ing it  as  they  enlarge  until  it  gives  way. 

When  the  leakage  is  slow,  there  may  be  no  symptoms  of  peritoneal  irritation 
at  all.  The  tumor,  if  the  loss  is  of  any  amount,  diminishes  in  size  ;  its  tension 
falls,  and  the  solid  jiarts  become  more  prominent.  At  the  same  time  signs  of  fluid 
in  the  peritoneal  cavity  make  their  appearance,  but  there  may  be  nothing  to  call 
attention  to  the  accident. 

When,  on  the  other  hand,  the  rupture  is  sudden  and  due  to  injury,  there  is 
the  most  intense  shock,  with,  if  the  patient  rallies,  great  danger  from  hemorrhage 
and,  later,  peritonitis. 

Immediate  operation  is  the  only  course.     The  peritoneal  cavity  may  be  filled 


OVARIOTOMY.   •  1155 

with  the  glairy,  colloid  contents  of  the  cyst,  or  with  blood  clot.  In  either  case 
this  must  be  turned  out,  the  jiedicle  secured,  and  the  tumor  removed  in  the  usual 
way.  The  peritoneum  must  then  be  thoroughly  cleansed  with  a  stream  of  warm 
water.  In  the  case  of  colloid  cysts  a  certain  amount  of  jteritoneal  irritation  is 
generally  present;  when  bathed  for  a  long  time  in  the  colloid  lluid,  the  membrane 
becomes  thickened  and  injected,  presenting  an  api)earance  like  that  of  l)oiled  sago. 
The  removal  of  this  material  is  a  matter  of  great  difficulty,  as  it  clings  with  great 
tenacity  to  the  intestines  and  abdominal  organs  ;  the  most  effectual  method  is 
repeated  flushing  with  warm  water,  in  which  it  is  partly  soluble. 

Twisting  of  the  Pedicle. — This  is  probably  due  to  the  tumor  being  pressed 
upon  by  the  viscera  above  and  the  pelvic  structures  below,  while  it  remains  free 
laterally  and  anteriorly  ;  each  time  the  patient,  lying  on  her  back,  rolls  over  on 
her  side,  it  rotates  a  little,  and  if  it  does  not  return,  or  if  there  is  any  irregularity 
of  shape  assisting  it,  it  may  at  last  be  carried  too  far  to  recover  itself.  An  accu- 
mulation of  faeces  in  the  rectum  can  impart  considerable  rotation  to  the  pelvic 
tumor. 

If  the  twisting  is  complete,  the  symptoms  are  very  characteristic.  Pain,  vom- 
iting and  shock  come  on  with  great  severity  ;  the  tumor  rapidly  increases  in  size  ; 
peritonitis  sets  in,  though  without  any  great  rise  in  temperature,  and  the  patient's 
condition  becomes  very  alarming.  If,  on  the  other  hand,  it  is  only  partial,  the 
symptoms  are  less  sudden,  but  equally  severe.  More  or  less  complete  strangula- 
tion occurs,  with  intense  venous  congestion,  hemorrhage  into  the  cyst,  and,  later, 
peritonitis.  Gangrene  is  rare,  owing  to  the  rapidity  with  which  vascular  adhe- 
sions develop  and  maintain  the  circulation.  Sometimes  the  pedicle  disappears, 
and  the  growth  of  the  tumor  depends  on  the  new  attachments  formed  in  this 
way  ;  exceptionally,  the  tumor  itself  atrophies. 

Ovariotomy  should  be  performed  as  soon  as  the  shock  has  subsided.  The 
cyst  is  generally  found  intensely  black  and  filled  with  clotted  blood,  and  the  peri- 
toneum everywhere  covered  with  lymph  and  soft  adhesions.  If  the  loss  of  blood 
is  not  excessive,  the  prognosis  is  not  unfavorable. 

Treatment. — Tapping. — This  can  only  be  recommended  for  cases  in  which 
immediate  relief  is  absolutely  necessary  and  the  condition  of  the  patient  too  serious 
to  admit  of  complete  removal.  It  has  been  followed  by  hemorrhage,  peritonitis, 
and  by  suppuration  in  the  cyst,  and  is  a  proceeding  to  be  avoided  if  possible.  .  For 
purposes  of  diagnosis  it  is  of  little  use. 

Ovariotomy. — The  time  selected  should  be  shortly  after  a  menstrual  period. 
An  aperient  is  given  the  day  before,  and  an  enema  the  morning  of  the  operation, 
to  ensure  that  the  bowels  are  fully  relieved  ;  and  a  catheter  should  be  passed  if 
there  is  any  question  as  to  the  condition  of  the  bladder.  The  extremities  should 
be  warmly  clad,  the  shoulders  slightly  raised,  and  the  abdomen  protected  with  a 
waterproof  sheet  in  which  there  is  a  central  opening  large  enough  to  expose  the 
skin  from  the  pubes  to  a  short  distance  above  the  umbilicus.  The  margin  of  this 
is  covered  on  its  under  surface  with  adhesive  plaster,  to  prevent  any  fluid  escaping 
beneath. 

The  assistant  stands  on  the  patient's  left,  opposite  the  operator.  A  nurse  is 
required,  whose  sole  duty  it  shall  be  to  attend  to  the  sponges.  All  instruments, 
ligatures,  etc.,  are  to  be  kept  immersed  in  a  five  percent,  solution  of  carbolic  acid  ; 
and,  like  the  sponges,  they  must  all  be  counted,  in  order  that  none  may  accidentally 
be  left  in  the  abdominal  cavity. 

Special  instruments  required  are  :  twelve  small  pressure-forceps ;  two  cyst 
trocars,  large  and  small,  either  Well's  or  Tait's,  with  tubing ;  four  large  cyst 
forceps,  angular  and  straight ;  two  pedicle  needles,  in  handles,  blunt ;  and  six 
sponge  holders.  Six  of  Keith's  glass  drainage  tubes  of  various  sizes  should  be  at 
hand. 

The  incision  is  from  two  to  three  inches  in  length,  according  to  the  thickness 
of  the  abdominal  walls,  midway  between  the  umbilicus  and  the  pubes  ;  and  planned 
to  hit  off  the  division  between  the  recti.     As  soon  as  the  peritoneum   is  exposed, 


1 156    DISEASES  AND  If^JURIES  OF  SPECIAL  STRUCTURES 

it  is  picked  up  with  a  pair  of  forceps  and  carefully  opened.  Unless  adhesions  are 
present,  the  bowels  fall  away  as  the  air  is  admitted,  so  that  there  is  no  danger  of 
their  being  wounded.  Considerable  difficulty,  however,  may  be  experienced  if  the 
peritoneum  is  thickened  and  vascular  from  old  attacks  of  inflammation,  or  adher- 
ent to  the  front  of  the  tumor  ;  the  sub-peritoneal  areolar  tissue  may  be  mistaken 
for  intra-peritoneal  adhesions,  and  the  serous  membrane  stripj^ed  away  from  the 
transversalis  fascia.  If  there  is  the  least  doubt,  it  is  always  advisable  to  prolong 
the  incision  upward,  until  a  space  that  is  certainly  free  from  adhesions  is  reached. 

If  the  length  is  not  sufficient  the  incision  may  be  extended  downward  to  the 
pubes  (care  being  taken  not  to  wound  the  bladder)  or  upward,  toward  or  even 
beyond  the  umbilicus,  passing  either  through  it  or  round  to  the  left  side. 

As  soon  as  the  tumor  is  exposed  and  its  general  character  and  relation  ascer- 
tained, the  size  should  be  reduced  as  far  as  i)ossible  by  emptying  it  of  its  contents. 
Simple  cysts  may  be  tapped  at  once,  the  trocar  being  driven  smartly  in  while  the 
tumor  is  steadied  and  pressed  somewhat  forward  by  the  assistant,  so  that  none  of 
the  fluid  enters  the  abdominal  cavity.  Multiple  cysts  may  be  treated  in  the  same 
manner,  the  trocar,  without  being  withdrawn,  being  driven  through  one  to  the 
other  until  all  the  larger  cysts  are  emptied.  If  the  contents  are  too  viscid  to  flow 
through  the  cannula,  it  should  be  withdrawn,  the  opening  enlarged,  the  septa 
thoroughly  broken  down,  and  the  debris  scooped  out  with  one  hand  while  the  walls 
are  drawn  forward  by  means  of  forceps  with  the  other,  the  assistant  meanwhile 
keeping  up  steady  pressure  upon  the  sides  of  the  abdomen,  and  preventing  the 
escape  of  the  intestines  by  the  side  of  the  tumor. 

As  the  cyst  diminishes  in  size  and  is  gradually  drawn  out  through  the  abdominal 
opening,  any  adhesions  that  may  be  present  come  into  view.  Recent  ones  may  be 
easily  separated  by  the  pressure  of  a  sponge  ;  older  ones  are  better  secured  with  a 
ligature.  For  obvious  reasons  it  is  not  advisable  to  leave  forceps  attached  inside 
the  abdominal  cavity.  If  the  cyst  is  so  firmly  attached  to  the  bowel  that  it  cannot 
be  separated,  the  adherent  portion  of  the  wall  should  be  cut  off  and  left  in  situ. 
Sessile  tumors  burrowing  between  the  layers  of  the  broad  layers  must  be  enucleated. 
Commencing  near  the  uterus,  the  peritoneal  investment  is  carefully  stripped  off  the 
tumor,  keeping  as  close  to  the  cyst  wall  as  possible.  The  flaps  of  the  broad  liga- 
ment are  then  sewn  together,  or  ligatured,  or,  if  the  cavity  be  very  deep,  sewn  to 
the  abdominal  incision  and  a  drainage  tube  inserted. 

The  pedicle  is  secured  with  a  silk  ligature,  and  returned  into  the  abdominal 
cavity.  If  it  is  too  large  to  be  embraced  in  one  loop,  it  may  be  transfixed  and  tied 
in  two  halves  with  a  figure-of-eight  ligature  ;  or  Lawson  Tait's  .Staffordshire  knot 
may  be  employed.  An  ordinary  handled  needle,  threaded  with  a  long  piece  of  silk, 
is  passed  through  the  pedicle  and  withdrawn,  leaving  a  loop  on  the  distal  side. 
This  is  drawn  over  the  tumor,  and  one  of  the  free  ends  passed  through  it,  so  that 
one  is  above  and  the  other  below  the  loop.  The  pedicle  is  then  fixed  with  the 
finger  and  thumb  of  the  left  hand,  and  the  two  ends  of  the  ligature  drawn  as  tightly 
as  possible,  and  secured  by  means  of  an  ordinary  knot.  The  thinnest  portion  of 
the  pedicle  should  always  be  selected,  and  if  it  is  very  bulky  it  may  be  reduced  in 
size  beforehand,  by  clamping  it  temporarily  with  a  pair  of  strong  forceps.  If  there 
is  the  least  doubt  as  to  its  being  properly  secured,  a  pair  of  catch-force])s  should  be 
fastened  to  it,  so  that  it  may  be  drawn  up  and  inspected  the  last  thing  before  the 
wound  is  closed. 

Finally,  the  other  ovary  should  be  examined,  taking  care  not  to  make  too 
much  traction  upon  the  uterus  for  fear  of  disturbing  the  ligature  already  applied. 

The  abdominal  cavity  should  be  thoroughly  cleansed  from  all  clots  and  foreign 
material,  warm  dry  sponges  being  carried  down  into  the  loins  and  Douglas's  pouch 
for  the  purpose.  If  any  of  the  contents  of  the  cyst  have  escaped,  thorough  irriga- 
tion with  hot  water  is  i)referable  ;  it  is  more  efficient  and  does  less  harm.  Drainage 
should  be  adopted  in  cases  of  enucleation,  and  where,  owing  to  the  depth  in  the 
pelvis  or  extent  of  the  adhesions,  it  is  difficult  to  see  and  control  the  hemorrhage. 
The  tube  should  be  sufficiently  long  to  reach  to  the  bottom  of  Douglas'  pouch  with- 


OVARIOTOMY.  1157 

out  pressing  upon  the  rectum.  There  is  a  small  collar  at  the  upper  extremity, 
which  rests  ui)on  the  edges  of  the  wound  at  the  lower  angle,  and  it  is  perforated  at 
the  sides  with  several  small  openings,  so  that  fluid  may  find  its  way  in,  and  be 
removed  as  reijuired  by  means  of  a  syringe. 

A  flat  sponge  is  placed  upon  the  surface  of  the  intestines,  while  the  sutures  are 
being  i)assed.  Silk  or  silkworm  gut  is  the  best  material  for  the  purpose  ;  all  the 
layers  of  the  wall  must  be  transfixed  ;  and  the  sutures  placed  .sufficiently  close  to 
ensure  thorough  adaptation  of  the  peritoneal  surfaces.  The  sponge  is  withdrawn 
when  they  are  all  in  position  and  tied,  except  the  last  one  or  two.  Absorbent  dress- 
ings are  laid  over  the  wound  of  sufficient  thickness  to  fill  up  the  natural  hollows 
of  the  abdomen  ;  and,  if  a  drainage  tube  is  used,  to  protect  it  from  pressure  ;  and 
over  all  a  many-tailed  bandage  is  applied.  'I'hen  the  patient  is  carefully  lifted  uj) 
from  the  table  to  a  well-warmed  bed  placed  by  its  side. 

The  thin  wall  of  a  broad  ligament  cyst  presents  a  characteristic  appearance, 
differing  greatly  from  the  shining,  opaque,  and  silvery-white  surface  of  an  ovarian 
cystoma.  When  pedunculated  it  can  easily  be  secured  with  a  ligature.  The  Fal- 
lopian tube  and  ovary  are  frequently  flattened  out  over  the  cyst,  and  need  not 
necessarily  be  removed  with  the  tumor;  but  it  is  better  to  remove  them  than  to 
complicate  the  operation  by  attempting  to  separate  them.  When  sessile  the  cyst 
burrows  deeply  between  the  layers  of  the  broad  ligament.  In  such  cases  it  is  neces- 
sary to  reflect  the  peritoneum  from  the  surface  of  the  cyst  and  carefully  enucleate 
it.  Care  must  be  taken  not  to  injure  the  uterine  artery,  which  forms  a  loop  with 
its  concavity  upward  close  to  the  neck  of  the  uterus,  and  the  ureter,  which  runs 
across  beneath  the  base  of  the  broad  ligament  to  its  insertion  in  the  bladder.  The 
flaps  of  the  broad  ligament  may  be  united  by  sutures  or  treated  as  a  pedicle  and 
partly  cut  away,  according  to  circumstances. 

After-treatment. — For  the  first  twenty-four  hours  it  is  better  to  give  nothing 
but  small  quantities  of  hot  water  or  hot  toast  water.  The  second  day  the  patient 
may  take  a  little  arrowroot  or  beef  tea.  An  irritable  condition  of  the  stomach  is 
frequently  a  troublesome  complication.  Drugs  are  of  little  use.  If  the  retching 
is  severe,  a  tumblerful  of  warm  water  will  often  help  the  patient  to  bring  up  a  large 
quantity  of  mucus,  and  relieve  the  symptoms.  Should  it  fail,  the  administration 
of  all  nourishment  by  the  mouth  must  be  discontinued,  and  the  patient  supported 
by  nutrient  enemata.  In  the  case  of  feeble  subjects  this  may  be  done  at  once  with 
advantage.  Peptonized  beef  tea  is  the  best  when  it  can  be  procured  :  three  ounces 
should  be  injected  into  the  rectum  about  every  four  hours.  Before  giving  an  enema 
the  rectal  tube  must  be  passed  two  or  three  inches  into  the  rectum,  and  allowed  to 
remain  there  for  a  few  minutes,  to  permit  the  escape  of  flatus  and  any  faecal  matter 
which  may  be  present. 

The  administration  of  an  opiate  after  the  operation  is  not  necessary  unless 
there  is  pain.  Many  patients  are  very  intolerant  of  the  drug.  It  is  especially 
deleterious  in  those  cases  in  which  the  urine  is  scanty,  slightly  albuminous,  and  of 
low  specific  gravity.     When  required  it  may  be  given  in  the  beef-tea  enemata. 

If  the  bowels  have  not  acted  spontaneously,  measures  should  be  taken  to  pro- 
cure an  evacuation  by  the  evening  of  the  fifth  day.  An  enema  of  four  ounces  of 
warm  olive  oil  may  be  injected,  and,  four  hours  later,  a  pint  and  a  half  of  soap  and 
water.  As  a  rule,  an  action  speedily  follows  ;  if  not,  the  enema  must  be  repeated. 
A  gentle  purgative  does  no  harm  ;  on  the  contrary,  when  the  appetite  is  lost  and 
the  tongue  thickly  furred,  it  is  certainly  beneficial.  A  drachm  of  compound 
liquorice  powder  or  some  other  laxative  may  be  given  with  the  preliminary  olive 
oil  enema. 

The  catheter  need  not  be  passed  until  the  patient  asks  to  be  relieved.  After- 
ward it  will  be  required  three  times  daily  for  the  next  two  or  three  days,  but  the 
use  of  the  instrument  should  be  discontinued  as  soon  as  possible.  The  majority 
of  patients  can  pass  their  urine  voluntarily  after  the  first  forty-eight  hours,  but  in 
some  cases  the  want  of  power  continues  for  several  days. 

A  water-bed  is  advisable,  especially  for  aged  patients.      Every  care  iir  such 


1 158    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

cases  must  be  taken  to  avoid  the  occurrence  of  a  bed-sore ;  the  jjatient  must  not 
be  strictly  confined  to  her  back,  but  be  allowed  to  change  her  position  from 
time  to  time  and  lie  on  her  side.  The  catheter  should  be  avoided  altogether,  if 
possible. 

The  dressings  need  not  be  touched  until  the  eighth  day.  By  that  time  the 
wound  should  be  united  and  the  sutures  may  be  removed.  The  wound  should 
then  be  washed,  carefully  dressed  with  carbolic  gauze,  and  supported  with 
strapping.  The  jiatient  must  not  be  allowed  to  get  up  under  a  fortnight,  and 
meantime  should  be  provided  with  a  well -fitting  abdominal  belt.  It  must  not  be 
forgotten  that  the  cicatrix  may  stretch  and  form  a  hernial  sac  into  which  a  large 
mass  of  intestines  and  omentum  may  obtrude  itself,  to  the  great  discomfort  of  the 
patient.  To  obviate  this  it  is  nece.ssary  to  protect  the  cicatrix  carefully  long  after 
convalescence. 

Complications. — Shock. — The  shock  may  be  severe,  especially  if  the  opera- 
tion is  prolonged.  Warm  blankets,  hot-water  bottles,  etc.,  must  be  used  freely  to 
keep  up  the  temperature,  and  a  little  brandy  or  ether  and  sal  volatile  may  l)e  given 
as  soon  as  the  patient  can  swallow. 

Rise  of  Temperature. — In  about  twenty-four  or  thirty-six  hours  after  the  opera- 
tion the  temperature  usually  reaches  its  highest  point.  In  many  cases  this  is  not 
above  100°,  but  a  considerable  rise  of  temperature  at  this  time  is  not  of  any  serious 
import.  If  it  rises  above  102°,  with  a  concomitant  rise  of  pulse,  the  application 
of  the  ice-cap  will  reduce  it. 

Secondary  hemorrhage  may  arise  from  the  pedicle  slipping  out  of  the  ligature. 
It  is  very  imjiortant,  when  securing  it,  not  to  exercise  too  much  traction  on  the 
pedicle  ;  the  outer  border  is  liable  to  retract  and  slip  out,  and  the  ovarian  artery 
thus  set  free  bleeds  freely.  If  there  is  any  fear  of  this,  the  ovarian  vessels  in  the 
outer  bonder  should  be  secured  separately.  The  splitting  of  the  pedicle  may  also 
be  a  cause  of  secondary  hemorrhage  ;  this  is  liable  to  occur  if  it  is  transfixed  and 
tied  without  the  threads  having  been  properly  crossed,  the  two  halves  of  the  pedi- 
cle being  pulled  asunder.  Secondary  hemorrhage  may  also  occur  from  vessels  in 
adhesions. 

The  symptoms  of  internal  hemorrhage  are  characteristic  and  usually  come  on 
within  a  few  hours  after  the  operation.  The  patient  becomes  faint  and  blanched, 
and  the  pulse  small  and  rapid.  There  must  be  no  hesitation  :  the  only  course  open 
is  to  place  the  patient  under  an  anaesthetic,  re-open  the  wound,  and  find  and  secure 
the  bleeding  point. 

Pei'itonitis  a7id  septiccemia  may  come  on  from  the  second  to  the  fourth  day. 
The  earlier  symptoms  are  very  insidious,  but  the  following  combination  is  suffi- 
ciently grave.  The  vomiting  which  most  patients  suffer  from  for  a  few  hours,  and 
is  probably  due  to  the  anaesthetic,  instead  of  subsiding,  persists.  At  first  it  is 
white  and  frothy,  but,  subsequently  green  or  dark  ;  the  pulse  increases  in  frequency, 
at  the  .same  time  decreasing  in  force  ;  the  respirations  are  more  frequent  ;  the  face 
becomes  pallid  or  slightly  jaundiced,  the  mental  condition  depressed  ;  the  tongue 
is  red,  rough,  and  dry,  though,  like  the  skin,  it  sometimes  remains  moist  through- 
out ;  the  abdomen  becomes  tympanitic  and  tender,  and  no  flatus  is  passed.  The 
temperature  in  many  cases  continues  low  from  the  first,  and  does  not  afford  any 
characteristic  indication. 

The  prognosis  is  most  unfavorable.  When  the  symptoms  are  those  of  gen- 
eral peritonitis,  active  treatment  is  of  little  avail.  When  they  point  to  the  forma- 
tion of  an  absce.ss  in  the  pelvis,  or  in  the  abdominal  walls  around  the  wound,  there 
is  more  hope. 

The  stomach  may  be  washed  out  with  warm  water  every  six  or  twelve  hours, 
if  the  vomit  be  dark  and  bilious,  until  it  ceases.  The  passage  of  the  rectum  tube 
may  enable  the  flatus  to  escape  and  relieve  somewhat  the  abdominal  distention. 
Beef-tea  enemata  must  be  administered  every  three  or  four  hours. 

Intestinal  obstruction  is  a  complication  that  occasionally  follows  ovariotomy. 
It  may  be  caused  in  various  ways — by  the  intestine  becoming  adherent  to  the  ab- 


TUMORS  OF  THE  UTERUS.  ,159 

dominal  incision  or  other  raw  surface,  or  Ijy  its  becoming  entangled  in  tlie  omen- 
tum. Sliould  the  comi)lication  occur  during  the  first  or  second  week  following  the 
operation,  its  symi)toms  are  very  liable  to  be  mistaken  for  those  of  peritonitis  or 
septicaemia.  If  the  condition  is  recognized,  the  abdominal  wound  should  be  re- 
opened and  the  obstruction  removed. 

Phlegmasia  may  occur,  especially  during  convalescence  ;  and  cases  have  proved 
fatal  from  portions  of  the  clot  becoming  detached. 

Tetanus  also  has  been  known  to  occur. 


Tumors  of  the  Uterus. 

Tumors  of  the  uterus  may  be  malignant  or  non-malignant.  The  former  in- 
clude sarcoma  and  carcinoma ;   the  latter,  fibromyoma,  fibroma  and  fibrocysts. 

I.   Non-malignant  Tumors  (^'^  Fibroids''''^. 

These  resemble  in  their  structure  the  tissues  that  normally  form  the  wall  of 
the  uterus,  but  the  proportions  in  which  they  occur  differ  very  considerably.  Some 
are  soft,  pale  or  flesh-colored,  rapid  in  growth,  and  ill-defined  in  outline,  consist- 
ing almost  entirely  of  unstriped  muscular  fibre — "■  miomay  Others  grow  very 
slowly,  present  a  white  and  glistening  surface  on  section,  and  are  almost  as  hard  as 
cartilage.  These  consist  of  nothing  but  fibrous  tissue — ^'fibroma'' — arranged 
concentrically  layer  upon  layer.  Unlike  the  former,  they  are  almost  non-vascular, 
and  are  surrounded  by  a  capsule  of  loose  connective  tissue,  which  differentiates 
them  from  the  surrounding  uterine  wall.  In  this  loose  fibrous  tissue  run  the  blood 
vessels  which  supply  the  tumor. 

Fibroids  occur  with  the  greatest  frecpiency  during  middle  life,  between  the 
ages  of  thirty  and  forty-five.  It  is  uncertain  whether  they  ever  originate  after  the 
climacteric  ;  but  they  may  continue  to  grow,  and  in  some  instances  very  rapidly, 
after  that  epoch.  Sometimes  they  remain  unchanged  for  years.  During  menstrua- 
tion and  in  pregnancy  they  frequently  increase  very  fast ;  subsequently  they  undergo 
involution  with  the  rest  of  the  uterus,  and  may  disappear  completely. 

Fibroid  growths  are  liable  to  degenerative  changes  of  various  kinds.  Occa- 
sionally the  central  portions  become  changed  into  mucous  tissue,  and  the  soft  semi- 
fluctuating  tumor  thus  formed  may  readily  be  mistaken  for  a  cystic  tumor  of  the 
ovary.  Sometimes  cavities  or  cysts  form  in  them,  containing  pus,  blood  or  serum. 
Such  cysts  may  attain  an  enormous  size,  and,  like  the  preceding,  simulate  ovarian 
disease  very  closely.  After  the  menopause,  fibroids  generally  cease  growing,  but 
exceptions  to  this  are  not  uncommon.  They  may  atrophy  and  disappear  ;  or  they 
may  undergo  calcareous  degeneration,  the  outer  layers  especially  being  affected  so 
that  sometimes  they  appear  to  be  .surrounded  by  a  kind  of  shell.  Sarcomatous  and 
carcinomatous  changes  are  supposed  by  some  to  occur  in  them,  but  it  is  open  to 
question  whether  the  occurrence  of  the  two  conditions  in  the  same  uterus  is  not  a 
mere  coincidence. 

There  is  no  limit  to  their  number.  They  may  occur  in  the  cervix,  but  are 
much  more  common  in  the  body  of  the  uterus.  Sometimes  they  grow  in  the 
centre  of  the  uterine  wall  {interstitial  fibroids')  ;  sometimes  they  develop  on  the 
surface,  either  the  internal  {submucotcs)  or  the  external  {subperitoneal).  In  this 
case  they  may  either  remain  sessile  or  become  pedunculated  and  project  as  polypi 
into  the  cavity  of  the  uterus  or  that  of  the  peritoneum.  A  submucous  fibroid  may 
be  gradually  separated  from  the  uterus  by  an  elongating  pedicle  and  expelled  by 
the  uterine  contractions  into  the  vagina.  Subperitoneal  fibroids  are  also  occasion- 
ally entirely  detached  from  the  uterine  surface.  When  connected  by  a  long  jjedicle 
these  tumors  are  very  liable  to  give  rise  to  serious  complications,  from  their  ten- 
dency to  fall  into  the  pelvis  and  become  incarcerated,  or  by  becoming  accidentally 
twisted  on  themselves  and  strangulated. 

Symptoms. — These  depend  to  a  great  extent  upon  the  situation,  of  the 


ii6o    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

growth.  Sometimes  they  are  entirely  wanting,  so  that  the  tumors  remain  latent 
for  the  whole  of  life. 

Hemorrhage  is  the  most  characteristic,  and  is  rarely  absent  except  in  the  case 
of  the  subi)eritoneal  variety.  With  large  interstitial  growths  it  is  often  profuse. 
Usually  it  takes  the  form  of  menorrhagia  coming  from  the  hypertrophied  mucous 
membrane  of  the  uterus,  and  beginning  as  an  aggravation  and  prolongation  of  the 
menstrual  flow.  With  submucous  fibroic's  it  may  occur  at  any  time,  coming  from 
the  ulcerated  and  granulating  surface  of  the  tumor,  and  accompanied  by  a  profu.se 
leucorrhueal  discharge.  This  latter  can  be  distinguished  from  the  discharge  present 
in  cancer  of  the  uterus,  by  being  less  watery  and  free  from  fetor. 

Pain. — I^iscomfort.  a  sense  of  weight  in  the  lower  part  of  the  pelvis,  and 
bearing-down  pains  are  generally  present,  and,  owing  to  the  increased  size  of  the 
tumor,  are  always  worse  at  the  menstrual  periods.  The  submucous  and  interstitial 
varieties  are  attended  by  characteristic  uterine  dysmenorrhcea,  the  tumors  acting 
as  a  foreign  body  and  exciting  irregular  contractions  like  the  pains  of  labor.  As 
a  rule,  this  is  not  present  in  the  subperitoneal  form. 

Pressure. — The  urinary  organs  suffer  the  most  frequently  .;  an  irritable  con- 


M 


Fig   504. — Uterine  Fibroids,  Subperitoneal,  Interstitial,  and  Submucous. 

dition  of  the  bladder  may  be  excited  by  the  presence  of  even  a  small  fibroid. 
Suppression  may  occur  from  compression  of  the  ureters  ;  incontinence  from  the 
bladder  being  dragged  into  the  abdomen  and  the  urethra  stretched  ;  or  retention 
if  the  tumor  presses  the  urethra  against  the  pubes.  Sometimes  this  is  intermittent, 
owing  to  the  varying  size  of  the  growth  during  the  menstrual  period. 

In  other  cases  the  rectum  is  compressed  so  that  constipation  and  even  obstruc- 
tion are  caused  ;  and  as  the  tumor  grows  in  size,  like  large  ovarian  cysts,  it  very 
seriously  interferes,  by  its  mere  bulk,  with  the  working  of  the  abdominal  and  even 
the  thoracic  viscera. 

Sterility  and  Abortion. — Pregnancy  seldom  occurs  when  there  is  a  submu- 
cous or  interstitial  fibroid  of  any  size.  If  it  does,  either  the  patient  miscarries, 
or,  if  the  full  term  is  reached,  there  is  great  danger  of  post-partum  hemorrhage, 
and  of  metritis  and  pyaemia  due  to  sloughing  of  the  tumor. 

Physical  Signs. — These  differ  according  to  the  locality. 

I.  Submucous. — If  pedunculated  and  in  the  lower  segment  of  the  uterus,  a 
fibroid  can  often  be  felt  projecting  through  the  cervix  as  a  hard,  smooth,  rounded 
mass.  It  may  be  necessary  to  dilate  the  os  before  this  can  be  done  By  intro- 
ducing the  finger  into  the  cavity  of  the  uterus,  the  position  and  extent  of  its  at- 


FIBROID   TUMORS  OF  THE   UTERUS.  1161 

tachment  can  then  be  ascertained.      If  sessile,  it  may  attain  a  large  size,  stretching 
the  uterus  like  a  capsule  and  reaching  as  high  as  the  umbilicus. 

2.  Interstitial. — As  with  a  former  variety,  the  uterus  is  always  increased  in 
size.  Its  cavity,  measured  by  the  uterine  sound,  may  be  found  to  be  six  or  eight 
inches  in  length.  The  canal  is  often  rendered  extremely  tortuous  by  the  tumors 
encroaching  uj^on  it,  so  that  the  passage  of  the  sound  may  be  very  difficult  or 
quite  impossible.  Small  growths  are  difficult  to  detect.  There  is  nothing  but  a 
peculiar  lumpiness  and  sense  of  resistance  in  the  walls  of  the  uterus  which  the 
healthy  organ  does  not  present.  A  projecting  growth  may  simulate  a  flexion  of 
the  uterus;  but  a  careful  bi-manual  examination  and  the  aid  of  the  uterine  sound 
will  always  obviate  an  error  of  this  kind.  When  large,  they  rise  up  into  the 
abdomen,  occupying  a  central  position,  and  form  a  solid,  rounded,  freely  movable 
tumor,  over  which  the  uterine  souffle  can  often  be  heard,  especially  at  the  sides. 
On  vaginal  examination  the  cervix  is  found  displaced  in  various  wa}s.  It  may  be 
drawn  up  in  the  abdomen  beyond  the  reach  of  the  finger,  or,  if  the  lower  part  is 
involved,  it  may  be  altogether  lost,  the  os  appearing  as  a  mere  depression. 

3.  Subperitoneal. — In  these  the  uterine  cavity  is  not  necessarily  enlarged, 
and  the  uterine  souffle  is  not  present.  In  addition  to  the  general  mobility  of  the 
tumor,  the  growths  have  a  certain  range  of  free  movement,  depending  on  the 
length  of  the  pedicle.  Palpation  gives  the  idea  of  a  number  of  hard  rounded 
masses  rolling  one  over  the  other.  This  characteristic,  when  present,  is  absolutely 
distinctive. 

Differential  Diagnosis. — From  Pregnancy. — When  normal,  pregnancy  is 
easily  distinguished  ;  but  a  difficulty  may  arise  if  the  foitus  is  dead,  and  all  the 
signs  of  pregnancy  have  disai)peared,  and  there  is  a  dark  sanguineous  discharge 
escaping  from  the  enlarged  uterus.  This  condition  bears  a  close  resemblance  to 
the  appearance  presented  by  a  partially  detached  submucous  fibroid  in  process  of 
expulsion.  In  extra-uterine  gestation  the  history  and  rapidity  of  the  growth  are 
sufficient. 

Pregnancy  co-existing  with  fibroid  sometimes  presents  a  difficulty  :  in  addition 
to  the  ordinary  signs,  most  reliance  must  be  placed  upon  the  want  of  uniformity 
in  the  shape  of  the  uterus,  and  the  size,  which  is  larger  than  would  correspond  to 
the  period  of  pregnancy. 

From  Ovarian  Tumors. — In  these  the  uterine  souffle  is  never  heard  ;  the  cavity 
of  the  uterus  is  not  enlarged,  and  the  tumor,  as  a  rule,  is  soft  and  fluctuating. 
Manipulation  of  the  mass  in  the  abdomen  does  not  move  the  sound  in  the  uterus 
unless  the  connection  between  the  latter  and  the  tumor  is  very  close.  Fibrocysts, 
however,  sometimes  cannot  be  distinguished. 

Abscess  of  the  ovary  or  Fallopian  tube,  haematocele  and  inflammatory  deposits 
occasionally  present  a  difficulty,  especially  as  inflammation  is  not  unlikely  to 
occur  around  a  fibroid  if  it  causes  pressure. 

Prognosis. — This  depends  upon  the  age  of  the  patient,  the  nature  of  the 
tumor,  the  rapidity  of  the  growth,  the  amount  of  hemorrhage,  and  of  pressure 
upon  other  organs.  Sometimes  fibroids  cease  growing  or  even  disappear ;  and 
sometimes  they  are  extruded  and  slough  off,  but  these  instances  are  exceptional. 
In  many  cases  death  results  from  hemorrhage,  exhaustion,  suppuration,  peritonitis, 
sloughing  of  the  tumor,  intestinal  obstruction  or  secondary  renal  mischief;  in 
many  more  the  patient's  health  is  thoroughly  broken  down,  and  some  intercurrent 
disorder  sets  in. 

Treatment. — Ergot. — The  hypodermic  injection  of  ergot  continued  for 
many  months  is  stated  to  have  some  influence  in  checking  the  growth  of  the  tumor. 
Its  action  is  very  uncertain.  The  gluteal  region  is  usually  selected  for  the  injec- 
tion. The  pain  is  extreme,  and  the  punctures  often  suppurate.  The  practice  has 
now  been  abandoned. 

Electricity. — It  is  claimed  that  a  constant  current  (commencing  with  50  milli- 
amperes  and  increasing  to  200  or  250)  passed  through  the  substance  of  the  tumor 
at  intervals  of  a  few  days  will  cause  it  to  disappear,  possibly  by  bringing  into  play 
74 


1 1 62    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

those  conditions  which  sometimes  normally  diirinj,'  life  brin^r  about  the  same  result. 
One  electrode,  insulated  to  within  two  or  three  inches  of  the  point,  is  inserted 
into  the  cavity  of  the  uterus;  the  other  (usually  the  positive)  is  applied  to  the 
surface  of  the  abdomen.  The  latter  should  be  of  very  large  size  (seventy  to  eighty 
square  inches),  and  very  well  and  evenly  covered  with  a  folded  linen  cloth  pre- 
viously dampened  in  water,  or  with  such  currents  the  skin  will  be  destroyed.  Each 
sitting  lasts  five  or  ten  minutes.  Opinions  are  as  yet  divided  as  to  the  merits  of 
this  i^roceeding.  In  some  cases  there  is  no  doubt  the  tumor  has  diminished  or 
disappeared  ;  in  many  it  has  been  entirely  unaffected  ;  and  in  some,  esjjecially 
when  high  currents  were  used,  sloughing  and  sei)tic?emia  followed.  At  jjresent 
the  method  is  entirely  empirical. 

Enucleation  per  Vaginani. — If  the  vagina  is  healthy  and  spacious,  and  the 
OS  and  cervix  capable  of  easy  dilatation,  small  tumors,  more  or  less  peduncu- 
lated, may  be  removed  this  way  ;  and  sometimes  it  succeeds  with  large  inter- 
stitial fibroids,  but  only — and  this  is  almost  impossible  to  tell — when  they  are 
encapsuled. 

The  patient  is  placed  in  the  lithotomy  position,  the  cervix  having  been  pre- 
viously dilated,  if  necessary.  The  uterus  is  [nilled  down  as  far  as  possible  by 
means  of  a  vulsellum,  and  the  attachment  of  the  tumor  carefully  made  out  with 
the  finger.  If  there  is  a  distinct  pedicle  an  ecraseur  may  be  ])Iaced  round  it  at 
once,  or  it  may  be  twisted  off. 

If,  on  the  other  hand,  it  is  sessile,  a  deep  incision  is  made  through  the  mucous 
membrane  and  the  capsule  at  the  most  convenient  spot,  and  the  substance  of  the 
tumor  seized  with  strong  vulsellum-forceps.  Then,  while  an  assistant  pushes  the 
fundus  down  from  the  abdomen  into  the  p.»elvis,  an  attempt  is  made  to  insert  the 
finger  between  the  capsule  and  the  growth,  and  shell  it  out.  Emmet's  nail  curette 
and  Thomas's  spoon-saw  may  be  used  with  advantage,  but  all  instruments  add  very 
greatly  to  the  risk,  especially  as  the  fundus  is  approached,  and  great  care  must  be 
taken  in  dragging  upon  the  tumor  not  to  invert  the  uterus,  or  its  wall  may  be 
included  in  the  ecraseur  and  the  peritoneal  cavity  laid  open.  The  cajxsule  is  then 
washed  out  with  iodine  water  and  plugged  with  pledgets  of  cotton  dipped  in  the 
same  or  some  other  antiseptic.  These  may  be  removed  in  forty-eight  hours  and 
the  vagina  washed  out  with  a  weak  antiseptic  night  and  morning  until  the  dis- 
charge has  ceased. 

The  operation  is  one  of  extreme  difficulty.  If  any  portion  of  the  tumor  is 
left  it  is  certain  to  slough  and  very  likely  to  cause  septicemia.  The  uterus  does 
its  best  to  extrude  it,  and  sometimes  a  second  operation  may  successfully  complete 
the  removal  ;  but,  except  in  those  cases  where  the  tumor  is  small  or  already  pre- 
sents at  the  OS,  the  operation  is  not  to  be  lightly  undertaken. 

Removal  of  the  Uterine  Appendages. — The  object  of  this  proceeding  is  to  pre- 
cipitate the  menopause  and  so  induce  the  condition  of  atrophy  which  may  be 
expected  to  occur  after  that  event.  Sometimes  it  is  performed  with  the  view  of 
checking  hemorrhage,  sometimes  with  the  view  of  arresting  the  growth  of  the 
tumor.  The  operation  is  commonly  known  as  Hegar's.  It  is  most  feasible  when 
the  tumor  is  interstitial  and  of  moderate  size,  the  hemorrhage  periodic  and  exces- 
sive, and  the  normal  menopause  remote. 

The  patient  is  prejjared  as  for  ovariotomy.  The  abdominal  incision  is  about 
three  inches  in  length  to  begin  with.  The  fore  and  middle  fingers  of  one  hand 
are  slipped  over  the  side  of  the  uterus  until  the  appendages  are  reached.  The 
tube  and  ovary  are  drawn  out  of  the  wound,  transfixed,  ligatured  and  divided. 
The  appendages  on '  the  opposite  side  are  then  treated  in  a  similar  way.  The 
operation  is  never  to  be  recommended  when  the  tumor  has  attained  a  large  size. 
The  appendages  are  often  displaced  by  the  irregular  outgrowths  ;  they  may  be  be- 
hind or  buried  in  the  pelvis  beneath  the  tumor  and  quite  inaccessible.  In  some 
cases  they  are  flattened  out  and  adherent  to  the  growth,  from  which  it  is  impossi- 
ble to  separate  them.  Great  care  must  be  taken  not  to  wound  the  surface  of  the 
tumor  during  the  operation  ;  hemorrhage  will  ensue,  which  it  is  extremely  dif^cult 


FIBROID   TUMORS  OF  THE  UTERUS.  1163 

to  clieck.  Ill  such  case  the  operator  must  be  prepared  to  proceed  with  the  supra- 
vaginal amputation  of  the  uterus. 

The  mortality  is  small,  and  in  many  cases  a  successful  result  is  obtained; 
menorrhagia  is  checked  and  the  tumor  ceases  to  grow  ;  in  some  it  has  completely 
disappeared.  Should  it  fail,  the  condition  of  the  patient  is  not  in  any  way  dete- 
riorated, and  in  suitable  cases  resort  may  be  had  to  the  graver  operation  of  supra- 
vaginal amputation. 

Sitprai'aginal Hysterectomy. — This  operation  is  advised  when  the  tumor  is  large, 
especially  if  it  is  soft,  growing  rapidly,  or  attended  with  menorrhagia.  It  is  neces- 
sary in  cases  of  fibrocyst,  unless  the  tumor  is  i)edunculated.  I'he  age  of  the 
patient  need  scarcely  be  taken  into  consideration  ;  the  menopause  is  indefinitely 
deferred,  and  it  is  useless  waiting  for  it  when  a  patient's  life  is  threatened  by  a 
bleeding  myoma.  Its  applicability  is,  however,  limited  to  those  cases  in  which 
sufficient  of  the  cervix  remains  in  a  healthy  condition  to  be  utilized  as  a  stump. 

The  instruments  recjuired  are  the  same  as  those  for  ovariotomy,  with  the  addi- 
tion of  Koeberle's  serre-nceud,  a  pair  of  pliers,  two  long  pedicle-needles,  and  a 
Tait's  screw.  The  latter  resembles  a  large  corkscrew,  and  is  often  of  great  service 
in  the  extraction  of  the  tumor.      A  second  serre-noeud  should  be  in  readiness. 

The  patient  is  prepared  as  for  ovariotomy.  An  incision  about  four  inches  in 
length  is  made  in  the  median  line,  care  being  taken  not  to  injure  the  bladder,  an 
accident  which  is  far  more  likely  to  happen  than  in  ovariotomy.  The  abdominal 
walls  are  usually  very  vascular,  and  all  bleeding  points  must  be  secured  with  jjres- 
sure  forceps.  On  exposing  the  tumors,  the  dark  fleshy  appearance  of  a  uterine 
fibroid  will  at  once  be  recognized. 

The  relations  of  the  tumor  to  the  broad  ligaments  are  then  explored,  and  if  it 
appears  capable  of  removal,  the  incision  is  enlarged  to  the  necessary  extent.  A 
fibroid  cannot  be  pulled  out  of  the  abdomen  unle.ss  the  incision  be  carried  almost 
to  the  level  of  its  upper  border,  especially  if  the  tumor  is  broad.  The  incision 
may  be  carried  through  the  umbilicus  or  to  the  left  of  that  structure  as  far  as 
required. 

The  presence  of  adhesions  is  then  ascertained.  These  are  most  fretjuently 
omental,  the  vessels  being  sometimes  enormously  dilated.  They  must  be  secured 
by  ligature,  both  on  the  proximal  and  distal  side,  and  divided. 

The  tumor  is  now  raised  through  the  abdominal  opening — not  always  an  easy 
matter.  It  is  slippery,  possibly  wedged  in  the  pelvis,  and  a  hand  passed  behind  it 
fills  up  the  abdominal  opening  to  such  an  extent  that  it  is  impossible  to  lift  it  out 
without  unduly  enlarging  the  incision.  The  screw  may  then  be  thrust  into  the  most 
prominent  part,  with  its  point  directed  toward  the  fundus.  By  depressing  the 
handle  and  raising  the  point,  at  the  same  time  drawing  the  tumor  forward,  while 
with  the  other  hand  the  abdominal  wall  is  retracted  over  the  fundus,  it  may  be  suc- 
cessfuly  coaxed  out  of  its  bed.  The  abdominal  viscera  are  at  once  protected  by 
a  large,  warm,  flat  sponge,  which  is  pushed  under  the  parietes.  Any  further  adhe- 
sions are  attended  to,  and  the  relation  of  the  bladder  to  the  front  of  the  tumor 
ascertained,  a  sound  being  passed  into  the  bladder,  if  necessary,  for  that  purpose. 
It  may  be  necessary  to  dissect  it  from  the  tumor. 

The  wire  of  a  Koeberle's  serre-nceud  is  then  passed  around  the  tumor  at  the 
level  of  the  os  internum,  including  the  tubes  and  ovaries  and  the  greater  part  of 
the  broad  ligaments,  which  are  pulled  up  by  the  assistant  above  the  level  of  the 
wire.  The  loop  is  then  tightened  by  means  of  the  key,  taking  care  that  the 
bladder  is  not  included. 

No  difficulty  is  experienced  when  the  appendages  lie  evenly  and  high  up  on 
the  sides  of  the  tumor.  If  they  are  situated  too  low  to  be  included  with  safety 
in  the  loop,  they  must  be  removed  separately. 

When  the  tension  on  the  broad  ligament  is  excessive,  it  may  be  transfixed  with 
a  stout  ligature  close  to  the  neck  of  the  uterus  and  tied  between  the  uterus  and 
the  ovary.  The  larger  vessels  being  controlled  by  this,  the  peritoneal  envelope  of 
the  uterus  is  freely  divided  at  a  distance  of  about  three  inches  from  the  wire  loop 


1 164    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

and  reflected  toward  it.      In  this  way  the  strain   is  relieved  and   a  better  pedicle 
can  be  obtained.     The  ovary  is  b'gatured  and  removed  separately. 

If  the  tumor  has  extended  laterally  between  the  layers  of  the  broad  ligament 
on  either  side,  enucleation  is  the  only  course.  The  torn  ligament  must  be  treated 
according  to  circumstances,  any  superfluous  portion  being  cut  away  and  the 
remainder  secured  by  sutures  or  ligature. 

The  pins  are  then  passed  through  the  pedicle,  parallel  to  each  other,  close  to 
the  wire  on  its  distal  side. 

Sponges  are  packed  round  the  pedicle,  and  the  tumor  cut  away  with  a  stout 
scalpel  about  two  inches  above  the  wire  ligature.  The  uterine  arteries  are  secured 
in  the  loop,  but  the  blood  in  the  tumor  pours  out  in  quantities  as  the  incision  is 
made.  The  assistant  presses  a  sponge  against  the  cut  surface,  and  endeavors  as 
far  as  possible  to  prevent  the  blood  getting  in  the  way  of  the  operator.  Imme- 
diately the  tumor  is  cut  away,  the  wire  of  the  serre-noeud  is  again  tightened,  and 
the  peritoneal  cavity  thoroughly  cleansed. 

The  free  edges  of  the  peritoneal  surface  and  the  cut  ends  of  the  broad  liga- 
ments are  secured  at  intervals  with  pressure  forceps.  The  stump  is  trimmed  down 
until  only  sufficient  tissue  is  left  to  prevent  the  pins  from  tearing  out  ;  then  it  is 
dusted  with  iodoform,  and  the  edges  stitched  together  over  the  face  of  the  stump 
to  make  it  as  small  as  possible  and  to  prevent  the  broad  ligaments  escaping  as  the 
tissues  shrink.  It  is  then  secured  in  the  lower  angle  of  the  abdominal  incision. 
The  parietal  peritoneum  is  carefully  applied  to  the  peritoneal  surface  of  the  stump 
and  secured  by  a  suture  ;  the  rest  of  the  wound  is  closed  as  in  ovariotomy. 

The  stump  is  surrounded  with  absorbent  dressings  carefully  packed  under  the 
pins,  and  the  whole  secured  with  a  many-tailed  binder.  The  object  is  to  keep  it 
dry  ;  if  the  dressings  become  moist  they  must  be  changed  ;  but  otherwise  the 
wound  may  be  left  for  several  days.  A  small  pedicle  may  dry  up  and  become 
quite  horny  ;  if  pus  wells  out  by  the  side,  in  the  course  of  a  week  the  loop  may  be 
removed  and  the  stump  dressed  so  as  to  facilitate  the  discharge  as  much  as  possible. 
Care  must  be  taken  not  to  allow  it  to  slip  back  into  the  abdomen  before  it  has 
begun  to  heal  by  granulation  and  is  free  from  shreds  and  sloughs,  as  the  wound 
forms  a  deep  pit  and  healing  is  greatly  retarded. 

Pedunculated  subperitoneal  fibroids  may  require  removal,  owing  to  their  size, 
or  to  the  presence  of  complications.  If  the  j)edicle  is  small,  the  uterus  need  not 
be  interfered  with  ;  but  if  it  is  thick  and  short,  or  the  growths  are  multiple,  the 
entire  organ  must  be  removed.  In  either  case  the  extraperitoneal  method  of 
dealing  with  the  pedicle  must  be  adopted.  Even  when  it  is  small,  transfixion 
and  ligature  are  very  unsafe.  The  muscular  fibres  contract ;  the  cut  surface 
begins  to  cup,  and  the  ligature  soon  becomes  loose.  If  it  slips,  the  stump 
appears  as  a  wide  bleeding  surface,  but  little,  if  at  all,  raised  above  the  sur- 
rounding tissue.  The  operation  is  just  as  serious  as  removal  of  the  whole 
uterus. 

Hitherto  the  results  obtained  by  the  extraperitoneal  treatment  of  the  stump 
in  hysterectomy  hav'e  been  so  immensely  superior  to  the  intraperitoneal  method 
that  it  has  been  almost  universally  acce])ted.  It  is  obvious,  however,  as  was  the 
case  in  ovariotomy,  that,  if  the  results  of  the  latter  could  be  improved,  it  possesses 
many  and  great  advantages  over  the  extraperitoneal  method.  Recent  exjjerience 
tends  to  show  that  a  change  may  be  expected  in  this  direction.  The  plan  adopted 
has  been  to  transfix  the  broad  ligaments  on  either  side  with  a  double  ligature.  One 
is  tied  e.xternally  to  the  ovary  and  tube,  the  other,  re-threaded  on  an  empty  needle, 
passed  close  to  the  neck  of  the  uterus  and  tied,  controls  the  uterine  vessels.  The 
tumor  is  then  cut  away,  and  the  edges  of  the  V-shaped  incision  carefully  brought 
together  so  that  the  j^eritoneal  surface  shall  be  turned  inward.  The  stump  is 
returned  into  the  abdominal  cavity  and  the  wound  closed.  This  treatment,  which 
has  met  with  consideral)le  success,  apj^ears  to  be  applicable  to  those  cases  in  which 
the  cervix  is  small  and  not  involved  in  the  growth. 


CARCINOMA   OF  THE  UTERUS.  1165 

2.    Malignant  Disease  of  the  Uterus. 

The  uterus  is  liable  to  be  attacked  by  carcinoma  and  sarcoma  ;  the  former  is 
much  the  more  common. 

Carcinoma  most  freciuently  occurs  from  forty  to  fifty  years  of  age.  Nothing  is 
known  as  regards  its  etiology.  Heredity  is  probably  of  little  importance.  It  is 
slightly  more  common  in  women  who  have  borne  children  than  in  others,  but 
there  is  no  proof  that  it  is  in  any  way  connected  with  lacerations  of  the  os,  as  has 
been  affirmed. 

It  may  begin  in  any  part — the  vaginal  portion,  the  cervix,  or  the  body,  and 
varies  in  character  according  to  the  site.  Carcinoma  of  the  body  is  much  the  most 
rare  (forming  only  two  per  cent,  of  the  whole),  and  is  usually  met  with  rather  later 
in  life  than  the  other  varieties.      Sarcoma  always  attacks  the  body. 

1.  The  Vaginai Fart. — This  is  rarely  the  seat  of  primary  carcinoma,  although 
it  is  often  involved  by  extension  from  the  cervix.  It  always  takes  the  form  of 
squamous  epithelioma.  At  first  the  surface  is  smooth,  shining  and  slightly  livid  ; 
then  the  lips  become  enlarged,  red  and  granular.  It  spreads  superficially  rather 
than  into  the  substance  of  the  organ,  and  grows  outward  on  to  the  vaginal  vault 
and  the  surface  of  the  vaginal  walls. 

2.  The  Cervix. — Carcinoma  commences  in  the  glands,  especially  at  the 
lower  part  of  the  cervix,  either  superficially  or  deep,  and  follows  the  type  of 
columnar  epithelioma.  It  may  assume  the  form  of  a  polypus,  hanging  from  one 
of  the  lips  ;  or  of  a  papillary  growth  on  the  surface  ;  or  a  small  nodule  deep  in 
the  mucous  membrane.  Wherever  it  grows  it  tends  to  spread  in  the  strata  outside 
it  and  involve  the  periuterine  connective  tissue.  Very  often  it  grows  downward 
as  well  as  outward  (extending  under  the  vaginal  mucous  membrane),  but  it  rarely 
trangresses  the  internal  os. 

3.  The  Body. — This,  like  the  former,  commences  in  the  glands  and  usually 
assumes  the  shape  of  nodules  deep  in  the  substance.  Sometimes,  however,  it  is 
superficial  and  spreads  rapidly  over  the  whole  interior,  making  the  surface  rough 
and  villous,  and  covering  it  with  warty  growths  and  polypoid  masses.  The  cavity 
of  the  uterus  is  enlarged  ;  the  walls  thickened  ;  peritoneal  adhesions  form  ;  the 
glands  in  the  broad  ligament  become  involved  ;  and  then  those  further  away  along 
the  internal  iliac  artery  ;   but  the  growth  rarely  extends  down  to  the  cervix. 

Symptoms. — At  the  commencement  these  are  remarkably  insidious  and 
obscure. 

1.  Hemorrhage,  either  with  the  menstrual  flow  or  irregularly,  after  exertion 
or  coitus. — Owing  to  the  vascularity  of  the  growth,  this  is  rarely  absent.  In  older 
women,  after  menstruation  has  ceased,  the  recurrence  of  periodic  hemorrhage  is 
of  great  significance. 

2.  Fain,  at  first  and  so  long  as  the  growth  is  confined  to  the  cervix,  is  gener- 
ally slight.  It  is  felt  chiefly  in  the  back  and  loins.  Later  it  becomes  more  severe, 
especially  at  night,  and  is  described  as  sharp  and  stabbing,  or  as  burning  or 
tearing.  When  the  growth  involves  the  peritoneum,  or  the  sacral  plexus,  or  the 
bladder,  or  rectum,  it  becomes  intense  and  alters  its  character.  Toward  the 
end,  fortunately,  it  very  often  diminishes. 

3.  Discharge  is  very  commonly  present,  watery,  and  serous,  or  stained  with 
blood  at  first,  then  becoming  brownish  from  the  debris  mixed  with  it,  and  usually 
peculiarly  offensive.  After  a  time  the  health  begins  to  fail ;  the  patient  becomes 
emaciated  ;  oedema  of  the  extremities  is  not  uncommon,  and  the  cachexia  becomes 
evident. 

Diagnosis  must  be  made  chiefly  by  the  sense  of  touch.  Hard  nodules  may 
be  felt ;  the  mucous  membrane  has  lost  its  mobility  ;  later  an  irregular  ulcer  is 
formed,  with  elevated,  hardened  borders,  which  feel  rough  and  friable  and  break 
down  readily  under  the  finger  nail.  Sometimes  the  hemorrhage  following  exam- 
ination is  profuse.     The  speculum  is  of  little  use  ;  a  certain  degree  of  lividity  can 


1 1 66     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

be  made  out  in  the  early  stages,  and  later  an  irregular  ulcerated  surface.  Rectal 
examination  should  never  be  omitted. 

In  carcinoma  of  the  body  of  the  uterus  pain  is  an  early  and  marked  symptom  ; 
the  cervix  is  normal  or  dilated  ;  the  uterus  enlarged  ;  hemorrhage  always  follows 
the  introduction  of  the  sound.  Introduction  of  the  finger  through  the  dilated 
cervix  as  a  rule  confirms  the  diagnosis  at  once. 

Treatment. — \\'hen  the  disease  is  confined  to  the  vaginal  portion,  the  cer- 
vix may  be  removed.  When  the  canal  is  involved  the  extent  of  the  disea.se  must 
determine  the  necessity  for  partial  or  complete  hysterectomy.  Cancer  involving 
the  body  can  be  treated  only  by  complete  extirpation. 

Amputation  of  the  Cervix. — This  may  be  performed  in  various  ways  :  with  the 
galvano-cautery,  the  ecraseur,  or  the  knife  and  scissors. 

The  patient  is  placed  either  in  the  semiprone  or  lithotomy  position.  The 
cervix  is  exposed  by  means  of  a  Sims'  speculum,  and  drawn  down  with  a  vulsellum 
to  the  vulva.  The  wire  is  pa.s.sed  over  the  handle  and  adjusted  around  the  cervix 
as  high  above  the  disease  as  possible.  Care  must  be  taken  not  to  place  the  wire 
too  high  posteriorly  for  fear  of  cutting  into  Douglas's  pouch.  The  circuit  is  closed, 
the  wire  kept  at  a  dull  red  heat,  and  just  sufficient  traction  rnaintained  to  keep  the 
wire  against  the  part  to  be  severed.  The  operation  requires  several  minutes.  Hem- 
orrhage is  usually  avoided,  but  it  may  occur,  and  the  possibility  of  secondary 
bleeding  is  not  to  be  lost  sight  of. 

The  ecraseur  is  more  portable  but  less  safe  ;  the  chain  is  not  so  easily  manipu- 
lated and  there  is  greater  danger  of  cutting  into  Douglas's  pouch.  For  this  reason 
a  curved  ecraseur  is  best. 

Supravaginal  Amputation  of  the  Cervix. — The  cervix  is  drawn  down  and  a 
semicircular  incision  made  in  the  anterior  reflection  of  the  vaginal  mucous  mem- 
brane with  a  scalpel  or  blunt-pointed  scissors.  The  bladder  is  easily  separated  by 
the  finger,  and  retracts  upward,  carrying  the  ureters  with  it.  The  utcro-vesical 
pouch  of  the  peritoneum  must  not  be  opened.  The  cervix  is  then  pulled  forward 
to  the  pubes,  and  a  semicircular  incision  made  through  the  posterior  reflection  of 
the  vaginal  mucous  membrane,  its  extremities  uniting  with  those  of  the  anterior, 
so  that  the  cervix  is  entirely  free  from  the  vagina.  Douglas's  pouch  is  liable  to  be 
opened,  but  this  is  of  little  consequence  ;  if  the  posterior  lip  must  be  divided  high 
up,  it  is  better  to  cut  into  the  pouch  and  remove  the  peritoneal  covering  with  the 
portion  amputated.  The  clearing  of  the  cervix  laterally  is  more  difficult,  on  ac- 
count of  the  firmness  of  the  connective  tissue  and  the  presence  of  large  branches 
of  the  uterine  artery.  Bleeding  vessels  should  be  secured  at  once  with  pressure 
forceps  and  then  tied.  As  soon  as  the  cervix  is  freed  all  round,  the  knife  is  car- 
ried through  the  anterior  wall  at  the  required  height,  obliquely  upward  toward  the 
canal,  and  a  conical  portion  excised  from  the  interior.  The  anterior  and  pos- 
terior vaginal  walls  are  stitched  to  the  lips  of  the  cervix,  and  sutures  are  also 
inserted  laterally  ;  they  heljj  to  control  the  hemorrhage.  The  ureters  retract  so 
that  they  are  not  in  danger  of  being  caught.  By  this  operation  a  considerable 
portion  of  the  body  of  the  uterus  may  ije  removed  as  well  as  the  cervix.  It  is  not 
free  from  danger;  even  with  the  best  statistics  there  is  a  mortality  of  twelve  per 
cent. 

Extirpation  of  the  Uterus. — This  may  be  done  either  by  abdominal  section 
through  the  vagina  [or  through  the  sacrum]  ;  the  mortality  in  the  case  of  the 
former  [formerly  high,  has  now  been  brought  so  low  by  improved  technique  as  to 
cause  it  to  be  preferred.  The  whole  uterus  is  rarely  removed  in  comparison  with 
partial  removal.  The  cervix  is  usually  retained,  as  in  the  following  operation  : 
The  operation  consists  in  the  removal  of  all  that  portion  of  the  uterus  above  the 
vagina,  and  is  thus  performed  :  The  abdomen  is  opened  rapidly  through  the 
median  line  and  the  uterus  disengaged  by  the  hand  or  fingers  from  its  superficial 
adhesions,  a  sound  is  passed  into  the  bladder  to  establish  the  exact  relation,  and 
when  entirely  free  an  elastic  cord  ligature  is  placed  tightly  around   the  cervix  ; 


CARCINOMA   OF  THE  UTERUS.  1167 

some  surgeons  with  two  heavy  ])ins  transfix  the  uterus  just  above  the  point  of 
application  of  the  ligature,  to  keep  it  from  slipping  and,  as  well,  from  including 
a  portion  of  the  bladder.  The  uterine  adnexa  are  then  tied  and  removed,  an 
antero-posterior  incision  made,  and  the  uterus  with  the  tumor  removed.  The 
uterine  stump  is  now  cauterized  with  the  Paccpielin  cautery  to  prevent  infection  of 
the  wound.  If  intended  to  treat  it  extra-i)eritoneal,  the  stump  is  now  drawn  out 
of  the  wound,  leaving  the  pins  and  the  ends  of  the  elastic  ligature  projecting.  If 
an  intra-peritoneal  method  is  desired,  the  stump,  after  cauterization  with  acid  or 
actual  cautery,  must  be  carefully  sutured  and  the  peritoneal  coat  of  the  uterus 
brought  in  accurate  ai)position.  By  the  extra-peritoneal  method  (Hegar),  the 
stump  being  brought  out  of  the  wound,  and  the  abdominal  wound  made  to  enclose 
it  firmly,  the  cut  surface  is  thus  extra-peritoneal,  and  the  possibility  of  infection 
reduced  to  a  minimum.  The  wound  is  dressed  by  placing  a  tamjjonade  of  cotton 
over  it,  wet  with  solution  bichloride  of  mercury  or  chloride  of  zinc,  and  over  that 
iodoform  gauze.] 

The  first  steps  in  vaginal  hysterectomy  are  identical  with  those  already  de- 
scribed for  supravaginal  amputation  of  the  cervix  ;  the  later  ones  admit  of  innu- 
merable modifications.  A  circular  incision  is  made  in  the  vaginal  vault,  the  blad- 
der separated  from  the  cervix  as  far  as  the  utero-vesical  fold  of  peritoneum,  and  a 
free  opening  made  into  Douglas's  pouch.  Two  fingers  of  the  left  hand  are  passed 
in  over  the  fundus  uteri  into  the  vesico-uterine  pouch,  and  the  peritoneum  is 
divided  anteriorly  by  cutting  down  upon  them  through  the  wound  in  front  of  the 
cervix.      The  uterus  is  now  free  in  front  and  behind. 

The  uterus  must  now  be  forcibly  pulled  down.  If  it  can  be  brought  outside 
and  fully  exposed,  the  broad  ligaments  may  be  secured  by  ligatures,  and  the  uterus 
cut  away.  If  this  cannot  be  done  the  ligament  must  be  clamped  on  one  side  as 
close  to  the  uterus  as  possible,  and  then  the  tissues  divided  on  the  uterine  side. 
There  is  no  difficulty  then  in  transfixing  the  other  ligament,  ligaturing  it  in  two 
halves,  and  cutting  it  away.  The  clamp  may  either  be  left  on  for  forty-eight  hours 
or  ligatures  maybe  applied  to  this  as  well.  If  the  ovaries  and  Fallopian  tubes  are 
allowed  to  remain,  the  stumps  are  sufficiently  long  to  ligature  easily  ;  but  if  they 
are  removed  the  ligatures  are  liable  to  slip. 

Another  method  is  to  secure  the  broad  ligaments  in  segments,  first  on  one 
side  and  then  on  the  other,  drawing  dowm  the  uterus  bit  by  bit,  in  a  zigzag 
manner. 

Great  care  must  be  taken  to  avoid  injury  to  the  ureters  or  including  them  in 
the  ligatures.  These  must  be  placed  as  near  the  cervix  as  possible  ;  the  ureters 
are  less  than  half  an  inch  to  the  side — higher  up  they  are  a  little  further  off. 

No  sutures  are  required  ;  the  parts  fall  naturally  into  apposition.  If  the 
clamps  are  used  and  left  they  serve  as  a  drain  ;  if  not,  a  glass  tube  must  be  passed 
into  the  peritoneal  cavity  and  left  for  three  or  four  days.  If  the  discharge  becomes 
offensive  the  wound  must  be  thoroughly  irrigated  with  an  antiseptic  by  means  of 
a  catheter.  The  tube  should  be  surrounded  with  antiseptic  wool  where  it  lies  be- 
tween the  labia,  but  any  further  plugging  is  unnecessary.  Hemorrhage  is  the 
chief  risk,  either  during  or  after  the  operation. 

Caution  must  be  exercised  in  separating  the  bladder,  as  its  walls  are  very 
thin. 

Mortality. — In  amputation  of  the  cervix  with  the  cautery  this  is  only  7  per 
cent.  ;  in  the  supravaginal  operation,  the  best  results  give  12  per  cent.  ;  but  in 
complete  extirpation  it  is  as  high  as  28.6  per  cent.  This,  however,  cannot  be 
regarded  as  final.     Later  results  are  much  better,  as  might  have  been  expected. 

The  prognosis,  so  far  as  cure  is  concerned,  is  very  unsatisfactory.  Recur- 
rence either  in  the  scar  or  in  the  periuterine  tissue  invariably  occurs  within  a  few- 
months. 

Cancer  of  the  body  is  so  rare  and  so  seldom  diagnosed  in  time  that  complete 
extirpation  can  hardly  ever  be  performed. 


1 1 68    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

Operations  about   thf.  Vulva  and  Vagina. 

Vascular  tumors  fre(]iiently  occur  at  the  orifice  of  the  female  urethra.  They 
form  small,  florid  excre.scences,  sometimes  attaining  the  size  of  a  large  pea,  and 
give  rise  to  increased  fre(iuency  and  pain  on  micturition,  with  hemorrhage  not 
unfrequently.  Sometimes  the  symptoms  bear  some  resemblance  to  those  of  cal- 
culus in  the  bladder.  The  mucous  membrane  around  and  extending  up  the 
urethra  is  often  involved  in  the  va.scular  growth.  The  tumor  should  be  removed 
with  a  pair  of  fine-pointed  scis.sors.  If  the  mucous  membrane  is  involved,  it  must 
be  thoroughly  treated  with  the  cautery.     The  condition  is  very  liable  to  recur. 

Cysts  of  the  labium  are  generally  due  to  obstruction  of  the  duct  of  Bartholin's 
gland.  The  cyst  usually  contains  a  glairy,  colorless  fluid  and  is  very  liable  to  sup- 
purate. Simple  incision  is  not  sufficient ;  the  cyst  invariably  refills  ;  if  jjossible, 
it  .should  be  enucleated,  and  if  this  cannot  be  done  a  portion  of  the  wall  should 
be  excised  and  the  interior  thoroughly  cauterized  with  nitrate  of  silver. 

Fibrous  and  fatty  tumors  are  occasionally  met  with  in  the  labium,  and  need 
no  special  comment. 

Cysts  of  the  vagina  diXQ  not  of  very  infrequent  occurrence.  They  re.sult  from 
distention  of  mucous  follicles,  and  sometimes  attain  the  size  of  a  small  egg.  When 
small  they  cause  no  trouble  ;  when  large  they  produce  the  symptoms  of  a  foreign 
body,  and  may  excite  a  chronic  leucorrhcjea.  A  portion  of  the  cyst-wall  should 
be  excised  and  the  interior  of  the  sac  freely  cauterized.  Enucleation  should  not 
be  attempted. 

Vesico-vaginal  fistuhe  result  usually  from  sloughing  following  protracted  and 
difficult  labor,  or  ulceration  around  a  foreign  body  impacted  in  the  vagina.  They 
give  rise  to  great  distress,  owing  to  the  constant  escape  of  the  urine  and  the  irrita- 
tion of  the  skin  which  it  causes.  The  fistulas  vary  much  in  size — some  hardly 
admit  a  probe.  In  severe  cases  nearly  the  whole  of  the  anterior  wall  of  the  vagina 
may  be  destroyed.  When  small,  the  opening  may  be  detected  by  filling  the 
bladder  with  milk  ;  the  point  where  it  flows  into  the  vagina  will  then  be  readily 
seen  through  a  speculum.  Vesico-vaginal  fistula  is  most  usually  found  about  half 
an  inch  in  front  of  the  cervix  uteri,  sometimes  close  to  it.  Very  occasionally  it 
opens  into  the  uterus  itself — utero-vesical.  When  the  fistula  is  very  small,  touch- 
ing it  with  the  actual  cautery  may  succeed  in  closing  it,  but  the  proceeding  usually 
terminates  in  failure,  and  an  operation  has  to  be  undertaken.  The  patient  may 
be  placed  either  in  the  lithotomy  or  semiprone  position,  a  duck-bill  speculum 
introduced,  and  the  uterus  drawn  down  as  low  as  possible  with  a  tenaculum.  The 
edges  of  the  fistula  should  then  be  pared  and  brought  together  with  sutures  j^laced 
sufficiently  close  to  prevent  the  passage  of  urine  between  them.  The  operation 
is  often  very  tedious  and  difficult,  on  account  of  the  difficulty  in  getting  at  the 
parts.  Various  ingenious  needles  and  needle-holders  have  l)een  invented  with  a 
view  to  overcome  this.  The  bladder  should  be  emptied  by  a  catheter  every  eight 
hours  for  the  first  three  days,  and  the  stitches  removed  at  the  end  of  a  week. 

Recto-vaginal  fistuhe  may  occur  from  the  same  causes  as  the  preceding.  They 
are  commonly  situated  just  within  the  entrance  of  the  vagina,  and  may  be  treated 
in  a  similar  way. 

Laceration  of  the  cervix  uteri  is  also  a  result  of  labor.  It  is  frequently  at- 
tended with  great  hyj)erplasia  and  cystic  degeneration  ;  the  lips  tend  to  become 
everted  (ectropion)  and  expose  the  inner  surface  of  the  cervical  canal ;  this  exposed 
surface  very  soon  becomes  denuded  of  epithelium,  and  is  the  source  of  a  profuse 
catarrhal  leucorrhaa  ;  the  condition  ]>ersists  indefinitely  and  may  be  the  cause  of 
many  troubles,  both  local  and  general.  "  Trachelorrhaphy  "  is  the  term  applied 
to  the  oi)eration  proposed  by  Emmet  for  the  rej)air  of  the  laceration. 

The  patient  is  i)laced  in  the  lithotomy  position,  and  the  uterus  drawn  down  as 
far  as  possible  by  means  of  a  tenaculum.  The  lacerated  surfaces  are  well  expo.sed, 
and  a  strip  of  mucous  membrane  removed  on  either  side,  leaving  a  broad  tract  un- 
denuded  between  them  ;   this  tract  will  form  the  cervical  canal  and  external  os 


RUPTURED  PERINEUM.  1,69 

when  the  operation  is  completed  ;  the  flaps  are  then  approximated  and  the  sutures 
applied.  The  insertion  of  the  sutures  is  not  an  easy  matter,  owing  to  the  difficulty 
of  getting  at  the  parts  and  the  toughness  of  the  uterine  tissue.  A  short,  very  stout, 
and  slightly-curved  needle  is  required  and  a  strong  needle  holder  ;  the  needle  should 
be  armed  with  a  silk  loop,  and  when  it  has  been  inserted  through  both  lips,  a  silver 
wire  threaded  into  the  loop  should  be  drawn  into  position  ;  three  or  four  sutures 
will  be  required  on  either  side  ;  they  are  best  secured  with  a  coil  and  clamped  shot, 
and  one  end  left  long  to  facilitate  removal.  They  may  be  removed  on  the  .seventh 
day,  though  some  prefer  to  leave  them  until  the  tenth  or  even  longer,  as  they  seem 
to  cause  but  little  irritation.  The  operation  should  not  be  undertaken  if  there  is 
any  pelvic  inflammation  or  cellulitis. 

Rupture  of  the  pei-ineum  is  also  an  accident  of  labor.  It  may  be  "  partial  " 
only,  extending  through  the  fourchette,  or  "complete,"  involving  the  sphincter 
ani  and  more  or  less  of  the  recto-vaginal  septum.  An  attempt  should  always  be 
made  to  repair  the  injury  at  the  time  of  the  accident,  although  it  is  not  always  suc- 
cessful. Innunlerable  modifications  have  been  proposed,  and  are  employed  jjy  dif- 
ferent operators  in  the  repair  of  the  perineum.  The  operation  for  complete  rupture 
is  as  follows  :  The  bowels  having  been  well  opened  and  an  enema  administered 
the  same  morning,  the  patient  is  placed  in  the  lithotomy  position.  An  assistant 
stands  on  either  side  supporting  the  patient's  knee  under  his  arm  ;  with  one  hand 
he  draws  the  labia  apart,  and  the  other  is  free  to  assist  the  operator.  Sitting  in 
front  of  the  patient,  the  operator  inserts  the  first  and  second  fingers  of  his  left  hand 
into  the  anus,  and  putting  the  parts  upon  the  stretch,  he  denudes  the  surface  in  the 
following  manner :  At  a  point  about  half  an  inch  external  to  the  septum,  the  point 
of  a  scal]jel  or  pair  of  scissors  is  passed  into 

the  tissues  and   carried  along  between  the         ^^._.^_—  ^^  ,  _^     ^   -_ 
mucous  surfaces  of  the  vagina  and  rectum,        v  '     -j.- 

dividing  the  septum  into  an  anterior  and 
posterior  flap  ;  the  incision  is  terminated  at 
an  equidistant  jjoint  upon  the  opposite  side. 
Sometimes  the  line  of  incision  is  more  or 
less  marked  out  by  an  area  of  pale  cica- 
tricial   tissue,    but    this    is    not   always   so. 

From    either    extremitv   of  this    transverse  .^.      .      ,  .,_..      .       ,,^ 

incision,  another  is  carried  forward  to  the  "^  SS^^     )     rS' 

lesser  labium,  and  backward  to  the  extrem- 
ity of  the  anal  orifice.     In  this  manner  an 
H-shaped    incision    is    formed.     The    inci- 
sions must  be  freely  made,  or  the  surface  de-  —  - 
nuded  will  be  insufficient  to  form  a  strong                 — —-I 
perineum,  and  the  flaps  will  require  further  ~i'V"  -—• 
dissecting   up.     Hemorrhage    is    generally 
considerable,  but  can  be  kept  in  check  by     " -^^^^^ii-^-^-  .^' 
sponges  and  pressure  forceps  ;   ligatures  are                                                 - 

not    required.        The     free     edge    of     the     an-        Fig.  505.— incision  in  Rupture  of  the  Perineum 

terior  flap  is  secured  by  a  couple  of  forceps 

and  held  up  by  the  assistants  on  either  side  ;  the  sutures  are  then  inserted.  Some 
prefer  to  bring  together  the  mucous  membrane  of  the  anus  first,  but  no  advantage 
is  gained  by  this.  Either  silver  wire  or  silk-worm  gut  may  be  employed.  Com- 
mencing at  the  lower  part,  the  needle,  which  is  moderately  curved  and  mounted 
on  a  strong  handle,  is  entered  on  one  side  about  a  quarter  of  an  inch  from  the 
margin,  or,  as  represented  in  the  figure,  into  the  denuded  surface  just  within  the 
margin.  ■  It  is  then  carried  between  the  layers  of  the  recto-vaginal  sejjtum  and 
brought  out  in  the  middle  of  the  denuded  surface,  threaded  with  one  end  of  the 
suture,  and  withdrawn.  The  needle  is  then  passed  on  the  opposite  side  in  a  similar 
manner,  the  point  being  made  to  emerge  at  the  same  hole.  It  is  threaded  with 
the  other  end  of  the  wire,  withdrawn,  and  the  suture  thus  completed.     Three  or 


II70    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTLRES. 

four  sutures  are  passed  in  this  way  through  the  recto-vaginal  septum  :  one  or  two 
more  are  reipiired  in  front,  and  one  or  two  for  the  rectum.  In  passing  the  rectal 
and  vaginal  stitches,  care  must  be  taken  to  enter  them  just  at  the  cut  edge  of  the 
mucous  membrane,  so  that  perfect  adajjtation  of  the  raw  surfaces  may  be  ensured. 

The  sutures  having  been  all  inserted,  the  wound  is  carefully  sponged,  and  the 
patient's  knees  brought  together.  The  sutures  are  then  tied  firmly,  but  not  too 
tightly,  commencing  from  the  lowest  ;  the  wire  may  either  be  twisted  or  secured 
with  shot  and  coil.  The  wound  is  dressed  with  some  absorbent  wool  and  a  T- 
bandage  applied.  A  morphia  suppository  should  be  administered,  as  the  pain  after 
the  operation  is  often  very  considerable. 

The  repair  of  a  partial  rupture  is  generally  unattended  with  much  difficulty. 


1  i 


\ 


Fk;.  506. — Method  of  Inserting  Sutures.  Fig.  507. — Sutures  in  a  case  of  Ruptured  Perineum. 

A  V-.shaped  incision  is  made  through  the  integuments,  the  apex  being  just  in  front 
of  the  untorn  remains  of  the  perineum  and  the  branches  extending  to  the  labium 
minus  on  either  side.  The  anterior  extremities  of  these  are  united  by  an  incision 
which  crosses  the  mucous  membrane  about  an  inch  and  a  half  from  the  apex,  and 
the  enclosed  surface  is  then  denuded  ;  or  the  V-shaped  flap  may  be  dissected  up 
and  carried  forward.     Sutures  are  inserted  as  in  the  previous  operation. 

The  after-treatment  consists  in  keeping  the  parts  clean.  The  catheter  is 
required  every  eight  hours  for  some  days.  The  bowels  generally  have  a  tendency 
to  act  of  themselves  about  the  fourth  or  fifth  day.  This  may  be  encouraged  by  a 
mild  aperient  followed  by  an  enema.  It  adds  greatly  to  the  discomfort  of  the 
patient  to  keep  them  confined  by  means  of  opium,  and  is  quite  unnecessary.  The 
stitches  may  be  removed  about  the  eighth  or  tenth  day. 


DISEASES  OF  THE  NIPPLE.  1171 


CHAPTER  XXVI. 

DISEASES  OF   THE  BREAST. 

Ahnormal  Development. 

Complete  absence  of  the  mammary  gland  is  very  rare  ;  imperfect  evolution  at 
puberty,  the  breast  retaining  the  infantile  type,  is  not  unfrequent,  especially  when 
the  sexual  organs  are  not  developed. 

Polymastia  is  more  common.  In  most  instances,  the  supernumerary  struc- 
tures are  rjuite  rudimentary,  merely  imperforate  nipples  with  a  linear  depression 
and  no  areola;  but  sometimes  they  are  well-formed  glands,  functionally  active. 
Usually  they  lie  in  pairs  along  the  line  of  the  internal  mammary  artery,  and  are 
lower  down  upon  the  thorax  ;  but  a  few  instances  are  recorded  in  which  they  have 
been  found  above  the  normal  level,  in  the  median  line,  and  even  in  distant  parts  of 
the  body  and  upon  the  limbs.  In  addition  to  this,  milk-producing  tracts  of  integu- 
ment, and,  more  rarely,  small,  well-defined  glands,  are,  as  Champneys  has 
pointed  out,  occasionally  developed  in  the  axillary  region  during  the  lying-in 
period. 

Hypertrophy. — Proportionate  overgrowth  of  all  the  parts  of  the  breast  is  very 
rare,  but  cases  of  enormous  and  rapid  enlargement,  affecting  the  connective  tissue 
only,  are  not  uncommon  in  young  women  about  the  time  of  puberty,  and  even  in 
men.  It  may  affect  one  side  or  both,  and  the  size  may  be  so  great  that  the  patient 
is  scarcely  able  to  support  the  weight.  The  skin  is  thickened  and  rather  coarser 
in  texture,  and  the  areola  much  longer  than  natural ;  but  in  other  respects  there 
is  no  very  conspicuous  alteration,  and  the  consistence  is  perfectly  uniform,  which 
serves  to  distinguish  this  at  once  from  enlargement  due  to  rapidly  growing  tumors. 
Nothing  is  known  as  regards  cause,  and  no  treatment  has  any  effect.  Excision 
may  be  performed  if  the  inconvenience  becomes  extreme,  but  the  operation  is  not 
a  light  one.  In  a  few  cases  the  enlargement  increases  very  seriously  during  preg- 
nancy ;  in  the  majority  the  breast  either  fails  to  secrete  altogether,  or  does  so  only 
to  a  very  limited  extent. 

Affections  of  the  Nipple  and  Areola. 

Inflammation  of  the  nipple  is  of  common  occurrence  during  lactation,  owing 
to  the  constant  moisture  and  friction  to  which  the  part  is  subjected.  The  delicate 
epidermis  is  detached,  leaving  a  superficial  excoriation  ;  this  deepens  into  a  fissure, 
usually  between  the  rugae  or  at  the  base,  and  in  bad  cases  ends  in  serious  ulcera- 
tion. The  pain  when  the  part  is  touched,  or  an  attempt  is  made  at  suckling,  is 
simply  agonizing,  and  even  when  mammary  abscess  does  not  follow,  often  leads 
to  grave  impairment  of  health  and  strength. 

It  usually  occurs  with  the  first  child,  and  in  those  whose  nipples  are  ill-de- 
veloped. During  the  period  of  pregnancy  the  skin  should  be  carefully  hardened 
by  bathing  it  night  and  morning  with  spirits  and  water,  and,  if  there  is  any  need 
for  it,  the  nipple  should  be  gently  drawn  out  by  suction  through  a  properly  con- 
trived tube.  Afterward  the  greatest  care  must  be  taken  to  keep  it  as  dry  as 
possible,  and  to  cleanse  it  thoroughly  every  time  the  child  leaves  it.  If  there  is 
the  least  excoriation,  a  mild  or  soothing  ointment,  such  as  almond  oil,  may  be 
applied,  and  a  shield  should  be  used.  If  it  continues  and  forms  a  fissure,  it  may 
be  necessary  to  make  use  of  a  breast-pump,  in  order  to  save  the  patient  the  pain. 
Lead  lotion,  glycerine  and  tannic  acid,  styptic  colloid,  and  similar  remedies 
may  be  used  at  first  (taking  care  that  the  nipple  is  cleansed  before  the  child 
is  put  to  it)  ;  but  if  the  ulceration  persists,  it  is  better  to  touch  the  base  with 


1 1 72     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

nitrate  of  silver,  the  pain  being  prevented  by  applying  a  solution  of  cocaine 
first.  When  the  scab  drops  off,  the  epidermis  is  sound  beneath,  though  very 
thin. 

In  addition  to  this,  eczema  of  the  nipple  is  occasionally  met  with  during 
suckling,  the  locality  being  determined  in  all  probability  by  the  continual  moist- 
ure ;  abscesses  may  occur  in  connection  with  the  sebaceous  glands  of  the  areola  ; 
small  sebaceous  cysts  and  papillomata  may  develop,  and,  especially  in  wet-nurses, 
typical  syphilitic  chancres  may  form,  the  infection  being  derived  from  the  fissures 
and  mucous  patches  so  commonly  found  at  the  angles  of  the  mouths  of  infants 
suffering  from  hereditary  disease. 

Facet's  Disease. 

Eczema  of  the  nipple  must  be  distinguished  from  a  peculiar  disease  of  the  skin 
closely  resembling  it,  which  was  first  described  by  Paget,  and  which  is  of  great 
im{X)rtance  from  the  frequency  with  which  it  ends  in  carcinoma.  It  affects  the 
nipple  and  the  areola.  The  surface  in  most  cases  is  raw,  intensely  red,  and  finely 
granular,  like  that  of  an  acute  diffuse  eczema,  with  a  copious  yellow  and  viscid 
discharge.  In  others  it  resembles  a  more  chronic  form,  or  it  is  like  psoriasis, 
spreading  beyond  the  areola,  and  covering  the  breast  with  scattered  blotches. 
Nearly  always  there  is  itching  and  sometimes  a  sensation  of  burning.  The  base  is 
always  considerably  thickened,  and  occasionally  the  ulceration  is  so  extensive  as  to 
lead  to  destniction  of  the  nipple. 

The  chief  features  distinguishing  it  from  ordinary  eczema  are  the  well-defined 
margin  it  presents,  and  the  evidence  of  deeper  infiltration  of  the  papillary  layer 
of  the  corium.  What  proportion  of  cases  ends  in  carcinoma  (it  is  probably  a 
large  one),  and  how  long  it  continues  before  this  breaks  out.  are  questions  still 
unsettled,  but  the  intimate  connection  of  the  two  (though  not  their  identity),  may 
be  considered  as  w^ell  established.  The  usual  form  is  duct  or  villous  carcinoma, 
but  the  squamous  typ)e  may  occur. 

The  microscopic  appearances,  according  to  the  earlier  observers,  merely  pre- 
sented a  certain  degree  of  proliferation  of  the  deeper  layer  of  the  epithelium, 
with  small-celled  infiltration  of  the  corium  beneath,  dilatation  of  the  ducts,  pro- 
liferation of  the  secreting  cells  in  the  acini,  and  finally  the  invasion  of  the  epi- 
thelium and  the  development  of  carcinoma.  Recently,  however,  another  signifi- 
cation has  been  assigned  by  Darier,  Wickham,  and  others,  to  certain  peculiar 
highly  refractile  cells  that  are  present  in  the  epidermis  and  in  the  ducts  of  the 
milk  and  sweat  glands,  and  are  usually  best  developed  at  the  growing  margin. 

They  may  be  found,  in  a  scraping  of  the  surface  mixed  with  water,  though 
their  relation  to  the  other  cells  can  only  be  seen  in  sections.  When  small,  they 
are  difficult  to  distinguish  ;  as  they  increase  in  size  a  doubly  refracting  membrane 
forms  around  them  ;  the  other  cells  are  pushed  aside  or  altered  in  shape,  and  at 
length  they  develop  into  {peculiar  rounded  bodies,  much  larger  than  the  other 
cells,  and  either  containing  a  mass  of  protoplasm,  or  else  divided  in  two,  very 
much  in  the  fashion  of  a  S|X) re-bearing  cyst.  The  irritation  causes  the  sui>erficial 
layers  to  desquamate,  the  inter-papillary  processes  grow  larger,  and  at  length  the 
exudation  accumulates  to  such  an  extent  that  the  line  of  separation  between  the 
epithelium  and  the  corium  disappears. 

These  cells  are  said  to  be  psorosperms  or  coccidia,  and  to  belong  to  the 
sporozoa.  Undoubtedly  they  are  characteristic  of  the  eczematous  stage,  and, 
according  to  Wickham,  they  occur  not  only  in  the  consecutive  carcinoma,  but  in 
other  forms  of  cancer  as  well.  Similar  structures  have  been  described  in  connec- 
tion with  moUuscum  contagiosum.  Cultivation  has  not  succeeded,  but  it  is  signifi- 
cant that  after  maceration  in  water  for  sixteen  days,  when  all  else  had  disappeared, 
they  still  remained  intact. 

Free  removal  is  the  only  treatment.  In  many  cases  this  means  excision  of 
the  breast,  as  the  nipple  with  the  areola  and  the  skin  around  must  be  taken  away. 


INFLAMMATION  OF  THE  BREAST.  1173 

It  is  possible,  however,  if  the  view  that  the  disease  is  really  the  product  of  these 
psorosperms  receives  confirmation,  that  microscopic  examination  of  obstinate  cases 
of  eczema  may  lead  to  earlier  operation,  while  the  disease  is  still  limited,  and 
before  such  drastic  measures  are  necessary. 


INFLAMMATION  OF  THE  BREAST. 

Inflammation  of  the  mammary  gland  may  be  acute  or  chronic.  The  latter 
(with  chronic  abscess)  will  be  dealt  with  by  itself,  as  its  pathology  is  not  certain. 

Acute  Inflammation. 

This  is  common  at  birth,  puberty,  and  during  lactation.  At  other  times  of 
life  it  may  be  caused  by  violence,  but  it  is,  comparatively  speaking,  rare,  and 
syphilis,  tubercle,  and  other  specific  diseases  seldom  attack  the  gland  (chancre,  of 
course,  is  different).  The  starting  point  is  usually  some  slight  injury,  such  as 
friction  or  a  blow.  When  it  occurs  at  birth  or  puberty,  it  nearly  always  under- 
goes resolution,  although  suppuration  may  occur  as  in  other  parts.  On  the  other 
hand,  when  it  breaks  out  during  lactation,  suppuration  is  exceedingly  common, 
the  pyogenic  organisms  entering  either  through  cracks  and  fissures  of  the  nipple, 
or,  po.ssibly,  finding  their  way  up  the  ducts  into  the  acini  and  the  periacinous 
spaces. 

1.  At  Birth. — The  breasts  of  infants  of  both  sexes  often  secrete  a  milk-like 
fluid  for  a  few  days  after  birth.  The  gland  is  slightly  swollen  on  the  third  or 
fourth  day ;  this  reaches  its  maximum  by  the  end  of  the  week,  and  then  subsides. 
The  only  treatment  necessary  is  to  protect  the  part  from  injury.  If  the  skin  is 
very  hot,  or  the  swelling  continues  to  increase,  a  compress  wetted  with  warm  lead 
lotion  may  be  laid  upon  it,  but  no  attempt  should  be  made  to  rub  the  milk  away. 
If  suppuration  occurs,  it  must  be  treated  as  an  ordinary  abscess. 

2.  .At  Puberty. — The  same  thing  is  occasionally  met  with  at  this  time,  owing 
to  the  rapid  developmental  changes  that  take  place,  but  unless  there  is  some  injury, 
or  the  general  health  is  greatly  enfeebled,  suppuration  rarely  occurs. 

3.  During  Lactation. — Toward  the  end  of  pregnancy,  and  during  the  first 
few  weeks  of  lactation,  inflammation  of  the  mammary  gland  is  exceedingly  com- 
mon, as  might  be  expected  from  the  extreme  rapidity  and  extensive  character  of 
the  changes  through  which  it  passes.  It  may  be  caused  by  any  trivial  injury, 
even  the  persistent  drawing  of  an  infant  at  a  breast  that  cannot  secrete,  or  the 
accumulation  of  the  milk  in  one  of  the  lobes.  The  whole  gland,  or  the  affected 
part,  becomes  even  more  tender  than  the  rest,  and  very  painful.  When  touched, 
it  feels  firm  and  dense,  and  if  the  area  involved  is  large  or  near  the  surface,  the 
skin  is  redder  and  warmer  than  that  of  the  opposite  side.  In  addition,  there  is 
usually  a  certain  degree  of  feverishness,  with  thirst  and  anorexia,  but  it  is  difficult 
in  most  cases  to  say  how  far  this  arises  from  the  affection  of  the  gland.  Distinct 
chills  rarely  occur  without  suppuration.  The  same  thing  may  take  place  toward 
the  end  of  prolonged  lactation,  especially  in  those  women  who  are  weakened  by 
having  borne  many  children  in  rapid  succession,  and,  more  rarely,  at  other  times 
when  the  gland  is  entirely  inactive. 

The  treatment  depends  upon  the  condition  of  the  gland.  If  it  is  at  rest,  the 
inflammation  is,  as  a  rule,  merely  periglandular,  and  it  is  sufficient  to  confine  the 
arm  to  the  side  (or,  if  the  attack  is  severe,  place  the  patient  in  the  recumbent 
position),  cover  the  breast  with  compresses  moistened  with  lead  lotion,  and  pack 
it  so  as  to  exert  a  certain  amount  of  uniform  gentle  compression.  Cold  is  very 
beneficial,  and  may  be  conveniently  applied  with  Leiter's  coils,  but  many  patients 
are  inclined  to  resent  it.  If,  however,  the  gland  is  in  a  state  of  functional  activity, 
this  is  not  sufficient.  The  nipple  must  be  carefully  examined  to  see  if  there  are 
any  obstructed  ducts.     Hardened  lobules  must  be  gently  rubbed  away  with  fric- 


1 1 74    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

tion  toward  the  nipple.  The  milk  must  l)e  drawn  off  witli  a  hreast-piimp,  or  better 
with  a  suction  tube.  The  patient  must  l)e  confined  to  bed,  the  breast  well  sup- 
ported from  beneath  and  at  the  side,  and  gentle  pressure  ai)plied  around  the  gland, 
except  toward  the  axillary  border.  If  this  does  not  succeed,  lead  lotion,  or  lead 
with  opium  or  belladonna,  may  be  applied  ;  but,  as  a  rule,  if  the  attack  is  taken  in 
time,  these  may  be  dispensed  with.  Constitutional  measures  must  be  guided  by 
the  condition  of  the  patient.  If  the  gland  is  at  rest,  or  if  the  inflammation  com- 
mences in  the  earlier  weeks  of  lactation,  and  the  attack  is  acute,  and  the  bowels 
confined,  saline  purgatives  are  very  beneficial.  If,  on  the  other  hand,  the  patient 
is  weak  and  exhaustetl,  and  has  been  already  suckling  too  long,  the  bowels  may 
require  to  be  opened,  but  (piinine  and  other  tonics  should  be  given  instead. 

Mammary  Abscess. 

Suppuration  occurring  in  the  mammary  gland  at  birth  or  puberty  requires  no 
special  description  ;  it  follows  inflammation  as  a  natural  consecpience  if  the  vitality 
of  the  tissues  is  much  lowered,  and  if  the  pyogenic  organisms  are  brought  in  suffi- 
cient numbers  by  the  blood.  That  variety,  however,  which  breaks  out  toward 
the  end  of  pregnancy  or  during  lactation,  when  the  gland  is  in  a  state  of  full 
physiological  activity,  is  very  different. 

It  usually  occurs  either  with  the  first  child,  in  the  first  few  weeks  after  partu- 
rition (and  then  it  is  nearly  alway  associated  with  cracked  or  defective  nipples), 
or,  in  those  who  have  borne  many  children,  as  a  result  of  unduly  i)rolonged  lacta- 
tion. One  or  more  of  the  lobules  become  inflamed  ;  the  pyogenic  organisms  gain 
entrance,  sometimes  through  the  blood-stream,  much  more  fretjuently  through  some 
minute  excoriation  of  the  nipple  (the  lymphatics  of  the  breast  radiate  from  this 
point  through  the  gland  to  its  base,  and  then  for  the  most  part  run  on  the  surface 
of  the  pectoral  fascia  to  the  axilla),  or,  perhaps,  through  the  ducts  themselves; 
and  suppuration  follows,  diffuse  or  limited,  according  to  the  size  of  the  area  in- 
flamed and  the  vitality  of  the  tissues  involved. 

It  is  usual  to  divide  mammary  abscesses  into  three  classes,  according  to  their 
situation — superficial,  intraglandular,  and  submammary. 

{a)  Superficial  Abscesses. — These  require  no  sjjecial  description  ;  they  should 
be  opened  and  drained  as  soon  as  the  diagnosis  is  made,  to  prevent  the  skin  becom- 
ing undermined. 

ij))  Intrai:[/anditlar  ones  are  more  serious.  It  is  i)robable  that  they  may  begin 
either  in  the  lobes  themselves,  or  in  the  loose  cellular  tissue  around  them  ;  but  it 
is  rarely  possible  to  distinguish  one  from  the  other.  The  earlier  symptoms,  those 
due  to  the  inflammation,  have  been  described  already;  sui)puration  may  begin 
acutely,  with  a  definite  chill ;  more  frequently  the  pain  and  swelling  merely  grow 
worse  and  worse  ;  the  breast  becomes  larger  and  larger  (the  ni[)ple  often  being 
retracted  owing  to  the  tension  on  the  ducts)  without  its  being  possible  to  indicate 
any  definite  locality  as  the  seat  of  the  mischief,  and  the  constitutional  symptoms 
more  and  more  severe.  After  a  few  days,  when  the  tough  fibrous  tissue  that  sur- 
rounds the  suppurating  lobule  (if  it  commences  in  one)  has  given  way,  there  is 
often  a  certain  degree  of  improvement  ;  the  pain  is  less  severe,  and  the  tempera- 
ture falls  a  little  ;  then,  by  degrees,  the  skin  at  one  spot  becomes  thickened, 
oedematous,  and  tied  down,  giving  some  indication  as  to  the  direction  in  which 
the  suppuration  is  progressing,  and  at  length  one  spot  softer  than  the  rest  can  be 
made  out  in  the  centre  of  the  swelling. 

The  sooner  the  pus  is  evacuated  the  better,  but  it  is  necessary  to  wait  until 
some  idea  can  be  gained  as  to  its  position  and  the  direction  it  is  following  ;  explor- 
atory operations  in  a  breast  in  a  state  of  full  physiological  activity  are  not  advis- 
able. The  incision  should  be  free,  radiating  from  the  nipple  so  as  not  to  cut  the 
ducts  across,  and  suitably  arranged  for  drainage.  As  the  interior  of  the  abscess  is 
always  irregular  in  shape,  it  should  be  thoroughly  explored  with  the  finger  ;  a 
drainage-tube  introduced  into  every  pocket ;  and  the  whole  circumference  packed 


INFLAMMATION  OF  THE   BREAST.  1175 

with  soft  absorbent  dressings,  so  that  the  Ihiicl  that  exudes  may  be  driven  toward 
the  opening.  More  than  one  incision  may  be  required  if  the  abscess  is  allowed 
to  burrow  in  all  directions  through  the  gland  before  it  is  opened.  Such  cases, 
and  still  more  those  in  which  the  pus  is  left  to  work  its  way  out  as  it  pleases,  often 
leave  irregular  sinuses  which  persist  for  years,  draining  the  patient's  strength,  and 
ultimately  leading  to  the  destruction  of  the  gland  as  a  secreting  organ. 

(f)  Submammary  abscesses  are  fortunately  rare.  They  may  commence  in  the 
deeper  lobes  of  the  gland  and  spread  through  the  subjacent  fascia,  or  be  due  to 
direct  infection  through  the  lymphatics.  In  many  cases  they  are  a.ssociated  with 
symptoms  of  pyasmia,  and  probably  they  are  often  embolic.  The  breast  itself  is 
but  little  affected  ;  it  is  thrust  out  from  the  chest-wall  and  floats  as  on  a  water-bed. 
Sometimes  they  develop  insidiously  ;  more  often  they  are  attended  with  very  severe 
symptoms.  If  left,  the  skin  usually  gives  way  below  the  gland  ;  but  frequently 
large  tracts  slough,  leaving  great  cavities  fringed  with  blue,  congested,  overhang- 
ing flaps.  I  have  known  an  abscess  of  this  kind  extend  from  the  sternum  to  the 
spine,  undermining  the  skin  and  destroying  the  cellular  tissue  half-way  round  the 
body  before  it  broke.  Great  care  must  be  taken  in  opening  these  to  secure  effi- 
cient drainage,  and  to  bring  the  opposing  surfaces  into  accurate  contact,  so  that 
no  decomposing  pus  may  be  retained  in  outlying  pockets. 

Chronic  Inflammation. 

Chronic  interstitial  mastitis,  affecting  one  or  more  of  the  lobules,  is  of  very 
great  importance,  from  the  pain  and  anxiety  it  occasions  and  from  the  difficulty  of 
distinguishing  it  from  the  early  stage  of  scirrhus.  The  interacinous  spaces  are 
filled  with  a  small-celled  infiltration,  which  becomes  organized  and  contracts  into 
dense  cicatricial  tissue.  The  acini  disappear  or  become  converted  into  retention 
cysts,  filled  with  a  clear  but  often  colored  liquid  ;  and  by  degrees  the  lobule 
becomes  changed  into  a  hardened  mass  of  very  irregular  shape,  adherent  to  the 
structures  around  (so  that  it  cannot  be  pushed  about  like  a  fibro-adenoma)  ;  and 
sometimes,  if  it  involves  one  of  the  larger  ducts,  attended  with  retraction  of  the 
nipple. 

No  cause  can  be  found  in  the  majority  of  cases.  It  is  most  common  about 
the  menopause  ;  it  is  often  associated  with  disorders  of  menstruation,  and  at  each 
period  it  usually  becomes  painful  and  tender  ;  but,  on  the  other  hand,  it  may  occur 
at  any  age  and  in  those  who  are  to  all  appearance  perfectly  healthy.  Pain,  often 
of  a  neuralgic  character  and  sometimes  very  severe,  and  made  much  worse  by 
handling,  is  usually  the  first  thing  noticed  ;  and  the  induration  is  only  found  on 
examination. 

The  diagnosis,  so  long  as  the  patient  is  under  thirty  years  of  age,  is  not 
very  difficult  (although  the  possibility  of  carcinoma  must  not  be  overlooked)  ;  in 
older  ones  it  rests  chiefly  upon  the  physical  signs.  The  hardness  is  not  of  that 
stony  description  characteristic  of  contracting  scirrhus  ;  the  surface  is  usually  more 
nodular,  from  the  presence  of  cysts)  ;  it  may  vary  in  size  at  each  menstrual  period  ; 
sometimes  there  are  several  separate  lobules  in  the  same  condition,  either  in  the 
same  or  in  the  other  breast ;  and  it  may  have  been  present  too  long.  In  many 
cases,  however,  the  difficulty  is  so  great  and  the  risk  so  disproportionate  that  every 
endeavor  should  be  made  to  induce  the  patient  to  submit  to  an  exploratory  inci- 
sion ;  the  question  can  be  settled  by  the  microscope  while  the  patient  is  still  under 
the  anaesthetic. 

The  treatment  of  chronic  interstitial  mastitis  is  very  unsatisfactory.  Some- 
times it  slowly  undergoes  resolution  or  disappears  so  far  that  the  patient  takes  no 
more  notice  of  it,  but  it  is  rarely  possible  to  connect  this  with  any  particular 
remedy.  Paget  recommends  small  doses  of  iodide  of  potash  with  liquor  potassse, 
well  diluted  ;  and  of  course  any  menstrual  irregularity  must  receive  careful  atten- 
tion. Tonics  (especially  iron)  often  succeed  better  than  anything  else  ;  but  the 
chief  thing   is   to   protect  the  breast  against   every  source   of  irritation,  and  to 


1 176     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

withdraw  it  as  far  as  possible   from   notice,  by  covering   it  with  a  well-shaped 

belladonna  plaster. 

Chronic  Abscess. 

Thick-walled  chronic  abscesses  are  occasionally  met  with  in  the  breast  with- 
out any  definite  sign  of  inflammation  around  them.  They  may  commence  during 
lactation  or  after  miscarriage,  but  they  are  also  met  with  indeijendently  of  any 
such  cause,  after  injury.  In  some  instances  they  may  be  of  tubercular  origin,  the 
caseous  material  gradually  becoming  surrounded  and  encapsuled.  Their  import- 
ance is  derived  from  the  extreme  difficulty  of  distinguishing  between  them  and 
carcinoma.  Like  it,  they  are  a  distinct  addition  to  the  substance  of  the  gland  (in 
which  they  differ  from  chronic  interstitial  mastitis)  ;  they  are  intensely  hard, 
painful  when  handled,  and  adherent  to  the  structures  around  ;  and  sometimes  they 
drag  distinctly  upon  the  skin  and  the  nipple.  It  is  true  that  a  certain  amount  of 
cedema  may  be  present  over  the  swelling,  but  this  by  itself  is  too  slight  a  sign  on 
which  to  base  so  important  a  diagnosis;  and  they  have  been  known  to  last  for 
months  and  even  years,  without  any  other  change  than  a  slight  increase  in  size. 

The  only  treatment  is  free  incision  and  drainage,  scraping  the  interior  out 
thoroughly  if  the  wall  is  dense  and  hard.  If  the  diagnosis  is  in  the  least  uncer- 
tain, a  preliminary  incision  should  always  be  made  before  attempting  anything 
further;  for  want  of  it  the  gland  has  before  now  been  removed,  under  the  impres- 
sion that  the  case  was  one  of  scirrhus. 

Gummata  are  met  w-ith  in  the  breast,  but  very  seldom.  Masses  of  caseous 
material,  possibly  of  tuberculous  origin,  are  rather  more  common,  forming  a  con- 
siderable proportion  of  the  so-called  galactoceles.  If  allowed  to  break,  they  leave 
chronic  ulcers  and  sinuses  fringed  with  congested  flaps  of  skin,  similar  to  those 
met  with  in  other  parts  of  the  body. 


TUMORS  OF  THE  BREAST. 

These  are  simple  or  malignant.  The  former  include  the  various  kinds  of  cyst 
and  the  different  forms  of  mammary  glandular  tumor  ;  the  latter,  carcinoma  and 
sarcoma.  In  addition,  melanotic  sarcoma  and  papilloma  may  grow  from  the  nip- 
ple and  areola;  squamous  carcinoma  may  extend  inward  from  the  skin  as  a  result 
of  Paget's  disease  (usually  this  gives  rise  to  duct  cancer)  ;  and  nsevi,  lipoma, 
chondroma,  and  some  other  forms  may  occur ;  but  they  do  not  so  much  belong  to 
the  breast  as  to  the  structures  around. 

In  the  case  of  a  suspected  tumor,  the  first  proceeding  is  to  exclude  lobular  in- 
duration. The  patient  should  be  placed  in  a  semi-recumbent  position  ;  the  dress 
arranged  so  that  the  whole  of  the  gland  is  uncovered  ;  and  the  arm  freed  from  all 
restraint.  Then,  before  the  fingers  are  allowed  to  feel  it,  the  palm  of  the  hand 
should  be  laid  flat  upon  the  suspected  spot,  and  made  to  roll  the  lobules  gently 
over  each  other.  If  there  is  a  new  growth  it  stands  out  distinctly  as  an  addition 
to  the  gland  ;  if,  on  the  other  hand,  there  is  merely  lobular  induration,  it  can 
scarcely  be  felt  unless  the  breast  is  very  thin.  If  this  precaution  is  neglected,  and 
the  hardened  tissue  is  grasped  with  the  fingers  first,  whatever  its  nature,  it  feels 
exactly  like  a  tumor.  Even  this,  however,  fails  to  distinguish  simple  induration 
from  malignant  infiltration  (scirrhus)  in  its  early  stages. 

No  examination  is  complete  without  thorough  investigation  of  the  axilla. 
The  arm  should  be  only  moderately  abducted,  and  the  glands  along  the  margin 
of  the  pectoral  muscle  felt  for  first,  then  those  that  lie  along  the  axillary  vein  and 
at  the  apex.  Unfortunately,  even  with  the  greatest  care,  it  is  only  possible  to 
detect  them  when  they  have  attained  a  considerable  size. 

Cysts. 
Cysts  of  the  breast  may  be  simple  or  filled   to  a  greater  or  less  extent  with 
new  growths   of   various    kinds — paitillomatous,   adenomatous,   sarcomatous,   or 


TUMORS  OF  THE   BREAST.  1177 

carcinomatous.  As  the  imi)ortance  of  the  latter  class  is  derived  from  the  solid 
structures  associated  with  them,  they  will  be  dealt  with  later,  under  their  several 
headings. 

Dcnnoid  and  liydatid  cysts  have  been  known  to  occur,  l)ut  they  are  very  rare  ; 
by  far  the  majority  of  cysts  are  developed  in  connection  either  with  the  fdjrous 
stroma  or  tlie  gland  tissue. 

Cysts  developed  from  the  fibrous  stroma  {serous  cysts')  are  usually  single  and 
more  or  less  globular  in  shape,  but  they  may  be  multiple  and  very  irregular.  Their 
walls  are  formed  of  fibrous  tissue  lined  with  epithelioid  cells,  and  they  contain  a 
clear,  albuminous  liquid.  The  mode  of  origin  is  very  doubtful,  but  possibly,  like 
the  similar  cysts  occasionally  met  with  in  the  neck,  they  are  connected  with  the 
lymphatic  interstices. 

Glandular  Cysts. — Of  these  there  is  a  great  variety. 

{a)  Involution  Cysts. — After  the  period  of  activity  is  past,  the  mammary  gland 
not  unfretjuently  becomes  studded  with  numbers  of  small  cysts,  developed  not  so 
much  from  the  acini  (which  atrophy  and  disappear)  as  from  the  minute  ducts.  If 
there  is  a  coincident  development  of  fat,  this  change  is  not  noticed  ;  but  in  thin 
people,  and  especially  when  the  change  is  prominently  developed  in  one  particular 
lobule,  it  may  give  rise  to  great  uneasiness,  owing  to  the  peculiar  hardness  of  the 
cysts.  Their  rounded  shape,  however,  the  free  mobility,  the  absence  of  any  ad- 
hesions, and  the  presence  in  nearly  every  case  of  a  similar  transformation,  either 
in  other  parts  of  the  same  breast  or  in  the  opposite  one,  are  usually  sufficient  to 
m^ke  the  diagnosis  certain. 

{b)  Cystic  Degeneration. — This  is  more  rare.  The  whole  gland,  or  the  greater 
part  of  one,  becomes  studded  with  myriads  of  minute  cysts,  developed  from  the 
acini.  They  are  lined  when  small  with  low  columnar  epithelium  ;  as  they  increase 
in  diameter  the  cells  become  flatter,  until  in  the  largest  (which  may  be  the  size  of 
a  small  marble)  they  are  almost  pavement-like  ;  and  they  contain  a  clear,  albumi- 
nous fluid,  which  may  be  green  or  brown,  and  even  almost  black  in  color,  from 
the  admixture  of  haemoglobin.  In  some  cases  the  basement  membrane  of  the  acini 
is  greatly  thickened  as  well.  This  has  nothing  to  do  with  the  period  of  involu- 
tion :  it  occurs  at  a  much  younger  age,  and  only  affects  one,  and  sometiuies  only 
part  of  one  of  the  glands,  but  its  real  nature  is  very  obscure.  Clinically,  it 
causes  a  rapid,  uneven  enlargement,  with  the  development  of  very  irregular,  hard- 
ened nodules ;  and  if  the  cysts  are  near  the  surface,  and  sufficiently  large  to  admit 
of  recognition,  it  is  usually  taken  for  a  variety  of  cystic  sarcoma. 

(c)    Cysts  Due  to  Chronic  Inflammation. — Minute  cysts  are  often  present  in 
chronic  interstitial  mastitis,  caused  by  the  constriction  of  the  ducts  ;  but,  except 
-for  the  way  in  which   they  add  to  the  size  of  the  lobule  and   increase  the  irregu- 
larity of  its  outline  and  the  hardness  of  its  texture,  they  are  of  but  little  im- 
portance. 

id)  Retention  Cysts. — These  are  the  largest  of  the  simple  glandular  cysts  ; 
sometimes  attaining  the  size  of  a  small  orange.  They  may  be  single  or  multiple, 
and  occur  at  any  age.  Undoubtedly,  they  are  developed  from  the  ducts  (whence 
their  name,  duct  cysts),  and  not  unfrequently  some  of  their  contents  can  be 
squeezed  out  (so  that  they  are  not  all  due  to  simple  obstruction)  ;  but  nothing  is 
known  as  to  the  cause  of  their  development.  Their  contents  are  usually  clear  and 
albuminous  (sometimes  colored),  and  many  of  them  contain  papillary  growths. 
The  diagnosis  rests  chiefly  upon  the  even  globular  outline,  and  the  absence  of  pain 
and  of  adhesions  ;  but,  especially  when  they  are  deeply  seated  and  in  a  large 
breast,  it  is  often  impossible,  owing  to  their  hardness,  to  distinguish  them  from 
chronic  abscess  or  carcinoma  without  an  exploratory  puncture.  As,  however,  it  is 
impossible  to  say  from  this  alone  whether  there  is  an  intracystic  growth  or  not, 
they  should  always  be  incised,  and,  if  they  are  really  simple,  drained  or  wiped 
out  with  a  sponge  dipped  in  some  strong  antiseptic,  so  as  to  ensure  their  ob- 
literation. 

(/j    Galactoceles  or  milk-cysts  may  be  caused  by  rupture  or  distention  of  one 
75 


1 1 78     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

of  the  ducts  during  lactation,  usually  in  one  of  the  early  months.  Sometimes 
there  is  a  history  of  injury.  The  swelling  makes  its  first  appearance  rapidly,  and 
in  some  of  the  ca.ses  has  varied  considerably  in  size,  increasing  during  the  actual 
time  of  suckling,  and  diminishing  to  some  extent  in  the  intervals  by  condensation. 
Spontaneous  cure  does  not  seem  to  occur;  the  contents  gradually  become  more 
and  more  inspissated,  but  the  tumor  does  not  disappear.  In  some  instances,  it  has 
attained  an  enormous  size. 

If  the  tumor  is  of  rapid  growth,  the  child  must  be  weaned  and  every  en- 
deavor made  to  arrest  the  secretion  of  milk.  The  size  of  the  swelling  should  be 
reduced  by  asi)iration,  and  the  increase  checked  as  far  as  possible  by  gentle  pres- 
sure. Aftervvard  the  cavity  must  be  drained  with  great  care,  to  avoid  suppuration. 
Small  cysts,  and  those  which  show  no  tendency  to  increase,  may  be  left  until  the 
period  of  suckling  has  expired.  It  is  probable,  however,  that  many  of  the 
smaller  stationary  galactoceles  are  really  caseous  ab.scesses,  the  contents  of  which 
are  more  or  less  dried  up,  and  which  possibly  were  originally  of  tuberculous 
origin.  The  same  may  be  true  of  the  calcareous  masses  which  have  occasionally 
been  described. 

Mammary  Glandular  Tumor. 

The  mammary  gland,  like  the  j)arotid  and  thyroid,  is  liable  to  its  own  form 
of  tumor.  The  histological  elements  that  compose  it  are  the  same  as  those  met 
with  in  other  growths  ;  but  its  features  are  so  distinctive  that,  like  parotid  glandu- 
lar tumor,  for  example,  it  requires  separate  description. 

It  originates  in  connection  with  the  lobules  of  the  breast  after  puberty,  some- 
times one  element,  sometimes  another,  being  in  excess.  Where  it  is  composed 
chiefly  of  glandular  structures,  it  is  known  as  adenoma  ;  if  there  is  a  fair  propor- 
tion of  fibrous  tissue  as  well  (the  most  common  form),  2&  fiiro- adenoma.  In  some 
cases  the  ducts  and  acini  are  flattened  into  slits ;  in  others  they  are  enlarged  into 
cysts  of  all  sizes  {cystic  adenoma).  Sometimes  these  cysts  are  simple,  lined  with 
one  or  more  layers  of  epithelial  cells,  and  contain  a  clear  gelatinous  or  colored 
fluid  ;  sometimes  there  are  growths  of  various  character  (adenomatous  or  papillo- 
matous) inside  {proliferoi/s  cysts).  In  other  varieties,  again,  the  matrix  of  the 
tumor,  instead  of  retaining  the  character  of  firm  fibrous  tissue,  resembles  that  of  a 
sarcoma,  and  from  this  further  forms  arise  :  adeno-sai-coma  when  the  gland  tissue 
is  not  enlarged  out  of  proportion  to  the  rest ;  cystic  sarcoma  (sero-cystic  sarcoma 
or  Brodie's  disease)  when  there  are  cysts  developed  from  the  acini  or  ducts  filled 

with  soft  sarcomatous  masses  sprouting  from 

j'x  their    walls.       These    tumors    may    occur    at 

y   W  %,  any  age  after  puberty  ;  there  may  l)e  only  one, 

or  there  may  be  any  number  in  one  or   both 

breasts ;    if  left  they  may  grow  to  any  size, 

\        especially  the  sarcomatous  forms  ;  and  at  length 

the  skin  over  them  may  give  way  so  that  they 

develop  into  gigantic  fungating  ma.sses,  causing 

the  death  of  the  patient  by  exhaustion  ;  but 

they  do  not  affect  the  surrounding  lobules  of 

the  gland  (except  by  their  pressure)  or  spread 

'i        through    the  lymphatics  or  the  blood -ves.sels, 

..  and  (though  it  often  happens  that  other  smaller 

ones  grow  up  to  replace  them)  they  do  not 

Fig.  508, — Cystic  Tumors  in  Breast  with  °  ^  J  ,  ri-.,  , 

Pedunculated  Adenom.-itous Growth.  recur  after  free  removal.      Ihe  slow-growing 

fibrous  forms  are  very  common  in  young 
women  ;  the  more  rapid  ones  rarely  occur  before  thirty  years  of  age  ;  but  some- 
times a  tumor  that  has  scarcely  made  any  progress  for  months  together  suddenly 
begins  to  grow,  and  then  it  may  attain  an  enormous  size.  Cysts  may  occur  at  any 
time  of  life. 

Diagnosis. — The  distinguishing  feature  of  mammary  glandular  tumors  is 


SARCOMA   OF  THE  BREAST.  1179 

their  mobility,  especially  while  they  are  small  ;  they  seem  capable  of  being  pushed 
among  the  other  lobules  in  all  directions.  Those  that  grow  rapidly,  and  are 
allowed  to  attain  a  large  size,  lose  this  feature  to  a  great  extent. 

Adenomata  and  fibro-adenomata  are  particularly  hard,  and  often  nodular  on 
the  surface  ;  adeno-sarcomata  are  softer,  growing  more  rapidly,  and  the  skin  over 
them  is  covered  with  enlarged  and  dilated  veins.  Cystic  adenoma  can  usually  be 
recognized  by  the  rounded  outline  and  the  elastic  sensation  it  gives  when  pressed 
upon  ;  moreover,  there  is  not  uncommonly  a  history  of  a  serous  or  blood  stained 
discharge  from  the  nipple,  and  sometimes  the  tumor  has  distinctly  varied  in  size  ; 
but  it  is  impossible  to  form  any  idea  of  the  character  and  scarcely  any  as  to  the 
presence  of  intracystic  growths.  They  may  be  large  or  small,  sarcomatous  or 
papillary  ;  the  fluid  around  them  altogether  conceals  their  rate  of  increase.  Pain 
is  seldom  complained  of  in  the  case  of  the  larger  growths,  although  their  weight 
and  size  may  prove  a  serious  inconvenience  ;  but  some  of  the  smaller  and  harder 
ones,  especially  those  that  occur  in  young  unmarried  women,  are  not  unfretpiently 
the  seat  of  intense  neuralgia,  especially  after  handling  and  during  the  menstrual 
period.  The  skin  never  becomes  involved  or  the  nipple  retracted  unless  the 
growth  has  attained  a  very  large  size,  or  has  spread  among  the  other  lobules  of  the 
gland. 

Treatment. — Excision  of  the  tumor  is  always  advisable.  It  is  true  that 
many  of  the  smaller  ones  persist  for  a  very  considerable  time  without  showing  any 
change,  but  there  can  be  no  certainty  of  this,  and  not  unfrequently  after  remain- 
ing latent  for  years  they  suddenly  begin  to  grow  at  a  rapid  rate.  The  gland  itself 
should  never  be  removed  unless  the  tumor  is  so  large  and  so  intimately  fused  with  it 
that  it  is  unavoidable  ;  and  unless  it  is  actually  adherent,  no  skin  need  be  sacrificed. 

The  plan  of  operation  depends  upon  the  size  and  situation  of  the  tumor.  If 
it  is  small  and  superficial  it  may  be  fixed  between  the  finger  and  thumb  of  the  left 
hand,  and  a  single  incision  radiating  from  the  nipple,  made  down  to  it  and  through 
its  capsule  ;  as  a  rule  it  shells  out  readily,  though  sometimes  a  certain  amount  of 
dissection  is  required.  If  it  is  deeply  placed,  or  if  there  are  several,  it  is  better 
to  adopt  the  method  advocated  by  Thomas,  of  New  York,  and  reflect  the  breast 
upward  from  below,  the  incision  being  made  in  the  groove  beneath  the  gland  so 
that  no  scar  is  visible.  Fortunately  these  tumors  are  for  the  most  part  so  freely 
movable  in  the  breast  tissue,  that,  if  there  are  several  of  them,  a  single  incision  will 
usually  serve  for  all.  For  the  larger  ones  no  rules  can  be  laid  down,  but,  especially 
if  the  patient  is  nearing  middle  life,  and  the  gland  tissue  is  much  involved,  it  is 
often  simpler  and  more  satisfactory  to  remove  the  whole.  Pressure  .should  be 
carefully  arranged  afterward,  so  as  to  ensure  complete  obliteration  of  the  cavity 
left.  Whether  a  drainage  tube  should  be  used  or  not  depends  upon  the  amount  of 
bruising. 

Sarcoma, 

All  varieties  of  sarcoma,  with  all  their  forms  of  secondary  degeneration,  are 
occasionally  met  with  in  the  breast,  but  the  only  one  at  all  common  is  the  spindle- 
celled.  It  may  occur  at  any  age  after  puberty,  and  forms  a  soft,  rounded,  or  lobu- 
lated  mass,  pushing  the  gland  on  one  side,  and  very  difficult  to  distinguish,  at  first 
at  least,  from  an  adeno-sarcoma.  If  there  are  cysts  in  it,  due  to  .softening  or 
hemorrhage,  or  even  if  there  are  isolated  masses  of  softer  round-celled  growth  in 
the  middle  of  the  firmer  part,  the  diagnosis  may  be  impossible. 

Growth  at  first  is  usually  slow  ;  after  a  little  while,  however,  the  tumor  begins 
to  increase  with  great  rapidity,  and  very  soon  it  develops  into  a  gigantic  mass, 
which,  if  left  to  itself,  ulcerates  through  the  skin  and  forms  a  huge  fungating 
excrescence  that  bleeds  with  the  slightest  touch.  The  only  treatment  is  free  exci- 
sion, not  only  of  the  tumor,  but  of  the  capsule  that  surrounds  it.  Afterward  the 
most  careful  watch  must  be  kept.  Infection  of  the  glands  or  of  distant  organs  is 
rare,  but  local  recurrence  is  exceedingly  common,  and  each  secondary  growth 
increases  in  size  more  rapidly  than  the  one  that  preceded  it.     Operations  may  liave 


1 1  So    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

to  be  performed  again  and  again  ;  sometimes  at  last  the  tendency  to  recurrence  is 
overcome  ;  more  frecjuently  before  this  occurs  the  time  arrives  when  surgical  inter- 
ference is  no  longer  practicable. 

Carcinoma. 

Carcinoma  of  the  breast  may  be  glandular,  columnar-celled,  or  squamous.  Of 
these  the  two  last  form  together  but  a  very  small  percentage  of  the  whole.  The 
columnar-celled  type  grows  from  the  ducts  (^duci  o?- villous  cancer)  ;  it  can  only  be 
diagnosed  by  the  cystic  appearance  it  presents  on  section,  although  its  nature  may 
be  suspected  if  there  is  a  blood-stained  or  milky  discharge  from  the  nipple  ;  the 
squamous  one  spreads  by  continuity  from  the  areola  and  is  sometimes  secondary 
to  Paget' s  disease. 

Glandular  carcinoma  presents  many  different  forms,  according  to  the  relative 
proportion  of  tlie  cells  and  stroma  that  compose  it.  The  more  rapidly-growing 
varieties  as  a  rule  occur  in  younger  patients  with  full  breasts,  but  there  are  many 
exceptions. 

(«)  Atrophic  Scirrhiis. — This  is  the  hardest  and  slowest  in  its  growth  of  all  : 
the  contraction  is  so  extreme  that  the  breast  grows  smaller  and  more  withered  the 
longer  it  lasts,  and  the  skin  and  the  surrounding  structures  become  bound  together 
as  if  by  dense  cicatricial  tissue.  It  is  usually  met  with  in  thin,  wasted  breasts  of 
old  people,  and  it  may  last  many  years  before  it  proves  fatal  ;  when  it  is  cut 
across  it  creaks  and  grates  before  the  knife  ;  the  surface  becomes  markedly  cupped, 
but  there  is  little  or  no  cancer  juice.  Its  color  is  grayish  white,  with  streaks  and 
dots  of  yellow,  and  it  has  no  outline,  but  shades  off  imperceptibly  into  the 
healthy  tissues  around. 

(U)  Nodular  Scirrhus. — The  wasting  is  much  less,  so  that,  although  the  con- 
traction of  the  stroma  renders  the  swelling  intensely  hard,  it  is  not  sufficient  to 
cause  a  diminution  in  size.  There  is  a  distinct  hard  nodule  which  can  be  felt  as 
an  addition  to  the  breast  gland  when  the  palm  of  the  hand  is  laid  flat  upon  it. 
The  cut  section  is  much  the  same  as  the  former,  but  it  is  more  juicy,  and  the 
fibrous  bands  that  traverse  it  are  not  so  inextricably  welded  together. 

(r)  Injil/ratifi!:^  Scirrhus. — This  differs  not  only  in  the  rapidity  of  its  growth 
and  the  absence  of  wasting,  but  in  the  peculiar  mode  of  its  extension  ;  it  seems  to 
spread,  not  by  gradual  continuity  of  structure,  but  by  leaps  and  bounds,  and  so 

quickly  that  it  may  even  seem  to  originate 
^^•^'JSs^K.  in   many  separate  points  at  the  same  time. 

-"^" "'       '"-^ -  '■  Its  course,  so  far  as  life  is  concerned,  is  pro- 

portionately fatal.     There  are  two  varieties 
of  it,  according  to  whether  it  involves  the 
x.       glandular  tissue  or  the  skin.      In  the  former 
/:  ;  .  V       the  whole  breast  rapidly  becomes  enlarged  ; 

/  f    ''---  '-.'  ;      no  definite  tumor  can  be  felt;   the  nipjjle  is 

p-  s„^  >::     buried   by  the  increased  growth  around   it 

M:  '■""  ._.'•    as  much  as  by  its  own  retraction  ;  and  the 

.^i  -      •    _     .if    1\  ..    whole  gland  is  converted  into  a  solid  mass 

-'''  ■  -  .'.  Qf  carcinoma.      In   the  latter   the   skin    is 

chiefly  involved;  it  becomes  peculiarly 
./  hard,  thick,  dense,  and  coarse  (it  has  been 
/  compared  to  a  jjig-skin  saddle)  ;  the  color 

&;  '/,'^  changes  to  a  dusky  red ;  the  texture  is  com- 

fv  \-^/l  pletely  altered  :    it   does  not  move  on   the 

C,  :  '  "S<^^  l)arts  beneath,  and  it  cannot  be  pinched  up 

"''-■-  "     "^  into  folds.      Minor  degrees  of  this  are  often 

Fir..  509.— Scirrhus  with  Retracted  Nipple,  under-  scen  ovcr  3.  carciuoma  as  it  approaclics  the 
going  Colloid  Transformation.  surfacc,  but  iu  this  particular  form  the  dis- 

ease may  spread  all  round  one  side  of  the  thorax  {caiicer  en  cuirasse),  and  invest 
it  with  an  absolutely  rigid  casing  within  the  space  of  a  few  weeks. 


CARCINOMA   OF  THE  BREAST. 


1181 


The  cut  surface,  owing  to  the  softness  and  rapidity  of  growth,  often  does  not 
cup  at  all  ;   but  the  cancer-juice  on  scraping  is  very  abundant. 

0/)  EncephaloicL — Very  soft  glandular  carcinoma,such  as  occurs  in  the  testicle 
for  example,  is  seldom  met  with  in  the  breast  ;  many  of  the  cases  formerly  de- 
scribed as  such  were  in  all  probability  sarcomata  ;  but  the  softer  infiltrating  forms 
are  sometimes  termed  encephaloid,  from  the  striking  contrast  they  present  to  the 
hardness  of  scirrhus.  As  a  rule  their  growth  is  even  more  rapid  than  that  of  the 
preceding  one. 

In  addition  to  these  cystic  carcinoma  has  been  described  (the  cysts  being  due 
to  hemorrhage  or  softening)  ;  and  occasionally  colloid  degeneration  is  met  with  ; 
but  though  this  form  of  carcinoma  is  peculiar  from  the  length  of  time  it  often  lastsi 
it  is  not  a  distinct  variety. 

Etiology. — Cancer  in  the  breast  is  very  rare  before  thirty  years  of  age  ;  then 
It  becomes  more  and  more  frequent  until  nearly  fifty ;  after  that  it  begins  to 
diminish  again  (not  only  absolutely,  but  relatively  to  the  number  living)  ;  but  it 
may  start  even  in  extreme  old  age.  Marriage,  child-bearing,  suckling  or  not,  and 
disorders  of  menstruation  have  never  been  proved  to  have  any  relation  to  it!  It 
occurs  in  all  social  conditions,  and  in  those  who  have  enjoyed  perfect  health  as 
much  as,  and  possibly  even  more  than,  in  others.  It  may  follow  a  blow,  though,  of 
course,  too  much  reliance  must  not  be  placed  upon  ordinary  histories  ;  and  in  a 
small  proportion  of  cases  it  follows  on  chronic  lobular  induration,  or  develops  in 
the  neighborhood  of  an  old  abscess.  Whether  locality  or  climatic  conditions  have 
any  effect  is  very  uncertain,  and,  probably,  owing  to  the  freedom  of  communica- 
tion at  the  present  day,  will  never  be  proved.  Statistics  show  that  it  is  not  hered- 
itary, but  as  individual  cases  of  the  most  striking  character  are  met  with  from  time 
to  time,  it  is  probable  that  this  statement  is  too  sweeping,  and  that  the  tendency 
exists,  though  it  may  not  be  marked,  and  may  require  other  circumstances  for  its 
development.  It  is  an  old  observation  that  carcinoma  rarely  develops  during 
pregnancy  or  lactation  ;  and  it  has  been  said  that  a  tumor  that  makes  its  appear*^ 
ance  during  either  of  these  periods  is  almost  certainly  not  cancer  ;  but  the  symp- 
toms at  its  first  commencement  are  so  exceedingly  slight,  and  the  changes  through 
Avhich  the  gland  tissue  passes  are  so  extensive,  that  this  is  very  difficult  to  prove* 

Symptoms. — These  naturally  present  considerable  variety,  but  essentially 
they  may  be  reduced  to  two. 

1.  The  presence  of  a  tumor.  Unfortunately,  this  fails  to  distinguish  com- 
mencing scirrhus  from  chronic  lobular  induration,  as  in  both  there  may  be  an 
actual  diminution  in  size. 

2.  The  way  in  which  the  tumor  infiltrates  and  (like  a  crab  that  has  been 
turned  upon  its  back)  drags  toward  itself  everything  round.  The  same  thing  is 
true,  though  to  a  less  extent,  of  chronic  abscess,  and  this  renders  the  difficulty  of 
separating  one  from  the  other  so  great. 

The  first  appearance  of  scirrhus  is  an  ill-defined,  intensely  hard  nodule  in  the 
substance  of  the  gland.  There  is  no  margin;  it  cannot  be' separated  from  the 
lobules  around  it  or  moved  freely  in  any  direction.  Whether,  when  the  hand  is 
laid  upon  it,  it  feels  like  an  addition  to  the  gland  or  not,  depends  upon  the  rela- 
tive amount  of  new  growth  and  contraction.  In  a  little  while  it  becomes  more 
definite.  If  it  is  near  the  skin  this  is  dimpled  over  it,  the  vertical  septa  of  con- 
nective tissue  and  the  deep  ends  of  the  cutaneous  glands  being  dragged  down 
first ;  the  nipple  (if  it  is  near  one  of  the  larger  ducts)  is  treated  in  the  same  way 
(often  this  can  be  best  seen  by  gently  pulling  the  growth  to  one  side)  ;  and  even 
the  fascia  beneath  the  gland  is  caught  as  well.  Soon  some  of  the  intercostal  nerves 
are  involved,  and  then  it  gives  rise  to  the  most  intense  pain,  sharp  and  stabbing, 
especially  at  night  and  when  the  breast  is  handled,  sometimes  limited  to  the  gland, 
but  more  often  spreading  round  the  thorax,  over  the  shoulder,  or  down  the  arm. 
In  a  little  while  the  tumor  grows  more  prominent,  still  retaining  its  extreme  hard- 
ness ;  the  skin  is  bound  down  over  a  wide  area  and  becomes  a  dusky  red  ;  the 
lymphatic  glands  in  the  axilla  are  enlarged  ;   the  nipple  is  perhaps  entirely  with- 


1 1 82    DISEASES  AND  INJURIES  OE  SPECIAL  STRUCTURES. 

drawn  ;  and  by-and-by  a  small  fissure  makes  its  appearance  about  the  centre  of  the 
swelling.  At  first  this  is  covered  by  a  scab  of  dried  epidermis  ;  soon  this  falls  off 
and  a  typical  scirrhous  ulcer  is  left,  with  a  pale,  waxy  base,  and  raised,  hardened, 
and  rolled- in  eiiges. 

The  subsequent  course  is  of  the  same  character.  The  patient's  health  begins 
to  fail,  although  it  may  be  some  time  before  there  is  a  definite  appearance  of  ca- 
chexia. The  ulcer  steadily  increases  in  size  ;  if  the  cancer  is  soft  and  of  rapid  growth 
it  may  fungate  and  bleed  ;  more  often  it  merely  melts  away  on  the  surface,  giving 
off  a  discharge  of  a  peculiarly  offensive  description.  The  axillary  glands  become 
matted  together  ;  the  veins  and  lymphatics  are  closed  ;  oedema  of  the  arm  sets  in  ; 
the  brachial  plexus  is  compressed,  causing  the  most  intense  neuralgia  ;  then  the 
supra-clavicular  glands  are  attacked  ;  pleurisy  perhaps  follows  (the  lymphatics  from 
the  inner  half  of  the  breast  communicate  freely  through  the  intercostal  spaces  with 
those  of  the  mediastinum  and  the  pleura)  ;  and  finally  secondary  deposits  make 
their  appearance  in  the  liver,  lungs,  vertebrae,  or  other  parts  of  the  body. 

The  relative  prominence  of  these  symptoms  differ,  of  course,  very  greatly.  In 
some  the  rapidity  of  the  growth  is  the  chief  feature  :  a  soft,  elastic,  almost  fluctu- 
ating swelling  seems  to  take  the  place  of  the  breast  almost  at  once.  In  others  the 
skin  is  the  part  attacked,  the  extreme  form  being  that  known  as  cancer  en  cuirasse. 
In  a  third  class  again  ulceration  begins  before  there  is  much  growth,  and  j>er- 
sists,  quietly  spreading  year  after  year.  The  pain,  the  implication  of  the  skin, 
the  retraction  of  the  nipple,  and  the  fixation  to  the  pectoral  beneath  (best  seen 
when  the  muscle  is  in  action)  depend  largely  upon  the  accidental  position  of  the 
growth  ;  and  so,  to  some  extent,  does  the  direction  in  which  lymphatic  infection 
spreads. 

Diagnosis. — ^^"hen  the  skin  is  involved,  the  nipple  retracted,  and  the  axil- 
lary glands  enlarged  (the  stage  at  which  the  majority  of  the  patients  present  them- 
selves for  treatment)  the  diagnosis  is  easy,  but  too  late.  If  there  is  to  be  any  hope 
of  definitely  curing  a  patient  suffering  from  cancer  of  the  breast,  the  diagnosis 
must  be  made  before  any  one  of  these  three  is  present. 

In  the  case  of  scirrhus  the  chief  difficulty  occurs  in  connection  with  chronic 
lobular  mastitis,  chronic  abscess,  fibro-adcnoma,  and  deep-seated  cysts.  The  softer 
varieties  are  frequently  not  distinguishable  from  adeno-sarcoma,  cysto-sarcoma,  or 
t7-ue  sarcoma,  but  this  is  less  material,  as  in  either  case  free  and  early  exploration 
is  the  rule. 

The  following  are  the  most  important  points  : — 

(a)  Age. — Carcinoma  is  very  rare  before  thirty,  and  rare  before  thirty-five 
years  of  age  ;   the  other  affections  may  occur  at  any  time  of  life. 

(b')  Fixity. — Unfortunately,  chronic  abscess  and  chronic  induration  are  as 
adherent  to  the  lobules  around  as  scirrhus  ;  and  in  any  case,  when  the  growth  is 
small  and  deeply  seated  in  a  full  breast,  this  is  most  difficult  to  estimate. 

(r)  Consistence. — Scirrhus  is  of  stony  hardness,  the  others  are  not ;  but  the 
difference  is  often  inappreciable.  A  cyst  near  the  surface  is  tense  and  elastic, 
chronic  induration  is  often  very  irregular  in  its  outline,  and  oedema  is  not  unfre- 
quently  present  over  a  chronic  abscess. 

(d)  Period  of  Origin. — Chronic  abscess  is  said  to  occur  most  frequently 
during  lactation  or  after  a  miscarriage.  This  is  not  the  case  with  carcinoma, 
although  it  is  impossible  to  deny  that  it  may  happen. 

(^)  Multiplicity. — If  there  are  several  nodules,  especially  if  they  are  at  some 
distance  from  each  other  (so  that  they  are  not  caused  by  latent  extension),  or  if 
there  is  asymmetrical  induration  in  the  other  breast,  it  is  strongly  against  carci- 
noma, and  in  favor  of  chronic  mastitis. 

(/)  Shape. — This  is  of  little  service  ;  but  if  the  swelling  is  tense  and  globu- 
lar, or  if  one  or  more  globular  enlargements  can  be  detected  on  it,  it  is  almost 
certainly  cystic,  in  part  at  least. 

(^)  Tenderness  is  very  important.  In  chronic  induration  the  lobe  is  nearly 
always  very  tender  on  pressure,  or  on  trying  to  separate  it  from  the  rest  of  the 


CARCINOMA   OF  THE   BREAST.  1,83 

gland  ;  carcinoma,  on  the  other  hand  (in  the  early  stage)  is  tolerably  insensitive. 
This  is  often  shown  by  the  way  in  which  the  nodule  is  discovered  ;  in  the  one  case 
the  tenderness  attracts  the  attention  of  the  patient,  in  the  other  it  is  the  presence 
of  a  hardened  lump. 

{h)  Pain. — The  pain  of  carcinoma,  whe-n  it  once  begins,  is  nearly  always 
described  voluntarily  by  the  patients  as  sharp  and  stabbing.  That  of  chronic 
induration  is  often  severe  after  handling  (especially  in  women  too  young  for  scir- 
rhus),  but  it  is  neuralgic  in  character  ;  there  are  neuralgic  points  down  the  axillary 
line  on  the  side  of  the  thorax  where  the  nerves  perforate  the  intercostal  muscles, 
and  it  varies  in  intensity  at  each  menstrual  period.  Sometimes  the  patient  is 
positive  that  the  size  of  the  suspected  lobe  varies  too. 

(/')  Dimpling  of  the  Skin. — The  skin  is  adherent  over  inflammatory  swellings, 
and  sometimes  over  large,  rapidly-growing  tumors,  other  than  carcinoma,  but  the 
dimpling  of  scirrhus  is  different.  At  the  first  it  is  due  to  the  dragging  on  the  sus- 
pensory ligaments  of  the  breast,  which  pass  vertically  inward  from  the  surface  ; 
later  the  ends  of  the  cutaneous  glands  are  involved,  and  then  the  subcutaneous 
tissue  and  the  skin  itself.  This  stage  is  of  very  great  importance,  not  so  much 
for  the  diagnosis  of  the  disease,  but  as  a  criterion  of  the  extent  to  which  it  has 
spread — practically  it  may  be  taken  that  the  lymphatics  are  involved  as  well, 
whether  they  can  be  felt  or  not. 

iji)  Retraction  of  the  nipple  is  to  a  large  extent  a  question  of  locality  ;  if,  that 
is  to  say,  scirrhus  develops  near  its  base,  retraction  appears  very  early  ;  if,  on  the 
other  hand,  it  is  far  away,  very  late.  It  is  due  to  the  dragging  upon  the  larger 
ducts,  and  it  may  arise  from  many  other  causes  besides  scirrhus.  It  may,  for  ex- 
ample, be  congenital,  or  it  may  be  the  result  of  inflammation,  past  or  present ;  or 
it  may  be  due  to  some  other  form  of  tumor  pressing  the  ducts  upon  one  side,  or 
causing  uneven  enlargement  of  the  gland.  Retraction,  therefore,  is  not  distinctive, 
but  when  it  occurs  in  connection  with  an  indurated  lobule,  before  this  has  attained 
any  size,  its  presence  is  highly  significant. 

Finally,  if  the  diagnosis  is  in  the  least  degree  doubtful,  an  exploratory  punc- 
ture should  be  made  under  an  anjesthetic,  and  if  this  is  not  satisfactory  a  free 
incision  with  full  permission  to  proceed  further,  if  it  is  thought  advisable. 

Prognosis, — The  duration  of  life,  in  cases  of  cancer  of  breast  that  are  not 
operated  upon,  is  under  three  years  on  the  average  of  a  large  number,  but  indi- 
vidual instances  vary  very  greatly.  The  soft  and  rapidly  infiltrating  growths,  and 
especially  those  which  implicate  the  skin  to  a  large  extent,  may  prove  fatal  within 
six  months  ;  atrophic  scirrhus,  on  the  other  hand,  may  last  for  ten  and  even  twenty 
years  unchanged.  Death  may  be  due  to  exhaustion,  septicaemia  from  the  absorp- 
tion of  the  foul  discharge,  or  to  the  occurrence  of  secondary  deposits.  Hemor- 
rhage from  the  surface  of  the  sore,  or  pleurisy  due  to  direct  extension  along  the 
lymphatics,  is  not  unfrequently  the  immediate  cause. 

Treatment. — Cancer  of  the  breast  can  only  be  cured  by  complete  incision 
at  the  very  earliest  moment  ;  it  can,  it  is  true,  be  removed  by  caustics,  but  the 
process  is  slower,  more  painful,  and  absolutely  uncertain.  Whether  an  operation 
is  to  be  recommended  or  not  depends  upon  {a)  the  condition  of  the  patient ;  {f) 
the  character  of  the  breast  ;  (^)  the  nature  of  the  growth;  and  (^)  the  stage  it 
has  reached. 

{a)  The  Patient. — In  this  the  surgeon  must  be  guided  by  the  ordinary  rules 
for  operating.  Excision  of  the  breast»is  a  very  favorable  operation  (so  far  as  im- 
mediate results  are  concerned — the  older  statistics  are  quite  valueless),  if  the 
patients  are  properly  selected  ;  primary  union  is  the  rule,  but  no  operation  should 
be  undertaken  in  cases  of  renal  disease,  diabetes,  advanced  pregnancy,  cirrhosis 
of  the  liver,  or  extreme  obesity,  especially  if  associated  with  shortness  of  breath 
and  a  tendency  to  bronchitis.     Age  of  itself  is  no  bar. 

(J))  The  Breast. — The  larger  the  breast,  whether  due  to  the  gland  itself  or  to 
an  accumulation  of  fat  around  it,  the  more  unfavorable  the  operation  in  every  way  ; 
the  wound  is  larger  (in  some  cases  the  gland  has  outlying  lobules  under  the  margin 


1 1 84    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

of  the  jjcctoral  muscle),  conii)lete  removal  is  more  difficult,  the  growth  is  almost 
certainly  not  of  the  nodular  or  atrophic  variety,  lymjjhatic  enlargement  is  more 
difficult  to  detect,  and  if  there  is  a  thick  layer  of  fat  the  wound  does  not  heal  so 
well. 

(r)  T/ii'  Nature  of  t)icGro7oth. — At  one  extreme  are  the  very  chronic  cases,  at 
the  other  the  rapidly  infiltrating  ones.  With  regard  to  the  former,  it  is  sometimes 
questionable  whether  operation  is  advisable — the  expectation  of  life  without  its 
being  done  is  so  much  better  than  in  the  other  varieties  ;  on  the  other  hand,  there  is 
the  certainty  that  ultimately  it  will  prove  fatal ;  and  the  possibility,  with  but  slight 
risk  (for  these  cases  are  very  favorable  ones),  of  freeing  the  patient  from  a  cease- 
less source  of  anxiety  and  pain.  With  regard  to  the  latter,  it  must  be  admitted 
the  results  are  exceedingly  bad  ;  it  seems  impossible  to  0{)erate  soon  enough,  and 
the  actual  prolongation  of  life  is  very  short.  Whether,  when  the  absolute  im- 
portance of  early  operation,  even  in  suspicious  cases,  comes  to  be  more  widely 
recognized  the  results  will  be  improved  upon,  especially  if  the  axillary  glands  are 
removed  as  well,  remains  to  be  seen. 

(r/)  The  Stage  the  Growth  has  Reached. — If  complete  excision  is  performed 
before  there  is  any  dimpling  of  the  skin  or  retraction  of  the  nipple,  prolongation 
of  life  is  certain  (taking,  of  course,  into  consideration  the  risk  of  the  operation), 
and  freedom  from  recurrence  highly  probable,  especially  if  the  growth  is  one  of 
the  harder  kinds.  It  is  for  this  reason  that  it  is  so  important  to  advise  an  explo- 
ratory operation  in  every  case  of  chronic  induration  of  the  breast,  in  a  patient 
nearing  forty  years  of  age,  if  the  diagnosis  is  in  the  least  doubtful. 

If  the  skin  is  dimpled,  relief  may  be  promised,  and  (almost  certainly)  local 
recurrence  prevented  again  under  the  same  conditions  (complete  excision,  and  one 
of  the  harder  varieties)  ;  but  absolute  cure  is  much  more  questionable.  In  such 
a  case  it  is  impossible  to  prove  that  the  axillary  glands  are  not  involved,  and 
consequently  the  whole  of  the  loose  cellular  tissue  and  the  lymphatics  that  cover 
the  mammary  portion  of  the  pectoral  muscle  and  fill  the  axilla,  must  be  syste- 
matically dissected  out.     The  fact  that  the  glands  cannot  be  felt  means  nothing. 

Some  advise  that  this  j^recaution  should  be  adopted  in  every  case  of  carci- 
noma, and  refuse  the  term  "complete"  to  every  operation  in  which  it  is  not 
done.  Undoubtedly  it  increases  the  patient's  chance  of  ultimate  cure;  and, 
accordingly,  where  it  does  not  too  much  increase  the  immediate  risk,  it  should 
be  practiced. 

In  the  later  stages,  when  the  skin  is  extensively  adherent,  and  the  glands  are 
definitely  enlarged  and  perhaps  matted  together,  it  must  depend  entirely  upon  the 
patient.  Cure  is  very  doubtful  ;  relief  from  pain,  and  from  the  i)rospect  of  an 
intensely  offensive  and  perhaps  fungating  ulcer,  is  fairly  certain  (^provided  the 
whole  of  the  affected  skin  can  be  freely  removed),  but  no  more,  and  often  the 
shock  necessarily  attendant  upon  such  an  0])eration  (even  when  primary  union  is 
assured)  seems  to  make  the  disease  light  up  elsewhere  and  grow  with  redoubled 
vigor.  If  the  supra-clavicular  glands  are  involved  ;  if  the  breast  is  adherent  to  the 
chest  wall  (not  the  pectoral  muscle,  but  the  fascia  near  the  sternum),  so  that  there 
is  reason  to  apprehend  the  speedy  onset  of  pleurisy;  if  there  is  oedema  of  the 
arms,  or  if  nodules  are  perceptible  in  the  liver  or  elsewhere,  operations  are  not 
advisable  unless  there  are  definite  local  reasons  for  it,  such  as  intense  pain  or 
imminent  hemorrhage. 

Recurrence. — Unhappily,  this  is  the  rule.  The  average  time  seems  to  be 
about  a  twelvemonth.  It  may  take  place  locally,  in  the  cicatrix  or  near  it  (some- 
times in  the  scars  left  by  the  sutures),  or  in  the  axilla.  The  cpiestion  of  further 
operation  must  be  determined  by  the  same  consideration  as  in  the  previous  case  ; 
permanent  cure  is,  it  is  true,  probably  not  to  be  hoped  for,  but,  with  very  small 
risk  and  suffering,  it  is  sometimes  possible  to  enable  a  patient  to  live  with  a  fair 
amount  of  comfort  and  without  pain  until  visceral  lesions  make  their  appearance. 

The  treatment  of  carcinoma  of  the  breast,  if  operation  is  declined,  is  very 
unsatisfactory.      Arsenic  in  continually  increasing  doses  has  been  recommended, 


EXCISION  OF  THE   BREAST.  1185 

but  it  has  not  been  proved  to  have  any  real  influence.  Cold  lead  lotion  checks 
the  growth  a  little  by  reducing  the  hyi)era3mia,  but  it  must  be  kept  up  continu- 
ously ;  poulticing  makes  it  increase  at  a  furious  rate.  Chloride  of  zinc  with 
opium  and  starch  paste  ai)pears  to  be  the  most  efficient  caustic,  strips  of  lint 
soaked  in  it  being  inserted  in  linear  incisions  made  through  the  superficial  layer, 
after  the  skin  has  been  destroyed  with  nitric  acid.  After  ulceration  has  set  in, 
the  surface  must  be  kept  clean  and  free  from  putrefaction  by  means  of  unirritat- 
ing  antiseptics.  Salicylic  acid  and  resorcin  have  been  used  as  local  applications, 
but  they  can  have  no  influence  upon  lymphatic  extension.  Opium  is  the  only 
drug  that  relieves  the  pain,  and  for  this  it  must  be  given  in  full  and  increasing 
doses.  Life  is  not  sufficiently  prolonged  for  the  evil  effects  of  continued  o[jium- 
taking  to  deserve  consideration. 


DISEASES  OF  THE   MALE  BREAST. 

Inflammation  may  occur  at  infancy  and  occasionally  later  in  life,  but  it  is 
nearly  always  periglandular  and  rarely  ends  in  suppuration.  Carcinoma  may 
occur,  but  other  forms  of  new  growth  are  very  seldom  met  with.  The  treatment 
presents  nothing  special. 

Excision  of  the  Breast. 

In  cases  of  carcinoma  it  should  be  the  rule  to  remove  the  whole  gland,  the 
nipple,  the  skin  for  a  wide  distance  over  the  tumor,  the  fascia  covering  the  mam- 
mary portion  of  the  pectoral  muscle,  the  lymphatics  running  up  from  this  to  the 
axilla,  and  to  clear  this  space  out  thoroughly  and  systematically.  If  the  operation 
is  performed  before  the  glands  are  enlarged,  or  while  they  are  still  small  and  iso- 
lated, there  is  little  difficulty  in  accomplishing  this  ;  if  they  are  already  matted 
together  and  to  the  surrounding  structures,  the  operation  becomes  at  once  one  of 
a  very  serious  character.  Mitchell  Banks,  Jacobson,  and  others,  recommend  that 
the  pectoral  muscles  should  be  divided,  completely  if  necessary ;  the  axillary  vein 
ligatured  above  and  below  and  cut  away,  and  even  more  sweeping  measures  taken, 
if  there  is  the  least  suspicion  as  to  the  thoroughness  of  removal.  It  may  be  noted 
that  ligature  of  the  vein,  even  when  all  the  axillary  lymphatics  are  cleared  away 
as  well,  merely  causes  transient  oedema. 

The  patient  is  prepared  in  the  usual  manner  ;  the  axilla  shaved  and  thor- 
oughly cleansed  ;  the  arm  moderately  abducted  from  the  side ;  and  the  rest  of 
the  body  and  the  opposite  side  of  the  chest  well  protected  with  mackintoshes.  The 
incision  depends  to  some  extent  upon  the  situation  of  the  tumor  ;  an  elliptical  one, 
running  upward  and  outward  to  the  axilla,  is  usually  recommended  ;  but,  in  many 

instances,  one  shaped  like  an  italic  /  placed  horizontally  ^^ ^  answers   better ; 

it  keeps  the  line  of  the  cicatrix  well  out  of  view  ;  it  can  be  carried  up  readily  along 
the  border  of  the  pectoral  muscle  to  the  axilla,  and,  owing  to  the  shape  of  the 
breast,  it  allows  a  greater  amount  of  skin  to  be  removed  without  sacrificing  imme- 
diate apposition  of  the  edges  of  the  wound. 

The  assistant  stands  on  the  opposite  side.  The  lower  incision  is  made  first, 
and  a  flap  of  skin  and  subcutaneous  tissue  reflected  from  off  the  gland  until  its 
margin  is  reached  and  the  edge  of  the  pectoral  exposed.  The  upper  incision  is 
then  made  in  the  same  way  ;  or,  if  the  gland  is  a  small  one,  the  pectoral  fascia 
with  the  structures  lying  on  it  is  stripped  up  at  once  from  the  muscle  until  the 
opposite  border  of  the  breast  is  reached.  As  soon  as  this  is  done  the  surgeon, 
holding  the  gland  in  his  left  hand,  divides  the  skin  over  the  upper  hemisi)here, 
and  with  a  ^tw  touches  of  the  scalpel  sets  the  whole  structure  free,  except  at  the 
upper  and  outer  angle ;  this  part  must  be  carefully  preserved,  as  it  contains  the 
majority  of  the  lymphatics  and  acts  as  a  guide  to  the  axilla. 

Hemorrhage  may  occur  from  the  incisions  in  the  skin  or  from  the  branches  of 


II 86    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  internal  mammary  artery  coming  through  the  pectoral  muscle  in  a  vertical 
direction.  The  bleeding  points  should  be  covered  at  once  with  a  sponge,  and 
haemostatic  forceps  applied.      Ligatures  are  seldom  needed. 

The  surface  of  the  wound  must  then  be  carefully  examined  to  see  that  the 
whole  of  the  gland  has  been  removed,  and  that  no  subjacent  fascia  is  left  behind 
(if  the  muscle  is  involved,  the  fibres  should  now  be  taken  away)  ;  and  if  the  skin 
will  come  together  with  the  arm  in  a  position  of  abduction,  the  sternal  end  of 
the  wound  may  be  washed  out  with  a  hot  solution  of  corrosive  sublimate  and 
united  as  soon  as  the  hemorrhage  has  been  stopped.  If  this  is  not  practicable,  it 
should  be  carefully  covered  over  with  hot  sponges,  to  avoid  the  chilling  effect  of 
exposure. 

The  arm  is  then  corai)letely  abducted  ;  the  incision  carried  along  the  lower 
border  of  the  pectoralis  major  nearly  up  to  the  biceps,  the  fascia  divided,  and  the 
contents  of  the  axilla  dissected  out,  beginning  at  the  pectoralis  major,  removing 
the  fascia  for  some  little  distance  between  it  and  the  pectoralis  minor,  and  then 
working  under  this  until  the  apex  is  reached.  If  there  is  the  least  difficulty,  there 
should  be  no  hesitation  in  dividing  these  muscles  at  their  insertion  as  far  as  may 
be  required.      The  intercosto-humeral   nerves  are  divided  and  some  branches  of 


Fig.  510. — Esmarch's  Operation  for  Excision  of  the  Breast. 

the  long  thoracic  and  other  arteries  cut,  but  there  is  very  little  hemorrhage.  If, 
when  approaching  the  axillary  vein,  or,  what  is  nearly  as  important,  the  end  of 
the  sub-scapular,  it  is  found  the  glands  are  extensively  adherent,  it  is  better  to 
pass  ligatures  beneath  the  vessels  and  give  them  to  an  assistant  to  hold  without 
tying  them.  In  this  way  hemorrhage  and  the  risk  of  air  entering  in  can  be  easily 
avoided.  Where  structures  require  dividing  high  up,  pressure  forceps  should 
always  be  applied  first. 

The  axillary  wound  is  then  thoroughly  sponged  out  with  hot  lotion  in  the 
same  way  ;  all  hemorrhage  stopped  ;  a  final  examination  made  to  see  that  the 
axillary  boundaries  are  really  clear,  and  the  arm  brought  down  to  the  side  to  allow 
the  edges  to  be  approximated. 

Owing  to  the  irregularity  of  its  shape,  a  thick  and  wide  drainage  tube  is 
always  required  for  the  axilla.  The  sternal  end  of  the  incision,  on  the  other  hand, 
unless  the  patient  is  very  stout,  may  be  left  without.  Three  or  four  deep  sutures 
of  adjustment  may  be  required  to  take  off  tension,  but  it  is  surprising  how  a  wound 
that  gapes  widely  when  the  arm  is  abducted,  falls  together  as  soon  as  it  is  placed 
by  the  side.  If  there  is  not  sufficient  skin,  the  surface  should  be  thoroughly 
cleansed  with  corrosive  sublimate,  dusted  lightly  with  iodoform,  and  covered  with 
a  piece  of  protective  cut  the  e.xact  size. 


EXCISION  OF  THE  BREAST.  ,,87 

Afterward  the  skin  of  the  arm  and  the  axilla  should  he  thoroughly  dried,  and 
the  whole  siJace,  behind  the  shoulder,  under  the  arm  and  along  the  thorax  care- 
fully packed  with  loose  j^ieces  of  some  absorbent  dressing.  The  elbow  must  be 
supported  ;  the  arm  fixed  to  the  side ;  the  hand  laid  on  the  thorax,  and  the  whole 
enclosed  in  a  linen  binder.  As  a  rule,  the  wound  drains  better  if  the  patient  lies 
upon  the  sound  side  ;  but  as  this  may  be  inconvenient,  or  cause  the  injured  one 
to  move  too  much  with  respiration,  this  should  not  be  insisted  on.  The  drainage 
tube,  if  there  is  any  oozing,  must  be  cleared  the  next  day;  if  the  wound  is  really 
dry,  it  may  be  left  till  the  second  or  third.  The  patient  should  on  no  account  be 
allowed  to  sit  upright,  or  move  the  arm  until  the  axillary  wound  is  practically 
sound. 


1 1 88     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


CHAPTER  XXVII. 

AMPUTATIONS. 

Amputation  of  the  Limbs. 

Amputation  may  be  required  for  injury  or  disease  :  and  the  former  may  be 
primarx  (within  twenty-four  hours),  intermediary  (before  suppuration;,  or  sec- 
ondary (after  suppuration).  But  this  division  is  of  doubtful  value.  It  is  more 
important  to  distinguish  those  cases  in  which  inflammation  has  not  yet  occurred 
from  those  in  which  it  has  already  broken  out  (and  the  operation  is  performed  with 
the  view  of  saving  the  patient  from  acute  septic  poisoning),  and  from  those  in 
which  the  tissues  have  recovered  and  are  beginning  to  protect  themselves  by  throw- 
ing out  a  barrier  of  granulations. 

The  chief  points  in  planning  an  amputation  are  :  (i)  to  sacrifice  as  little  as 
possible  ;  (2)  to  provide  an  ample  covering  of  skin  ;  (3)  to  arrange  the  flaps  so 
that  their  weight  shall  keep  them  in  position  :  (4)  to  make  sure  there  is  free  exit 
for  any  fluid  that  may  accumulate  ;  and  (5)  to  keep  the  scar  away  from  the  line  of 
pressure. 

The  various  methods  can  be  reduced  to  three  :  {a)  the  circular  ;  {F)  the  old 
flap  operation,  in  which  all  the  tissues  down  to  the  bone  are  included  ;  and  (<:)  the 
modified  flap  operation,  in  which  the  covering  is  formed  of  skin  alone,  all  the 
other  structures  being  divided  on  a  level  with  the  end  of  the  bone. 

(dr)  The  Circular. — The  limb  is  divided  by  a  succession  of  circular  sweeps  : 
the  first  through  the  skin  ;  the  second  (after  the  skin  has  been  retracted)  through 
the  superficial  muscles  ;  the  third  through  the  deep  ones  and  the  periosteum  ; 
and  the  fourth,  when  all  the  tissues  are  drawn  back,  through  the  bone.  It  is  prac- 
tically limited  to  the  arm  :  it  cannot  be  used  over  conical  parts  (as  the  skin  cannot 
retract),  or  where  the  bone  would  lie  in  the  centre  of  the  stump,  as  then  it  would 
abut  upon  the  cicatrix.  If  the  limb  is  injured  on  one  side  only,  it  may  be  very 
wasteful ;  and  in  cases  of  disease  in  which  the  tissues  are  hard  and  brawny,  or  the 
skin  tied  down  by  adhesions,  it  is  impracticable.  Where  it  can  be  performed  the 
covering  of  skin  is  good,  without  much  muscle,  drainage  is  satisfactory,  and  the 
scar  very  small. 

{b)  The  Old  Flap  Operation. — This  maybe  performed  either  by  transfixion, 
cutting  from  within  outward,  or  by  dissection,  separating  the  soft  tissues  from  the 
bones  in  an  upward  direction  ;  and  the  flaps  may  be  antero-posterior,  lateral,  and 
equal  in  length,  or  one  may  be  much  longer  than  the  other.  With  the  exception 
of  one  special  modification  (Teale's  amputation),  the  old  operation  is  seldom 
performed  on  any  part  but  the  extremities  :  the  flaps  are  heavy  and  thick, 
containing  a  large  amount  of  muscle  ,:  the  vessels  may  easily  be  slit,  or  wounded 
higher  up  than  they  are  divided  ;  the  surface  of  the  wound  is  very  large ;  and 
the  nerves  are  contained  in  the  flaps. 

In  Teale's  amputation  (which  is  reserved  almost  entirely  for  the  lower 
third  of  the  lower  limb),  the  anterior  flap,  which  contains  all  the  tissues  dissected 
up  from  the  bones,  is  perfectly  square,  equal  in  length  and  breadth  to  half  the 
circumference  of  the  limb  at  the  spot  at  which  the  bones  are  to  be  divided. 
The  posterior  flap  is  of  the  same  breadth,  but  only  one-fourth  the  length.  The 
bones  are  divided  at  the  line  from  which  the  flajjs  spring,  and  the  long  flap 
folded  round  the  end,  and  united  behind  it  to  the  posterior  one,  the  cut  surfaces 
facing  each  other.  The  flaps  are  measured  out  and  marked  down  first,  and  the 
two  lateral  incisions  made  before  the  transverse  ones.  The  drainage  is  admirable 
and  the  stump  left  very  soon  becomes  serviceable,  if  care  is  taken  to  keep  the 


AMPUTATION  OF  THE  LIMBS. 


1 1 89 


larger  vessels  and  nerves  in  the  shorter  flap  :  in  any  other  part  of  the  body  it  is 
much  too  extravagant. 

(^)  The  Modified  Flap  Operation. — In  this,  one  flap  (or  sometimes  both)  is 
formed  from  the  skin  and  subcutaneous  tissue  only  ;  the  rest  of  the  structures  are 
divided  by  a  circular  s\veei)at  thesame  level  as  the  bone.  It  is  a  method  capable 
of  far  wider  application  than  any  other,  and  may  be  modified  in  a  number  of 
different  ways. 

In  Garden's  operation,  for  example  (which,  though  first  devised  for  the  knee, 
may  be  employed  in  many  other  parts),  a  rounded  or  semi -oval  flap  is  reflected 
from  the  front  of  the  limb,  and  everything  else  divided  down  to  the  bone,  this 
being  sawn  through  slightly  above  the  plane  of  the  muscles.  This  leaves  an 
almost  flat  stump,  covered  with  integument ;  the  edges  of  the  wound  are  depend- 
ent, and  the  cicatrix  lies  well  out  of  the  way.  In  other  cases  (amputation  of 
the  forearm,  for  instance)  both  flaps  may  be  formed  in  this  way,  of  equal  length 
or  not,  according  to  the  amount  of  tissue  available  ;  or  lateral  flaps  may  be  cut, 
as  in  the  leg,  or  a  kind  of  hood  dissected  up,  as  in  Stephen  Smith's  method. 

The  position  of  the  surgeon  in  performing  an  amputation  is  always  such 


Fig.  511. — Teale's  .imputation. 


Fig.  512. — Garden's  Amputation  with  Short  Posterior  Flap. 


that  he  can  raise  the  flap  with  his  left  hand,  without  crossing  with  the  right ; 
usually,  therefore,  he  stands  on  the  right-hand  side  of  the  limb.  The  number 
of  assistants  required  depends  naturally  upon  the  part  to  be  removed  ;  one 
holds  the  limb,  and  afterwards  supports  the  stump  in  a  convenient  position ; 
another  assists  the  surgeon  in  retracting  the  flaps,  sponging,  and  tying  vessels; 
and  a  third  may  be  required  to  control  the  main  artery.  Where  it  is  possible  the 
patient  should  be  carefully  prepared  ;  the  bowels  opened  ;  the  urine  examined  ;  the 
pulse,  respiration,  and  temperature  noted  ;  and  the  limb  thoroughly  cleansed, 
and  if  necessary  shaved.  'I'he  last  meal  should  be  a  light  one  and  three  hours 
at  least  before  the  operation.  The  anaesthetic,  of  course,  requires  a  special 
assistant. 

During  the  operation  the  bed  should  be  thoroughly  warmed,  and  hot  bottles, 
pillows,  etc.,  arranged,  so  that  the  patient  may  be  placed  in  a  comfortable  posi- 
tion at  once,  with  the  stump  slightly  raised  and  secured  against  any  accidental 
movement  or  spasmodic  contraction  of  the  muscles.  Unless  the  patient  is  thor- 
oughly covered  up,  the  loss  of  heat  during  an  operation  (especially  under  ether) 
adds  seriously  to  the  shock. 


II90    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

SPECIAI-  AMPUTATIONS. 

[Amputation  of  the  Humerus  and  Scapula. 

Although  this  operation  has  been  performed  at  intervals  for  a  great  many 
years,  no  definite  rules  were  laid  down  for  its  performance  until  Berger's  Mono- 
graph appeared  in  1887.  Professor  Chas.  T.  Parkes,  of  Chicago,  after  experi- 
ments on  the  cadaver,  and  its  successful  performance  on  the  living  subject  in  .1889, 
thus  formulated  the  method  of  procedure,  in  an  article  before  the  Chicago  Medi- 
cal Society  :  — 

"  Following  the  suggestion  of  Mr.  May,  who,  in  a  late  issue  of  the  Annals 
of  Surgery,  reports  two  cases  of  this  operation,  I  have  looked  through  all  the 
books  in  my  library  and  have  not  found  any  specific  method  given.  It  remained 
for  Paul  Berger  to  give  a  plan  for  it.  He  was  led  to  the  plan  he  suggests  after 
several  trials  upon  the  cadaver.  The  quickest  and  easiest  method  of  doing  the 
operation  and  securing  the  blood-vessels  is  according  to  his  plan  of  i)rocedure. 
He  makes  his  first  incision  from  the  inner  extremity  of  the  clavicle  outward  to 
the  top  of  the  shoulder,  immediately  uncovers  the  clavicle  and  turns  it  out  of  the 
way  ;  this  leaves  the  subclavian  vessels  exposed  so  that  they  are  easily  secured. 
You  all  remember  well,  as  a  result  of  past  experience,  that  as  the  front  of  the  axil- 
lary space  is  uncovered  there  is  always  to  be  seen  a  ridge  across  it  produced  by 
the  raising  of  loose  tissue  upon  the  external  thoracic  nerve.  It  is  easily  found, 
and  I  call  attention  to  it  because  passing  outward  this  nerve  leads  directly  to  the 
interval  between  the  artery  and  vein,  and  hence  to  them.  With  the  clavicle  out 
of  the  way,  the  vessels  are  superficially  situated,  easily  isolated,  and  free  from  di- 
verging branches.  The  artery  should  be  tied  in  two  places,  an  inch  a])art,  and 
divided,  and  the  vein  also  ;  then  the  circulation  is  al)Solutely  under  control.  May 
advises  that  just  before  the  vein  is  tied  the  arm  should  be  elevated  for  a  few 
minutes  to  allow  the  venous  blood  to  drain  from  it,  thus  saving  as  much  blood  as 
possible  for  the  patient.  In  my  second  case  I  applied  the  Esmarch  bandage  up 
to  the  axilla.  As  soon  as  the  arteries  are  secured  in  this  position,  by  a  rapid  cut 
with  the  scissors  the  brachial  plexus  can  be  divided  and  the  pectoralis  major  and 
minor  be  severed. 

The  flap  portion  of  the  operation  is  done  in  this  way:  Commence  at  the 
centre  of  the  anterior  incision  and  carry  the  knife  directly  across  the  anterior  part 
of  the  axilla  and  inner  arm  to  the  lower  angle  of  the  scapula  ;  then  from  the  outer 
edge  of  the  incision,  posteriorly,  carry  the  knife  behind  the  joint  to  the  same 
point  ;  rapidly  reflect  the  posterior  flap  ;  then  all  the  muscular  attachments  should 
be  divided  and  the  extremity  removed  without  any  trouble.  This  gives  a  per- 
fectly even  anterior  and  posterior  flap,  coming  together  easily  and  nicely,  and 
avoids  the  unseemly  appearance  of  the  anterior  part  of  this  wound  which  was 
caused  by  the  too  redundant  anterior  flap."] 

Amputation  at  the   Shoulder   Joint. 

Spence's  operation  is  the  most  usefiil,  as  in  case  of  doubt  it  enables  the  head 
of  the  bone  to  be  examined  with  the  least  disturbance.  The  subclavian  may  be 
compressed  by  an  assistant  ;  but  as  this  is  often  a  difficult  proceeding,  the  vessels 
may  be  caught  in  the  flap  by  the  surgeon  or  his  assistant,  or  isolated  and  secured 
before  division.  The  position  of  the  patient  is  semi-recumbent,  with  the  shoulder 
projecting  over  the  edge  of  the  table  and  the  arm  moderately  abducted. 

The  incision  runs  from  just  outside  the  coracoid  process  to  the  insertion  of 
the  pectoralis  major,  which  should  be  divided.  The  incision  is  then  carried 
horizontally  across  the  outer  side  of  the  arm  to  the  posterior  border  of  the  axilla, 
dividing  the  deltoid.  The  inner  incision,  from  the  same  point  to  join  the  ter- 
mination of  the  outer,  may  be  marked  out  now,  but  it  must  not  be  deeper  than 
the  skin.     The  outer  flap  is  raised  ;  the  capsule,  the  tendons  attached  to  the  tuber- 


AMPUTATION  AT  THE  SHOULDER  JOINT. 


1 191 


osities,  and  the  long  tendon  of  the  biceps  divided  l)y  cutting  on  to  the  bone  ;  the 
limb  disarticulated  and  the  soft  structures  on  the  inner  side  cut  through,  the  artery 
being  either  secured  by  an  assistant,  or  exposed  and  ligatured  before  division. 
"^I'he  axillary  and  the  anterior  circumflex  are  the  only  vessels  necessarily  cut. 

In  cases  of  malignant  disease,  in  which  it  is  wished  to  retain  as  little  of  the 


Fig.  513. — Spence's  Amputation. 


Fig   514. — Amputation  by  Transfixion. 


soft  Structures  as  possible,  skin  flaps  may  be  used  instead.  Lateral  ones  are  marked 
out :  {a)  by  an  incision  beginning  in  the  middle  of  the  axilla,  pa.ssing  down  nearly 
as  low  as  the  insertion  of  the  deltoid  on  the  outer  side  of  the  arm,  and  then  curv- 
ing upward  to  end  just  outside  and  below  the  coracoid  process  ;  and  (/;)  by  a  second 
beginning  and  ending  at  the  same  points,  only  passing  a  sufficient  distance  down 
the  inner  side  of  the  arm.      Or  a  racquet -shaped  incision  maybe  employed,  start- 


FiG.  515  — Amputation  at  Elbow  Joint. 


ing  from  the  same  point  near  the  coracoid,  and  running  first  down  the  outer  side 
of  the  arm  and  then  circularly  round  it.  In  either  case  the  skin  is  dissected  up, 
the  soft  parts  divided,  and  the  vessels  secured  as  before.  In  this  method  the  pos- 
terior circumflex  is  usually  divided  as  well  as  the  anterior. 

Other  methods  are  by  transfixion  from  behind  forward  (or  vice  versa,  according 


1 192    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

to  the  side),  forming  a  great  external  flaj)  of  the  deltoid  and  the  skin  covering  it; 
and  Furneaux  Jordan's,  circular  through  the  arm  below,  and  then,  after  the  ves- 
sels are  secured,  dissecting  out  the  upper  end  of  the  humerus. 

Amputaiion  of  the  Arm. 

The  circular  method  usually  gives  an  excellent  result  ;  but  skin  flaps  with 
circular  division  of  the  muscles,  or  one  of  these  in  front,  and  a  short  transfixion 
flap  behind,  may  beado])ted  instead.  In  this  amputation,  as  in  all  others  through 
the  shaft  of  a  bone,  the  periosteum  should  be  divided  some  little  distance  below 
the  bone,  so  that  it  may  invest  and  adhere  to  the  face  ot  the  section. 


Amputation  of  the  Forearm. 

Skin  flaps  with  circular  division  of  the  muscles  should  be  adopted  wherever  it 
is  possible;  but  the  circular  operation,  Teale's  method,  and  transfixion  (for  one 


Fig.  516  — Ainpui.>t;uii  of  Forearm  by  Jlixed  Method. 

flap)  may  be  employed.      Care  should   be  taken  to  supinate  the  limb  while  the 
bones  are  being  sawn,  to  ensure  their  being  parallel. 

Disarticulation  at  the  elbow  and  wrist  does  not  require  special  mention. 

Amputation  of  the  Thumb. 

This  may  be  performed  either   with  a   racquet-shaped   incision   or  with   a 
palmar  flap   formed  by  transfixion.     In  the   former  case  tlie  thumb   is  held  in 


Fig.  517. — Amputation  of 
Hand. 


Fig.  5:8. — Amputation  of  tlie  Thumb  by  Transfixion. 


the  extended  position  ;  the  point  of  the  knife  introduced  on  the  dorsal  surface 
of  the  base  of  the  metacarpal  bone,  and  the  incision  carried  down  the  bone, 
nearly  to  the  phalangeal  articulation  ;  then  it  winds  around  the  bone,  descending 
on  the  ulnar  side  (in  the  case  of  the  left  hand)  and  ascending  on  the  radial 
until  it  joins  the  dorsal  incision  again.     The  skin  is  then  dissected  back,  the 


AMPUTATION  OF  THE  FINGERS. 


1 193 


carpo-metacarpal  articulation  opened,  and  the  soft  tissues  divided,  taking  especial 
care  of  the  radial  artery.  In  the  latter  the  thumb  is  slightly  abducted,  and  a  flap 
cut  by  transfixion  from  the  muscles  of  the  ball.  If  the  left  hand  is  in  question. 
the  point  is  introduced  on  the  palmar  side  of  the  carpal  joint,  carried  obliquely 
over  the  dorsal  surface  of  the  metacarpal  bone  to  the  ulnar  side  of  the  phalangeal 
joint,  and  thrust  through  the  ball  of  the  thumb  until  its  point  emerges  through 
the  original  puncture.  In  cutting  out  it  is  advisable  to  keep  close  to  the  bone, 
but  care  must  be  taken  not  to  lock  the  blade  against  the  sesamoids.  On  the 
right  hand  the  flap  is  cut  first  and  its  two  extremities  joined  over  the  dorsum. 


Amputation  of  the  Fingers. 

It  must  be  remembered  that,  in  all  these  joints,  the  bone  that  projects  on  the 
dorsal  surface  is  the  proximal  one,  and  that,  on  the  palmar  surface,  although  the 
fold  of  the  skin  corresponds  fairly  well  to  the  first  inter-phalangeal  joint,  this  is 
not  the  case  either  with  the  one  above  or  the  one  below ;  the  circle  formed  by  the 
skin  (when  the  fingers  are  flexed)  is  smaller  than  that  formed  by  the  bones,  and 
consequently  the  distance  between  the  folds  is  less  than  that  between  the  joints ; 
the  nearest  of  the  three  is  the  thickness  of  the  metacarpal  bone  below  the  articu- 
lation ;  the  middle  one  corresponds  to  it,  and  the  furthest  is  the  thickness  of  the 
phalanx  above. 

{a)  Amputation  at  the  ■  Metacarpo-phalangeal  Joint. — A  racquet-shaped  in- 
cision is  the  best,  commencing  on  the  neck  of  the  metacarpal,  running  straight 
down  on  to  the  phalanx,  and  then  winding  round  the 
finger  below  the  web.  It  should  divide  the  extensor 
tendon  at  once,  and  pass  right  down  to  the  bones. 
Afterward,  the  lateral  ligaments  and  a  few  other 
structures  require  division.  In  the  case  of  the  index 
and  little  fingers,  the  incision  should  be  made  at  the 
side,  as  it  is  less  conspicuous.  Where  strength  is  re- 
quired, the  head  of  the  metacarpal  should  be  left,  but, 
if  it  is  wished  to  minimize  the  deformity  at  all  cost,  it 
may  be  removed  obliquely  with  bone-forceps. 

(U)  iTtterphalangeal  Amputation. — This  is  usually 
performed  with  a  single  palmar  flap  ;  but  single  dor- 
sal, lateral  ones,  or  equal  dorsal  and  palmar,  may  be 
selected  instead. 

When  a  long  palmar  flap  is  chosen,  the  finger  is 
bent  to  a  right  angle,  and  the  knife  (which  should  be 
long  and  very  narrow)  drawn  across  the  front  of  the 
joint,  so  as  to  open  it,  and  divide  the  extensor  tendon 
at  one  sweep.  The  lateral  ligaments  are  then  divided, 
and  the  knife  insinuated  behind  the  distal  phalanx, 
and,  following  its  palmar  surface,  made  to  cut  a  long 
square-shaped  flap  from  the  under  portion. 

It  is  usually  recommended  not  to  amputate  through  the  proximal  phalangeal 
joint,  or  through  the  proximal  phalanx  itself;  but,  as  Jacobson  points  out,  this 
rule  should  not  be  followed  in  the  case  of  the  index  or  little  fingers,  when  all  the 
fingers  are  amputated,  or  when  the  patient  prefers  to  have  it  left.  If  the  flexor 
tendons  are  stitched  to  the  theca,  the  periosteum,  or  even  to  the  skin,  the  stump 
follows  all  the  movements  of  the  other  fingers. 


Fig.  519. — Outline  Diagram  for  Ampu- 
tation of  the  Thumb  and  Fingers. 


Amputation  at  the  Hip  Joint. 

The  older  operations  (antero-posterior  transfixion  flaps,  and  lateral  skin  or 
transfixion  ones)  have  given  place   to  Furneaux  Jordan's  method  ;  the  shock  is 
very  much  less  ;   the  risk  of  hemorrhage  not  so  great ;   the  wound  is  as  far  away 
76 


1 194    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 


from  the  anus  as  it  can  be,  and  the  stump  is  sufficiently  long  and  well-nourished 
to  carry  an  artificial  limb,  at  any  rate  for  a  short  time. 

The  patient  is  brought  well  down  to  the  edge  of  the  table,  and  the  vessels 
controlled  either  by  Lister's  tourniquet,  Davy's  rectal  lever  (p.  209),  or  Jordan 
Lloyd's  elastic  strap.  This  consists  of  a  piece  of  stout  rubber  tubing  carried 
obliquely  from  high  \\\)  in  the  groin,  across  the  hip  (one  end  above,  the  other 
beneath),  to  the  middle  of  the  iliac  crest,  where  it  is  held  by  an  a.ssistant.  thither 
a  pad,  or  a  properly  shaped  block  of  wood  grooved  on  its  upper  surface  to  prevent 
the  strap  slipping  from  off  it,  is  fitted  over  the  vessels  at  Poupart's  ligament. 
[Trendelenburg  first  recommended  that  a  steel  pin  be  thrust  through  the  thigh  on 
the  inner  side,  close  to  the  bone,  and  then  compressed  with  an  elastic  cord  thrown 
over  the  ends  in  figure-of-eight  fashion.]  A  circular  amputation  is  then  performed 
through  the  lower  third  of  the  thigh,  the  skin,  fascia,  and 
muscles  being  divided  down  to  the  bone,  and  the  vessels  secured. 
As  soon  as  this  is  done,  the  wound  is  packed  with  sponges  wrung 
out  of  hot  corrosive  sublimate  lotion,  and  an  incision  made 
along  the  outer  side  of  the  limb,  from  the  circular  wound  to  a 
spot  midway  between  the  trochanter  and  the  iliac  crest ;  the 
soft  parts  (including  the  periosteum,  if  it  is  thought  advisable) 
are  stripped  off  the  bone  ;  the  joint  opened  by  cutting  on  to  the 
neck,  and  the  femur  disarticulated  by  the  assistant.  It  is  doubt- 
ful if  any  bone  is  ever  reproduced,  but  there  is  no  question  that 
the  preservation  of  the  periosteum  adds  to  the  stability  and  nu- 
trition of  the  stump. 

In  the  operation  by  lateral  flaps,  the  surgeon  stands  on  the 
right-hand  side,  and  marks  out  the  incisions  successively,  start- 
ing from  the  tuber  ischii  behind,  running  down  a  hand'sbreadth 
below^  the  trochanter  (or  a  corresponding  distance  on  the  inner 
side  of  the  limb),  and  ending  in  the  centre  of  the  groin,  imme- 
diately outside  the  femoral  vessels.     The  external  flap  should  be 
^'dan'\°'Mrtho"d  orAml  dissectcd   up  first ;  the  vessels  secured,  and  the  joint  opened  ; 
putation  at  the  Hip  and  then   the   tissues   on  the  inner  side  of  the  limb,  this  part 
being  finished  either  by  dissection  or  transfixion.      Disarticula- 
tion is  ])erformed  last. 
In  the  antero-posterior  method,  a  flap,  five  inches  long,  is  formed  by  trans- 
fixion from  the  tissues  of  Scarpa's  triangle.     The  knife  enters  midway  between 


Fig.  521. — .Antero-posterior  Method. 


the  anterior  superior  spine  and  the  great  trochanter,  passes  across  the  front  of 
the  joint  (opening  the  capsule  if  possible),  and,  avoiding  the  obturator  foramen, 
emerges  close  to  the  tuberosity  of  the  ischium.     On  the  left  limb  it  takes  the  re- 


AMPUTATION  AT  THE   HIP  JOINT.  1195 

verse  course.  One  assistant  holds  the  Hmb  slightly  flexed,  while  a  second,  as  the 
knife  cuts  out  the  flap,  follows  it  with  his  fingers,  and  seizes  and  compresses  the 
vessels  as  they  are  divided.  The  flap  is  drawn  up  as  far  as  possible  ;  the  first  as- 
.sistant  extends  and  rotates  the  limb  outward,  to  put  the  capsule  on  the  stretch  ; 
the  joint  is  opened  freely,  an  incision  made  around  the  great  trochanter,  and  the 
head  of  the  bone  dislocated  by  over-extension  and  abduction.  As  soon  as  this  is 
accomplished,  the  ligamentum  teres  is  cut,  and  while  the  assistant  raises  the  limb 
and  draws  it  away  from  the  body,  the  surgeon  places  the  knife  transversely  in  the 
wound,  behind  the  head  of  the  l)one,  and  cuts  a  short  posterior  flap.  The  ves.sels 
on  the  front  of  the  limb  can  be  controlled  in  this  operation,  but  unless  measures 
are  taken  to  secure  the  internal  or  common  iliac,  the  hemorrhage  from  those 
behind,  and  from  the  cut  surface  of  the  muscles,  is  very  severe. 

[Notwithstanding  the  great  advances  made  in  the  control  of  hemorrhage  and 
prevention  of  infection,  there  is  still  great  mortality  attending  the  operation  from 
shock,  death  occurring  in  about  60  per  cent,  of  the  cases. 

Professor  Nicholas  Senn  has  devised  an  entirely  new  plan  for  amputation  at 
the  hip  joint.  In  a  paper  read  before  the  Surgical  Section  of  the  Suffolk  District 
Medical  Society,  February  i,  1893,  he  thus  describes  his  operation:  — 

Exh-rnal  Incision. — The  external  incision  is  Langenbeck's  incision  for  resection  of 
the  hip  joint,  differing  from  this  only  in  so  far  that  it  is  carried  a  little  further  in  a  down- 
ward direction  in  order  to  afford  more  ready  access  to  the  shaft  of  the  femur  as  far  as 
the  proposed  Ime  of  section  through  the  deep  soft  parts.  The  incision  is  made  about 
eight  inches  in  length,  parallel  to  the  long  axis  of  the  femur  directly  over  the  centre  of 
the  great  trochanter,  extending  about  tiiree  inches  above  the  upper  border  of"  the 
trochanter.  When  the  knife  reaches  the  trochanter  from  above  downward,  its  point 
should  be  kept  in  contact  with  the  bone  the  whole  length  of  the  remaining  part  of  the 
incision.  The  margins  of  the  wound  are  now  retracted  and  any  spurting  vessels,  such 
as  the  circumflex  arteries,  secured  by  applying  pressure  forceps. 

Dislocation  of  Head  oj  Fcmnr  and  Clearing  of  Upper  Portion  of  Shaft. — During 
this  and  remaining  steps  of  the  operation  the  body  is  drawn  down  so  that  the  pelvis 
rests  upon  the  lower  edge  of  the  table,  so  that  the  position  of  the  thigh  can  be  conveni- 
ently changed  by  the  assistant  who  is  entrusted  with  this  work.  The  pelvis  is  tilted 
sufficiently  upon  the  opposite  healthy  side  to  facilitate  this  step  of  the  operation.  The 
trochanteric  muscular  attachments  are  now  severed  close  to  the  bone  with  a  stout  scalpel. 
The  clearing  of  the  digital  fossa  and  division  of  the  tendon  of  the  obturator  externus 
requires  special  care.  The  thigh  is  now  flexed,  strongly  adducted,  and  rotated  inward, 
when  the  capsular  ligament  is  divided  transversely  at  its  upper  and  posterior  aspect. 
The  remaining  portion  of  the  capsular  ligament  is  severed  while  the  thigh  is  brought 
back  to  a  position  of  slight  flexion.  After  complete  division  of  the  capsular  ligament 
the  thigh  is  rotated  outward,  and,  if  possible,  the  ligamentum  teres  is  divided  ;  if  this 
cannot  be  readily  done  the  head  of  the  bone  is  forcibly  dislocated  upon  the  dorsum  of 
the  ilium  by  flexion,  adduction  and  rotation  inward  of  the  thigh.  After  dislocation  has 
been  effected,  the  trochanter  minor  and  upper  part  of  shaft  of  femur  are  cleared  by 
using  alternately  scalpel  and  periosteal  elevator.  In  cases  where  it  is  deemed  advisable 
the  periosteum  can  be  preserved.  At  the  completion  of  this  part  of  the  operation  the 
femur  is  in  a  position  of  extreme  adduction.  By  pushing  the  femur  through  the  opening 
as  much  of  the  shaft  can  be  cleared  as  may  be  desired  for  the  purpose  of  making  a  low 
amputation. 

Elastic  Constriction. — During  the  operation  so  far,  if  the  surgeon  has  kept  in  close 
contact  with  the  bone,  and  has  used  the  knife  sparingly  and  the  periosteal  elevator  freely, 
the  hemorrhage  has  been  very  slight,  much  more  so  than  if  this  part  of  the  operation  had 
been  reserved  for  the  last,  as  is  done  in  Esmarch's  method.  Further  loss  of  blood  during 
the  subsequent  steps  of  the  operation  is  now  prevented  by  elastic  constriction  applied  in 
the  following  manner  :  The  limb  is  brought  down  in  a  straight  line  with  the  body,  the 
thigh  slightly  flexed  so  as  to  push  the  upper  free  end  of  the  femur  forward  into  and 
beyond  the  wound,  when  a  long,  stout  haemostatic  forceps  is  inserted  mto  the  wound 
behind  the  femur  and  on  a  level  with  the  trochanter  minor  when  in  normal  position  ; 
the  instrument  is  pushed  inward  and  downward  in  a  direction  about  two  inches  below  the 
ramus  of  the  ischium  and  just  behind  the  adductor  muscles.  As  soon  as  its  point  can  be 
felt  under  the  skin  in  this  location  an  incision  is  made  through  the  skin  about  two  inches 
in  length,  through  which  the  instrument  is  made  to  emerge.  After  enlarging  the  tunnel 
made  in  the  soft  tissue  by  expanding  the  branches  of  the  forceps,  a  piece  of  aseptic  rubber 
tubing  three-quarters  of  an  inch  in  diameter  and  about  three  or  four  feet  in  length  is 


1196    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

grasped  with  the  forceps  in  the  middle,  and  is  drawn  along  the  tunnel  as  the  forceps  is 
withdrawn.  After  tiiis  has  been  done  the  rubber  tube  is  cut  in  two  at  the  point  where  it 
was  grasped  l:)y  the  forceps.  With  one-half  of  the  tube  the  anterior  segment  of  the  thigh 
is  constricted  sufficiently  firm  to  com|)lete]y  interrupt  both  the  arterial  and  venous  circu- 
lation. Prior  to  constriction,  the  limb  is  rendered  bloodless  by  elastic  compression,  or  by 
keeping  it  in  a  vertical  position  for  a  few  minutes,  or  both  of  these  methods  are  combined 
in  preventing  unnecessary  loss  of  blood.  The  elastic  constrictor  is  either  tied,  or,  still 
better,  after  having  secured  the  necessary  constriction  both  tubes  are  caught  and  held  by 
a  strong  pair  of  forceps  at  a  point  where  they  cross  each  other.  The  posterior  segment 
of  the  thigh  is  constricted  by  the  remaining  rubber  tube,  which  is  drawn  sufficiently  tight 
behind,  when  the  ends  of  the  tube  are  made  to  cross  each  other  and  are  brought  forward 
and  made  to  include  the  anterior  segment,  when  they  are  again  firmly  drawn  and  tied, 
or  otherwise  fastened,  above  the  first  constrictor.  As  the  anterior  segment  of  the  thigh 
contains  the  principal  blood-vessels  this  method  of  applying  the  posterior  constrictor 
furnishes  an  additional  security  against  hemorrhage  from  the  large  vessels  when  divided 
by  the  circular  incision. 

Cutaneous  Flaps. — Muscular  flaps  should  be  avoided  in  all  amputations  at  the  hip 
joint.  Inclusion  of  muscles  in  the  flaps  is  often  accountable  for  incomplete  removal  of 
malignant  or  infective  disease  for  which  the  amputation  is  made.  An  ideal  stump  can 
be  made  by  cutaneous  flaps  and  circular  section  of  the  muscles.  If  the  conditions  per- 
mit it,  a  long  oval  anterior  and  short  posterior  skin  flaps  should  be  made.  If  this  is 
impracticable  healthy  skin  must  be  obtained  by  making  long  external  and  short  internal 
flaps,  or  a  long  posterior  or  short  anterior,  according  to  the  location  and  extent  of  the 
disease.  The  long  anterior  and  short  posterior  flaps  are  best  adapted  for  a  useful  stump 
and  efficient  drainage.  In  making  the  anterior  flap  the  incision  is  commenced  at  the 
lower  tcrminusof  the  straight  incision,  dividing  the  tissues  down  to  the  muscles;  it  is  carried 
downward  in  a  gentle  curve  across  the  anterior  aspect  of  the  thigh,  embracing  about 
two-thu'ds  of  the  circumference  of  the  thigh;  it  is  finally  carried  upward  to  a  point  on  the 
inner  side  just  below  the  opening  in  the  skin  occupied  by  the  constrictors.  The  posterior 
flap  is  made  in  a  similar  manner,  but  about  one-third  shorter.  The  flaps  are  now  reflected 
to  the  point  where  the  muscles  are  to  be  divided,  and  should  always  include  the  deep 
fascia.  The  flaps  are  to  be  held  out  of  the  way,  while  the  operator  completes  the  ampu- 
tation by  dividing  the  muscles  with  an  amputating  knife.  This  last  incision  will  corres- 
pond to  a  point  on  the  femur  to  where  the  bone  has  deen  deprived  of  soft  parts.  The 
incision  through  the  muscles  should  be  slightly  conical  with  the  apex  of  the  cone  directed 
upward  and  corresponding  to  the  location  of  the  tube  made  by  the  enucleation  of  the 
femur. 

The  sciatic  nerve  is  now  resected  to  the  extent  of  an  inch  or  more,  and  the  femoral 
artery  or  arteries  tied  with  catgut  in  the  usual  manner.  The  femoral  artery  and  vein  are 
now  isolated,  and  a  second  catgut  ligature,  including  both  of  these  vessels,  applied  half 
an  inch  higher  up.  In  this  manner  the  vein  is  ligated,  while  the  artery  is  secured  by  a 
double  ligature,  which  places  the  end  of  the  vessel  in  the  best  possible  condition  for 
definitive  closure  and  cicatrization.  The  intermuscular  septa  are  now  examined,  and  any 
vessels  that  can  be  seen  are  tied.  While  the  posterior  constrictor  is  removed  the  poste- 
rior half  of  the  stump  is  firmly  compressed  by  applying  a  hot  moist  compress  of  aseptic 
gauze,  over  which  manual  pressure  is  made  for  a  short  time,  for  the  purpose  of  diminishing 
parenchymatous  oozing.  After  removal  of  the  compress  additional  bleeding  vessels  are 
secured.  The  anterior  part  of  the  amputation  surface  is  treated  in  a  similar  manner; 
after  the  removal  of  the  anterior  constrictor  but  few,  if  any,  additional  ligatures  will  be 
required  here.  The  double  constrictor  presents  many  advantages  in  the  prevention  and 
treatment  of  hemorrhage  in  this  amputation.  Slipping  of  the  constrictors  is  an  impossi- 
bility, and  they  control  the  hemorrhage  absolutely,  while  their  proper  use  divides  the 
wound  into  two  halves,  each  of  which  is  separately  treated,  thus  reducing  the  loss  of 
blood  to  a  minimum.  I  applied  this  method  to  one  case  recently,  and  every  one  present 
was  favorably  impressed  with  the  ease  with  which  the  hemorrhage  was  controlled  during 
the  amputation,  and  astonished  at  the  small  amount  of  blood  lost  after  the  removal  of 
the  constrictors.  As  this  method  of  amputation  does  not  require  the  presence  of  a  skilled 
assistant,  it  will  prove  of  special  value  in  emergency  cases.  The  operation  can  be  per- 
formed with  instruments  contained  in  every  pocket  case.  Should  an  elastic  tube  not  be 
at  hand  the  constriction  can  be  made  in  the  manner  describea  by  substituting  for  it  a 
cord  made  of  sterilized  gauze  or  bandage.] 


Amputation  Through  the  Femur. 

{a)   In  amputations   through  the  shaft,  the  mixed  method  (an  anterior  skin 
flilj  with  a  shorter  posterior  one  by  transfixion)  answers  so  well,  that  any  other  is 


AMPUTATION  THROUGH  THE   KNEE  JOINT. 


1 197 


seldom  needed.  Care  must  be  taken  not  to  slit  or  jjrick  the  artery  as  it  is  passing 
out  of  Hunter's  canal,  and,  in  arranging  the  dressings,  it  must  be  remembered 
that,  owing  to  the  rotation  of  the  thigh,  the  (laps  very  soon  assume  a  lateral 
l^osition. 

(J))  Amputation  tlirough  the  condyles  may  be  performed  according  either  to 
Garden's  or  Stokes's  method.  The  section  of  the  bone  in  the  former  runs  through 
the  base  of  the  condyles,  and  the  anterior  flap  passes  across  the  limb  midway  be- 
tween the  apex  of  the  patella  and  the  tubercle  of  the  tibia  ;  in  the  latter,  the  bone 
is  divided  above  the  condyles  (supracondyloid),  and  the  anterior  flajj  reaches  down 
to  the  tubercle,  the  increased  length  being  recpn'red  by  the  patella,  the  sawn  surface 
of  which  is  removed,  so  that  it  may  face  and  become  adherent  to  the  cancellous 
tissue  of  the  femur.  They  are  both  far  superior  to  amputation  through  the  thigh, 
owing  to  their  enabling  the  pressure  to  be  borne  (in  part  at  least)  on  the  face  of 
the  stump  and  their  preserving  the  insertion  of  the  adductor,  and,  in  Stokes's,  the 
extensor  muscles.  Gritti's  amputation  is  similar  to  Stokes's,  but  the  bone  is  divided 
half  an  inch  lower,  and  the  patella  does  not  fit  so  well.  In  Garden's  operation 
there  is  no  posterior  flap  at  all  ;  in  Stokes's  it  is  nearly  as  long  as  the  anterior,  and 
is  cut  either  by  dissection  or  transfixion,  according  to  the  bulk  of  the  limb. 

Amputation  through  the  Knee  Joint. 

Stephen  Smith's  is  the  most  satisfactory,  as  antero-posterior  flaps  require  to  be 
of  such  length  (both  on  account  of  the  depth  of  the  femur  and  the  tendency  of 


Fir..  522. — Stephen's  Smith's  Method  of 
Amputating. 


Fig.  523.- — Posterior  Aspect  of 
Stump  after  Stephen  Smith's 
Amputation  at  Knee  Joint, 
showing  Cicatrix. 


the  posterior  one  to  retract)  that  there  is  always  danger  of  sloughing.  The  stump 
(w^hich  includes  the  patella)  is  of  excellent  shape,  and  well  calculated  to  bear 
weight. 

The  incision  commences  one  inch  below  the  tubercle  of  the  tibia,  runs  curv- 
ing downward  with  a  wider  sweep  on  the  inner  side  than  the  outer,  owing  to  the 


'f'}'':i 


Fig.  524 — Amputation  through  Knee  Joint  by   Long  Anterior  Flap  (Erichsen). 


greater  depth  of  the  inner  condyle,  over  the  side  of  the  leg  to  the  middle  line 
behind,  and  then  upward  for  about  three  inches  and  a  half  to  the  centre  of  the 
popliteal  space.  A  similar  flap  is  shaped  from  the  other  side  ;  the  skin  and  fascia 
are  reflected  upward  ;  the  ligamentum  patellae  divided  ;  the  joint  opened,  and  the 
soft  part  separated  by  a  circular  sweep  round  the  limb.      It  is  recommended  to  leave 


1 198    DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  semilunar  cartilages  attached  to  the  femur,  as  they  jirevent  retraction  to  some 
extent.  This  operation  does  not  enable  the  suprajiatellar  pouch  to  be  dealt  with  in 
any  way,  and  accordingly  is  better  suited  to  cases  of  injury  than  of  disease. 

Amputation  throucjh  the  Leg. 

In  the  uj^per  half,  Stephen  Smith's  method,  or  that  in  which  lateral  flaps  are 
combined  with  circular  division  of  all  the  subjacent  tissues,  gives  the  best  result; 
but,  particularly  in  cases  of  injury,  it  may  be  advisable  to  adopt  others.      In  sawing 


Fig.  525. — Amputation  of  the  Leg  by  the  Mixed  Method. 


Fig.  526. — Stump  after 
an  Amputation  of  the 
Leg  by  the  Mixed 
Method. 


the  bones,  care  must  be  taken  to  divide  the  fibula  before  the  tibia,  and  to  remove 

the  sharp  angle  left  by  the  crest  of  the  latter,  for  fear  of  its  causing  undue  pressure. 

The  lower  half  of  the  leg  is  the  favorite  situation  for  Teal's  amputation. 

Amputations  at  the  Ankle  Joint. 

The  most  important  are  those  known  by  the  names  of  Syme,  Roux,  and  Piro- 
goff. 

Symes. — The  whole  of  the  foot  is  removed  with  the  malleoli,  and  the  stump 
covered  with  a  flap  formed  from  the  heel.  The  incisions  are  :  (i)  from  the  tip  of 
the  external  malleolus  across  the  front  of  the  ankle  joint  (very  slightly  convex 


•A 


Fig.  527. — Syme's  Amputation  of  the  Foot. 


Fig.  528. 


downward)  to  the  corresponding  point  (half  an  inch  below  and  behind  th«  inter- 
nal malleolus)  on  the  inner  side  ;  and  (2)  between  the  same  points  across  the  sole 
of  the  foot,  slanting  slightly  backward  on  to  the  point  of  the  heel.  On  the  left 
foot  the  incisions  are  begun  on  the  inner  side. 

The  ankle  is  su])ported  on  the  ^(VgQ  of  a  form  cushion  at  a  suitable  height  and 
the  fore  part  of  the  foot  held  by  the  operator's  left  hand  in  a  position  of  extreme 


AMPUTATIONS  AT  THE  ANKLE  JOINT. 


1 199 


dorsal  flexion.  The  plantar  incision  is  made  first,  carrying  it  right  down  to  the 
bone  (the  knife  is  short  and  stout)  ;  then,  the  grasp  being  altered  so  as  to  place  the 
foot  in  extreme  plantar  flexion,  the  dorsal  one,  taking  care  not  to  cut  on  to  the 
astragalus  (or  still  more  the  joint  in  front  of  it),  but  to  open  the  ankle  joint  at 
once.  The  foot  is  now  depressed  more  and  more  ;  the  lateral  ligaments  divided  ; 
the  upper  surface  of  the  os  calcis  exposed,  and  then  the  tendo-Achillis.  This  is 
separated  from  its  insertion  with  the  point  of  the  knife,  taking  care  not  to  button- 
hole or  score  the  flap,  and  with  a  few  touches  the  foot  is  detached.  The  tendons 
must  be  shortened  with  scissors,  and  the  malleoli  removed  ;  but  unless  the  lower 
end  of  the  tibia  is  diseased,  there  is  no  need  to  remove  the  cartilage.  The  arteries 
divided  are  the  dorsalis  pedis  and  the  two  plantars.  It  is  of  consequence  not  to  cut 
the  posterior  tibial  before  its  division,  as  the  nutrition  of  the  flap  depends  mainly 
upon  the  calcanean  branches. 

Roux' s. — In  this  the  flap  is  taken  from  the  inner  side.  The  incision  forms 
an  irregular  oval,  commencing  at  the  apex  of  the  external  malleolus,  running 
across  the  front  of  the  ankle  as  far  as  the  scaphoid  on  the  inner  side,  then  sweeping 
round  to  gain  the  middle  line  of  the  sole,  passing  up  the  posterior  border  of  the 
tendo-Achillis,  and  ending  where  it  began. 

Pirogoff^ s. — The  posterior  portion  of  the  os  calcis  is  sawn  off  and  brought 
face  to  face  with  the  cut  surface  of  the  tibia.  The  limb  is  longer  than  after  a 
Syme's,  and  the  stump  wastes  less,  but  it  is  not  suited  to  cases  in  which  the  bones 
are  diseased. 

The  position  of  the  foot  and  the  incisions  are  almost  the  same  as  in  a  Syme's, 
but  the  plantar  one,  instead  of  sloping  backward,  passes  transversely  across  the  sole 
from  point  to  point,  or,  if  the  arch  of  the  foot  is  very  high,  may  even  slant  a  little 


Fig.  529. — PirogofTs  Amputation. 
Heel  Flap  with  Os  Calcis. 


Fig.  530. — Stump  after  Piro- 
goff's  Amputation.  ■ 


forward.  The  amputation  may  either  be  performed  in  the  same  order  as  a  Syme's, 
the  OS  calcis  being  sawn  through  from  above  instead  of  being  detached,  or  the  bone 
may  be  divided  through  the  plantar  incision  as  soon  as  this  is  made,  the  chief 
advantage  being  that  it  is  more  easily  held.  In  either  case  the  line  of  section 
should  run  from  above  downward  and  forward  so  as  to  secure  a  large  surface  and 
prevent  tension  upon  the  tendo-Achillis.  Pirrie  advocates  sawing  the  tibia  through 
in  the  same  way  from  the  dorsal  incision  without  opening  the  joint,  a  itw  tendi- 
nous and  ligamentous  bands  only  requiring  division  afterward.  Apposition  of  the 
bony  surfaces  is  best  secured  by  one  or  two  chromic  gut  sutures  passed  through 
them. 


Amputations  through  the  Foot. 

The  most  important  are  Chopart's,  Tripier's,  the  subastragalar  operation,  and 
Hey's  or  Lisfranc's.  Formal  oj^erations,  however,  are  seldom  performed  ;  in  cases 
of  disease  in  which  local  measures  have  failed,  it  is  rarely  possible  to  leave  much  of 


I200     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

the  tarsus  ;  and  after  injury  it  is  better  simply  to  prevent  decom])Osition  and  wait 
until  it  is  seen  how  far  the  tissues  can  repair  the  damage  of  themselves.  P'ollowing 
this  principle,  on  one  occasion,  in  which  the  contents  of  a  gun  had  blown  a  hole 
through  a  man's  foot,  I  succeeded  so  well  that  within  six  months  the  patient  could 
walk  three  or  four  miles  and  ascend  ladders  without  inconvenience. 


Fig.  531. — I.  The  Incisions  in  Pirogoff 's  Amputation.     The  dotted  line  shows  the  direction  of  the  plantar 
incision  in  that  of  Syme.     2.  The  incision  is  subastragaloid  ;  and  3,  those  in  Chopart's  amputation. 

Choparf  s  Amputation  through  the  Mid-tar  sal  Joint. — The  foot  is  supported 
as  in  Syme's  operation,  and  the  anterior  part  held  in  the  left  hand  so  that  it  may 
be  placed  in  extreme  plantar  or  dorsal  flexion  as  required.  The  tubercle  of  the 
scaphoid  and  the  corresponding  point  on  the  opposite  side  (midway  between  the 


!•  ir,.  532. — Stump  left  after 
Chopart's  Amputation. 


tic.  533. — Tripier's  Amputation  of  the  Foot, 
(a)  Section  through  the  skin ;  {J>)  through  the  soft  parts. 


external  malleolus  and  the  base  of  the  fifth  metatarsal)  are  defined,  and  the  plantar 
flap  marked  out  first.  It  extends  from  behind  the  tuberosity  of  the  fifth  metatarsal 
along  the  outer  side  of  the  foot  to  the  ball  of  the  toe,  then  obliquely  forward 
across  the  sole  (.so  that  it  may  be  longer  on  the  inner  side  than  the  outer),  and 
back  along  the  inner  border  to  the  scaphoid.     The  dorsal  incision  may  be  made 


AMPUTATION  7HR0UGH  THE   FOOT 


I20I 


next,  but,  as  in  disarticulating  there  is  some  risk  of  wounding  the  structures  in  the 
sole,  it  is  better  to  dissect  the  plantar  flap  back  from  off  the  bones  (taking  care  to 
include  the  artery)  and  have  it  held  well  out  of  the  way.  The  two  ends  of  the 
plantar  incision  are  then  connected  over  the  dorsum  by  a  second,  slightly  convex 
forward,  the  extensor  tendons  and  ligaments  divided,  and  disarticulation  com- 
pleted. 

The  stump  left  by  this  operation  is  in  many  cases  exceedingly  good  ;  but  some- 
times it  tilts  so  far  forward  that  the  cicatrix  presses  against  the  ground.  It  is 
probable  (as  the  os  calcis  and  astragalus,  having  lost  the  support  of  the  anterior 
pillar  of  the  arch  of  the  foot,  must  always  tilt  downward  in  this  way)  that  this 
arises  from  the  i)Iantar  flap  being  too  short ;  or  it  may  result  from  unopposed  con- 
traction of  the  gastrocnemius.  It  can  usually  be  prevented  by  dividing  the  tendo- 
Achillis  and  suturing  the  extensor  tendons  in  front  into  the  periosteum  or  the  cut 
ends  of  the  ligaments. 

Tripicr  s. — The  under  part  of  the  os  calcis  is  sawn  off  horizontally  just  below 
the  sustentaculum  tali  (having  as  far  as  possible  preserved  the  periosteum)  in  order 
to  leave  a  surface  at  right  angles  to  the  axis  of  the  tibia. 

The  incision  (through  the  skin  only)  begins  at  the  outer  edge  of  the  tendo- 
Achillis,  on  a  level  with  the  external  malleolus,  and  runs  downward  and  forward 
below  that  projection  to  the  base  of  the  metatarsal  bone  of  the  fifth  toe.  Thence 
it  passes  slightly  convex  forward,  across  the  sole,  until  it  reaches  the  inner  side  of 


Fig.  534. — Stump  after  Hey's  Amputation. 


the  foot,  well  in  front  of  the  projection  caused  by  the  base  of  the  first  metatarsal ; 
and  winding  upward  over  the  inner  border,  continues  across  the  dorsum  until  it 
joins  the  first  over  the  calcaneo-cuboid  articulation.  As  soon  as  the  skin  has  re- 
tracted, the  soft  parts  are  divided  down  to  the  bones ;  disarticulation  effected  at 
the  mid-tarsal  joint ;  the  periosteum  detached  from  the  under  surface  of  the 
OS  calcis,  and  the  bone  sawn  through,  from  behind  and  within,  forward  and 
outward. 

The  Subastragalar  Operation. — The  incision  for  this  is  nearly  the  same,  but  it 
commences  an  inch  below  the  external  malleolus  (instead  of  at  the  tendo-Achillis) 
and  does  not  run  quite  so  far  forward  on  the  sole  of  the  foot.  The  soft  parts  must 
be  dissected  off  the  under  surface  of  the  cuboid  and  os  calcis  ;  the  interosseous 
ligament  between  the  latter  bone  and  the  astragalus  divided  from  in  front  (space 
can  be  obtained  by  depressing  the  toes)  and  then  the  tissues  on  the  inner  side  and 
the  tendo-Achillis.  The  operation  is  one  seldom  performed  in  England,  and 
opinions  as  to  its  merits  are  undecided. 

Hef  s  afid  Lisfranc' s  Amputation  of  the  Toes  at  the  Tarso-metatar sal  Articu- 
lation.— In  the  former  the  saw  was  used  to  a  limited  extent  (in  one  of  the  original 
operations  the  internal  cuneiform  was  divided)  ;  in  the  latter  the  disarticulation  is 
complete.  The  operation  is  performed  in  the  same  way  and  by  the  same  incision  as 
Chopart's,  with  the  exception  that  instead  of  the  scaphoid  and  the  calcaneo-cuboid 
articulation  being  used  as  landmarks,  the  bases  of  the  first  and  fifth  metatarsals 


I202     DISEASES  AND  INJURIES  OF  SPECIAL  STRUCTURES. 

are  taken.  A  ])lantar  flap  running  across  the  heads  cf  the  metatarsals  and  longer 
on  the  inner  side  than  the  outer,  is  marked  out  and  dissected  back  ;  the  posterior 
ends  of.  the  lateral  incisions  are  joined  by  one  across  the  dorsum,  and  the  toes 
being  depressed  as  far  as  possible,  the  dorsal  ligaments  of  the  three  outer  and  the 
inner  metatarsal  articulations  divided.  The  articulation  of  the  second,  which  is 
placed  in  a  recess  posterior  to  the  others,  must  either  be  dealt  with  by  itself,  using 
the  point  of  the  knife  lightly,  or  the  base  of  the  bone  sawn  off. 

Amputation  of  the  Toes. 

The  incisions  are  the  same  as  in  the  case  of  the  fingers,  but  on  no  account 
may  the  part  of  the  sole  that  receives  the  pressure  of  the  foot  be  interfered  with. 


Fig.  535. — Incision  for  Amputation 
of  the  Great  Toe. 


■-^^li^J 


Fig.  537. — Incision  for  Removal  of  the  Meta- 
tarsal Bone  of  the  Great  Toe. 


Fig.  536.-  Dubreuil's  Opera- 
tion for  the  Removal  of  all 
the  Toes. 


Fig.  538. — Stump  after  the  Removal  of 
Metatarsal  Hone. 


The  tendon-sheaths  should  be  secured  by  sutures,  as  otherwise  they  form  open  ver- 
tical drains  (when  the  patient  is  lying  in  bed),  conducting  into  the  sole  of  the  foot 
any  discharge  that  does  not  escape  at  once. 

Amputation  of  the  great  toe  is  jjerformed  by  means  of  a  racquet-shaped  inci- 
sion ;  the  head  of  the  metatarsal  should  always  be  preserved  if  possii)le,  and  when 
it  is  necessary  to  remove  this  bone  (which  may  be  done  through  a  similar  incision 


DISEASES  OF  STUMPS.  1203 

commenced    further  back),  the  base,  with   the  insertion  of  the  pcroneus  longus, 
shouUl  be  left  intact. 

Diseases  of  Stumps. 

The  tissues  in  a  stump  always  waste  to  some  extent ;  the  bones  atrophy,  the 
muscular  fibres  disappear,  the'  vessels  contract,  and  the  temperature  falls.  The 
skin,  however,  should  retain  its  natural  texture  and  color,  there  should  be  no 
tender  spot,  the  scar  should  be  well  out  of  the  way  of  pressure,  and  not  adherent 
to  the  bone,  and  there  should  be  a  good  pad  of  fatty  and  fibrous  tissue  around 
the  end. 

Conical  Stump. — A  stump  may  become  conical  either  from  a  deficiency  in  the 
soft  parts,  or  from  growth  of  the  bone.  The  former  usually  arises  from  the  flaps 
having  been  originally  too  short,  from  their  having  retracted  owing  to  the  amount 
of  muscle  contained  in  them,  or  from  their  having  sloughed.  The  latter  seldom 
occurs  except  in  children,  and  in  them  especially  in  the  leg.  The  treatment  con- 
sists either  in  excising  the  end  of  the  bone,  slitting  up  one  side  of  the  stump  to 
render  it  more  accessible,  or  re-amputation,  according  to  the  condition  of  the  part. 

Necrosis. — This  may  arise  from  the  periosteum  having  been  stripped  off  too 
far,  so  that  the  end  of  the  bone  is  deprived  of  its  blood  sui)i)ly,  or  from  inflam- 
mation. In  the  latter  case  the  extent  depends  upon  the  severity  of  the  attack — 
there  may  be  merely  a  scale  from  the  end  of  the  bone,  or  a  long,  tubular  seques- 
trum. 

Aneurysm  has  been  known  to  develoj),  and  one  or  two  cases  of  arterio-venous 
ajieurysm  are  on  record. 

Neuralgia  (p.  177)  may  arise  from  a  nerve  being  involved  in  the  cicatrix,  so 
that  it  is  dragged  upon  by  the  scar  tissue,  or  from  the  end  of  one  becoming 
bulbous.  In  the  latter  case  there  appears  to  be  a  growth  of  nerve  fibres,  but  the 
bulk  of  the  mass  is  made  up  of  connective  tissue  (pp.  137  and  305).  The  pain, 
when  one  of  these  is  touched,  is  described  as  like  an  electric  shock,  shooting  down 
the  distribution  of  the  nerve.  The  only  treatment  is  excision,  and  usually  it 
succeeds  at  once. 

There  is,  however,  another  variety  of  neuralgia  very  much  more  serious  in 
character.  The  stump  is  red  and  glazed  ;  to  the  touch  it  is  icy-cold,  but  the 
patient  complains  of  an  intense  ceaseless  burning;  no  one  part  is  worse  than  the 
other ;  the  whole  of  the  limb  for  some  distance  is  exquisitely  tender  and  the  seat 
of  agonizing  pain.  It  is  not  known  to  what  this  is  due ;  nerve  section  and  nerve 
stretching  have  only  a  transient  influence  on  it,  and  I  have  known  it  return  again 
and  again  in  the  stump  after  amputation  had  been  performed  in  the  hope  of  secur- 
ing relief. 

Muscular  spasm  of  a  chronic  character  is  sometimes  met  with.  Usually  it  is 
due  to  reflex  irritation,  but  in  many  cases  no  cause  can  be  found.  Relief,  when 
only  a  single  muscle  is  affected,  can  be  obtained  by  tenotomy,  but  unless  the 
source  of  irritation  is  removed  the  spasms  are  very  likely  to  recur. 

In  addition,  stumps  are  liable  to  be  attacked  by  epithelioma,  cheloid,  and  the 
other  affections  of  scars  ;  and  in  cases  of  amputation  for  disease,  if  the  line  of 
section  is  not  sufficiently  high,  recurrence  takes  place  in  the  stump. 


I204  THE  PRINCIPLES  OF  MILITARY  SURGERY. 


CHAPTER  XXVIII. 

THE  PRINCIPLES  OF  MlL/TAIiY  SURGERY. 
Bv  THE  Editor,  John  B.  Hamilton,  m.u. 

It  is  not  contemplated  in  this  chai)ter  to  touch  upon  any  of  the  duties  of  the 
military  surgeon,  except  those  i)urely  surgical,  or  which  relate  directly  to  the  care  of 
the  wounded.  It  is  recognized  that  the  most  important  military  duty  of  the  medical 
officer  is  the  preservation  of  the  health  of  the  troops,  by  the  application  of  general 
hygienic  rules,  modified  according  to  the  local  environment  and  the  duty  on 
which  the  command  is  engaged.  There  are  important  military  regulations  relating 
to  the  official  conduct  of  young  officers,  their  duty  in  the  field  and  the  camp, 
hospital  organization,  medical  and  subsistence  supplies,  and  the  examination  of 
recruits.  However  appropriate  the  consideration  of  these  topics  to  a  special 
work  on  military  medicine  and  surgery,  it  may  well  be  omitted  here.  The  Medical 
Department  of  the  U.  S.  Army  now  issue  very  complete  instructions  on  these 
points,  and  on  api)lication  through  jjroper  channels,  it  is  understood  that  the 
medical  officers  of  the  U.  S.  National  Guard  will  be  supplied  with  the  following  :  — 
"U.  S.  Army  Regulations,"  ''Standard  Supply  Table,"  "  The  Manual  of  Drill 
for  the  Use  of  the  Hospital  Corps,"  "  An  Epitome  of  Tripler's  Manual  and  other 
Publications  on  the  Examination  of  Recruits,"  by  Deputy  Surgeon  General 
Greenleaf;  and  the  "Handbook  for  the  Hospital  Corps,"  by  Major  Charles 
Smart,  Surgeon,  U.  S.  A.  The  Bureau  of  Medicine  and  Surgery  of  the  U.  S. 
Navy  issue  the  "Regulations  of  the  Medical  Department  of  the  Navy,"  and 
"First  Aid  to  the  Injured  and  Transportation  of  the  Wounded,"  by  P.  A. 
Surgeon  Beyer,*  U.  S.  N. 

First  Aid  to  the  Wounded. — ^The  U.  S.  A.  Hospital  Corps  consists  of 
hospital  stewards  and  enlisted  men.  This  corps,  under  the  command  of  medical 
officers,  perform  all  necessary  hospital  service  in  garrison  and  in  the  field,  and  the 
ambulance  service  in  action.  In  addition  to  this  force,  there  are  in  each  company 
four  men  who  are  designated  as  company  litter  bearers.  These  men,  as  well  as  the 
Hospital  Corps  proper,  are  instructed  four  hours  each  month  in  the  duties  of  litter 
bearer  and  the  methods  of  rendering  first  aid  to  the  wounded.  During  an  en- 
gagement the  company  litter  bearers  maybe  designated  to  give  first  aid  and  carry 
wounded  to  the  dressing  station  in  the  rear,  and  continue  to  so  act  until  relieved 
by  the  Hospital  Corps,  when  they  immediately  rejoin  their  company. 

Under  existing  regulations  those  wounded  during  an  engagement  receive 
attention  in  the  following  order  :  i,  With  the  line  of  battle  under  fire  ;  2,  at  the 
first  dressing  station  ;  3,  at  the  ambulance  station  ;  4,  at  the  division  hospitals. 
"  The  first  dressing-station  is  established  at  the  nearest  place  to  the  combatants, 
where  the  wounded  and  those  caring  for  them  may  not  be  unnecessarily  exposed  to 
fire."  Ambulance  stations  are  established  "  at  some  ])lace  of  security  in  the  rear, 
or  in  some  convenient  building  near  the  field  of  battle."  The  division  hospital 
may  be  establi-shed  in  such  secure  place  as  the  medical  director  may  designate. 

*  In  addiiion  to  the  official  publications  above  mentioned,  the  following  will  be  found  useful : 
"  First  Aid  in  Illness  and  Injury,"  by  Captain  James  E.  Tilcher,  .Assistant  .Surgeon  U.  S.  A.,  New 
York,  1892  ;  "  The  Surgeon's  Pocketbook,"  by  Surgeon- Major  ].  H.  Porter;  revised  and  edited  by 
Brigade  Surgeon  C.  II.  Y.  Godwin;  and  an  article  in  the  "International  Encyclopedia  of 
Surgery,"  vol.  vi,  page  764,  by  Bvt.  Lieutenant  Colonel  Bennett  A.  Clements,  Surgeon,  U.  S.  A., 
entitled  •'  Preparation  of  Military  Surgeons  for  Field  Duties ;  Apparatus  Required  ;  Ambulances ; 
Duties  in  the  Field." 


HANDKERCHIEF   BANDAGES. 


FIRST  AID   TO  THE   WOUNDED. 


1205 


Each  soldier  should  l)e  supplied  with  a  packet  which  will  contain  the  materials 
necessary  for  a  first  dressing  in  case  of  wound.  The  contents  of  this  package  are 
those  recommended  by  Esmarch.  viz.  ;  Two  antiseptic  compresses  of  sublimated 
gauze  in  oiled  paj^er  ;  one  antiseptic  bandage  of  sublimated  cambric  with  safety 
pin  ;  one  E.smarch's  triangular  bandage  with  safety-pin  ;  mode  of  application 
illustrated  on  same.  The  directions  accompanying  the  packet  are  as  follows  : 
"  Place  one  of  the  compresses  on  the  wound,  removing  the  oiled  paper.  In  cases 
of  large  wounds  open  the  compress  and  cover  the  whole  wound.     Apply  the  anti- 


FiG.  539. — Esmarch's  Triangular  Randage. 

septic  bandage  over  the  compress.  Then  use  the  triangular  bandage  as  shown  by 
the  illustrations  on  the  same."  The  packet  may  also  contain  a  tag  on  which  the 
soldier's  name,  company,  and  regiment  may  be  written.  The  company  litter 
bearers  may  be  so  well  instructed  that  in  many  cases  the  second  dressing  at  the 
dressing  station  may  be  dispensed  with.  The  accompanying  illustration  from 
Pilcher  shows  the  methods  of  application  of  the  triangular  bandage.  It 
will  be  seen  on  investigation  that  the  figures  show  the  bandage  is  really  the 
triangular  bandage  invented  by  M.  Matthias  Mayor  in  1838.     Surgeon  General 


I   jf^"*^ 


Fig.  540. — Lifting  the  Patient. 


Esmarch,  however,  although  giving  due  credit  to  M.  Mayor,  caused  them  to  be 
introduced  into  the  Prussian  Army  in  1869,  and  they  have  borne  his  name  in 
Germany. 

The  bandages  having  been  applied,  the  wounded  man  is  placed  on  the  litter 
and  carried  to  the  dressing  station,  where  a  medical  officer  examines  the  patient, 
and  again  dresses  the  wound  if  necessary. 

In  case  the  nature  of  the  wound  is  such  that  immediate  attention  is  necessary, 
a  cloth  tag  is  then  pinned  on  to  the  wounded  man,  of  a  certain  color,  which  in- 
sures such  attention  at  the  hospital,  to  which  the  patient  is  then  taken  by  litter  or 


I2o6 


THE   PRINCIPLES  OF  MILITARY  SURGERY. 


ambulance.       The   following  illustrations   from  the  "  Drill  Manual  "   show  the 
method  of  bearing  the  wounded  to  the  litter  by  the  company  bearers. 


Fig.  541. — By  Two  Bearers. 


Fig.  542. — Carbines  Used  as  Stretcher. 
"The  Rifle  Seat." 


The  wounded  man  is  usually  taken  from  the  dressing  station  by  an  ambu- 
lance or  by  the  travois. 


Fig.  543. — By  One  Bearer  Across  Shoulders. 


Fig.  544. — By  One  Bearer  Astride  of  Back. 


In  the  naVy  the  first  care  of  the  wounded  falls  directly  upon  the  medical 
officer,  who  has  to  assist  him,  the  apothecaries  and  bay  men.  The  bay  men  are 
appointed  by  the  senior  medical  officer,  with  the  approval  of  the   commanding 


FIRST  AID  TO  THE   WOUNDED. 


[207 


Fig.  545.— The  Travois 


Fig.  546. — The  Gorgas  Cot 


Fig.  547.— The  Gihon  Cot. 


i2o8  THE   PRINCIPLES  OF  MILITARY  SURGERY. 


Fig.  548— Walton-Wells  Cot. 


Fig.  349. — The  McDonald's  Ambujance  Lift. 


GUNSHOT  WOUNDS.  1209 

officer,  and  act  under  the  orders  of  the  medical  officer  on  duty.  The  wounded 
are  cared  for  usually  by  being  brought  immediately  into  the  sick  bay,  or  hos])ital, 
where  their  wounds  are  dressed  as  in  a  field  hospital.  No  system  of  litter  drill 
has  as  yet  been  adopted  by  the  Navy  Dei)artment,  although  it  would  seem  desir- 
able. Various  forms  of  cot  or  combined  stretcher  with  cot  have  been  devised  by 
naval  surgeons  for  the  transportation  of  the  wounded  on  shipboard,  and  from  one 
ship  to  another.  The  respective  cots,  of  Gorgas,  Gihon,  and  Wells  are  shown  in 
the  diagram. 

The  Walton-Wells  cot  is  made  of  canvas,  and  when  rolled  tightly  takes  up 
much  less  space  than  any  other.  The  figure  rei)rescnts  the  Wells  cot — a,  rolled  ; 
h,  at  an  angle  ;  c,  cot  without  poles  ;  d,  with  poles. 

McDonald's  ambulance  lift  as  shown  in  the  cut  (Fig.  549)  will  be  found  very 
useful  either  in  lowering  a  wounded  man  over  the  shii)'s  side  or  in  bringing  him  on 
board. 

Gunshot  Wounds. 

The  literature  of  this  branch  of  military  surgery  is  almost  wholly  modern, 
the  use  of  gunpowder  having  been  rediscovered  by  Schwartz  in  1320.  The  first 
important  engagement  in  which  cannon  was  used  in  Europe  was  at  the  battle  of 
Crecy,  August,  1346.  At  first  stones  were  used  as  projectiles  in  cannon,  but  lead 
and  iron  soon  came  into  use,  and  muskets  and  pistols  caused  new  varieties  of 
wounds.  While  the  general' subject  was  new,  the  surgeons  of  the  time  considered 
that  gunshot  wounds  were  poisoned  by  the  action  of  the  powder,  an  idea  which 
was  not  dissipated  until  the  beginning  of  the  fifteenth  century. 

"Giovanni  de  Vigo"  (b.  1503),  says  Sprengel,  "  attributed  the  danger  from 
gunshot  wounds  to  the  round  form  of  the  balls,  the  burning  of  the  parts,  to  the 
poisonous  qualities  of  the  firearm,  and  of  the  powder.  After  this  he  established 
two  indications  for  treatment:  first,  a  humectant  (moistener),  to  cure  the  burn  ; 
second,  a  desiccator,  for  the  abatement  of  the  poison.  He  applied  a  red-hot  iron 
with  a  view  of  destroying  the  poison.  He  also  had  recourse  to  '  Egyptian  ' 
ointment  or  boiling  oil,  followed  by  friction  with  fresh  butter  to  detach  the  eschar, 
and  he  highly  praised  a  '  digestive  '  composed  of  yolk  of  egg  and  spirits  of  tur- 
pentine to  calm  the  pain." 

Alphonse  Ferri  {b.  1515  d.  1595),  of  Naples,  also  believed  that  these  wounds 
were  poisoned.  He  was  probably  the  first  to  speak  of  the  "  wind  of  the  bullet," 
which  he  asserted  caused  death  almost  as  often  as  the  bullet  itself.  He  treated 
these  wounds  by  a  caustic  composed  of  corrosive  sublimate,  sulphate  of  copper  and 
impure  carbonate  of  lead  (litharge).  He  regarded  the  extraction  of  the  ball  as 
precedent  to  cure,  and  invented  a  bullet  forceps,  which  after  him  was  called  the 
Alphonsin.  The  accompanying  plate  from  Scultetus  shows  the  instrument  as 
supplied  to  surgeons  in  his  time.  It  will  be  noticed  that  what  would  now  be 
termed  antiseptic  treatment,  although  rather  heroic,  figures  largely  in  the  means 
of  cure. 

Gunshot  wounds  differ  in  few  essential  particulars  from  other  wounds.  The 
velocity  of  the  ball  determines  its  course  through  the  tissues  and  the  relative  lac- 
eration. The  results  show  that  these  wounds  are  distributed  over  the  regions  of 
the  body  in  pretty  close  ratio  to  the  area  of  exposed  surface.  The  changes  in  the 
shape  of  projectiles  have  correspondingly  changed  the  character  of  the  wounds ; 
stronger  powder,  conical  projectiles,  and  rifled  bores  have  increased  the  velocity  of 
bullets  and  lessened  the  laceration.  This  remark  can  only  apply  to  small  arms, 
for  the  immense  weight  and  size  of  cannon  projectiles  produce  crushing  wounds, 
like  those  of  railway  wrecks.  The  effect  of  smokeless  powder  can  now  only  be 
conjectured,  as  no  engagement  has  taken  place  where  it  has  been  used,  but  it  is 
probable  that,  with  the  greater  accuracy  of  aim,  the  relative  proportion  of  wounded 
to  the  whole  number  engaged  will  be  increased.  The  effect  of  velocity  has  been 
mentioned.  A  ball,  striking  the  body  at  a  very  high  velocity,  may  pass  directly 
through  a  bone  without  splintering,  or  may  perforate  the  body  or  the  skull.  A 
77 


I210 


THE  PRINCIPLES  OF  MILITARY  SURGERY. 


ball,  having  its  velocity  reduced  by  distance  or  obstacles,  on  striking  the  body 
produces  greater  laceration,  and  may  pursue  a  quite  erratic  course,  being  deflected 
by  bone,  tendon,  or  skin.  Instances  are  frequent  where  a  ball  has  passed  almost 
around  the  body,  around  the  skull,  or,  striking  a  long  bone,  has  traversed  its 
length  At  short  range,  and  with  modern  weapons,  we  should  expect  the  bullet 
to  take  a  nearly  straight  course.  Neglect  of  this  presumption  sometimes  causes 
the  patient  much  unnecessary  suffering,  and  the  surgeon  much  annoyance  in  his 
search  for  the  ball. 

TaBVLA  2CV 

A  1 


=© 


Fig.  550.— Ancient  Bullet  Extractors.    (From  Scultetus  ) 

Examination  of  Gunshot  Wounds.— \^  is  useless  to  expect  that  the  company 
bearers  at  the  front  will  have  the  time,  knowledge,  or  disposition  to  make  a  com- 
plete examination,  and  their  duties  should  be  considered  as  satisfactorily  performed 
when  they  apply  the  compress  or  plug  the  wound,  put  on  the  triangular  bandage, 
and  carry  the  wounded  to  the  dressing  station.  At  the  dressing  station,  if  the 
hemorrhage  is  stopped,  and  there  is  little  shock,  no  further  examination  should  be 
made    nor  any  attempt  to  remove  the  ball,  but  the  patient  sent  immediately  to  the 


GUNSHOT  WOUNDS. 


121  I 


hospital.  If  there  is  hemorrhage,  both  ends  of  the  bleeding  vessel  should  be  tied 
in  the  wound,  and  at  this  time  the  ball  should  be  extracted  when  i)racticable.  If 
there  is  shock,  apjjropriate  remedies  should  Ijc  administered,  and  heat  applied  if 
possible.  If  there  is  fracture  of  the  arm  or  leg,  a  temporary  splint,  or  compress, 
should  be  applied.  When  the  patient  arrives  at  the  hospital,  systematic  examina- 
tion should  be  made  as  soon  as  practicable  after  reaction  shall  have  taken  place. 


Q= 


K.  A.  YAUNAI 


Fii;.  551. — The  Nelaton  Probe. 

No  anaesthetic  should  be  administered  while  there  is  shock,  the  presence  of 
which  is  an  excellent  reason  for  postponing  examination  until  reaction  is 
complete. 

Gunshot  wounds  are  divided  into  perforating,  penetrating,  and  lacerated 
wounds  and  fractures.  No  ball  passes  into  the  tissue  with  such  velocity  as  to 
make  an  incised  wound,  but  some  of  them  come  very  near  it.  The  clothing 
should  be  examined  for  the  purpose  of  ascertaining  whether  there  is  loss  of  its 


Fig.  5:2.— Longmore's  Electric  Explorer.  A,  Pocket  compass  ;  B,  Copper  sheeting 
(a  penny  piece  will  answer)  ;  C,  Plate  of  zinc  ;  D,  Flannel  saturated  with  dilute 
acid  ;  E  and  F,  Insulated  wires  ;  G,  Exploring  needles.     (Porter.) 


substance,  and  whether  any  pieces  were  carried  into  the  wound.     Sometimes  the 
projectile  itself  is  found  during  the  examination  of  the  clothing. 

The  hands  of  the  surgeon  and  his  assistant  having  been  cleansed  and  rendered 
aseptic,  the  skin  about  the  wound  is  shaved,  scrubbed  with  soap  and  water,  and 
then  with  alcohol  or  ether.  The  wound  may  now  be  probed  by  the  little 
finger  of  the  surgeon  or  the  bullet  probe.  The  Nelaton  probe  is  one  of  the 
most  generally  useful.     Lecompte's  probe  nippers  (stylet  pince)  are  occasionally 


1 212  THE  PRINCIPLES  OF  MILITARY  SURGERY. 

useful.  Fluhrer's  aluminium  probe,  on  account  of  its  light  weight,  is  less 
objectionable  than  many  others.  It  is  especially  useful  in  wounds  of  the  brain 
or  lungs.  Electricity  has  been  brought  into  use  by  the  construction  of  electric 
probes.  Taylor's,  DeWilde's,  Liebreich's,  Bell's,  and  Sir  Thomas  Longmore's 
are  those  which  have  recently  been  used.  Longmore's  instrument,  which  can 
be  readily  made  by  any  electrician  instrument  maker,  or  mechanician,  is  thus 
described  by  Porter:  "The  magnet  of  an  ordinary  pocket  compa.ss,  which  has 
had  some  turns  of  wire  covered  with  thread  wound  round  it  as  an  induction 
coil,  is  employed  for  the  electric  indicator,  while  a  piece  of  zinc  sheeting  bent 
round  a  small  plate  of  copper,  but  separated  from  it  by  a  flannel  padding 
saturated  with  the  usual  dilute  acids,  forms  the  voltaic  pile.  Thfe  exploring 
instrument  is  formed  by  two  insulated  wires  bound  together  but  the  points 
left  free.  These  parts  being  connected,  when  the  circuit  is  completed  by 
contact  with  metal,  the  indication  is  given  by  movement  of  the  magnet  of  the 
compass." 

Extractiofi  of  Balls. — The  number  of  instruments  devised  for  this  purpose 
is  almost  infinite,  but  what  is  known  as  the  American  bullet  forceps  will  be 
found  adapted  to  the  greatest  number  of  cases.  For  fragments  of  shells,  the  ordi- 
nary elevator  from  the  trephining  set  or  a  lithotomy  scoop  will  be  found  useful. 
When  the  bullet  is  near  the  skin  it  should  be  fixed  by  needles  or  grasped  between 
the  thumb  and  finger  while  the  incision  is  made  over  it.  In  case  the  ball  is 
lodged  in  the  bone,  it  must  be  cut  out.  After  the  ball  has  been  extracted  the 
wound   should  be  irrigated   thoroughly  Avith  some  antiseptic  solution,  sublimate, 


Fig.  553. — American  Bullet  Forceps. 

iodine,  or  bromine,  and  during  the  irrigation  the  surgeon  may  re-introduce  his 
finger  to  search  for  pieces  of  clothing,  buttons,  or  spiculae  of  bone.  All  foreign 
substances  having  been  removed,  a  drainage  tube  should  be  inserted  to  the  bottom 
of  the  wound  (in  the  brain  aseptic  horsehairs  may  be  used  instead  of  drainage 
tubes),  and  the  wound  then  dresssd  by  antiseptic  compresses,  absorbent  cotton, 
and  bandage.  In  case  there  is  no  rise  in  the  temperature,  or  hemorrhage,  on  the 
fourth  day  the  wound  should  be  examined,  the  drainage  tube  permanently 
removed,  the  bullet  track  irrigated  with  an  antiseptic  solution,  rebandaged  and 
allowed  to  close.  In  cases  where  the  patient  arrives  at  the  hospital  with  the 
wound  septic,  the  most  thorough  irrigation  should  be  made  twice  a  day,  or 
oftener  if  there  is  need.  Almost  any  wound  may  be  made  aseptic  if  sufficient 
care  is  taken  that  the  antiseptic  fluids  touch  every  portion  of  the  pyogenic  track. 
In  case  an  abscess  cavity  has  formed,  a  counter  opening  should  be  promptly 
made,  so  that  perfect  drainage  may  be  secured. 

Gunshot  Fractures. — These  injuries,  after  the  ball  has  been  extracted, 
should  be  treated  the  same  as  open  fractures.  That  is  to  say — the  ball  is 
removed,  the  bleeding  arrested,  the  wound  irrigated  with  sterilized  water,  or 
weak  sublimate  solution  until  entirely  clean,  the  skin  is  shaved  and  properly 
cleansed,  all  loose  fragments  of  bone  are  removed,  the  limb  is  placed  in  position, 
and,  when  practicable,  the  fractured  ends  are  brought  together  by  sewing  the 
periosteum  across  the  line  of  fracture,  or  fastened  by  Senn's  bone  thimble ; 
drainage   is   secured,  the  wound  is  dressed  aseptically.  and   over  all   a  plaster 


GUNSHOT  FRA  CTURES.  1 2 1 3 

bandage  is  applied.  After  the  plaster  hardens  a  fenestra  may  be  cut  opposite 
the  wound.  When  treated  in  this  way,  and  treated  early,  amputation  will  rarely 
be  required.  Ihe  special  symptoms  and  treatment  necessary  in  wounds  of  the 
various  regions  have  been  treated  of  so  thoroughly  by  our  author  that  separate 
mention  here  is  not  required,  and  the  reader  is  referred  to  the  chapters  on 
injuries  for  the  discussion  of  wounds  of  the  particular  organs.  Wherever  a  joint 
is  involved  it  should  be  immobilized. 

Bayonet,  lance,  and  sword  wounds  are  in  no  respect  different  from  other 
punctured  and  lacerated  wounds.  The  requirements  are  the  same,  and  in  their 
treatment  antiseptics  and  drainage  are  the  essentials.  *        '     • 


INDEX. 


Abbe,  trephining  spine,  721 

Abdominal  aneurysm,  256;  Loreta's  case,  247; 
nephrectomy,  1015;  aorta,  ligature  of,  273; 
compression  of,  273 ;  distention  in  strangu- 
lation, 919;  section  in  ectopic  gestation, 
1 146 

Abdomen,  injuries  of,  870;  wounds  of,  872 

Abduction,  in  hip  disease,  591 

Abductors  of  larynx,  paralysis  of,  81 1 

Abnormalities.      See  Malformations 

Abnormal  mobility  in  fracture,  361 

Abscess,  46;  alveolar,  766  ;  antral,  767  ;  of  bone, 
448,  451 ;  of  breast,  1173;  cerebellar,  667, 
670 ;  cerebral,  665,  671  ;  chronic,  1 175;  of 
chest  wall,  S64;  diagnosis  of,  51  ;  hemorrhage  i 
into,  56;  of  hip,  595;  ischio-rectal,  973; 
of  liver,  949;  lumbar,  704;  mediastinal,  j 
863;  perineal,  I119;  peri-urethral,  109S; 
pointing  of,  46;  psoas,  705,  709;  pus  of, 
46;  pyremic,  75;  ^e^idual,  369;  retro- 
pharyngeal, 704,  709 ;  sacro-iliac,  603 ; 
spinal,  703,  709;  subcranial,  661;  subdural, 
669;  symptoms  of,  47;  treatment  of,  51; 
tubercular,  586;  urinary,  11 20;  varieties 
of,  49 

Absorbents,  diseases  of,  281 

Absorbent  wool,  168 

Absorption  of  bone,  446;  callus,  351,  354; 
cartilage,  546  ;  of  neck  of  femur,  421,  570, 
589  ;   sequestra,  445;  of  thrombi,  228 

Accessory  thyroids,  84 1 

Accidents,  railway,  amputation  in,  376 ;  from 
taxis,  889 

A.  C.  E.  mixture,  189 

Acetabulum,  disease  of,  589;  fracture  of,  411, 
and  neck  of  femur,  420 

Acids,  application  of,  in  piles,  963 

Acne,  ill  syphilis,  100 

Aconite  in  inflammation,  38;  in  aneurysm, 
241 

Acquired  talipes,  332;  varieties  of,  333;  tumors 
of  scalp,  656 

Acromion,  fracture  of,  391 

Actinomycosis,  89 

Active  clot,  236 

Actual  cautery  in  piles,  963 

Acupressure,  211,  229 

Acupuncture,  247  ;  in  aneur\'sm,  247  ;  for  hydro- 
cele, 1 141  ;  in  neuritis,  301 

Acute  arthritis  of  infants,  462  ;  epiphysitis,  454, 
559  ;  necrosis,  453  ;  progressive  myositis,  31 1  ; 
rickets,  479;    suppurative  osteomyelitis,  453, 

493.  559 
Adams,  318 


Addison's  cheloid,  178 

Adduction  in  hip  disease,  591 

Adductor  longus,  rupture  of,  307 

Adductors  of  larynx,  paralysis  of,  811 

Adenitis,  282 

Adenoma,  144;  of  breasts,  1178;  mouth,  770; 
testis,  1 135 

Adeno-sarcoma,  141 

Adhesions  in  intussusception,  915  ;  as  a  cause 
for  strangulation,  911;  in  hernia,  893;  in 
ovariotomy,  11 54 

Age  as  a  cause  for  fracture,  347  ;  influence  of, 
in  repair,  356;  in  lithotrity,  I051  ;  in  lith- 
oiomy,  105S 

Agnew,  325 

Aid  to  the  wounded,  1204 

Air,  entry  of,  into  veins,  219;  exclusion  of,  in 
burns,  182 

Air-passages,  wounds  of,  814  ;  foreign  bodies  in, 
818 

Albumin  in  urine,  1009 

Albuminoid  degeneration,  55 

Albumose  in  anthrax,  84 

Alcohol  as  a  cause  of  neuritis,  300  ;  in  inflam- 
mation, 38 

Alcoholic  coma  and  concussion,  647 

AUingham,  formation  of  spur  in  colotomy,  939  ; 
speculum,  957 

Alopecia,  syphilitic,  loi 

Alphonse  Ferri,  1209 

Alternating  strabismus,  724 

Alveolar  abscess,  766;  sarcoma,  140 

Amastia,  1 1 71 

Ambulance  lift,  1208 

Ammonia  in  inflammation,  38  ;  erysipelas,  81  ; 
shock,  152 

Amputation,  11 88;  in  aneurysm,  244 ;  at  ankle 
joint,  1 198;  of  arm,  1192  ;  in  arthritis,  563  ; 
of  breast,  1185;  in  burns,  183;  Garden's, 
1 189  ;  of  cervix  uteri,  1166  ;  Chopart's,  1 200  ; 
in  dislocations,  503;  of  foot,  1200;  of  fore- 
arm, 1 192;  in  fractures,  376, 428;  in  frostbite, 
68;  Furneaux  Jordan's,  1192;  in  gangrene, 
68;  Gritti's,  1197;  for  hemorrhage,  215: 
for  hip  disease,  603  ;  Senn's  new  method, 
1195;  of  the  hand,  I192;  Iley's,  1201  ;  at 
the  hip,  II93;  humerus  and  scapula,  119O; 
in  inflammation,  74;  at  the  knee,  1197; 
Erichsen's  method,  1197;  of  the  leg,  1 198; 
Lisfranc's,  1201  ;  of  the  penis,  1 124;  Piro- 
gofif's,  1200;  Roux's,  1 199;  at  the  shoulder, 
1 189;  Stephen  Smith's,  1198;  Spence's, 
1 189;  Stokes's,  1 197;  subastragalar,  I20I  ; 
Syme's,  119S;  Teale's,  I188  ;  of  the  toes, 
1202;  Dubreuil's  operation  for,  1202;  Tri- 
pier's,  1 20 1 


I215 


I2l6 


INDEX. 


Amussai's  operation,  9_}7 

Ancemia  in  syphilis,  loo 

Anceslhesia  in  reduction  of  fracture,  371  ;  of 
larynx,  81 1;  after  nerve  section,  292;  in 
spinal  injury,  690 

Anaesthetic  leprosy,  117 

Anesthetics,  1S5  ;  in  fractures,  371;  in  intes- 
tinal strangulation,  91S;  in  ophthalmic  work, 
73S  ;   in  taxis,  8S9 

Anast(jmosis  of  nerves,  292  ;  intestinal,  946 

Anatomical  tubercle,  91 

Anatomy  of  hernia,  S7S 

Anel's  method  of  ligature,  243 

Aneurysm,  235  ;  abdominal,  256;  by  anastomo- 
sis, 136,  221  ;  arterio-venous,  217,  737;  of 
aorta,  248;  and  atheroma,  226,  235  ;  axillary, 
25s  ;  cirsoid,  221  ;  of  carotid,  251  ;  of  femoral, 
259;  of  gluteal,  25S;  of  innominate,  248; 
of  internal  iliac,  ligature  of,  257,  269;  nee- 
dles, 262;  non-pulsating,  240;  of  orbit,  253; 
of  popliteal,  259;  of  pudic,  258;  at  root  of 
neck,  248;  sciatic,  258;  subclavian,  254: 
traumatic,  206,  217,  235,  248,  367 

Aneurysmal  dilatation,  240,  251  ;  varix,  217, 
252 

Angeioma,  137,  220  ;  cavernosum,  I37 

Angeiolithic  sarcoma,  142 

Angle  of  neck  of  femur,  414 

Angular  curvature  of  spine,  710;  splints  for 
fracture  of  humerus,  398 ;   staff,  1058 

Ankle,  amputation  of,  1198;  disease  of,  611  ; 
dislocation  of,  540;  compound,  542;  exci- 
sion of,  628 ;  Mickulicz's  operation  on,  612; 
shape  of,  in  synovitis,  550. 

Ankle  joint,  excision  of,  628;  tubercular  disease 
of,  611 

Ankylosis,  616 ;  in  caries  of  spine,  701;  after 
fractures,  359 ;  of  hip,  604 ;  of  jaw,  769  ; 
after  nerve-section,  294 

Annular  structure,  1102 

Anodynes  in  pyiemia,  78 

Antal's  cystectomy,  1071 

Anterior  tibial  artery,  ligature  of,  279  ;  in  frac- 
tures, 366,  441 ;  tibial  tendon,  division  of,  330 

Antero-posterior  curvature  of  spine,  710 

Anthrax,  84;  on  face,  746 

Antimony  in  inflammation,  38 

Antiseptic  baths  in  arthritis  563;  in  burns,  i8i  ; 
in  fractures,  379 ;  gangrene,  67  ;  in  wounds 
of  joints,  416,  504. 

Antiseptics,  in  treatment  of  wounds,  165 

Antrum,  dropsy  of,  768;  polypi,  767:  suppura- 
tion in,  767  ;  tumors  of,  770 

Anus,  artificial,  947  ;  dilatation  of,  in  piles,  962  ; 
epithelioma  of,  983 ;  fissure  of,  974;  fistula, 
976;  imperforate,  955  ;  inflammation  of,  973  ; 
malformations  of,  955  ;  prolapse  of,  967  ; 
pruritus,  970 

Aorta,  aneurysm  of,  245,  248;  ligature  of, 
273  ;   wounds  of,  858 

Aphasia  in  brain-injury,  644 

Aphonia,  functional,  812 

Aphthous  stomatitis,  763 

Apparent  lengthening  in  hip  disease,  592 

Appendages,  removal  of  uterine,  i  146,  1 162 

Appendix,  inflammation  of,  931 

Apple-jelly  deposit  of  lupus,  189 

Apposition  of  wound  surfaces,  167 

Approximation  plates,  945 

Arachnoid  cysts,  663,  673 


Arch,  of  foot,  ji-^gging,  338;  hemorrhage  from 
palmar,  210 

Areola.     See  Nipple 

Arm,  amputation  of,  1 192;  innervation  of  mus- 
cles of,  692 

Arrest  of  gnjwth  after  fracture,  363,  394,  426, 
441  ;  of  hemorrhage,  203,  207 

Arsenic  in  lymphadenoma,  2S8;  onychia,  200 

Arterial  angeioma,  221  ;  hemorrhage,  201  ;  after 
fractures,  366;  hamatoma,  206,  217  ;  throm- 
bosis, 226  ;  varix,  221  ' 

Arteries,  compression  of,  242;  division  of  coats 
of,  261 ;  operations  on,  261  ;  rules  for  ligature, 
262;  rupture  of,  205  ;  as  a  cause  of  aneurysm, 
236  ;  wounds  of,  207  ;  injury  of,  205  ;  diseases 
of,  222;  degeneration  of,  226 

Arterio-venous  aneurysm,  217;  of  orbit,  737 

Arteritis,  222;  in  syphilis,  102 

Artery  and  vein,  ligature  of,  218 

Arthrectomy,  587 

Arthritis,  554;  acute,  of  infants,  462,  558;  acute 
suppurative,  454,  593,  consecutive,  558;  com- 
plicating gonorrhoea,  1098;  deformans,  570; 
after  dislocations,  498 ;  exanthematic,  566 ; 
gouty,  564;  neurotic,  547,  576;  puerperal, 
564;  pyamic,  563;  rheumatic,  569;  of  hip, 
420,  570;  suppurative,  558;  tubercular,  580; 
urethral,  564,  I097 

Articular  osteitis,  tubercular,  605 

Artificial  anus,  947;  after  hernia,  894;  eyes, 
739;   feeding  and  rickets,  498;  nose,  751 

Arytenoid,  muscles,  paralysis  of,  812 

Ascending  paralysis,  of  Landry,  122 

Ascites  and  ovarian  cysts,  1 152 

Aspect  in  hernia,  886 

Aspiration  in  abscess,  53;  in  arthritis,  561  ;  of 
bladder,  1035;  of  extravasated  blood,  156; 
in  fracture  of  patella,  43 1;  in  osteo-arthritis, 
575;  of  thorax,  1035 

As[Mrator  tor  lithotrity,  1049 

Asthenic  fever,  43 

Asthenopia,  726 

Astigmatism,  725 

Astley  Cooper  on  fracture  of  neck  of  femur,  416, 
418 

Astragalus,  angle  of,  325 ;  dislocation  of,  543  ; 
excision  for  talipes,  332;  of  head  of,  338 

Astringents  in  inflammation,  37 

Asymmetry  in  fractures,  360 ;  as  a  cause  of 
scoliosis,  712 

Atheroma,  206,  224,  235 

Atlas,  dislocation  of,  688,  691 

Atlo-axoid  disease,  702 

Atony  of  the  bladder,  1029,  1074;  of  rectum, 
966 

Atrophic  catarrh  of  nose,  753;  scirrhus,  1180 

Atrophy  in  ankylosis,  617;  of  bone,  444;  of 
cartilage,  546;  of  choroid,  734;  as  a  cause  of 
fracture,  347;  after  fracture,  568;  of  muscles, 
309,  571,  593;  after  nerve-section,  293,  310 ; 
after  strains,  306;  of  neck  of  femur,  416;  of 
testis,  1229;  and  varicocele,  1138 

Atropin  in  iritis,  731 

Attitude  in  hip  disease,  591 ;  in  spinal  disease, 
705 

Auditory  nerve,  injury  to,  650 

Auricle,  blood  tumors   of,  800 ;  malformations, 

799 
Auriscope,  799 
Auscultation  of  oesophagus,  850 


INDEX. 


1217 


Avery,  method  of  suture,  760 

Axillary  aneurysm,  255;  artery,  ligature  of,  268; 

rupture    of,    518;   pad    in  fractured    clavicle, 

389 


Bacillus  anthracis,  84;  of  glanders,  73;  of 
tubercle,  91  ;  of  leprosy,  1 16;  of  tetanus,  119  ; 
mallei,  87  ;  pyrocyaneus,  46 

Back,  injuries  and  diseases  of,  685  ;  malfurmation 
of,  680 

Ball,  on  colotomy,  939;  on  radical  cure  of 
hernia,  901 

Ballance,  669 

Bandages,  dextrin,  507 ;  in  fractures,  372  : 
Pick's,  390;  Sayre's,  389;  in  sprains,  496; 
for  fracture  of  clavicle,  388 ;  triangular,  387  ; 
Velpeau's,  508 

Bandaging,  188 

Bands,  as  a  cause  of  strangulation,  912 

Bardenheuer,  exci.sion  of  rectum,  986 

Barker,  587,  625  ;  on  excision  of  tongue,  789 

Bartholin's  gland,  126,  1 168 

Barwell's  adhesive  straps,  327;  shoe,  335  ;  sling 
for  scoliosis,  717 

Base  of  skull,  fracture  of,  637 

Bassini's  operation  for  hernia,  904 

Baths  in  compound  fractures,  379 ;  in  gan- 
grene, 69  ;  in  wounds  of  joints,  494,  50  5, 
562;    in    phagedcena,   69;  in  taxis,  889 

Bavarian  splint  for  fractured  leg,  438 

Bayonet  wounds,  1213 

Beading  of  ribs,  476 

Bearing  the  wounded,  methods  of,  1206 

Bed,  fracture,  369 

Bed-sores,  65 ;  after  fractures,  365  ;  in  injuries 
of  spine,  694 

Belladonna  in  aneurysm,  242  ;  in  incontinence, 
1032 

Bellocq's  sound,  752 

Berlin  wool  truss,  882 

Biceps  tendon,  absorption  of,  573  ;  dislocation. 
309  ;  rupture,  306 

Bichloride  of  metliylene,  as  an  anaesthetic,  187  ; 
of  mercury,  165 

Bigelow,  1047  ;  on  fracture  of  femur,  417 

Bilharzia,  1023 

Biliary  calculi,  951 

Bird's  nest  bodies,  146 

Birth  palsy,  662 

Black  eye,  727 

Bladder,  atony  of,  1029 ;  with  enlarged  pros- 
tate, 1072;  calculus,  1041  ;  diagnosis  by 
cystoscope,  107 1  ;  drainage  of,  1040,  1063, 
1070;  in  enlarged  prostate,  1079;  excision 
of,  107 1;  extroversion  of,  1024;  fissure  at 
neck  of,  II23;  foreign  bodies  in,  1071  ;  after 
fracture  of  spine,  693,  695  ;  inflammation  of, 
1037  ;  injuries  of,  1026  ;  irritability  of,  1030  ; 
sacculated,  1038,1045,1104;  tapping,  1035; 
tumors  of,  1064;  treatment  of  after  cystoto- 
my, 1069;  washing  out,  1039;  with  en- 
larged prostate,  1079 

Blandin's  gland,  126,  770 

Bland  Sutton,  130 

Bleeding,  arrest  of,  204,  207  ;  in  inflammation, 
37  ;  from  varicose  veins,  228 

Blepharitis,  735 

78 


Blister  in  erysipelas,  82 

Blood-clot,  cystic  transformation  of,  156;  or- 
ganization of,  156;  suppuration  of,  156 

Blood-cysts,  127  ;  of  neck,  826 

Blood  in  urine,  1019  ;  vessels,  diseases  of,  220  ; 
injuries  of,  218 

Blucher's  splints,  423 

Boils,  192 

Bone  setting,  555,  618 

Bones,  abs(jrption,  446;  abscess,  448;  ankylo- 
sis, 616;  atrophy,  444 ;  chronic  abscess  of, 
451;  curving  in  rickets,  475;  diseases  of, 
444;  failure  of  growth  in  rickets,  475  ;  in 
syphilis,  469 ;  hypertrophy,  444 ;  inflam- 
mation of,  444;  skull,  diseases  of,  657;  tumors 
of,  484 

Bones  and  joints,  diseases  of,  322 

Bony  ankylosis,  618 

Boracic  acid,  165  ;  baths  in  burns,  181  ;  fo- 
mentations, 192  ;  as  an  antiseptic,  166 

Bose  on  tracheotomy,  828 

Bottini's  prostatotomy,  108 1 

Bougies,  dangers  of,  1108;  oesophageal,  849; 
size  of,  1 106;  varieties  of,  1 109 

Boutonniere,  la,  I079 

Bowlby,  223,  245,  292,  690 

Brachial  artery,  ligature  of,  270;  plexus,  distri- 
bution of,  692  ;  rupture,  294,  518 

Brain,  abscess  of,  665;  concussion  of,  640 ; 
contusion,  641  ;  compression,  645  ;  cysts  in, 
673;  diseases  of,  660;  glioma  of,  664;  gum- 
ma, 662,  673  ;  hemorrhage  into,  641  ;  hernia 
of,  672  ;  incisions  in,  676  ;  inflammation  of, 
676;  chronic,  662  ;  injuries  of,  640;  lacera- 
tions of,  64 1;  sarcoma  of,  674  ;  softening  of, 
660  ;  suppuration  in,  664;  syphilitic  disease 
of,  107;  tubercle  of,  664,  673;  tumors  of, 
673  ;  wounds  of,  648 

Branchial  cysts,  827  ;  fistula,  814 

Brasdor's  method  of  ligature,  243,  246  ;  opera- 
tion for  aneurism,  246 

Breast,  abnormalities  of,  1172  ;  adenoma,  1 178, 
1179;  adenosarcoma  of,  141  ;  cystic  disease 
of,  126,  1 1 76;  enchondioma  of,  134;  fibro- 
adenoma, 144;  hypertrophy  of,  II71  ;  inflam- 
mation of,  1073  ;  lobular  induration  of,  1 175  » 
pigeon,  476;  removal  of,  I185 

Bridle  stricture,  1 103 

Brisement  force,  328 

Broad  ligament  cysts,  127,  1151 

Brodie's  disease  of  the  breast,  127,  1178 

Bromide  eruptions. 

Bromine  as  an  antiseptic,  166 

Bronchi,  foreign  bodies  in,  819 

Bronchocele.     See  Thyroid 

Broncho  pneumonia  after  operations  on  the 
tongue,  790;  after  wounds  of  the  neck, 
816 

Brown's  solution  in  gangrene,  70;  vapor,  pre- 
venting erysipelas,  82 

Bruiiton's  speculum,  799 

Bryant,  212;  on  osteitis  deformans,  481  ;  splint 
for  femur,  426 ;  splint  in  hip  disease,  597  ; 
triangle,  415 

Bubo,  282  ;  syphilitic,  97,  99  ;  suppurating,  98, 
282  ;  in  chancroid,  97 

Bubonocele,  11 26 

Buccal  cysts,  770 

Buckston- Browne's  tampon,  1057 

Bulb,  suppuration  in,  1121 


I2l8 


INDEX. 


Bulbous  sounds,  1107 

Bullse,  after  extravasation,  156;  after  nerve- 
section,  293  ;  in  pemphigus,  203 

Bullet  extractors,  1210 

Bullet  forcejis,  12 12 

Bunion,  3  10 

Buphtlialinos,  733 

Buried  sutures,  168 

Burn<!,  classification  of,  179;  of  the  eye,  726; 
scars  of,  175 

Bursre,  affections  of,  319,  340 

Bursal  cysts,  827 

Button  sutures,  168 

Buzzard  on  neuntis,  300 


Crecectomy,  946 

Civcum,  iiiHammalion  of,  931 

Calcareous  degeneraiion  oi   arteries,  226 

Calcification  of   enchondroma,   134  ;   in  rickets, 

474 

Calcium  sulphide,  192 

Calculous  pyelitis,  1002 

Calculus  biliary,  951  ;  in  the  female,  1064  ;  phy- 
sical characters  of,  1041  ;  prostatic,  1087;  of 
kidney,  988;  in  pelvis  of  kidney,  1002  ;  renal, 
998;  salivary,  795  ;  solution  of,  1003;  sound- 
ing for,  1046;  tests  for,  1043;  tonsillar,  794; 
vesical,  1041 ;  in  ureter,  993,  IO02 

Callus,  350;  in  fracture  of  patella,  430;  of 
skull,  637  ;  tumors,  354 

Calomel  fumigation  in  syphilis,  113 

Canal,  suture  of  inguinal,  904 

Cancellous  exostosis,  135,  484 

Cancroid,  I46 

Cancrum  oris,  746 

Canula,  Watson's,  in  position,  1080 

Capillary  angeio:Tiata,  220 ;  hemorrhage,  201  ; 
hemorrhoids,  960 

Carbines  used  as  stretcher,  1206 

Carbolic  acid,  166;  in  bleeding,  201  ;  in  boils, 
193;  in  hydrocele,  1 146;  in  piles,  962;  in 
treatment  of  wounds,  165 

Carbuncle,  192  ;  of  face,  746 

Carcinoma,  144 ;  of  bladder,  1066;  of  bone, 
491;  breast,  1 180;  en  cuirasse,  IlSo;  as  a 
cause  of  fracture,  348  ;  of  jaws,  773  ;  kid- 
ney, 998;  larynx,  809,  835  ;  oesophagus,  848; 
penis,  1 1 25;  prostate,  1083  ;  rectum,  983; 
uterus,  1165;  villous,  126 

Carcinomatous  cysts,  827 

Garden's  amjjutation,  1189,  1197 

Caries,  448  ;  in  auditory  canal,  802  ;  fungosa  or 
sicca,  446,  472  ;  of  spine,  701  ;  syphilitic, 
465  ;    tubercular,  449,  472 

Carotid,  aneurysm  of,  251  ;  compression  of,  264, 
ligature  of,  263  ;  external,  265  ;  internal, 
265  ;    wounds  of   internal,  762  ;    wounds  of, 

Carotid  and  subclavian,  ligature  of,  245 
Carpus,  dislocation  of,  524  ;    fracture  of,  410 
Carr's  splint  for  fracture  of  Colles,  407 
Carron  oil,  182;    in  burns,  1S2 
Cartilnge,  absorption  of,  546,  569 ;    atrophy  of 

546;     in   callus,    351;     fibrillation    of,    570; 

fracture  of,  353  ;    fracture  of,  in   larynx,  817; 

inflammation   of,  547;    necrosis  of,  546;    in 

rickets,  474;    sloughing  of,  560;    tubercular 

infiltration  of,  581 


Cartilages,  loose,  in  joints,  571,613;  of  knee- 
joints,  dislocation  of,  537 

Caruncle,  urethral,  11 23,  1 1 67 

Caseation  in  actinomycosis,  89  ;  farcy,  87  ; 
hip-disease,  596,  602;  leprosy,  116;  lym- 
phatic glands,  284  ;  syphilis,  103  ;  tubercle, 
93, 582,  606 

Caseous  abscesses,  50 

Castration,  1 137 

Cataract,  73' >  anteri(jr  polar,  731;  concus- 
sion, 732;  lamellar,  732;  ojierations  for, 
740  ;  posterior  polar,  731 ;  senile,  732  ;  trau- 
matic, 726 

Catarrhal  inflammation  of  conjunctiva,  728; 
larynx,  804;  nose,  753;  mouth,  762;  oph- 
thalmia, 728 ;  rectum,  970;  stomatitis,  763 ; 
tonsil,  791 

Catarrhal  suppuration  in  joints,  550 

Catgut,  168;   ligatutes,  212 

Catheterization  of  ureter,  loii 

Catheters,  accidents  from,  1093  ;  in  enlarged 
prostate,  1077;  method  of  tying  in,  1095; 
size  of,  1 106 

Cauda  equina,  injury  to,  689,  695 

Causalgia  after  nerve  section,  294;  in  neuritis, 
299 

Caustics  in  lupus,  191 ;  phagedsena,  115 

Cautery  in  hemorrhage,  210,  237  ;  in  laryngeal 
growths,  811  ;  joint  disease,  557;  in  nsevi, 
197;  for  piles,  963;  prolapse  of  rectum, 
968;  tonsillitis,  792;  tubercular  glands, 
286 

Cavernous  angeioma,  137,220;  lymphangeioma, 
289;  tumors,  137 

Cell-nests,  146 

Cellulitis,  diffuse,  70;  and  erysipelas,  70;  after 
lithotomy,  71  ;  of  orbit,  71;  of  neck,  71,  824; 
after  poisoned  wountls,  70;  of  scalp,  71,  623, 

655 

Celsus  on  the  su'geon,  184 

Central  necrosis,  460;  sarcoma  of  bone,  488 

Cephalhematoma,  155,  450,  632 

Cephalhydrocele,  635 

Cerebellar  abscess,  667,  670 ;  trephining  for,  672 

Cerebral  abscess,  665;  trephining  for,  672; 
localization  of,  670 

Cerebral  hemorrhage,  649;  hernia,  672  ;  hyper- 
emia, 663;  after  injury,  643;  irritability,  663  ; 
localization,  678 

Cerebritis,  660 

Cerebrospinal  fluid,  escape  of,  639 

Cerumen,  accumulation  of,  799 

Cervical  fascia,  section  of,  824;  nerves,  distri- 
bution of,  691  ;  vertebrce,  injuries  of,  691 

Cervix  uteri,  amputation  of,  1 1 66;  laceration, 
1 168 

Chalazion,  736 

Chancre,  98;  duration  of,  99;  of  eyelid,  736; 
excision  of,  lio;  relapsing,  99;  soft,  96; 
treatment  of,  114 

Chancroid,  96;  of  skin,  146 

Charcot's  disease,  577 

Chassaignac's  drainage-tubes,  172 

Chaulmcogra  oil  in  treatment  ol   leprosy,  117 

Cheloid,  178;  in  cicatrice,  178 

Chemical  irritants  causing  inflammation,  71,  452, 
547  ;  causing  fever,  82 

Chest,  abscess  of,  862  ;  aspiration,  865  ;  drain- 
age, 865;  injuries  of,  853;  tubercle,  864; 
wounds  of,  855 


INDEX. 


1219 


Chicken-bone  drains,  172 
Chills  in  suppuration,  163 
Chimiiey-sweep's  cancer,  146,  I125 
Chloride  of  zinc,  166  ;  for  abscesses,  53 
Chloroform  in  delirium,  152;  as  an  anaesthetic, 

186 
Cholecystectomy,  953 
Cholecystotomy,  953 
Chondro-sarcoma,  135 
Chordee,  1097 
Choroid,   diseases   of,    734;    in    myopia,    724; 

rupture  of,  728 
Chojiart's  amputation,  1200 
Chromic  acitl  applied  to  the  tongue,  782,  783 
Chronic   abscess,    50;    of  bone,  448,  451  ;    of 

breast,    1 1 76;    osteitis,   451  ;  synovitis,    55  H 

ulcer,  193  ;  of  leg,  195 
Chylous  hydrocele,  291 
Chyluria,  291,  1021 
Cicatrices,  175  ;  in  syphilis,  loi  ;   treatment  by 

transplantation  of  flap,  176 
Cicatrized  wounds,  159 

Circular  amputation,  11 88;  of  the  arm,  1192 
Circulation  in   fracture  of  spine,  692;  effect  of 

irritants  on,  26 
Circumcision,  1124 
Circumflex  nerve,  rupture  of,  518  . 
Cirsoid  aneurysm,  221  ;  of  scalp,  657 
Civiale's  urethrotome,  11 13 
Clamp,  for  enterectomy,  942  ;  for  piles,  964 
Clavicle,  dislocation  of,  506  ;  Ellis's  splint,  390 ; 

fracture,    385  ;    sarcoma,    490 ;   Pick's    quad- 
rangular bandage,  390 ;  Sayre's  dressing,  390; 

triangular  bandage  for,  387 
Clavus,  198 

Cleanliness  in  treatment  ot  wounds,  164 
Cleft  palate,  759;  operation  for,  760 
Cloaca;,  456 
Closure  of  jaws,  768 
Clot;     active    and    passive,    237;    cysts    from, 

156;    in    hemorrhage,  202;   laminated,    237, 

241  ;  organization    of,  29,  156;  suppuration, 

156    . 
Clove-hitch,  516 

Clover's  crutch,  1052  ;  inhaler,  lS6 
Club-foot,  325 
Club-hand,  324 

Coagulation  necrosis,  45  ;  and  thrombosis,  230 
Coates's  truss,  882 
Cocaine  as  an  anesthetic,  185;   in  enterotomy, 

920;  in  stricture,  I  no 
Coccidia,  1 172 
Coccygodynia,  412 
Coccyx,  fracture  of,  412 
Cock's  operation,  1 117 
Cod-liver  oil  in  rickets,  475 
Coin-catcher,  846 
Colchicum  in  gout,  568 
Cold   abscesses,  50;    affusion  in  delirium,  152 ; 

in   arthritis,  551,   557;  in  bleeding,   2og ;  as 

a  cause  of  shock,  149  ;  inflammation,  36,  380  ; 

in  taxis,  889 ;   as  a  cause  of  neuritis,  299 
Colectomy,  945 
Coleman's  gag,  760 
Cole's  truss,  880 
Colic,    renal,    998;    in    intestinal    obstruction, 

926 
Collapse  in  burns,  180;  in  strangulation,  864 
Collateral  circulation,  215,  232 
CoUes'  fracture,  405  ;  law,  109 


Colloid  carcinoma,  148 

Color  of  syphilitic  eruption,  loi 

Colotomy,  937  ;  inguinal,  939 ;  lumbar,  937,  940  ; 
in  stricture  of  rectum,  983 

Coma,  distinguished  from  concussion,  646 

Comminuted  fractures,  346 

Common  iliac,  ligature  of,  273 

Compact  exostosis,  136 

Compensatory  curve  of  spine,  711 

Complete  fractures,  345  ;  dis'ojations,  497 

Complicated  fractures.  345 

Compound  dislocations,  497,  503;  fractures, 
345  ;  in  vault,  635;  amputation  in,  377,  381, 
428;  into  joints,  381  ;  treatment  of,  375; 
ganglion,  315 

Compression  in  abdominal  aneurysm,  257 ;  in 
aneurysm,  242,  246;  of  aona,  273;  of 
oesophagus,  849;  in  arthritis,  551,557;  of 
brachial  artery,  271  ;  of  brain,  645;  of  caro- 
tid, 264;  in  caries,  703;  in  extravasations, 
157  ;  for  hemorrhage,  210;  as  a  cause  of  in- 
testinal obstruction,  924;  of  nerves,  295  ;  of 
spinal  cord,  698 ;  in  sprains,  496;  of  sub- 
clavian, 268 

Concussion  and  alcoholic  coma,  647  ;  of  brain, 
640;  of  eye,  727;  cataract,  731  ;  and  opium 
coma,  647  ;  of  spinal  cord,  698;  and  uraemia, 
647  ;  treatment  of,  651 

Condylar  fracture  of  humerus,  398  ;  separation 
of,  401  ;    fracture  of  femur,  426 

Condylomata,  198;  in  syphilis,  100;  treatment 
of,  114 

Cone  of  light,  799 

Confinement  as  a  cause  of  ankylosis,  616 

Congenital  cyst,  127;  cystic  tumor,  289;  affec- 
tions of  tongue,  778;  dislocation,  322;  hy- 
drocele 1 140 ;  hygroma,  130,  288,  826  ;  hyper- 
trophy, 290;  inguinal  hernia,  878;  lipoma, 
132,  684;  sacral  tumor,  129,  684;  syphilis, 
109.  See  Hereditary;  of  bone,  467;  talipes, 
325  ;  varieties  of,  325  ;  torticoUi,  824  ;  tumors 
of  scalp,  656;  umbilical  hernia,  907 

Congested  ulcer,  194 

Congestion  in  burns,  181  ;  after  fractures,  366; 
due  to  thrombosis,  228 

Congestive  stricture,  1 103;  abscess,  50 

Conical  stump,  1203 

Conjunctiva,  diseases  of,  728 

Conjunctivitis,  728 

Consecutive  arthritis,  558;  displacement  in  dis- 
location, 497 ;  meningitis,  660 

Constipation  after  fractures,  366 ;  in  hernia,  888, 
915  ;   in  obstruction,  926 

Contagiousness,  duration  of,  in  syphilis,  I02 

Continued  fever,  34 

Continuous  baths  in  compound  fractures,  379 ; 
extension  in  fractures,  371 ;  suture,  170 

Contraction  of  muscles,  31 1;  as  a  cause  of 
fracture,  349,  430;  in  arthritis,  55 1  ;  after 
nerve  injury,  299 

Contraction    of    palmar   fascia,  318;    of    scars, 

175 

Contracture,  31 1  ;  after  fractures,  369 

Contrecoup,  637,  644;   fracture  by,  349 

Contused  wounds,  157,  174 

Contusions,  155;  of  abdomen,  S70;  of  brain, 
641;  of  chest,  853;  as  a  cause  of  osteitis, 
450;  of  eye,  727;  of  joints,  495  ;  of  muscles 
and  tendons,  306 ;  of  nerves,  294 ;  scalp, 
632  ;  spinal  cord,  698  ;  signs  of,  156 


INDEX. 


Convergent  strabismus,  724 

Convul>ions  and  rickets,  477  ;  after  injuries  to 
the  brain,  643  ;  in  compression,  644 

Copaiba  rash,  1099 

Coracoid  process,  fracture  of,  391 

Coredialysis,  728 

Corns,  198 

Cornea,  diseases  of,  729 ;  foreign  bodies  in, 
729 

Cornu  cutaneum,  199 

Coronoid  process,  separation  of,  409  ;  fracture  of, 
409 

Corpus  spongiosum,  abscess   of,  1 1 21 

Corrosive  sublimate,  165 

Cortical  lesions,  643;  in  cerebral  tumors,  673 

Coryza,  753 

Costal  cartilages,  fracture  of,  S54 

Cots  for  wounded,  1207,  1208 

Counter-irritants,  in  intlammation,  37,  41  ;  in 
delayed  union  of  fractures,  35S;  in  neuritis, 
301 

Counter-ojienings  in  compound  fractures,  379 

Coup  de  fouet,  307 

Cowper's  glands,  126;  suppuration  in  1097, 
I121 

Cramp,  writer's,  310 

Cranial  nerves,  injuries  of,  639,  650 

Craniotabes,  no,  475,  659;  in  congenital  syph- 
ilis, no;  in  rickets,  475 

Cranium,  nodes  on,  465.  See  Skull 

Crepitus  as  a  sign  of  fracture,  360 

Cretification  in  tubercle,  94 

Cretinism,  838 

Crico-thyroid  muscles,  paralysis  of,  812 

Croup  and  rickets,  47S  ;  spasmodic,  820 

Crushing  for  piles,  964 

Crutch  paralysis,  295 

Cubebs,  1099 

Cupping,  37 

Curdy  pus,  46 

Curvature  of  spine,  710;  in  rickets,  476 

Cut  throat,  814 

Cyanide  of  zinc  and  mercury,  165 

Cyclitis,  731 

Cylindrical  celled  carcinoma,  147 

Cylindroma,  141 

Cyrtometer,  Wilson's,  679 

Cystic  adenoma  of  breast,  1179  ;  of  ovary,  1149  ; 
adenoma  of  testis,  1135;  degeneration  of 
breast,  126,  1177;  of  enchondroma  134; 
sarcoma,  4S7  ;  ganglion,  315  ;  goitre,  842  ; 
sarcoma  of  breast,  1187 

Cystin  in  urine,  1017 

Cystitis,  1036;  in  fracture  of  spine,  693 

Cystoscope,  1067;  in  diseases  of  bladder,  1071  ; 
in  position,  107 1 

Cystotomy,  106S,  1069 

Cysts,  125  ;  of  antrum,  768,  773  ;  arachnoid, 
673;  from  blood,  156;  in  bone,  491 ;  brain, 
673;  branchial,  S27  ;  of  breast,  11 76;  car- 
cinomatous, 827  ;  dentigerous,  773  ;  eyelids, 
737;  face,  748 ;  hyo-lingual,  826;  inflamma- 
tory, 125;  jaws,  773;  kidney,  997 ;  labium, 
I168;  broad  ligament,  II51  ;  larynx,  810; 
of  mouth,  771 ;  meibomian,  736;  of  neck, 
826  ;  periosteal,  768,  773  ;  of  pharynx,  827  ; 
popliteal,  321  ;  of  scalp,  656;  from  the  semi- 
membranosus bursa,  575;  thyroid,  S26;  of 
tongue,  784;  of  vagina,  1168 

Czerney's  suture,  943 


Dactylitis,  473 

Davies  Colley,  84 

Davy's  rectal  lever,  209,  274 

Deafness  in  hereditary  syphilis.  III 

Decalcified  drainage  tubes,  172 

Decomposition  in  wounds,  163 

Defecation  after  injuries  to  spine,  694 

Definite  callus,  350 

Deformity    in    caries  of  spine,  702;  in  disease 

of  knee,  608;   in  fracture  of  spine,  688  ;  in 

hip  disease,  593;   in  infantile  paralysis,  333; 

in  leprosy,   1 17;   as  a  sign  of  fracture,  360; 

in  rickets,  478  ;  of  limbs,  322  ;  of  nose,  75 1 
Degeneration    of    arteries,    226 ;     from   arterial 

obstruction,  223;  gelaiiniform  of  bone,  468; 

of   nerves    after    division,    292  ;    of  thrombi, 

231 
Delayed  union,  354 
Delirium    after    fractures,   364;  tremens,    152; 

traumatic  153 
Demarcation  in  gangrene,  67  ;  in  necrosis,  460 
Dentigerous  cysts,  773 
Deposits  in  urine,  1021 
Derangement  of  knee,  internal,  537 
Dermato-keras,  199 
Dermoid    cysts,    128;    of    brain,   673;    breast, 

1 1 77;  eyelids,  737;  face,  748;  mouth,  770; 

ovary,  1150;  sacrum,  684;  scalp,  656;  spine, 

6S4 ;  tongue,  784 
Desault's  splint,  422 
Descent  of  testes,  1 128 
Detachment  of  iris,  728;  in  myopia,  724 
Dextrin  bandages,  507 
Diabetes,  102 1 
Diaphragm,  rupture   of,  858;    hernia   through, 

909 
Diathesis,  hemorrhagic,  222 
Didot,  325 

Dieulafoy's  aspirator,  53 
Diet  in  inflammation,  37;  in  syphilis,  113 
Diffuse  lipoma,   133;    inflammation  of  cellular 

tissue,  70;  suppuration,  51 ;  of  meninges,  665 
Digital  compression,  243;  for  hemorrhage,  2 lo 
Digitalis  in  aneurysm,  242 
Dilatation,  aneurysmal,  240 ;  of  stricture,  II08; 

of  oesophagus,  850 ;  of  rectum,  982  ;  of  female 

urethra,  1069;  of  lymphatics,  289 
Dilator,  Golding  Bird's,  821 
Dioptric  system,  723 
Diijhtheria,  tracheotomy  in,  S3I 
Diphtheritic  exudation,  34;    of  cellular  tissue  of 

neck,  823 
Direct  inguinal  hernia,  898 
Dislocations,    497;    amputation    for,    503;    of 

ankle.  540;  anomalous,  534;  astragalus,  543; 

clavicle,    506;    compound,    503;    congenital, 

322  ;  by  destruction,  563,  590;  by  distention, 

566,  594;  diagnosis  of,  500;  of  elbow,  519  ; 

excision  for,  503  ;  of  finger,  527  ;  and  fractures, 

368,    396,    504;   of   foot,   541  ;   of  hip,  527  ; 

of  humerus,  50S;  of  knee,  536;  of  lens,  728; 

of    lower    jaw,    504;    of    muscles,    30S;    by 

muscular  action,  504  ;  old,  535  ;  of  os  magnum, 

505;  of  patella,  535;  of  pisiform  bone,  525  ; 

pubic,    534;  of   radius,   522;  of   radius   and 

ulna,  519:  recurrent,  511  ;  reduction  of,  513; 

by  manipulation,  501,  515  ;  by  extension,  502, 

516;    by   hyperabduction,    516;    of  scapula, 

508;  of  semilunar  cartilages,  537;  of  spine. 


INDEX. 


688;  subastragalar,  544  ;  subclavicular.  510; 
subcoracoid,  509;  subjjlenoid,  510;  subpen- 
ous,  510;  of  tendons,  308;  of  thumb,  526; 
of  ulna,  522;  unreduced,  517;  of  wrist,  524 
Disorders  of  muscles,  functional,  308 
Displacement,  consecutive,  in  dislocation,  497 ; 
as  a  si^jn  of  fracture,  360;  of  tibia  in  disease 
of  knee,  607 

Dissecting  aneurysm,  235 

Distal  compression  for  aneurysm,  246  ;  ligature, 
for  aneurysm,  245 

Distention  of  abdomen  in  strangulation,  918; 
of  bladder,  method  of,  1060;  in  intestinal 
obstruction,  926;  of  rectum,  method  of,  1062 

Distribution  of  leprosy,  115 

Divergent  strabismus,  724 

Division  of  coats  of  arteries  by  ligature,  261 ;  of 
stricture  of  rectum,  981  ;  of  stricture  of  ure- 
thra, I123  ;  of  ligament  in  talipes,  330 

Doran,  128 

Dorsal  abscess  in  disease  of  spine,  704 ;  disloca- 
tion of  hip,  530;  region  of  spine,  injuries  of, 
694  ;  vertebriv,  fracture  of,  695 

Dorsalis  pedis,  ligature  of,  2S0 

Double  inclined  plane,  424;  ligature  for  arteries, 
213,  262 

Douching  in  inflammation,  41 

Drainage  of  abscesses,  709  ;  of  antrum,  768; 
in  arthritis,  562;  of  bladder,  1040,  1063, 
1080 ;  in  compound  fractures,  379;  of  chest, 
866;  in  goitre,  842  ;  of  hydrocele,  1141;  of 
knee-joint,  494 ;  of  the  medulla  of  bones, 
458;  of  pleura,  865;  tubes,  52,  172;  in 
wounds,  167,  171 

Dressings  of  compound  fractures,  377 ;  of 
wounds,  167  ;   for  gangrene,  67 

Drilling  in  fracture  of  patella,  432 

Dropsy  of  antrum,  768  ;  of  gall  bladder,  952 

Dry  gangrene,  59,  63,  232 

Dumb  madness,  122 

Duodenal  ulcer  in  bums,  iSo 

Duodeno-jejunal  fossa,  911 

Dupuytren's  classification  of  burns,  179 

Dupuytren's  contraction,  317  ;  enterotome,  948; 
fracture,  439  ;  splint,  441 

Dura  mater,  fungus  of,  658;  inflammation  of, 
659 ;  sarcoma  of,  658 ;  tumors  of,  673 ; 
wounds  of,  648 

Duverney,  523 

Dysentery  as  a  cause  of  stricture,  923 ;  and 
ulcer  of  rectum,  971 

Dysphagia  from  compression,  849  ;  paralysis,  848 

Dyspnoea  in  ansesthesia,  1187;  after  trache- 
otomy, 832 


E 


Ear,  eczema  of,  800  ;  examination  of,  797  ;  ex- 
ostoses of,  800;  foreign  bodies  of,  800;  fungi, 
800;  furuncles,  800;  granulations,  802; 
hemorrhage  from,  639;  inflammation  of,  665, 
801 ;  polypi,  802  ;  suppuration  in,  801 ;  spec- 
ula. 799 

Eburnated  exostosis,  1 35 

Eburnation,  570 

Ecchymoses,  156;  in  fractures,  362 

Ecraseur  for  removal  of  tongue,  787 

Ectopic  gestation,  1147 

Ectopia  vesicae,  1024 


Eczema  of  nipple,  1 172  ;  of  scalp,  644 
Eczematous  ulcers.  193;  urethritis,  1098 
Elastic    ligature    for    fistula,    979;     tourniquet, 

Lloyd's,  1 194 
Elbow,  ankylosis  of,  613;    dislocation  of,  497, 

519;     excision  of,  621  ;    fracture   near,  398, 

402  ;  shape  of,  550  ;  syphilis  of,  469  ;  tubercle 

of,  612 
Electric  bullet  explorer,  121 1 
Electrolysis    in     ectopic     gestation,     1147;    '" 

goitre,    843;    for    n;T:vi,  197,  220;    for    nasal 

polpi,  756;    in   stricture  of  the   rectum,  982 ; 

of  the    urethra,    11 18;    in    uterine    fibroids, 

II61 ;  in  trichiasis,  98 
Elephantiasis,  290,  I126 
Elevation   in   arthritis,  557  ;    in  fractures  of  the 

skull,  636;  in  hemorrhage,  212 
Ellis's  splint,  390 
Embolic  abscesses,  75;  arteritis,  222;  gangrene. 

Embolism,  232  ;  in  aneurysm,  238  ;  as  a  cause 
of  aneurysm,  236;  fatty,  366,  457;  in  frac- 
tures, 367  ;  in  pyxmia,  74 ;  in  suppuration, 
49;  in  tubercle,  92,  472,  545,  580 

Emotion  as  a  cause  of  shock,  149 

Emphysema,  861 ;   interstiiial,  853,  861 

Emprostholonos,  118 

Empyema,  863;  as  a  cause  of  scoliosis,  7 1 2 ;  of 
gall-bladder,  952 

Encephalocele,  630 

Enchondroma,  134;  of  bone,  477;  of  jaw, 
772  ;  of  testis,  1 1 35 

Enchondromata,  134 

Enclavement,  128 

Encysted   calculus,    looi,    1002;    hernia,  898; 
hydrocele,  1141 

Endarteritis,  222 

Endocarditis,  223,  233 

Endothelioma,  142 

Endotheliomata,  142 

Enemata  in  intussusception,  921;  in  obstruc- 
tion, 930 

Enlarged  prostate,  1072;  catheterism  for,  1078; 
retention  in,  1033  ;  tonsils,  791 

Enterectomy,  941 

Enterocele,  879 

Enteroepiplocele,  879 

Enterorrhaphy,  942 

Enterostomy,  936 

Enterotome,  Dupuytren's  948 

Enterotomy  in  strangulation,  9I9 

Enucleation  of  thyroid  gland,  S42 ;  of  uterine 
fibroids,  1 162 

Epicondyle  of  humerus,  separation  of,  401 

Epidemic  goitre,  839;  tetanus,   119 

Epidermic  globes,  119;  grafting,  146,  160 

Epidermis,  repair  of,  160 

Epididymitis,  syphilitic,  101,1131;  tubercular, 
1 133;   urethral,  1 129 

Epilepsy  after  nerve-injury,  298 ;  traumatic, 
654;  neuralgia,  301  ;  nerve-stretching  in  303  , 
ligature  of  vertebral  arteries  for,  268 

Epiphora,  735 

Epiphyses,  acute  inflammation  of,  454 ;  462 ; 
tubercular  inflammation,  582;  separation  of 
363;  of  humerus,  395,  402,  521 ;  of  femur, 
426 ;  of  radius,  404 ;  of  tibia,  441  ;  in  osteitis, 
457;  premature  union  of  in  rickets,  475;  in 
syphilis,  467;  union  after  separation,  393, 
425.  441,  448 


INDEX. 


Epiplocele,  879 

Epispadias,   1 1 24 

Epistaxis,  751 

Epithelial  tissue  tumors,  143 

Epithelioma,  144;  of  bladder,  1065 ;  face,  749; 
gums,  771,774;  intestines,  924;  after  lu])us, 
190;  of  cvsopiiagus,  S49  ;  penis,  1 124;  rec- 
tum, 9S3  ;  scars,  17S;  scrotum,  1 125  ;  tongue, 
784  ;   in  cicatrix,  178 

Epulis,  139,  486,  771 

Erasi m,  619  ;  in  caries,  474 

Ergot  in  uterine  fibroids,  1161 

Erichsen's  splint,  393 

Eruptions,  after  nerve  section,  294  ;  iodide,  114; 
serpiginous,  105  ;  syphilitic,  loi 

Erysipelas,  79,  290 ;  and  cellulitis,  70,  79  ;  of 
face,  747  ;  of  seal]),  655 

Erythema  in  leprosy,  116 

Erythematous  tonsillitis,  791  ;  lupus,  192 

Escape  of  cerebro-spinal  fluid,  638 

Eserine  in  glaucoma,  733 

Esmarch's  bandage,  208,  244;  operation,  769 ; 
operation  for  excision  of  the  Ijreast,  1 186; 
tourniquet,  208;  triangular  bandage,  1205 

Estlander's  operation,  867 

Eiher  in  inflammaiion,  38;  as  an  anccsthetic, 
186;  spray  in  burns  of  fauces,  183 

Eucalyptus  oil,  166 

Eustachian  catheter,  798 

Evacuating  tubes,  1049 

Evolution  cyst,  127 

Examination   of  bladder, 
n8o;    calculi,    1043; 
wounds,  1210;   joints, 
rectum,    929 ;     spine, 
testis,  1136;   urethra,  1092,  1107 

Exanthematic  arthritis,  564;   necrosis,  464 

Exostosis,  484 

Excision  of  ankle,  628  ;  compared  with  arthrec- 
tomy,  586;  of  the  astragalus,  332  ;  of  wall  of 
bladder,  1071  ;  of  breast  1 185  ;  of  cancer,  112; 
of  cirsoid  aneurysm,  221  ;  of  joint,  619,  of 
condyle  of  jaw,  769  ;  in  compound  dislocation, 
508;  of  the  elbow,  621  ;  of  eyeball,  738;  of 
the  hip,  603,  625;  hydrocele,  1143;  jaws, 
774  ;  knep,  434,  626  ;  lymph  glands,  285  ; 
larynx,  810,  835;  Meckel's  ganglion,  304; 
ofnsevi.  197,220,  piles,  965;  prolapse  of  rec- 
tum, 968;  rectum,  9S5;  rib,  868;  shoulder, 
620;  stricture,  II18;  subperiosteal,  621  ; 
thumb,  625;  tongue,  787  ;  tonsils,  793;  vari- 
cocele, 1139;  varicose  veins,  228 ;  wrist  joint, 
623 

Excitement  in  shock,  149;  during  anaesthesia, 
187 

Exclusion  of  aneurysm,  247 

Exercises  in  lateral  curvature,  716 

Exfoliation,  459;  after  scalp  wounds,  633 

Exfolium,  59 

Exophthalmic  goitre,  839,  844 

Exostoses,  136,  484  ;  of  cranium,  659;  of  audi- 
tory meatus,  800;  of  jaws,  772 

Expansile  pulsation,  237 

Expansion  of  bone,  447,  473 

Exploring  needle,  51 

Extension  in  arthritis,  557;  as  a  cause  of  an- 
kylosis, 617;  for  cicatrices,  176,  183;  in  dis- 
locations, 501,  516;  in  dislocation  of  the 
spine,  696;  in  fractures,  371 ;  in  hip  disease, 
598 


1046;  breast,  1 176, 
eye,  722 ;  of  gunshot 
548;  prostate,  1076; 
716;    scrotum,    1 1 25; 


Extensor  tendons  of  wrist,  dislocation  of,  309 

External  hemorrhoids,  959;  iliac,  ligature  of 
275;  urethrotomy,  1 1 15;  incision  in  removal 
of  tongue,  787 

Extirpation  of  uterus,  1 166;  by  extra-peritoneal 
method,  1 167 

Extra-articular  ankylosis,  616 

Extraction  of  cataract,  740;   of  balls,  I2I2 

Extrauterine  fo-tation,  1147 

Extravasation  of  blood,  changes  in,  29,  155  ; 
treatment  of,  156;  of  urine,  1118;  from  kid- 
ney, 990 

Extroversion  of  bladder,  1024 

Exudation  in  chronic  inflammation,  39;  cysts, 
125  ;  varieties  of  34 

Eye,  diseases  of,  722;  injuries,  726;  examina- 
tion of,  722 

Eyeball,  excision  of,  738 

Eyelids,  diseases  of,  735 


Face,  acne  of,  anthrax,  84,  746 ;  carbuncle 
on,  746;  dermoid  cysts  of,  128,748;  epithe- 
liomi,  749;  erysipelas,  747  ;  fracture  of  bones 
of,  381  ;  injuries  and  diseases  of,  745  ;  lujjus, 
192,  747  ;  leprosy,  1 16,  748;  malformations, 
742;  moUuscum,  749;  rhino-scleroma,  748; 
syphilis,  lio,  747;  rodent  ulcer,  146,  749; 
tumors  of,  748 

Facial  artery,  ligature  of,  266;  nerve,  injury  to, 
650;  neuralgia  of,  301 

Fsecal  accumulation,  treatment  of,  930;  fistula, 

895.  947 
Faeces  as  a  cause  of  obstruction,  927 
Failure  of  growth  in  rickets,  475;   in    syphilis, 

469;  of  union,    354;    of   humerus,    398;    of 

patella,  433 
Fallopian  tubes,  inflammation  of,  1 145 
False  joints,  355  ;    of  humerus,  398;    passages, 

1094,  1 110;  spina  bifida,  680;  pelvis,  fracture 

of,  41 1 
Farabfjeuf,  526 

P^aradic  excitability  after  nerve  section,  293 
Faradization  in  dysphagia,  848 
Farcy,  87 
Fascia,  section  of  cervical,  824  ;    of  plantar,  328  ; 

con'raction  of  palmar,  317  ;    lata,  in  diagnosis 

of  fractured  femur,  420 
Fat-emboli-m   after  fracture-,  364;     in  osteitis, 

457  ;  in  urine,  1021 
Fatty  degeneration  of  arteries,  226 
Fauces,  injuries  of,  762 
Feeding  after  herniotomy,  894 ;  laparotomy,  921  ; 

tracheotomy,  831 
Fehleisen,  79 
F'emoral  aneurysm,  259;  ligature  of  artery,  276  ; 

compression,  276;  hernia,  905 
Femur,  absorption  of  neck,  421,  571;    amputa- 
tion   of,    1 196;    compxjund  fracture  of,  428; 

dislocation  of,  527  ;   fracture,  413  ;  necrosis  of 

head  of,  589;    osteitis  of  neck,  582,  588;    in 

rickets,  477 
Fergusson's  staff,  1053 
Ferments,  fever-causing,  33,  86,  154 
Fever,  causes  of,  32  ;    asthenic,  in  inflammation, 

33  ;  irritative,  in  inflammation,  34  ;  in  fracture, 

363;  neurotic,  154;    septic,  42,  163;  sthenic, 


INDEX. 


1223 


in  inflammation,  33  ;  surgical,  44  ;  syphilitic, 
100 ;  traumatic,  44,  154;  varieties  of,  34 

F"il)rin  ferment,  42 

Fil)rin()us  synovitis,  546 

Fibroblasts,  30 

Fibro-cellular  tumor,  130 

Fibro-enchoniiroma,  134 

Fibroid  polypi  of  n  j^e,  756  ;  tumors  of  uterus, 
1 159;  recurrent,  I42 

Filuoma,  130;  of  bone,  487;  of  breast,  117S 
dura  mater,  673;  jaws,  771  ;  larynx,  810 
ovary,  1 148  ;  sarcoma,  I42  ;  of  scalp,  657 
of  testis,  1 135  ;  within  the  mouth,  771 

Fibrous  ankylosis,  618  ;  goitre,  842  ;  union  of 
fractures,  355 

Fibula,  fracture  of,  439 

Fisjure-of-eight  bandai^e,  390;  suture,  169 

Filaria  sanguinis  hominis,  290 

Finger  and  thumb  joints,  excision  of,  625 

Fmgers,  amputation  of,  1193;  dislocation  of, 
527;  enchondroma  of,  134;  supernumerary, 
322 ;  webbed,  324 

First  aid  to  the  wounded,  1204;  intention,  union 
by,  158 

Fissure  of  anus,  974;  at  neck  of  bladder,  1123  ; 
of  tongue,  783  ;   syphilitic,  loo 

Fissured  fracture,  634 

Fistula,  56;  in  ano,  976;  bi-mucosa,  896; 
branchial,  814;  frecal,  947;  recto-vaginal, 
I168;  renal,  loil;  urethral,  II2I;  urinary, 
II2I  ;  vesico-vaginal,  I168 

Fistula  and  phthisis,  9S0 

Fitzgerald,  332 

Fixation  of  talipes,  328 

Fixed  splints  for  fractures,  374;  virus,  123 

Flail  joints,  621 

Flap  amputations,  11 88 

Flat  foot,  336  ;  after  fracture,  440 ;  gonorrhoeal, 
566 

Flexion  in  aneurysm,  246 ;  in  hip  disease,  593 

Flexor  tendons,  sprain  of,  407 

Floating  kidney,  9S9 

Fluctuation,  48 

Fluhrer's  aluminum  probe,  1212 

Foetus,  attached,  684  ;  parasitic,  129 

Folding  a  hernial  sac,  902 

Follicular  prostatitis,  1084;  stomatitis,  763; 
tonsillitis,  791 

Food,  as  a  cause  of  rickets,  477 

Foot,  amputation  of,  1200 ;  dislocation  of,  541  ; 
fracture  of,  443 

Forcipressure,  211 

Forearm,  amputation  of,  1192  ;  dislocation,  519 

Forehead,  dermoid  cysts  of,  128 

Foreign  bodies  in  air  passages,  818;  in  aneu- 
rysm, 246;  in  ear,  800;  in  the  eye,  726,  729; 
in  joints,  571,  614;  in  larynx,  818;  in  lung, 
819;  nose,  745;  as  a  cause  of  obstruction, 
I109;  in  palate,  762 ;  in  pharynx,  846  ;  in 
trachea,  819;  in  thorax,  862;  in  urethra, 
1090;    in   wounds,  162 

Fossa  duodeno  jejunalis,  9II  ;  intersigmoid,  91 1  ; 
subcjecal,  911 

Fourth  nerve,  injury  to,  649 

Fractures,  345  ;  of  acetabulum,  41 1  ;  acromion. 
391 ;  amputation  in,  376,  380,  428  ;  of  base  of 
skull,  637;  bed  for,  370;  of  bones  of  face, 
3S1,  745;  of  carpus,  410;  clavicle,  385; 
complications,  363  ;  by  contre-coup,  637  ;  of 
coccyx,  412;  coracoid  process,  391 ;  coronoid 


process,  409  ;  depressed,  of  skull,  601  ;  diag- 
nosis of,  363;  and  dislocation,  396,  504;  in 
reduction  of  dislocation,  518;  Dupuytren's 
439;  of  elbow, 401;  femur,  413;  riliula,439; 
foot,  443  ;  of  hyoid  bone,  817  ;  humerus,  392 
into  knee  joint,  428,434;  larynx,  817  ;  malar 
bone,  382  ;  maxillx,  382  ;  metacarpus,  410  ; 
by  muscular  action,  349,429;  of  nasal  bones, 
381;  of  patella,  429;  Pott's,  439,  540;  of 
pelvis,  41 1;  reduction  of,  371  ;  of  radius,  403  ; 
of  radius  and  ulna,  408  ;  of  ribs,  853  ;  in  sar- 
coma, 489  ;  of  scapula,  390;  of  sacrum,  412  ; 
into  shoulder  joint,  396 ;  of  spine,  687 ;  of 
sternum,  825;  of  skull,  634;  of  tibia,  438  ; 
of  tibia  and  fibula,  435;  of  trochanters,  419; 
treatment,  369 ;  of  ulna,  408 ;  of  vault  of 
skull,  634 

Fragilitas  ossium,  348 

Friction,  as  a  cause  of  inflammation,  39 

Fringes,  synovial,  570,  614 

Frog's  skin,  grafting  of,  162 

Frostbite,  63 

Fumigation  in  syphilis,  113 

Function,  impairment  of,  in  inflammation,  32 

Functional  aphonia,  812;  disorders  of  muscle, 
310 

Fungi  in  auditory  meatus,  800 

Fungus  of  dura  mater,  659 ;  of  actinomycosis, 
89 

Furneaux  Jordan's  amputation,  1193;  plaster 
jacket,  708 

Furuncles  in  ear,  800 

Fusiform  aneurysm,  235 


Gags,  760 

Galactocele,  1177 

Gall-bladder,  diseases  of,  951 ;  operations  upon, 

953 
Gall-stones,  951 ;  as  a  cause  of  obstruction,  925  ; 
of  strangulation,  915;  treatment  of  impacted, 

9'9 

Galvanic  excitability,  after  nerve-section,  293 

Galvanism  in  nerve  injury,  296;  in  delayed 
union, 358 

Galvanopuncture  in  aneurysm,  247 

Gamgee's  antiseptics,  378;  dressings,  166; 
splints,  373 

Ganglion,  125,315 

Gangrene,  amputation  in,  57  ;  in  aneurysm, 
244,  260;  after  ligature  of  artery,  215,  232  ; 
causes,  59;  embolic,  63,  232;  in  fractures, 
368,  379;  due  to  nerve-irritation,  60;  in  her- 
nia, 894;  in  intussusception,  914,  922;  hos- 
pital, 69;  moist,  64;  senile,  6  v.  in  spinal  in- 
jury, 690 ,  symmetrical,  63  ;  thrombotic,  63 

Gangrenous  stomatitis,  746 

Gartner's  duct,  128 

Gastroduodenostomy,  875 

Gastrojejunostomy,  875 

Gastrostomy,  851 ;   for  stricture,  874 

Gastrotomy,  S47,  876 

Gelatiniform  degeneration  of  bone,  468 

Generalization  of  sarcoma,  142 

Genu  recurvatum,  324  ;   valgum,  34I 

Gestation,  ectopic,  1 146 

Giant-cells  in  syphilis,  103  ;  in  tubercle,  93 

Gihon  cot,  1207 

Glanders,  87 


1224 


INDEX. 


Glands,  caseating,  284 ;  excision  of,286 ;  in  ery- 
sipelas, 81  ;  inflammation  of,  282;  in  neck 
824 ;  tubercular,  284 

Glandular  enlargements  in  syphilis,  99;  tumors 
of  breast,  1 1 76 

Glaucoma,  733 

Gleet,  1097,  1 100 

Glenoid  fossa,  fracture  of,  in  dislocation,  518 

Glioma,  141 ;  of  brain,  673  ;  of  choroid,  734 

Globe,  rupture  of,  728 

Glossitis,  779 

Glottis,  scald  of,  821 

Glower's  suture,  1 70 

Gluteal  aneurysm,  258;  ligature  of  artery,  275 

Godlee,  868 

Goitre,  S39 

Golden  Rule  of  Guthrie,  214 

Golding-Bird's  dilator,  821 

Gonococcns,  1095 

Gonorrhoea,  1095 ;  complications  of,  1098  ; 
epididymitis,  1129;  prostatiti-,  1084;  rheu- 
matism, 337,  565.  1097 

Gooch's  splint,  397 

Gordon  on  Colles'  fracture,  406  ;  splint,  407 

Gorgas  cot,  1207 

Gorget,  1054;  Teale,  11 17 

Gout,  39  ;  arteritis  in,  224  ;  arthritis,  566;  iritis, 
730;  neuritis,  299;  orchitis,  11 34;  phlebitis, 
234;  prostatitis,  1085  ;  urethritis,  1098 

Gowers'  tumor  of  spinal  cord,  720 

Graafian  follicle  cysts,  127,  1150 

Grafting,  bone,  360 ;  in  bums,  183;  frog's  skin, 
162;  mucous  membrane,  162;  nerves.  297; 
omentum,  944;  skin,  160;  tendons,  308;  for 
ununited  fracture,  360 

Granulation  tissue,  29,  158 

Granulations,  in  ear,  802  ;  healing  by,  159 

Granuloma,  31 ;  fungoides,  482 

Graves's  disease,  839 

Grawitz  on  peritonitis,  934 

Gray  tubercles,  93 

Great  toe.  deformities  of,  339 

Greenstick  fracture,  346 

Greig  Smith  on  enterectomy,  941  ;  on  intestinal 
strangulation,  919;  on  peritonitis,  935 

Grittrs  amputation,  II97 

Growth,  arrest  of  after  fracture,  363,  395,  425, 
440  ;  in  rickets,  475  ;  in  syphilis,  469 

Gum  and  chalk  bandage,  373,  436 

Gummata  in  bone,  104,465  ;  brain,  674 ;  bursae, 
319;  in  hereditary  syphilis,  lio;  histology 
of,  104  ;  in  muscle,  312  ;  of  skull,  658,  662  ; 
of  testis,  1 1 32  ;  tongue,  783 ;  treatment  of,  1 1 5  ; 
of  sternum,  864 

Gums,  hypertrophy  of,  770 

Gunn's  rule  for  dislocation,  508 

Gunshot  fractures,  12 12;  wounds,  1209 

Gurjun  oil  in  leprosy,  1 1 7 

Guthrie's  perineal  section,  11 17 

Gutta-percha  in  fracture  of  jaw,  383 

Gutter  fractures,  634 

Gymnastics  in  lateral  curvature,  717 


H 

Haemarthrosis,  550 
Haematocele,  155,  1 143 

Ha^matoma,  155  ;  anerial,  206,  217  ;  auris,  800 ; 
of  chest-wall,  855 


Hxmatomyelia,  698 

Haematuria,  1019;    after  spinal  injury,  686;   in 

enlarged    prostate,   1075  ;    in    villous  tumor, 

1065 
Haemothorax,  859 
Haemophilia,  222 
Hc^emoptysis,  860 
Hagedorn's  needles,  170 
Hahn's  tampon,  831 
Hallus     flexus,    339 ;     rigidus,    339 ;     valgus, 

340 
Hamilton,  irrigation  of  abscesses,  53 
Hammer-toe,  338 
Hand,    club,    324;    fractures   of,    410;    tendon 

sheaths  of,  315  ;  incisions  into,  315  ;  steriliza- 
tion of,  184 
Hard  cataract,  extraction  of,  740 
Hare  on  cerebral  localization,  679 
Hare-lip,  742;  pins,  169 
Harrison's  truss,  904 ;  whip  bougies,  loio ;  on 

enlarged   prostate,    1074;    draining    bladder, 

1079 
Head,  injuries  of,  631,  655 
Healing   by   fir^t   intention,    158;    under  scab, 

159 

Heart,  failure  of,  in  anaesthesia,  188;  wounds 
of,  857 

Heat,  in  arthritis,  551  ;  hemorrhage,  2IO;  taxis, 
889;  a  symptom  of  inflammation,  31 

Hectic,  49,  55 

Hegars  method  in  extirpation  of  uterus,  1167 

Helplessness  in  fractures,  362 

Hemianaesthesia  in  railway  injuries,  699 

Hemorrhage,  201,  214  ;  into  abscesses,  56  ;  in 
aneurysm,  240  ;  as  a  cause  of  shock,  149;  in 
cleft  palate,  761 ;  in  chest  injuries,  858 ;  in 
cut  throat,  814;  diagnosed  from  shock,  150; 
from  ear,  639  ;  into  eye,  727 ;  in  fractures, 
365,  378  ;  intracranial, 648;  from  kidney,  995; 
after  lithotomy,  1057;  in  myopia,  724;  from 
middle  meningeal,  648  652 ;  afier  ovari- 
otomy, 1 1 60;  into  peritoneum,  871  ,  after 
piles,  970  ;  into  spinal  canal,  698;  secondary, 
201,  243;  treatment  of,  215  ;  subperiosteal  in 
479 ;  in  tracheotomy,  830 ;  after  wound  of 
tonsil,  762,  794;  after  urethrotomy,  1 114; 
from  varicose  veins,  228 

Hemorrhagic  diathesis,  222 ;  exudation,  31 ;  in- 
farct, 76,  233;  sarcoma,  127 

Hemorrhoids,  957 

Hereditarj"  sjrphilis,  109 ;  laws  of  transmission, 
108 :  osteitis  in,  487 

Heredity  in  syphilis.  102;  in  tubercle,  91 

Hernia,  877;  anatomy  of,  S77;  causes  of,  877; 
cerebri,  672;  congenital,  896  ;  diaphragmatic, 
909;  direct  inguinal,  896;  encysted,  898; 
femoral,  905  ;  inflamed.  884;  inguinal,  896; 
diagnosis  of,  1126:  internal,  911;  infantile, 
898;  irreducible,  S82  ;  oflunp,  861  ;  lum- 
bar, 910  ;  Liltre's,  883  ;  ol«tructed,  883  ;  ob- 
turator, 909  ;  perineal,  910  ;  pudendal,  910  ; 
radical  cure  of,  900,907  ;  sciatic,  910  ;  strangu- 
lated. 885;  of  testis,  1 134;  tunicary  of  blad- 
der, 1 104;  of  joints,  552,572,575;  umbilical, 
907  ;  ventral,  909 

Herniotomy,  892,900 

Herpes  labialis,  after  nerve-seciion,  293;  pre- 
putial, 97. 

Hey,  538,  1 201 

Hill's,  Berkeley,  urethrotome,  1113 


INDEX. 


1225 


Hilton's  case  of  gangrene,  60;  on  opening  ab- 
scesses, 51 
Hip :  amputation  of,  1 193  ;  Senn's  method,  1 195  ; 
ankylosis,  603;  contusion,  420  ;    disease   of, 
588;  and   hysteria,  594;    and    bursitis,  596; 
and    osteitis  of   femur,  596 ;    and    sacro-iliac 
disease,    595,    603 ;    stages   of  disease,   596 ; 
shape   of,    550;    dislocations   of,    527;    con- 
genital,   322  ;    unreduced,  499 ;    excision    of, 
603,  625 
Hodj^en's  splint,  424,  436 
Holt's  dilator,  11 13 
Homatropin,  722 

Horns.  199;   on  scalp,  657;  on  eyelids,  737 
Horse-hair  suture,  168 
Horse-shoe  fistula,  977 

Horsley :  on  intracranial  tumors,   673 ;    on  te- 
tanus, 122;  on  tumors  of  spinal  cord,  720 
Hospital  gangrene,  69 
Hot  water  bags,  in  gangrene,  67 
Howse  on  gastrostomy,  876 
Howship"s  lacunre,  481 

Humerus:  amputation  of,  1190;  dislocation  of, 
508;  reduction  of,  514;  unreduced,  517; 
fracture  of,  392;  in  reducing  dislocation,  518; 
ununited,  357 ;  separation  of  epiphysis  of,  393, 
512 
Humphry,  529,  614 
Hunter's   canal,    ligature  in,    276  ;   method   of 

ligature,  243 
Hunterian  operation  for  aneurysm,  243 
Hutchinson:      amputation     in    gangrene,    58; 
massage  in    intestinal   obstruction,    1116;    on 
osteitis  deformans,  483;  teeth,  in 
Hydatid:  of  brain.  674;  breast,  1177;    kidney, 
997;    liver,    950;    of    Morgagni,    128;    and 
ovarian  cyst,  1153 
Hydramnios,  1 152 
Hydrarthrosis,  546,  554,  575 
Hydrencephalocele,  630 

Hydrocele,  1139:    diagnosis  of,  1 126;  of  her- 
nial sac,  878;  of  neck,  289,  826 
Hydrogen  gas,  injection  of,  871 
Hydronaphthol,  166 
Hydronephrosis,    994;     spurious,     991  ;      and 

ovarian  cyst,  1 153 
Hydrophobia,  121 
Hydrophobic  tetanus,  118 
Hydrops  antri,  768;  articuli,  546,  554,  575 
Hydrosalpinx,  125,  1145 
Hygroma,  congenital,  130,  138,  289,  826 
Hyoid,  fracture  of,  817 
Hyolingual  canal,  128;  cysts,  826 
Hyperabduction  in  reducing  dislocation,  516 
Hyperseniia  of  brain,  664 

Hyperesthesia  of   larynx,    81 1;     in    spinal    in- 
jury, 690 ;  in  railway  injury,  700 
Hypermeiropia,  723 
Hyperostosis,  469 
Hyperplasia  and  inflammation,  39 
Hyperpyrexia  in  tetanus,  I20 
Hypertrophic  catarrh  of  nose,  753 ;  lupus,  748 
Hypertrophy  of   bone,  444;    breast,    1171;    in 
cicatrix,   178;  congenital,  289;    tonsils,  793  ; 
of  bones  of  skull.  657 
Hypnotic  sleep,  700 
Hypodermic  use  of  mercury,  113 
Hypospadias,  1 124 

Hypostatic  congestion  in  spinal  injury,  709 
Hysterectomy,  1163 


Hysteria  and  hip  disease,  595;  in  railway  ac- 
cidents, 699 

Hysterical  dysphagia,  848;  jsaralysis  of  a-so- 
phagus,  848 


Ice-bag,  for  checking  inflammation,  380 

Ichorous  pus,  46 

Ichthyosis  of  tongue,  781 

Idiopathic  aneurysm,  235 

Ileus  paralyticus,  895,  917,  926 

Iliac  abscess,  705;  aneurysm,  257;  common 
artery,  ligature  of,  273;  external,  275;  in- 
ternal, 274 

Immediate  treatment  of  talipes,  3^0 

Immobility  in  treatment  of  wounds,  173 

Immovable  splints,  373 

Impacted  calculus  in  ureter,  1002 ;  in  urethra, 
1087;  fracture,  346,  361 ;  of  femur,  418 

Impaired  mobility  in  hip  disease,  593 

Imperfect  repair  after  dislocation,  498 

Impermeable  stricture,  mo 

Implantation  of  intestine,  946 

Impulse,  loss  of,  in  strangulation,  887 

Incised  wounds,  157 

Incisions:  on  hand,  315;  to  relieve  tension,  67, 
73  ;    in  hydrocele,  1 143 

Incomplete  fracture,  345  ;  dislocations,  497 

Incontinence  in  spinal  injury,  695  ;  after  fistula, 
948  ;  of  urine,  103 1 

Incubation  of  hydrophobia,  121  ;  of  syphilis, 
98;  of  tetanus,  119;  of  tubercle,  92 

Indian  operation  for  rhinoplasty,  751 

Induration   of  chancre,  98 ;  lobular,  of  breast, 

"75 

Inequality  of  limbs  in  scoliosis,  712 

Infantile  hernia,  898;  hydrocele,  1 140;  par- 
alysis, causing  talipes,  -^-XiZ ;  ^s  a  cause  of 
fracture,  347  ;  simulating  rickets,  47S  ;  pseu- 
doparalysis, no;  umbilical  hernia,  908 

Infarcts,  233  ;  in  pyaemia,  76 

Infected  wounds,  1 74  ;  pus,  46 

Infective  arteritis,  223 ;  softening  of  thrombi, 
230 

Inferior  maxilla,  fracture  of,  382;  dental  nerve, 
in  fracture,  385  ;  section  of,  304 

Infiltrating  scirrhus,  1 180 

Inflammation,  30;  of  bone,  444 ;  brain  660, 
670;  in  burns,  180;  chronic,  38;  diffuse  of 
neck,  823  ;  in  fracture,  368  ;  of  hernia,  884; 
and  hyperplasia,  39  ;  of  joints,  545  ;  of  men- 
inges, 660 ;  due  to  poisons,  70;  phlegmon- 
ous, 70;  of  skull,  658;  after  sprains,  symp- 
toms of,  30,496;  of  tongue,  779;  varieties  of, 
34;  temperature  in,  31  ;  treatment  of,  35  ; 
in  wounds,  162 

Inflammatory  ulcer,  I94;    of  leg,  195 

Infractions  in  rickets,  477 

Ingrowing  toe-nail,  200 

Inguinal  aneurysm,  257  ;  canal  in  hernia,  902  ; 
colotomy,  939;  glands,  inflammation  of  in 
chancroid,  97  ;  hernia,  896  ;  radical  cure  of, 
900;  tumors,  diagnosis  of,  1126 

Inhalations,  803 

Injection  in  delayed  nnion  of  bone,  358  ;  gon- 
orrhcea,  1099;  hydrocele,  1 142  ;  hernia,  901  ; 
hydrops  articuli,  575  ;  piles,  962  ;  synovitis, 
554;  syphilis,  113 


1226 


INDEX. 


Injury,  25  ;  as  a  cause  of  arthritis,  547  ;  to  the 
head,  631  ;  of  blood-vessels,  201  ;  histological 
changes  after,  29 ;  and  repair,  25  ;  general 
pathology,  1 50 

Innominate  aneurysm,  241,  250 ;  ligature,  262 

Inoculation  of  tubercle,  92  ;  treatment  in  hydro- 
phobia, 123 

Insanity,  traumatic,  654 

Inspection  in  intestinal  obstruction,  929 

Instrumental  compression,  243 

Instruments,  1S5 

Insufflation  in  intussusception,  92 1  ;  of  larynx,  805 

Intention,  healing  by  first,  158 

Intercostal  arteries,  wounds  of,  858 

Interdental  splints,  383 

Intermaxilla,  treatment  of  in  harelip,  744 

Intermediary  amputation,  II88 

Intermittent  fever,  34 

Internal  derangement,  537  ;  hemorrhage,  I  go; 
hemorrhoids,  959  ;  hernia,  91 1 ;  iliac,  aneur- 
ysm of,  257  ;  ligature  of,  274  ;  mammary, 
ligature  of,  269;  wounds  of,  859;  pudic, 
hemorrhage  from,  21 1,  1056;  strangulation, 
911  ;  urethrotomy,  11 12 

Interrupted  suture,  170 

Intersigmoid  fossa,  91 1 

Interstitial  absorption  of  neck  of  femur,  421  ; 
condensing  osetitis,  469  ;  emphysema,  853  ; 
fibroids,  1161 ;  gestation,  1 147  ;  keratitis,  1 1 1  ; 
syphilitic  osteomyelitis,  465 

Interrupted  suture,  170 

Intestinal  anastomosis,  946  ;  hemorrhoids,  959  ; 
implantation,  946;  obstruction,  911,  922; 
symptoms  of,  926  ;  sutures,  942  ;  treatment  of, 
941  ;  toxa'mia,  44;  strangulation,  919; 
evacuation  in,  919 

Intestines,  inflation  of,  871;  in  hernia,  894; 
malignant  disease  of,  923;  operations  on, 
936 ;  resection  of,  942 ;  strangulation  of, 
884;  stricture  of,  871  ;  wounds  of,  873 

Intoxication,  septic,  43 

Intra-articular  ankylosis,  616;  fracture,  352; 
of  femur,  515 

Intracranial  hemorrhage,  648 ;  abscess,  667  ; 
suppuration,  664;  tumors,  673 

Intracystic  growths,  127 

Intradental  splint,  383 

Intralaryngeal  operations,  810 

Intraparietal  sac,  878,  890 

Intrapelvic  abscess  in  hip-disease,  595,  602 

Intrathoracic  aneurysm,  248 

Intrauterine  fracture,  346 

Introduction  of  foreign  bodies  in  aneurysm,  246, 

Intubation  of  larynx,  833;  oesophagus,  85 1 

Intussusception,  913;  treatment  of,  921  ; 
chronic,  926  ;  treatment  of,  930 

Inunction  of  mercury  in  syphilis,  113 

Inversion  as  an  aid  to  taxis,  889 

Involution  cysts,  126 

Iodide  of  potasli,  coryza,  114;  eruptions,  114; 
in  syphilis,  113;  in  aneurysm,  241;  in 
osteitis,  451 

Iodine  in  goitre,  842  ;  in  hydrocele,  1 142;  as 
an  antiseptic,  166 

Iodoform  in  abscesses,  54,  587 ;  in  fractures, 
378;  hydrocele,  1 143;  after  removal  of 
tongue,  789;  in  synovitis,  554;  in  syphilitic 
ulcers,  194;  in  phagedena,  69;  in  wounds, 
167  ;  poisoning,  167  ;  in  tubercular  arthritis, 
585,  603 


Iridectomy,  739;   for  glaucoma,  734 

Iris,    diseases    of,    729;   in    syphilis,    80;    after 

cataract,  741  ;   in  rheumatism,   730;  prolai)se 

of,   726 
Iritis,  730;   in  syphilis,   102;  treatment  of,  1 15 
Iron  in  erysipelas,  81 

Irreducible  hernia,  882;  umbilical,  882,  907 
Irrigation  of  joints,  494,  562;  of  wounds,  165; 

of  abscess  cavity,  54 
Irritability  of  bladder,   1030;   brain,  642,  662; 

urethra,  1 108 
Irritants,  classification  of,  25  ;   causing  gangrene, 

60;   effect  of,  30  ;   causing  inflammation,  30 
Irritation,  sympathetic,  of  eye,  727 ;  continued, 

effect  of  30 
Irritative  fever,  33 
Ischiorectal  abscess,  973 
Italian  ojjeration  for  rhinoplasty.  75 1 
Itching  of  scars,  178 
Ivory  exostoses,  136,484, 


Jack-towel  in  extension,  501,  516 

Jaws,  closure  of,  768;  dislocation,  504;  exci- 
sion, 774;  of  condyle  of,  769;  fracture  of, 
382;  necrosis  of,  446,  765;  resection,  757; 
tumors,  770 

Joints,  contusions  of,  495  ;  excision  of,  and 
arthrectomy,  586;  compound  fractures  into, 
381,  402,  410;  dislocations  of,  497;  unre- 
duced, 498;  examination  of,  548;  hemor- 
rhage into,  222;  inflammation  of,  546;  of 
ankle,  61 1  ;  elbow,  608  ;  hip,  58S  ;  knee,  604  ; 
sacro-iliac,  fo3 ;  shoulder,  612;  wrist.  613; 
injuries  of,  492;  in  fractures,  36S ;  of  elbow, 
399,  402;  of  knee,  429,  434;  of  shoulder, 
395;  of  wrist,  410;  irrigation  of,  562;  loose 
bodies  in,  570,  614;  shape  of,  when  inflamed, 
550.  552,  558  ;  sprains  of,  495  ;  of  spine,  685  ; 
wounds  of,  492 

Jordan  Lloyd's  elastric  strap,  1 194 

Joubert's  suture,  943 

Jugular  vein,  ligature  of,  in  pyfemia,  669;  wound 
of,  815 

Junker's  inhaler,  817 

Jury-mast,  708 

K 

Kangaroo  tendon,  213 

Keegan  on  lithotrity,  105 1 

Keloid.     See  Cheloid. 

Kelotomy,  892 

Keratitis,  interstitial,  ill 

Kerato-iritis,  730 

Key-note  position  in  scoliosis,  716 

Key's  staff,  1053 

Kidney,  abnormalities  of,  988  ;  calculus  in,  998; 
differentiation  of  secretion  of,  loi  i  ;  examina- 
of,  996;  floating,  989  ;  inflammation  of,  1003  ; 
injuries  of,  990 ;  operations  on,  ioi2;  solid 
growths  of,  998  ;  tumors  096  ;  wounds  of,  992  ; 
cysts  of,  997 

Knee-joint,  amputation  through,  1 197;  arthrec- 
tomy of,  587  ;  aspiration,  431  ;  in  Charcot's 
disease,  579;  dislocation  of,  536;  dr.iinage  of, 
562;  excision  of,  626;  in  fiaciured  patella, 
434;  fracture  into,  428,  434;  internal  derange- 
ment of,  537  ;  irrigation  of,  562 ;  shape  of,  in 


INDEX. 


1227 


synovitis,  550,  552;  Thomas's  splint  for,  609  ; 

tubercle  of,  605 
Knock-knee,  341 
Knott,  538 

Kocher,  removal  of  tongue,  789  ;  on  fractured 
^patella,  433 

Koerbele,  resection  of  intestine,  942 
Krenig,  581 

Kraske,  on  excision  of  the  rectum,  986 
Krohne,  mociitied  Thomas's  splint,  70S 
Kussmaul,  919 
Kyphosis,  710 


Labial  cysts,  1 168 

Lacerated  wounds,  157 

Lachrymal  obstruction,  735 

Lactic  acid  in  lupus,  191 

Lamellar  cataract,  732 

Laminated  clot,  237,  240 

Landry,  122 

Langenbeck,  624;  nasal  polypi,  756;  operation 

for  nose,  751  ;  resection  of  maxilla,  758 
Laparo  colotomy,  939 

Laparotomy    in     intestinal    obstruction,    930; 
strangulation,  919  ;  intussusception,  922  ;  peri- 
tonitis, 934  ;  perityphlitis,  933 
Laryngeal  growths,  removal  of,  811 ;  diagnosis, 

836;  phthisis,  807 
Laryngitis,  804  ;  erysipelatous,  81  ;  from    scald, 

822;   in  syphilis,  100,  107 
Laryngotomy,  828  ;  preliminary,  788 
Laryngo-tracheotomy,  833 

Larynx,  diseases  of,  804  ;  disorders  of  sensation, 
811  ;  excision  of,  8315 ;  examination  of,  803  ; 
foreign  bodies  in,  818  ;  fracture  of,  817  ;  intu- 
bation of,  833;  lupus  in,  808;  muscular 
paralysis  of,  81 1  ;  operations  on,  828  ;  paraly- 
sis, 811  ;  perichondritis,  807  ;  phthisis  in,  807; 
spasm  of  muscles  of,  813;  syphilitic  disease 
of,  808;  tumors,  809;  wounds,  S15 
Latent  calculus,  looi,  1045  ;  fracture  of  spine, 

689 
Lateral    curvature   of    spine,    712;    lithotomy, 

1052  ;  sinus,  thrombosis  of,  669 
Lawn-tennis  leg,  307 
Leather  splint  for  fractured  patella,  433 
Leg,  amputation  of,  1 198  ;  chronic  ulcer  of,  195, 

228  ;   fracture  of,  434,  441 
Leiter's  coils,  36;  panelectroscope,  iioi 
Lembeit's  sutures,  943 
Length  of  mesentery  in  hernia,  877 
Lengthening  in  hip  disease,  594 
Lens,  dislocation  of,  728 
Leontiasis  ossea,  482 
Lepra  cells,  1 16 
Leprosy,    116;    of    the    face,  748;    laryngeal, 

809 
Leucocytes,  action  of  in  repair,  29 
Leucoma,  781 
Leucoplakia,  781 
Levers  for  hallux  valgus,  340 
Lichen,  in  syphilis,  98 
Ligaments,  division  of,  in  talipes,  330 ;  strain  of 

spinal,  685 
Ligature  of  abdominal  aorta,  273  ;  in  aneurysm, 
243,248;  of  arteries,  212  ;  after  compression, 
242;  for  inflammation,  380  ;  of  vein,  229; 
of  anterior  tibial,  279;  of  axillary,  269;  of 
brachial,    270 ;     carotid,    263;    of    common 


iliac,  273  ;    dorsalis   pedis,  280 ;    of  external 
iliac,  275;  facial,  266;  femoral,  276  ;  gluteal, 
275  ;  jugular  vein  in  pya-mia,  669;  of  lingual,' 
265  ;   internal   mammary,  269  ;   internal    iliac, 
274;    innominate,  262  ;    popliteal,  277  ;  pos- 
terior tibial,  278  ;   for  piles,  964  ;  radial,  27 1; 
subclavian,  266  ;  temporal,  266  ;  ulnar,  272  • 
varicose  veins,  229;  vertebral,  268 
Lime  in  rickets,  478 
Limping  in  hip-disease,  590 
Line  of  demarcation,  61 
Linear  osteotomy  in  osteitis,  452 
Lingual  artery,  ligature,  265  ;  nerve,  operations 

on, 784 
Lip,  malformations,  742  ;  epithelioma,  749 
Lipoma,    132 ;    congenital,   684  ;    myxomatous, 
133  ;  nasi,  748  ;    of  sacrum,  684  ;    of  tongue 
784  ^     ' 

Liquefaction  of  tubercular  deposit,  94 
Lisfranc's  amputation,  1201 
Lister's  dressings,  54,   165;    excision  of  wrist, 

623;  tourniquet,  209;  sounds,  11 11 
Liston's  splint,  422 

Lithotomy,   lateral,    1052;    accidents  in,  1057 ; 
cellulitis  after,  71;  prognosis  of,   1058;  me- 
dian,   1058;    suprapubic,     1060;    compared 
with  lithotrity,  1062 
Lithotrity,  1047;    accidents  in,  1050 ;    at  differ- 
ent ages,    1041  ;    difficulties  in,    1052;    com- 
pared with  lithotomy,  1062 
Little's  shoes  for  congenital  varus,  330 
Littre's  hernia,  887  ;  operation,  939 
Liver,  abscess  of,  949;    hydatids,  950;  opera- 
tions on,  950;  rupture,  870 
Lobular  induration  of  breast,  1175 
Localization,  cerebral,  678 
Locality  of  pain  in  hip-disease,  590  ;  of  leprosy, 

116 
Longitudinal  fractures,  346 
Longmore's  electric  explorer,  1211 
Lockjaw,  1 18 
Lonsdale's  clamp,  385 
Loose  cartilages  in  joints,  571,  614 
Lordosis,  592,  710 
Loreta's  case  of  abdominal  aneurysm,  247,  257  ; 

operation,  876 
Lower  jaw,  fracture  of,  382  ;  dislocation  of,  504 
Lucas,  538 
Lumbago,  686 

Lumbar  abscess,  704;    colotomy,  937;    hernia, 
910 ;    nephrectomy,  1014;  vertebrae,  fracture 
of,  695 
Lungs,    foreign    bodies  in,    819,   862;    hernia, 

861  ;  injuries  of,  856 
Lupus,  92,    189;    of  face,   747;    hypertrophic, 
748;     of    larynx,   808;     rectum,     971  ;    of 
tongue,  784 
Lupus,  erythematosus,  192 
Luschka's  gland,  683 
Luxatio  erecta,  509 
Lymph,  organization  of,  158 
Lymphadenitis,  282  ;  in  syphilis,  loO 
Lymphadenoma,  287 
Lymphangioma,  138,  289 
Lymphangiectasis,  289 
Lymphangitis,  281 

Lymphatic   glands,   diseases   of,    281  ;    in    ery- 
sipelas, 80;    inflammation  of,  in  neck,  824; 
tumors  of,  286 
Lymphoma,  287 


1228 


INDEX. 


Lymphorrhcea,  290 
Lymphosarcoma,  141,  288 


M 

MacCormac,  612 

MacEwen,  360,  646;  chisels,  342;  drainage- 
tubes,  162;  intubation  tubes,  833;  operation 
for  genu- valgum,  343;  radical  cure  of  hernia, 
902 

MacGill,  360,  10S2 

McDonald's  ambulance  lift,  1 208 

Mclntyre  splint,  424 

Marcrocheilia,  2S9 

Macroglossia,  137,  289,  778 

Macrostoma,  742 

Madelung,  939 

Maisonneuve's  urethrotome,  11 13 

Makins'  clamp,  943  ;  artificial  anus,  949 

Malar  bone,  fracture  of,  382 

Malformations  of  back,  680 ;  of  neck  and  throat, 
814;  of  pharynx  and  cesophagus,  845;  of 
bladder,  1024;  of  breast,  117I;  of  face, 
742;  of  head,  630;  of  nose,  751  ;  of  kidney, 
9S8 ;  of  limbs,  322 ;  of  rectum,  955  ;  of 
tongue,  778 

Malgaigne's  hooks,  432  ;  operation  for  hare-lip, 

743 

Malignant  disease  of  thyroid  gland,  S44 ;  stric- 
ture of  intestine,  923  ;  stricture  of  rectum,  983  ; 
pustule.  84 

Metacarpal,  fracture  of  410 

Malignancy,  143 

Malignant  disease  of  intestine,  923 ;  redema, 
84 ;  pustule,  84 

Malingering,  ulcers  in,  196 

Malnutrition  after  sprain,  496 ;  as  a  cause  of 
non-union,  357 

Malposition  of  testis,  1127 

Malum  coxse  senile,  570,  575 

Mal-union  of  fracture,  351 

Mammary  abscess,  11 73;  gland  [see  Breast); 
glandular  tumor,  1 178;  ligature  of  internal, 
269 

Mammilla.     See  Nipple 

Manipulation  in  aneurysm,  246 ;  in  dislocation 
of  the  spine,  695  ;  in  CoUes'  fracture,  407  ; 
in  lateral  curvature,  717  ;  in  reduction  of  dis- 
location, 501,  5J5 

Manual  examination  of  rectum,  929,  956 

Marriage  in  svphdis,  108,  1 15 

Marsh,  538,  5S5 

Martin's  bandage,  196 

Massage  in  lateral  curvature,  717;  in  inflamma- 
tion, 41  ;  in  intestinal  obstruction,  931  ;  in 
nerve-injury,  296,  301 ;  in  oedema,  234;  in 
sprains,  496;  in  leno-synovitis,  314;  in 
writer's  cramp,  310 

Mastitis,  1172;  chronic  interstitial,  1175 

Mastoid  cells,  suppuration  in,  665,  669,  802 

Maxilla,  fracture  of,  382;  dislocation  of,  504; 
necrosis  of,  452 

Maydl's  colotomy,  940 

Measurement  for  truss,  881 

Mechanical  stimulation  in  delayed  union,  358; 
support  in  caries,  706;  curvature,  718 

Meckel's  diverticulum,  128,  912;  ganglion,  ex- 
cision of,  304 

Median  lithotomy,  1059;  compared  with  lat- 
eral, 1059 


Mediastinal   abscess,    863 ;    in    Potts    disease, 

703 

Medulla,  drainage  of,  458;  in  fractures,  349; 
oblongata,  pressure  on  in  caries,  702 

Medullary  carcinoma,  148;  lesions  of  brain, 
645,  674  ;  sarcoma  of  bone,  4S7 

Meibomian  cyst,  736 

Melanotic  sarcoma,  140;  choroid,  734 

Melon-seed  bodies,  313,  320,  614 

Meningeal  artery,  rupture  of,  648 

Meninges,  diseases  of,  660 

Meningitis,  660;  of  cord,  718;  consecutive  to 
otitis,  666,  802  ;  disease  of  spine,  703;  sup- 
purative, 664;  acute  traumatic,  718 

Meningocele,  630,  631 

Meningomyelitis  and  railway  spine,  699,  719 

Meningomyelocele,  681 

Mental  emotion  as  a  cause  of  shock,  149 

Mercier's  prostatotomy,  loSi 

Mercurial  necrosis,  453;  stomatitis,  764,  766; 
and  cataract,  752 

Mercury  in  inflammation,  38,  40,  41  ;  in  iritis, 
731  ;  inunction  in  syphilis,  113,  115 

Mesentery,  length  of,  S77;  prolapse  of,  877 

Metacarpal  bones,  fracture  of,  410;  tubercular 
disease  of,  472  ;  dislocation  of  thumb,  525 

Metastasis  in  erysipelas,  80 

Metastatic  abscesses,  49  ;  in  pyaemia,  74,  75  ;  or- 
chitis, I F29 

Meteorism  in  obstruction,  926 

Methylene  bichloride,  187 

Mickulicz,  612;  on  peritonitis,  934 

Microbes  causing  gangrene,  62 ;  non-infective, 
42  ;  pathogenic,  45 

Micrococcus  cyaneus,  47 

Micro-organisms  of  suppuration,  45  ;  in  pyemia, 
74 

Micturition  in  fracture  of  spine,  693 

Middeldorpf 's  triangle    for  fractured  humerus, 

397 

Middle  ear,  disease  of,  801 ;  meningeal,  rupture 
of,  648,  652 

Military  surgery,  1 204 

Milk  cysts,  1177 

Mind-blindness  in  lesions  of  cortex,  645 

Minor  surgery,  184 

Mobility,  as  a  sign  of  fracture,  361 ;  in  hip  dis- 
ease, 594 

Mocmain  truss,  8S0 

Moist  gangrene,  59,  64 

Moles,  197 

Mollities  ossium,  483  ;  and  fracture,  348 

Molluscum  fibrosum,  131,  138;  on  face,  749 

Monoplegia,  643 

Monospasm,  643 

Morbus  coxii;,  5 88 

Morgagni,  hydatid  of,  128 

Morrant  Baker,  on  excision  of  tongue,  758 

Morris,  529;  i)itrochanteric  measurement,  415 

Mortification.     See  Gangrene. 

Morton's  fluid,  683  ;  club-foot  stretcher,  328 

Mother's  marks,  137 

Mouth,  inflammation  of,  762 ;  injuries  of,  762  ; 
lupus,  189;  malformations,  759;  tumors  of, 
770  ;  wounds  of  floor  of,  815 

Movable  kidney,  9S9  ;  splints,  373 

Movement,  as  a  cause  of  non-union,  357 

Mucocele,  735 

Mucous  lining  of  nose,  inflammation  of,  753 ; 
cysts,  126;  of  mouth,  770,  773  ;  tongue,  784; 


INDEX. 


1229 


tubercle,  198;  memljrane,  grafting  of,  162; 
patches,  loo ;  on  tongue,  783;  polypi,  755 

Mucus  in  urine,  1021 

Miiller's  ilucls,  128 

Multilocular  cysts  of  jaws,  774;  ovary,  I149 

Multifile  periostitis,  457  ;   fractures,  346 

Mumps,  795  ;  and  orchitis,  1129 

Musca;  volitantes  in  myopia,  724 

Muscles,  rupture  of  abdominal,  S70;  diseases  of, 
306 ;  ossification  of,  307 ;  rupture  of,  307, 
870 

Muscular  atrophy,  306,  309 ;  after  fractures,  369  ; 
in  arthritis,  551,593;  after  nerve-section,  292  ; 
sprains,  306;  contraction,  as  a  cause  of  frac- 
ture, 349,  429;  of  displacement,  361  ;  after 
nerve  injury,  298;  in  arthritis,  551  ;  contrac- 
ture, 311  ;  rigidity,  causing  talipes,  336; 
spasm,  after  head  injuries,  644;  in  swallowr- 
ing,  848;  in  tetanus,  120;  in  stumps,  1203; 
strain,  686 ;  in  spinal  injury,  685  ;  twitching 
in  fracture  of  spine,  694  ;  wasting,  as  a  cause 
of  curvature,  91 1 

Musculo-spiral,  paralysis  of,  293,  398 

Mycelium  in  actinomycos-is,  90 

Mydriasis,  traumatic,  727 

Myelitis,  719 

Myeloid  sarcoma,  139;  of  Ijone,  487 

Myofibroma,  137 

Myolipoma,  congenital,  6S4 

Myomata,  136 

Myopia,  723 

Myosarcoma,  141 

Myositis,  31 1 

Myxoedema,  838 

Myxoma,  133  ;  of  larynx,  810 

Myxomatous  carcinoma,  147  ;   lipoma,  133 

Myxosarcoma,  140 


N 

Nsevi,  137,   197,220;    of   auditory  canal,  802  ; 

of  eyelid,  737;  of  face,  748;  of  mouth,  770; 

neck,  826;  of  scalp,  656  ;  tongue,  784 
Nails,    affections    of,    199;     after    nerve-action, 

293  ;   ingrowing,  200 
Narcotics  in  neuritis,  301 
Nares,  tumors  of,  755 
Nasal  bones,  fracture  of,  381  ;  inflammation  of, 

754  ;  passages,  tumors  of,  755 
Nasopharyngeal  polypi,  756 
Nathan  Smith's  splint,  424,436 
Natiform  skull,  468 
Neck,  cellulitis  of,  71,  823  ;  cysts  of,  iio,  128; 

dislocation  of  tendons  of,  309  ;    inflammation 

of  glands   of,  823;    malformations   of,  814; 

ncevi,  826  ;  tumors,  826 ;  wry,  824  ;   wounds 

of,  814 
Neck  of   femur,  absorption  of,  421  ;    angle  of, 

414;   atrophy,  4(5;   fracture,  417  ;  diagnosis, 

421 
Necrogenic  lupus,  190 
Necrosis,    59 ;     acute,  453 ;    after   amputation, 

462 ;  coagulation,  45  ;   of  cranium,  659  ;    of 

cartilage,  546;   exanthematous,  464 ;  of  jaws, 

765;    mercurial,  453;    of   nasal  bones,  754; 

of  last  phalanx,  314;  phosphorus,  452;  quiet, 

447,  451  ;  of  scalp  wounds,  633  ;  of  stumps, 

1203 
Needle,  exploring,  41 ;  for  cataract,  740 


Nelaton's  line,  415 ;  operation  for  harelip,  743  ; 
enterostomy,  936 

Nephralgia,  icoo 

Nephrectomy,  1014 

Nephritis,  1003;  causing  suppression,  992 

Nephrolithotomy,  1012 

Nephrorrhaphy,  990 

Nephrotomy,  1012 

Nerve-bulb,  292 

Nerves,  anastomosis  of,  293;  compression  of,  208, 
294.  367  ;  contusions  of,  294  ;  evulsion,  304  ; 
grafting,  297  ;  inflammation  of,  299 ;  injuries 
of,  292,  650;  injury  of  in  fractures,  367  ;  ir- 
ritation as  a  cause  of  gangrene,  50;  of  te- 
tanus, 113;  in  leprosy,  117;  operations  on, 
302;  in  syphilis,  107;  regeneration  of,  292 ; 
wounds  of,  292 

Nerve-section  in  tetanus,  I2i  ;  as  a  cause  of 
ankylosis,  617 

Nerve-splitting  in  leprosy,  119 

Nerve  stretching,  302  ;  in  leprosy,  119  ;  tetanus, 
121 

Nerve-suture,  295 

Nervous  system,  diseases  of,  in  arthritis,  548, 
575  ;  as  a  cause  of  fracture,  347  ;  in  syphilis, 
107  ;   in  railway  accidents,  699 

Neuber's  drainage  tubes,  172 

Neuralgia,  301;  of  scars,  177;  stumps,  1203; 
testis,  1 128  ;  nerve  section  for,  721 

Neurectomy,  304 

Neurenteric  canal,  cysts  from,  129 

Neuritis,  299  ;  as  a  cause  of  tetanus,  119 

Neurofibroma,  plexiform,  130 

Neuroma,  138,  305 

Nine-day  spasms,  119 

Nipple,  affections  of,  1171  ;  Paget's  disease  of, 
1 172;  retraction  of,  11 83 

Nitric  acid  in  piles,  963 ;  in  prolapse,  96S 

Nitrous  oxide  gas,  186 

Nocturnal  incontinence,  103 1 

Nodes,  446,  465  ;  Parrot's,  no,  468;  periosteal, 
464  _ 

Nodosity  of  joints,  569 

Nodular  scirrhus,  1180 

Noma,  746 

Non  union    of    fracture,    355  ;    of    lower    jaw, 

385    . 

Nose,  diseases  of,  751  ;  hemorrhage  from,  752  ; 
foreign  bodies  in,  745 ;  malformations  of, 
751  ;  plastic  sugery  of,  751;  syphilitic  affec- 
tions of,  106,  109 

Nostrils,  plugging,  752 

Nothnagle's  test,  943 

Nuclear  cataract,  732 

Nuhn's  gland,  126,  770 

Nussbaum,  311,  359 

Nutrition,  influence  of,  in  repair,  18;  lesions  in 
spinal  injury,  691,  719 


Obesity  and  ovarian  cysts,  1 152 

Oblique  fractures,  346;   illumination  of  eye,  722 

Obsolescence  of  tubercle,  94 

Obstructed  hernia,  883;  in  oblique  inguinal  her- 
nia, 896  ;   lymphatics,  290 

Obstruction,  intestinal,  91 1,  922;  diagnosis  of, 
928;  symptoms,    925,  treatment,  930;  after 


1230 


INDEX. 


ovariotomy,   1 158;    of  lachrymal   duct,   735; 
of  ureter,  993;  of  veins,  231 

Obturator  artery  in  hernia,  907,  909;  internus 
in  dislocation  of  hip,  529 

Occlusion  of  vessels,  effects  of,  206 

Odontomata,  772 

O'Uwyer's  tul)es,  834 

CEdema,  acute,  of  neck,  S24 ;  in  fractures,  367  ; 
malignant,  84;  solid,  39,  290;  of  scrotum, 
I125 

(Edematous  pile^,  959 

Qisophagostomy,  J>5i 

Qisophagotomy,  S47 

Qisophagus,  epithelioma  of,  848 ;  foreign  bodies 
in,  S46 ;  inflamm:ition  of,  847  ;  injuries  of,  845  ; 
malformations  of,  S45 ;  paralysis  of,  S47  ; 
stricture  of,  ^49;   tumors  of,  848 

Ogston,  36,  324,  33S,  343 

Old  dislocations,  535 

Olecranon,  fracture  of,  408 

Olfactory  bulbs,  injury  to,  650 

Omentum  grafting,  944  ;  injuries  of,  873  ;  strang- 
ulation of,  SS5  ;  treatment  of,  894 

Onychia,  199 

Oophorectomy,  1 146;  and  osteomalacia,  483 

Open  fractures,  treatment,  375  (icv  Compound); 
wounds,  157,  174;  dislocations,  497 ;  method 
for  treatment  of  inguinal  hernia,  901 

Opening  of  ab^cesse^,  53 

Operations  on  arteries,  261  ;  on  nerves,  302; 
for  genu-valgum,  343  ;  on  the  eye,  738  ;  sub- 
cutaneous, 174;  in  shock,  15 1 

Ophthalmia,  catarrhal,  728  ;  sympathetic,  727 

Ophthalmoplegia,  107,111 

Ophthalmoscope,  722 

Ophthalmoscopy,  examination,  272 

Opium  in  aneurysm,  243  ;  coma  and  concussion, 
647  ;  in  delirium  tremens,  153;  in  obstruction, 
930;  strangulation,  918;  intussusception,  921  ; 
peritonitis,  934;  phagedena,  196;  in  senile 
gangrene,  68 

Opisthotonos,  1 1 7 

Optic  nerve,  injury  to,  650 

Orbit,  cellulitis  of,  71 ;  diseases  of,  735 

Orbital  aneurysm,  253;  tumor,  pulsating,  737 

Orchitis,  gouty,  1134;  metastatic,  1129;  in 
mumps,  795;  syphilitic,  1131;  suppurative, 
1 134;  tubercular,  1133 

Ord,  on  arthritis,  565 

Organization  of  extravasated  blood,  29,  155  ;  of 
granulations,  160 ;  lymph,  158;  thrombi,  230 

Organisms,  classification  of  pathogenic,  45  ;  in- 
fective diseases  due  to,  44;  non-infective  dis- 
eases due  10,  42 

Origin  of  calculi,  104I 

Os  magnum,  dislocation  of,  524 

Osseous  ankylosis,  627  ;  of  hip,  603 ;  nodes,  465 

Ossification  of  callus,  351 

Ossifying  myositis,  312 

Osteitis,  445,  765;  of  cranium,  65S;  chronic,  451  ; 
as  a  cause  of  cerebral  abscess,  667 ;  of  frac- 
ture, 34S  ;  of  delayed  union,  357  ;  deformans, 
40,  4S0  ;  of  femur  and  hip  disease,  595  ;  of 
jaws,  765  ;  in  knee-joint  diseases  606 ;  in 
inflammation  of  joints,  546;  of  nose,  727; 
rheumatic,  471  ;  in  syphilis,  106,  111,465; 
tubercular,  472,  558;  of  vertebrae,  701 
Osteo-aneurysm,  31S 

Osteo-arihritis,  509;  and  loose  cartilages,  614  ; 
after  dislocations,  503 


Osteoclasis,  344 

Osteocopic  pains,  loi,  464 

Osteoid  tissue  in  rickets,  465 

Osteoma,  135.  4S4 ;  of  skull,  659 

Osteomalacia;  483;  skull  in,  482  ;  asacau-eof 
fracture.  348 

Osteomyelitis,  451 ;  acute,  453,  462;  after  am- 
putation, 463  ;  septic,  462;  syphilitic,  465 

Osteophytes,  571 

Osteoplastic  resection  of  ankle,  611  ;  in  intra- 
cranial tumors,  676 

Osteo-sarcoma,  140 

Osteo-sclerosis,  446,  466;  rheumatic,  471 

Osteotomy,  342;  in  osteitis,  452,  458 

Othematoma,  800 

Otis's  urethrameter,  1 1 1 5  ;  urethrotome,  1 1 1 3 ; 
as  a  cause  of  meningitis,  665 ;  suppurative, 
671  ;  of  the  spine,  701 

Ovaries,  cysts  of,  130;  inflammation  of,  1 145; 
pedicle,  twi-.ting  of,  1155  ;  tumors  of,  1 148 

Ovariotomy,  1 155 

Over-extension,  as  a  cause  of  ankylosis,  617 

Overflow  of  urine,  961,  1031  ;  in  enlarged  pros- 
tate, 1075  ;  in  spinal  injury,  693 

Overgrowth,  290,  322 

Oxalate  of  lime,  1017 

Ox  aorta,  ligature  of,  213 

Ozjena,  755 


Pads  in  fractures,  373 

Page,  railway  accidents,  699 

Pain  in  fractures,  362  ;  in  hernia,  887,  916;  in 
hip-disease,  590  ;   in  obstruction,  926 

Painful  subcutaneous  tubercle,  131 

Palate,  clefr,  759  ;  deviations  of,  after  injury  to 
brain,  650  ;  wounds  of,  762 

Palatine  arteries,  hemorrhage  from,  211 

Palliative  treatment  of  epithelioma  of  tongue, 
786 

Palmar  arch,  wound  of,  210  ;  fascia,  contraction 
of,  316;  section  of,  318;  ganglion,  315; 
tendon-sheaths,  315 

Palpation  in  obstruction,  929 

Pancreas,  cysts  of,  954 

Panelectroscope,  iipi 

Papillary  cysts,  127,  I150;  synovitis,  460,  570 

Papilloma,  143  ;  of  bladder,  1064;  gums,  770; 
larynx,  810  ;   tongue,  784 

Paracentesis  thoracis,  864  ;  pericardii,  868 

Parjesthesia  of  larynx.  Si  I 

Paraffin  as  a  splint,  374 

Paralysis,  ascending,  of  Landry,  122;  cortical, 
644 ;  as  a  cause  of  fracture,  347  ;  infantile, 
7>Zl)->  2>Z^ '^  of  larynx,  811  ;  afier  nerve  sec- 
tion, 292  ;  of  oesophagus,  847,  S49  ;  reflex, 
298;  of  shoulder,  501,  512;  spastic,  662; 
spinal,  705 

Paraphimosis,  1 1 25 

Paraplegia  in  spinal  disease,  705,  766 ;  in  in- 
jury, 690 

Parasitic  foetus,  1 29,  684 

Parenchymatous  goitre,  839  ;  prostatitis,  1085 

Parker,  325  ;  on  tracheotomy,  828 ;  suction 
cannula,  830 

Paroophoron,  128,  1 151 

Parotid,  division  of  duct,  745  ;  inflammation  of, 
794  ;   tumor  of,  134,  I42,  795  ;  bubo,  45 


INDEX. 


1231 


Parovarian  cysts,  128 

Parruis  noJes,  1 10,  468,  658  ;  pseudo  paralysis, 
469 

Parulis,  766 

Pas-ive  clot,  237  ;  motion  in  arthritis,  555  ;  after 
di-.locations,  502  ;  excision,  620,  625  ;  sprains, 
496  ;  synovitis,  555 

Pasteur,  124 

Patella,  dislocation  of,  535  ;   fracture  of,  429 

Pathogenic  organisms,  classification  of,  36 

Pedicle  of  ovarian  tumor,  1 155;  in  hysterec- 
tomy, 1 165 

Pedunculated  hemorrhoids,  961 

Pegging  arch  of  foot,  338  ;  in  delayed  union,  358 

Pelvic  cellulitis,  71,  974 

Pelvis,  fracture  of,  411  ;  in  rickets,  476 

Pemphigus,  109 

Penetrating  wounds  of  abdomen,  872 

Penis,  amputation  of,  11 25;  epithelioma  of, 
I125;  gangrene.    I118;  malformations,  1 1 24 

Perchloride  of  iron,  in  goitre,  842  ;  in  erysipals, 
81 

Percussion  in  intestinal  obstruction,  929 

Perforating  ulcer,  294,  571 

Perforation  of  appendix,  932 

Periadenitis,  283 

Periarteritis,  223  ;   as  a  cause  of  aneurysm,  235 

Pericardium,  paracentesis  of,  868;  wounds,  857 

Perichondritis  of  larynx,  807 

Pericranium,  nodes  on,  465  ;  separation,  633 

Perineal  abscess,  1120;  cystotomy,  1069;  dislo- 
cation,534;  fistula,  I122;  hernia,  910;  pros- 
tatectomy, 1082 

Perinephritis,  loio 

Perineum,  rupture  of,  I169 

Periosteal  abscesses  of  jaw,  767  ;  changes  in 
rickets,  474;  cysts,  768,  773;  nodes,  464 ; 
sarcoma,  487 

Periosteum,  division  of,  in  inflammation,  458  ; 
function  of,  349  ;  grafting,  360  ;  preservation 
after  excision,  619 

Periostitis,  445  ;  acute,  453  ;  of  femur  and  hip 
disease,  59b  ;  of  last  phalanx,  314  ;  syphilitic, 
101,115;  multiple,  457  ^ 

Periphlebitis,  233 

Periproctitis,  973 

Peritonitis,  933  ;  after  taxis,  891 ;  herniotomy, 
893;  after  ovariotomy,  1158  ;  and  strangula- 
tion, 917 

Perityphlitis,  931;  and  hip  disease,  598  ;  dis- 
tinguished trom  strangulation,  917 

Peronsei  tendons,  displacement  of,  299 

Petifs  tourniquet,  208 

Phagedsena,  (39,  115;  and  chancroid,  97 

Phalanges,  enchondroma  on,  134;  strumous 
nodes,  473 

Phalanx,  necrosis  of  last,  314 

Pharyngitis,  erysipelatous,  81 

Pharyngocele,  827,  845 

Pharyngotomy,  subhyoid,  833 

Pharynx,  foreign  bodies  in,  846 

Phimosis,  1 1 24 

Phlebitis,  230,  233;  syphilitic,  loi 

Phlegmasia,  alba  dolens,  290 

Phlegmonous  inflammation,  70 

Phosphates  in  urine,  1017 

Phosphorous  necrosis,  452,  766 

Phthisis  and  fistula,  980 

Pick's  bandage,  390 

Pigeon-breast,  476 


Pigmentation  in  syphilis,  loi 

Piles.     See  Hemorrhoids 

Pinning  in  fracture  of  patella,  432 

Pirogoft's  amputation,  1200 

Pirrie,  1200 

Piriform  bone,  dislocation  of,  525 

Pityriasis  versicolor.     See  Tinea 

Placenta,  in  ectopic  gestation,  1147 

Plantar  fascia,  section  of,  328 

PlaiUaris,  rupture  of,  308 

Plaster  splints,  373,  437  ;  in  caries  of  spine, 
683  ;  in  fracture,  696  ;   in  talipes,  327 

Pleura,  rupture  of,  856;  inflammation,  863 

Pleurosthotonos,  118 

Plexiform  neurofibroma,  131 

Plugging  nostrils,  752 

Pneumocele,  862 

Pneumonia,  857,  863;  in  burns,  iSo;  after  ope- 
rations on  tongue,  790;  wounds  of  neck,  817  : 

Pneumonotomy,  868 

Pneumothorax,  860 

Poisoned  wounds,  cellulitis  after,  70 

Poisons,  chemical,  as  cause  of  inflammation,  70 

Polar  cataract,  731 

Polk's  method  of  collecting  urine,  ion 

Polymastia,  1171 

Polymorphism  in  syphilis,  lOI 

Polypi,  113;  of  antrum,  767;  bladder,  1063; 
ear,  802  ;  mucous,  755;  nasopharyngeal,  756  ; 
rectum,  969 

Poore,  Vivian,  310 

Popliteal  aneurysm,  259  ;  rupture,  240 ;  cysts, 
321,575;  artery,  ligature  of,  216;  in  frac- 
tures, 36b,  428 

Poroplastic  jacket,  706;   splints,  373,  437 

Position  in  arthritis,  551 ;  fractures,  371  ;  in  in- 
flammation, 36;  in  wounds,  168 

Posterior  staphyloma,  724  ;  tibial  artery,  ligature 
of,  278;  in  fractures,  366,  440;  wound  of, 
210 ;  tibial  tendon,  division  of,  328 

Pott's  disease,  700 ;  fracture,  439,  540 ;  as  a 
cause  of  flat-foot,  336  ;  on  fractures  of  the 
femur,  425 ;  puffy  tumor,  635,  665,  660 ; 
splint,  436 

Prjemaxilla,  treatment  of,  in  hare-lip,  744 

Pregnancy  in  fibroids,  I161 ;  and  ovarian  cysts, 
1 152;  and  osteomalacia,  4S3 

Presbyopia,  725 

Pressure,  36;  in  arthritis,  551,  556;  in  aneu- 
rysm, 238,  250;  hemorrhage,  209;  in 
wounds,  167 

Priapism  in  fracture  of  spine,  693 

Primary  amputations,  376,1188;  hemorrhage, 
201  ;  operations  in  shock,  151 

Probangs,  846 

Proctitis,  970 

Proctotomy,  982 

Progressive  multiple  neuritis,  300  ;   myositis,  31 1 

Prolapse  of  anus,  966  ;  kidney,  992  ;  iris,  727  ; 
mesentery,  877;  piles,  961  ;  rectum,  966; 
excision  of,  968 

Proliferous  cysts,  127,  130 1 

Proptosis,  738 

Prostate,  calculi  in,  1087;  enlargement  of,  H04; 
and  atony,  1075;  and  cathcterism,  1077; 
inflammation  of,  1083  ;  gouty,  1085;  suppura- 
tion in,  1087  ;  tumors  of,  1083 

Prostatectomy,  1082 

Prostatitis,  retention  in,  1034 

Prostatotomy,  108 1 


INDEX. 


Provisional  callus,  351 

Pruritus  ani,  970 

Psainmoma,  142 

Pseudo-arthrosis,  355 

Pseudo-paralysis,     Iio;     of     infants,    469;    in 

rickets,  47S,  479  ;  in  strains,  686 
Pseudo-strangulation,  917 
Psoas  abscess  in   Pott's  disease,  705,  709  ;  in- 

rtammation  of,  and  hip-disease,  596 
Psoriasis  in  syphilis,  lOO,  109,  1 15 
Psorosperms,  11 73 
Ptomaines,  42 
Pubic  dislocation,  534 
Pudendal  hernia,  910 
PudJc  aneurysm,  258;  artery,  hemorrhage  from, 

211 
Puerperal  arthritis,  564 

Pulleys  for  reduction  of  dislocation,  5or,  535 
Pulmonary  congestion  after  fracture,  364 
Pulsating  bronchocele,  839  ;  orbital  tumor,  737  ; 

sarcoma  and  aneurysm,  240,  257,  490;  tumor 

of  bone,  490 
Pulsation,  expansile,  237  ;  recurrent,  244,  260 ; 

of  vessels  in  glauconia,  735 
Pulse  in  aneurysm,  23S,  250 
Puncture  of  bladder,   1034;  of  kidneys,  1012; 

of  testis,  10S7  ;  in  delayed  union,  358 
Punctured  fracture  of  skull,  636;  wounds,  157, 

174;  hemorrhage  from,   210,  214;  of  neck, 

Pupil  in  injuries  of  the  sympathetic,  691 

Purgatives  in  peritonitis,  83 1 

Purpura  and  rickets,  479 

Purulent  exudation,  39;  synovitis,  459 

Pus,  46;  in  urine,  1020 

Pustule,  malignant,  84 

Pyaemia,  74 ;  and  cerebral  abscess,  668 

Pyaemic  arteritis,  223;  phlebitis,  234;  arthritis, 

563  ;  suppuration  in  tendon  sheaths,  314 
Pyelitis,    1006;    calculous,    1002;    suppurative, 

1006;  tuberculous,  1007 
Pylorectomy,  876,  946 
Pyogenic  membrane,  46,  448;    organisms,   45, 

74  ;  in  tubercle,  93 
Pyonephrosis,  1007 
Pyosalpinx,  1 145 
Pyramidal  cataract,  731 
Pyrogenous  agents,  33,  154 


Quiet  necrosis,  447,  451 
Quill  suture,  169 
Quilt  suture,   170 
Quinsy,  792 


Rabies,  121 

Radial  artery,  ligature  of,  271 

Radical  cure  of  hernia,  899,  906  ;  of  varicose 
veins,  230 

Radius,  dislocation  of,  522  ;  fracture,  403  ;  sub- 
luxation, 524;  and  ulna,  dislocation  of,  520 

Railway  accidents,  amputations  in,  476;  spine, 
687,  699,  719  » 

Rand,  distinction  of  coils  of  intestine,  919 


Ranula,  126,  770 

Rapid  coagulation  in  aneurysm,  245 

Rarefying  osteitis,  446;  of  cranium,  658 

Rat  tail  pads,  880 

Raynaud's  disease,  63 

Reaction  in  concussion,  641 

Readjustment  in  delayed  union,  358 

Rectal  gonorrhoea  in  women,  1097 ;  lever, 
Davy's,  209 

Rectovaginal  fistula,  1 168 

Rectum,  atony  of,  after  piles,  966  ;  epithelioma 
of,  983;  examination  of,  929,956;  excision, 
985 ;  fistula,  976 ;  inflammation  of,  970 ; 
lupus,  971,  malformations,  955  ;  plugging  for 
hemorrhage,  965  ;  polypus,  969  ;  prolapse  of, 
966  ;  resection  of,  980  ;  stricture  of,  965,  979  ; 
ulcer  of,  971,  975  ;   villous  tumor  of,  986 

Recurrent  dislocations,  511  ;  fibroid,  142;  hem- 
orrhage, 202,  215  ;  pulsation,  243,  260 

Reclressment,  343 

Red  softening  of  brain,  660  ;  of  cord,  689,  719 

Reduction  of  dislocations,  501 

Reef-knot,  262 

Referred  pain  in  hip-disease,  590 

Reflex  paralysis,  298  ;  spasm  after  nerve  injury, 
298 

Reflexes  in  spinal  injury,  690 

Regeneration  of  nerves,  291 

Keid's  bandage  for  aneurysm,  245,  260 

Relapsing  typhlitis,  932 

Reminders  in  syphilis,  102 

Remittent  fever,  34 

Renal  calculus,  998;  colic,  998;  cysts,  997; 
fistula,  loii  ;  haematuria,  1020 

Repair,  action  of  leucocytes  on,  28;  of  arteries, 
203;  complications  of,  162;  of  dislocations, 
47S  ;  effect  of  nutrition  on,  28 ;  of  fractures, 
349;  epidermis,  159;  of  nerves,  293;  tissue 
changes  in,  28  ;   of  wounds,  158 

Resection,  osteoplastic,  of  ankle,  611  ;  in  de- 
layed union,  359  ;  in  fractured  patella,  434  ; 
of  intestine,  943;  rectum,  986;  ribs,  867; 
subperiosteal,  458;  superior  maxilla,  758 

Residyal  abscesses,  50,  369,  5S7  ;  urine,  1073 

Resilient  stricture,  1103 

Resolution  of  thrombi,  230 

Respiration  in  fracture  of  spine,  692  ;  in  scolio- 
sis, 715 

Rest  as  a  cause  of  ankylosis,  616;  compared 
with  arthrectomy,  587  ;  in  arthritis,  556 ;  in 
caries,  706;  after  dislocation,  503  ;  in  inflam- 
mation, 36  ;  in  synovitis,  556 

Restraint  in  delirium  tremens,  153 

Retained  testis,  1127 

Retention  cysts,  126 

Retention  of  urine,  1032 ;  in  fractures,  364  ;  after 
piles,  965;  in  stricture,  1109 

Reticular  lymphangeiectasis,  290 

Reticulated  urethra,  1104 

Retina,  in  myopia,  724  ;  rupture  of,  728 ;  gli- 
oma of,  141 

Retinochoroidilis,  728 

Retromaxillary  polypi,  757 

Retropharyngeal  abscess.  704 

Rha'L)dosarcoma,  141 

Rhagades,  100,  104 

Rheumatic  arthritis,  569;  gout,  570;  inflamma- 
tion, 39;  iritis,  730;  nodes,  470;  osteitis,  471  ; 
phlebitis,  233 

Rheumatism,  gonorrhceal,  565 


INDEX. 


1233 


Rheumatoid  arthritis  after  dislocations,  502 ; 
compared  with  fracture  of  femur,  420 

Rhinoscleroma,  748 

Ribs,  beading  of,  476;  fracture  of,  853  ;  resec- 
tion, 868 

Rickets,  474  ;  acute,  479 ;  as  a  cause  of  flatfoot, 
336;  knock-knee,  341 ;  fracture,  347;  and 
scurvy,  479 ;  of  skull,  475,  482,  657 ;  of 
spine,  711  ;  visceral  changes,  477 

Rider'sbone,  136,  306 

Right-angled  contraction,  336 

Rigidity  of  jaws,  768 ;  of  muscles,  336 

Rigor,  48,  163;  in  pyivmia,  76 

Risus  sardonicus,  120 

Rizzoli's  operation  on  jaws,  769 

Robson,  Mayo,  297 

Rodent  ulcer,  146 ;  on  eyelid,  736 ;  on  face, 
74S 

Rosenmuller,  organ  of,  127 

Roseola,  recurrent,  100  ;  syphilitic,  99 

Rotation  in  reduction  of  dislocated  humerus, 
515  ;  in  scoliosis,  713 

Roth  on  curvature  of  spine,  716 

Rouge's  operation,  754 

Roux's  amputation,  1199 

Reduction  en  j/iasse,  890 

Ruffer,  124 

Rules  for  ligature  of  arteries,  261 

Rupia,  100,  115 

Rupture  or  aneurysm,  240,  259 ;  arteries  in 
fractures,  365  ;  bladder,  1026 ;  ectopic  gesta- 
tion, 1 146;  globe,  728;  hernial  sac,  890  ; 
muscles,  308;  of  abdomen,  870;  perineum, 
1 1 69;  stricture,  ilil;  urethra,  1088;  in 
lithotomy,  1058 


Sac,  anatomy  of  hernial,  878  ;  in  radical  cure, 
900  ;  rupture  of,  890 

Sacculated  aneurysm,  235 

Sacculus  of  bladder,  1037,  1045,  1104 

Sacrococcygeal  cysts,  1 29  ;   tumors,  684 

Sacroiliac  disease,  603  ;    and  hip  disease,  596 

Sacrum,  fracture  of,  412 

Sailors,  fractures  in,  357 

Sal  aleni broth,  164 

Salicylic  creosote  plaster  in  lupus,  191  ;  warts, 
198 

Salivary  calculi,  795  ;  division  of  duct  of,  745  ; 
fistula,  745  ;  inflammation  of  gland,  794 ; 
tumors  of,  795 

Salivation  in  syphilis,  112 

Salmon  and  Ody's  truss,  881 

Saphena  vein,  varix  of,  227 

Sapraemia,  43,  163 

Sarcoma  and  aneurysm,  240,  258 ;  of  bone, 
487;  of  breast,  1 1 79;  cysts  in,  126;  of  dura- 
mater,  660,  673  ;  degeneration  of,  141  ;  as  a 
cause  of  fracture,  349 ;  generalization  of, 
142;  jaws,  772  ;  kidney,  998;  ovary,  1 148; 
mahgnancy  of,  141  ;  skull,  659,  673  ;  testes, 
1 192;  varieties  of,  138 

Sayre's  bandage  in  fracture  of  clavicle,  389 ; 
jacket  in  caries  of  spine,  706  ;   fracture,  696 

Scabbing  of  wounds,  159 

Scalds,  179;  of  the  eye,  726;  of  glottis,  821 

Scalp,  cellulitis  of,  71,  655;  diseases  of,  654; 
cysts  of,  128,  656;  tumors  of,  656;  wounds 
of,  632 

79 


Scapula,   dislocation    of,    508;    fracture,    391  ; 

sarcoma,  490 
Scarification  of  larynx,  822 
Scarlatinal  arthritis,  564  ;  inflammation  of  neck, 
^  823 

Scarpa's  shoe,  331 
Scars,  175 

Scliede's  dressing,  171 
Schizomycetes,  25 
Schrapiiell  s  membrane,  799 
Sciatic  aneurysm,  258  ;   dislocation  of  hip,  530 ; 

compared    with    fracture,  419;    hernia,  910 ; 

nerve,  stretching  of,  302 
Scirrhus,  148,  1180;  of  intestine,  923 
Scissor-legged  progression,  592 
Sclerosis,  447,  465 
Scoliosis,  710 
Scott's  dressing,  553 
Scraping     lupus,      190;      lymph-glands,     287 

tongue,  780,  785 
Scrofula,  91 

Scrofulous  arthritis,  580 
Scrotum,    diseases    of,  1125  ;    examination    of, 

1 126 
Scurvy,  as  a  cause  of  fracture,  348;  and  rickets, 

479 

Sebaceous  cysts,  126;  of  scalp,  656  ;  of  face,  772 

Secondary  amputation,  380,  11 88;  hemorrhage, 
201,  243;  in  fractures,  368,  381  ;  after  piles, 
965  ;  in  cleft  palate,  761  ;  treatment  of,  216; 
nodes,  464 

Section  of  spinal  cord,  partial,  698;  perineal, 
I117 

Semilunar  cartilages,  dislocation  of,  537 

Semimembranosus  bursa,  321 ;  cysts,  575 

Senile  cataract,  732 ;  gangrene,  68 ;  struma, 
III;  tuberculosis,  585 

Senn,  amputation  of  thigh,  1195;  on  enteror- 
rhaphy,  944;  intestinal  anastomosis,  946; 
omental  grafting,  944;  injection  of  hydrogen 
gas,  871 

Sensation  in  injury  to  spine,  691 

Separation  as  a  cause  of  non-union,  357 ;  of 
epiphyses,  363 ;  of  femur,  426,  428 ;  of 
humerus,  393,  521  ;  in  osteitis,  457  ;  of  radius, 
405  ;  osseous  union  after,  425  ;  of  tibia,  440 

Septic  fever,  42,  163  ;  infection,  82 ;  inflamma- 
tion in  wounds,  162;  intoxication,  43 

Septicemia,  82 

Sequestra  after  amputation,  462 

Sequestrotomy,  461 

Serocystic  disease,  127,  11 78 

Serous  cysts  of  breast,  1176;  exudation,  39; 
iritis,  730 

Serpiginous  eruptions,  105;  ulcers,  194 

Sessile  hemorrhoids,  961 

Shattock,  325 

Sheath  of  arteries,  method  of  opening,  262 

Shock,  149  ;  death  from,  669  ;  diagnosis  from 
hemorrhage,  151;  in  fractures,  365;  as  a 
cause  of  suppression,  992  ;  operations  during, 
151  ;  from  passage  of  catheter,  1093  ;  in  rail- 
way accidents,  669 

Shortening  in  hip-disease,  594 

Shoulder,  amputation  at,  11 90;  dislocation  of, 
508;  unreduced,  498,  527;  disease  of,  612; 
excision  of,  620;  fracture  into,  396;  fre- 
quency of  dislocation  of,  497  ;  growing  out  of, 
713  ;  osteo-arthritis  of,  573 ;  paralysis  of  mus- 
cles of,  501 ;    shape  of,  in  synovitis,  55° 


1234 


INDEX, 


Signoroni's  tourniquet,  209 

Silicate  of  soda  s[)lints,  374 

Silk  ligatures,  213 

Simple  caries,  448 

Sinus,  56;  tliroinbosis  of  lateral,  669 

Size  of  urethra,  1106 

Skin,  diseases  of,  1S9;  grafting,  160 ;  trans- 
plantation, 176 

Skull :  craniotabes,  657  ;  exfoliation  from,  459  ; 
fracture  of,  643;  inflammation  after,  662  ; 
hypertrophy  of,  657  ;  nodes  on,  464  ;  osteoma 
of,  658,  662  ;  in  osteomalacia,  483  ;  osteitis  of, 
658  ;  in  osteitis  deformans,  480 ;  in  rickets, 
474,  4S2,  657  ;  sarcoma  of,  659  ;  syphilitic 
inflammation,  107,  465,  658  ;  tubercular  dis- 
eases, 658;  tumors  of,  659 

Sloughing  in  fracture,  368  ;  in  intussusception, 
914,  922  ;  in  spinal  injury,  690 

Smith's  gag,  760 ;  tubular  needles,  761 ;  Nathan 
Smith's  splint,  424,  436 

Smoker's  patch,  105,  780 

Snuffles,  109,  753 

Soft  chancre,  98 

Softening  of  brain,  660 ;  of  spinal  cord,  688, 
718;  of  thrombi,  231 

Solid  oedema,  39,  290 

Solution  of  calculi,  1003 

Sonnenburg,  cystectomy,  1070 

Sounding  for  calculi,  1045 

Sounds,  Bellocq's,  752;  bulbous,  1 108;  for 
diagnosis,  1107 

Spasm  in  arthritis,  551,  556;  cortical,  after 
head-injury,  644;  of  larynx,  812;  in  swal- 
lowing, 847 ;  in  tetanus,  118 

Spasmodic  closure  of  jaws,  768;  contraction 
after  nerve-injury,  299;  croup  and  rickets, 
478;  stricture,  1102,  1107 

Spastic  paralysis,  662  ;  rigidity,  336 

Speculum  :   anal,  957  ;  aural,  799 

Spence's  amputation,  1189 

Spermatic  cord,  diagnosis  of  tumors  of,  1127 

Spermatocele,  127 

Spheroidal-celled  carcinoma,  147 

Spina  bifida,  680;  false,  680 ;  ventosa,  472 

Spinal  canal,  narrowing  of,  in  caries,  702  ;  cord, 
compression  of,  in  caries,  703  ;  curvature,  712  ; 
inflammation  of,  718  ;  injuries  of,  697  ;  tumors 
of,  720 

Spine,  caries  of,  700 ;  dislocation  of,  687;  frac- 
ture, 687  ;  railway,  686,  699  ;  in  rickets,  476  ; 
sprains  of,  6S5 

Splicing  nerves,  297 ;  tendons,  308 

Splint,  Bavarian,  438 ;  Bryant's,  426,  598 ; 
Carr's,  407  ;  Croft's,  438  ;  Desault's,  422  ; 
Dupuytren's,  440 ;  Ellis's,  390;  Erichsen's, 
393:  extemporized,  370;  in  fractures  of  the 
leg,  435;  Gamgee's,  373,  438;  Gordon's, 
407;  Hammond's,  3S4;  Ilodgen's,  424,  436; 
interdental,  383 ;  leather  for  fracture  of  pa- 
tella, 433  ;  Lister's,  for  wrist,  624  ;  Liston's, 
422  ;  Maclntyre's,  425  ;  Middeldorpf's,  397  ; 
movable,  373,  436;  Nathan  Smith's,  424, 
436  ;  plaster,  373, 438 ;  poroplastic,  373,  437  ; 
Pott's,  439;  in  rickets,  478;  for  semilunar 
cartilages,  539  ;  in  spinal  caries,  706  ;  in  sjMnal 
fracture,  695  ;  stocking,  436;  in  talijies,  327, 
330  ;  Thomas's  hip,  599  ;  knee,  423,  609  ;  for 
jaw,  384 

Splinters  in  fractures,  37S 

Spontaneous  aneurysm,  235  ;  cure  of  aneurysm, 


238  ;  fracture  in  sarcoma,  490  ;  regeneration 
of  nerves,  292 

Sprains,  495  ;  of  back,  685  ;  of  flexor  tendons, 
408 

Spur  formation  in  artificial  anus,  947  ;  in  col- 
otomy,  948 

Staff  in  lithotomy,  1054,  105S  ;  Syme's,  III5; 
Wheelhouse's,  II 17 

Stages  of  hip  disease,  598 

Staphylococci,  25,  45,  74,  163,  454 

Staphyloma,  jiosterior,  724 

Starch  in  rickets,  477  ;  for  splints,  373 

Starting  pains,  556 

Stasis,  27 

Stephen  Smith's  amputation,  1197 

Stercoral  ulcers,  923 

Sterility  and  varicocele,  1138 

Stemo-mastoid,  division  of,  825  ;  induration 
825 

Sternum,  injuries  of,  855 

Sthenic  fever,  33 

Stiffness  after  dislocations,  503 

Stimson,  524 

Stimulants  in  delirium  tremens,  153;  in  gan- 
grene, 66  ;  gout,  568  ;  hemorrhage,  204  ;  in- 
flammation, 40,  73,  81  ;  intestinal  strangula- 
tion, 917,  921  ;  shock,  151 

Stirrup  for  fracture  of  femur,  422 

Stocking  splint,  436 

Stokes,  338  ;  amputation,  1197 

Stomach,  operations  on,  874 

Stomatitis,  746,  763 

Strabismus,  724 

Strangulation  by  bands,  911 ;  in  hernia,  884 ; 
internal  91 1  ;  of  peritoneum,  888 ;  of  piles, 
961 ;  symptoms  of,  in  hernia,  885 

Strangury,  1038 

Strapping,  168;  of  testis,  1131 

Streptococcus,  26,  45,  69,  163,  454;  erysipelatis, 

79 

Stretching  nerves,  301,  407 

Stricture  of  intestine,  923  ;  after  hernia,  895 ; 
as  a  cause  of  strangulation,  915 

Stricture  of  cesophagus,  849;  of  rectum,  980; 
after  piles,  967  ;  of  urethra,  1 102  ;  cure  of, 
1 108;  dilatation  of,  II09;  division  of,  IIII  ;• 
effects  of,  1103  ;  electrolysis  in,  1118;  exci- 
sion of,  1 118;  locality,  1 103;  measurement, 
1 108;  retention  in,  1033;  rupture  of,  nil; 
symptoms  of,  1105  ;  treatment,  1089 

Struggling  in  ancesthesia,  371 

Strumous  arthritis,  580  ;  lupus,  1 7 1  ;  osteitis,  472 ; 
and  syphilitic  nodes,  470 

Stumps,  diseases  of,  1203;  hemhorrage  from, 
216;  neuralgia  of,  301 

Styes,  735 

Styptics,  214 

Subarachnoid  hemorrhage,  642,  649 

Subastragalar    amputation,    1201  ;     dislocation, 

544 

Subciecal  fossa,  912 

Subclavian  aneurysm,  245,  254 ;  artery,  com- 
pression of,  268;  ligature,  266;  and  carotid 
arteries,  ligature  of,  245 

Subclavicular  dislocation.  510 

Subcoracoid  dislocation,  509 

Subcranial  hemorrhage,  648  ;  nodes,  465  ;  sup- 
puration, 664 

Subcutaneous  nerve-stretching,  302 ;  urethro- 
tomy, 1 II 5 


INDEX. 


1235 


Sulnlural  abscess,  669 ;  suppuralion,  664 ; 
hemorrhage,  642,  64S 

Subglenoid  dislocation,  509 

Sul)hyoid  cysts,  129;   pharyngotomy,  825 

Subbngiial  bursa,  771  ;  cyst,  129 

Subluxation,  497  ;  of  clavicle,  505  ;  humerus, 
510  ;  lower  jaw,  505  ;  radius,  523 

Submammary  abscess,  1 175 

Submaxillary  tumors,  796 

Submucous  fibroids,  I161 

Suliperiosteal  cysts,  773 ;  excision,  620  ;  hem- 
orrhage in  rickets,  479;  resection,  458 

Sub]ieritoneal  fatty  hernia,  909  ;  fii)roids,  1 161  ; 
lipoma,  132 

Subsi:)inous  dislocation,  510 

Subungual  exostosis,  485 

Suction  cannula  for  tracheotomy,  830 

Sugar  in  urine,  1020 

Suggestion,  700 

Suicidal  wounds  of  throat,  814 

Sulphide  of  calcium,  193 

Superficial  glossitis,  780   ■ 

Superior  maxilla,  fracture  of,  382 ;  resection, 
756 

Supernumerary  fingers,  322 

Supports  in  caries  of  spine,  706  ;  in  curvature, 
718 

Suppression  of  urine,  1033 

Suppurating  bubo,  97,  283 

Suppuration  in  aneurysm,  239,  244;  in  antrum, 
766;  in  burns,  180;  in  compound  fractures, 
353;  catarrhal  of  joints,  550;  diffuse,  46, 
5 1;  and  embolism,  50;  after  extravasation 
of  blood,  156;  and  hemorrhage,  216;  intra- 
cranial, 664;  of  scalp,  657  ;  in  spinal  caries, 
703,  709  ;  symptoms,  46  ;  in  syphilis,  102  ; 
in  wounds,  158,  163 

Suppurative  arthritis,  495,  559  ;  arteritis,  222  ; 
bursitis,  320;  fever,  49;  meningitis,  664; 
microbes,  45;  orchitis,  11 34;  osteitis,  456; 
of  skull,  658,  462;  otitis,  671;  parotitis, 
795  >  peritonitis,  934 ;  phlebitis,  233 ;  pyel- 
itis, 1002,  1007;  prostatitis,  1084;  tenosyno- 
vitis, 313 

Supra-coracoid  dislocation,  509 

Suprapubic  cystotomy,  1062;  lithotomy,  1060 ; 
prostatectomy,  1082 

Supraspinous  dislocation,  535 

Supravaginal  hysterectomy,  1163;  amputation 
of  cervix,  11 66 

Surgical  emphysema,  861  ;  kidney,  993,  1008 

Sutures,  168;  of  bladder,  1028;  after  cystot- 
omy, 1061,  1069;  Czerny's,  945;  Greig 
Smith's,  945  ;  in  fracture  of  patella,  432 ; 
Joubert's,  943  ;  Lembert's,  943 ;  of  nerves, 
295  ;  in  scalp  wounds,  632  ;  of  tendons, 
308;  of  urethra,  1089;    in  wounds  of  neck, 

815 
Sweep's  cancer,  1125 
Sycosis,  735 
Syme's   amputation,    H99 ;    gluteal    aneurysm, 

258;    staff,    1115;      tenotomy,   of    posterior 

tibial,  330;  urethrotomy,  11 15 
Symmetrical  gangrene,  80 
Symmetery  in  syphilis,  loi 
Sympathic    irritation,    727 ;    ophthalmia,    727 ; 

paralysis,  691 
Syncope  from  catheters,  1093 
Synovial  fringes,  hypertrophy  of,  460,  567,  614; 

hernise,  552,  572;  pouches,  552;  sheaths  of 


tendons,  arrangement  of,  in  palm,  315;    in- 
flammation of,  312 

Synovitis,  545,  549;  after  injury,  493 ;  hem- 
orrliagic,  222;  in  osteoarthritis,  570 ;  papil- 
lary,  571  ;  in  syphilis,  611  ;  tubercular,  580 

Syphilis,  95  ;  acquired,  97  ;  as  a  cause  of  frac- 
ture, 348  ;  duration  of  contagiousness,  I02  ; 
of  hereditary  transmission,  102,  108;  erup- 
tions, lOI  ;  on  the  face,  747  ;  hereditary,  1 10  ; 
intermediate,  33  ;  lupus,  190;  mifcarriage'in, 
109  ;  and  phagedaiia,  69  ;  prognosis  of,  107  ; 
second  attacks  of,  108;  secondary,  99;  teeth 
in  hereditary,  no;  tertiary,  103 

Syphilitic  arteritis,  224;  as  a  cause  of  aneurysm 
236;  caries,  449;  epididymitis,  1 1 29;  glos 
sitis,  782 ;  laryngitis,  808 ;  neuritis,  299 
orchitis,  1131  ;  osteitis,  465,  467,  658;  phle 
bitis,  234;  pemphigus,  109;  stomaiitis,  764 
synovitis,  608 ;  ulcers,  193;  of  rectum,  971 
urethritis,  1098 

Syringocele,  682  ' 


Tagliacotian  operation,  751 

Tait,  on  operations  on  the  gall-bladder,  953 

Talipes,   325;    acquired,  332;    arcuatus,  334; 

calcaneus,  325,  334;  equinovarus,  326  ;  equi- 

'^"s,     T,T,})  ;    plantaris,  334;    relapsed,    331  ; 

valgus,  325,  334 
Tampon   for  rectum,  965  ;   Buckston  Browne's, 

1057  ;  laryngeal,  831 
Tapping  the  bladder,  1035  ;    hydrocele,  114I; 

ovarian  cysts,  1 155 
Tar  in  lupus,  192 
Tarsectomy,  331 
Taxis,  889;    accidents  from,  889 ;    duration  of, 

859 ;  for  inguinal  hernia,  898 
Teale's  amputation,  1 188,  II9S 
Teeth   in  hereditary  syphilis,    no;    in  rickets, 

475  .    ^ 

Temperature  in  cortical  lesions,  646;  in  fracture 

of  spine,  693  ;  after  nerve-section,  294 
Temporal  artery,  ligature  of,  266 
Temporo-maxillary    articulation,    ankylosis    of, 

769 
Tendo-Achillis,  contraction  of,  336;  rupture  of, 

307  ;  section  of,  330,  427,  436,  440 
Tendons,  dislocation   of,  309  ;  section  of,  329 ; 

splicing,  308  ;  suture,  308  ;  union,  329 
Tenosynovitis,  330 
Tenotomy,  174,  330;  of  palmar  fascia,  317  ;  in 

fractures,  371,  427,  439;   of  sterno-mastoid, 

825  ;  for  strabismus,  739 
Tension  of  eyeball,  733;  as  a  cause  of  inflamma- 
tion, 39,  155, 172 
Teratomata,  129 
Tertiary  nodes,  465 
Testis,  dermoid  cysts  of,  129  ;  enchondroma  of, 

135;      hernia,'    1134;    inflammation,    1129; 

malformations  of,  1127;    puncture   of,  1131; 

sarcoma  of,  141  ;  strapping,  1131  ;  tumors  of, 

1 135;  undescended,  with  hernia,  900 
Tetanus,  118,  299  ;  hydrophobicus,  118 
Thecal  abscess,  313 
Thiersch  amputation  of  penis,  025;  dressing  for 

wounds,  165;  extroversion  of  bladder,  1026; 

method  of  grafting,  160 
Third  nerve,  injury  to,  650 


i2i;6 


INDEX. 


Thomas'   boot    for  flat-foot,  337 ;    diagnosis   of 

hip-disease,  591 ;  splint  for  hip,  599 ;  jaw,  384  ; 

knee,    423,   610;    double,    for    spine,    708; 

wrench,  600 
Thompson's  bladder-forceps,  1068 
Thoracic  duct,  wounds  of,  281 
Thoracoplasty,  867 
Thorax  \Sei  Chest)  ;  deformity  in  caries,  702  ; 

in  curvature  of  spine,  715 
Thorburn,  injuries  of  spine,  690,  700 
Thrill  in  aneurysm,  237 
Throat,  scald  of,  82 1  ;   wound  of,  762 
Thrombosis,    27  ;    of  arteries,  225  ;  in  fractures, 

364  ;  of  lateral  sinus,  253,  669 ;  in  pycemia, 

74;  traumatic,  217  ;  of  veins,  228 
Thrombotic  abscesses,  75  ;  gangrene,  63  ;  piles, 

959 

Thrush,  763 

Thumb,  amputation  of,  1 192;  avulsion  of,  307; 
dislocation  of,  525 

Thyroarytenoid  muscles,  paralysis  of,  812 

Thyroid  gland,  cysts  of,  827,  839;  accessory  ones, 
841;  enlargement  of,  839 ;  fibrous  degenera- 
tion, 839;  inflammation,  838;  malignant, 
disease  of,  S44  ;  operations  on,  884 

Thyroid  dislocation  of  hip,  533 

Thyro-lingual  canal,  826 

Thyrotomy,  833  ;  for  carcinoma,  809 

Tibia,  fracture  of,  438 ;  with  fibula,  435  ;  in 
rickets,  476  ;  separation  of  epiphysis  of,  441 ; 
s}-philitic  disease  of,  469  ;  tubercular  65. 

Tibial  arteries,  ligature  of,  27S;  wounds  of,  212 
366,  477  ;  tendons,  dislocation  of,  309 ;  divi- 
sion, 329. 

Tic,  301 

Tilleman,  297 

Tilting  of  pelvis,  592 

Toes,  amputation  of,  1202  ;  deformities  of,  328 

Tongue,  hypertrophy  of,  778 ;  inflammation, 
779;  leucoplakia,  781  ;  malformations,  778; 
operations  on,  787  ;  syphilis  of,  783  ;  tubercle 
of,  784;  tumors  of,  784;  ulceration,  780 

Tonsillotome,  793 

Tonsils,  calculi  in,  794  ;  excision  of,  793 ; 
hypertrophy  of,  792  ;  inflammation,  791  ;  sup- 
puration, 792;  tumors,  794:  wounds,  214, 
265 

Tophi,  567 

Torsion  of  arteries,  212  ;  of  hernial  sac,  901 

Torticollis,  824 

Tourniquets,  20S;  Jordan  Lloyd's,  1194;  for 
reduction  of  dislocated  jaw,  505 

Trachea  dilator,  821,  830;  exploration  of,  820 ; 
foreign  bodies  in,  819;  ulceration  after 
tracheotomy,  833;  wounds  of,  815 

Tracheotomy,  828;  for  foreign  bodies,  820 ;  in 
goitre,  843  ;  for  scald,  822  ;  tubes,  830 

Transfusion  in  hemorrhage,  204;  in  shock,  151 

Transmissibility  of  syphilis,  102 

Transplantation  of  bone,  359 ;  frog's  skin,  162  ; 
muscle,  307  ;  mucous  membrane,  161  ;  nerves, 
298  ;  skin,  162,  176 

Traumatic  aneurysm,  205;  in  fractures,  366; 
treatment  of,  217,  248;  cataract,  726  ;  mydri- 
asis, 727;  delirium,  153;  epilepsy,  654; 
fever,  42,  154,  173;  gangrene,  65;  insanity, 
654;  nodes,  451  ;  stricture  of  oesophagus, 
850  ;  urethra,  1088  ;  synovitis,  493  ;  ulcers, 
196 

Traumatopncta,  856 


Travois,  1207 

Tremor  in  delirium,  152 

Trendelenburg's  operation  for  ectopia,  1026 ; 
tampon,  S31  ;  on  amputation  of  thigh,  1194 

Trephining,  675;  for  cerebral  abscess,  671; 
hemorrhage,  653 ;  tumor,  675  ;  the  chest, 
865  ;  in  chronic  meningitis,  670 ;  for  epilepsy, 
654  ;  for  fracture  of  skull,  636  ;  for  insanity, 
654  ;  in  osteitis,  451,  458,  559,  61 1 ;  for  rup- 
ture of  middle  meningeal,  652 

Trephining  the  spine,  720  ;  for  disease,  709  ;  for 
injury,  697 

Treves  on  intussusception,  920 ;  obstruction, 
925;  splint,  286;  on  strangulation,  918; 
typhlitis,  932 

Tripier's  amputation,  I20I 

Tripolith,  374 

Trismus,  118,  neonatorum,  118 

Trophic  lesions  after  nerve-section,  294 ;  in  spinal 
injury,  691,  718 

Trusses,  880 

Tubage  for  dyspnoea  after  tracheotomy,  832  ; 
of  larynx,  834  ;  oesophagus,  851 

Tubercle,  anatomical,  91 ;  bacillus  of.  9I;  in- 
fection by,  92  ;  in  lupus,  189;  painful  sub- 
cutaneous, 130 

Tubercular  abscesses,  treatment  of,  5S7  ;  adenitis, 
284;  of  neck,  824;  arthritis,  5S0,  588;  bur- 
sitis, 320;  caries,  449,  474;  of  skull,  658; 
of  spine,  700 ;  disease  of  brain,  673  ;  of  bone, 
558,588,606;  of  choroid,  734;  of  chest  wall, 
830;  of  larj-nx,  807;  of  tendons,  314;  of 
tongue,  785 ;  peritonitis,  936 ;  prostatitis, 
1085  ;  pyelitis,  1007  ;  sequestra,  587  ;  stoma- 
titis, 765 ;  ulceration  of  skin,  1 95  ;  of  intestine, 
causing  stricture,  923 ;  of  rectum,  971 ;  ureth- 
ritis, 1098 

Tubercular  leprosy,  116 

Tuberculosis,  senile,  585 

Tubes,  tracheotomy,  830 

Tubular  lymphangeiectasis,  290 

Tufnell's  treatment  of  aneurysm,  241 

Tumor  albus,  605;  of  bladder,  1064;  brain, 
673;  bone,  4S4  ;  choroid,  734  ;  jaws,  770; 
kidney,  99S;  larynx,  809;  mouth,  770;  men- 
inges, 673;  nares,  755  ;  orbit,  737  ;  salivary 
glands,  795;  scalp,  656;  skull,  673  ;  spinal 
cord,  720;  scrotum,  1 125;  testis,  1 135; 
tongue,  784  ;  tonsils,  793 

Tying-in-catheter,  1094 

Tympanitic  abscesses,  51 

Typhlitis,  931 

Typhoid,  arthritis  after,  564  ;  necrosis,  464 

Twisted  suture,  170 

Twisting  of  ovarian  pedicle,  1 155 


U 

Ulcer,  193;  atheromatous,  225;  of  bladder, 
1038;  cancerous,  148;  of  duodenum,  181  ; 
face,  748,  750;  intestine,  923  ;  leg,  194,229; 
perforating  of  foot,  294,  57S  ;  of  rectum,  971 ; 
rodent,  146;  on  eye,  736;  of  scars,  177; 
syphilitic,  105,  194;  of  tongue,  780;  varie- 
ties, 58,  193 

Ulceration,  58 

Ulcerative  endocarditis,  223,  233  ;  stomatitis, 
763 


INDEX. 


1237 


101 1  ;    impaction, 


dilatation    of,  in 


Ulna,  dislocation  of,  519  ;  fracture,  408    ^ 

Ulnar  artery,  ligature  of,  272 

Umbilical  hernia,  907 

Union  of  epiphyses,  394,  426,  441,  447  ;  pre- 
mature in  rickets,  475  ;  in  syphilis,  469  ;  by 
first  intention,  158;  by  second  and  third 
intention,  159;  by  granulations,  159;  under 
a  scab,  159  ;  of  fractures,  349  ;  delayed,  354  ; 
failure  of,  355  ;  fil)rous,  355  ;  of  neck  of 
femur,  416;  of  patella,  430;  of  skull,  605  ; 
of  nerves,  292 

Unna,  191 

Unreduced  dislocations,  498;  of  elbow,  522  ; 
femur,  535  ;  radius,  522  ;   shoulder,  578 

Ununited  fracture,  355  ;  of  patella,  433 

Urachus,  cysts  in,  128 

Uraemia  and  concussion,  646 

Urate  of  soda  in  gout,  567 

Urea,  amount  of,  1017 

Ureter,    catheterization    of, 
1002 

Ureterotomy,  1002 

Urethra,    calculus  in,    1090 

stricture,  1 104  ;  of  female,  1069 ;  diseases 
of  female,  li 22 ;  effect  of  catheters  on, 
1091  ;  foreign  bodies  in,  1090 ;  inflamma- 
tion of,  1095;  irritable,  H08 ;  rupture  of, 
1088  ;  in  lithotomy,  1058  ;  stricture  of,  1 102  ; 
suture  of,  1089 ;  tying  catheter  in,  1094  ; 
traumatic  stricture  of,  1088 ;  washing  out, 
1099 

Urethral  arthritis,  564  ;  caruncle,  1 123  ;  epididy- 
mitis, 1129,  fistula,  1121;  fever,  1093; 
hematuria,  1020  ;  prostatotomy,  1081 

Urethrameter,  1106 

Urethritis,  retention  in,  1024 

Urethrocele,  1123 

Urethroscope,  iioi 

Urethrotomy,  11 12 

Uric  acid,  amount  of,  1017 

Urinary  abscess,  1119;  fistula,  loil,  1121 

Urine,  deposits  in,  1021  ;  examination  of,  1015  ; 
extravasation  of,  11 18;  from  kidney,  990; 
incontinence  of,  1031  ;  organisms  in,  1022  ; 
reaction  of,  1016;  retention  of,  1032;  after 
piles,  965  ;  secretion  of,  in  fractured  spine, 
693;  specific  gravity,  1015  ;  suppression  of, 
992  ;  surgical  aspect  of,  1015  ;  variations  in 
quantity,  I015 

Uterine   appendages,   removal  of,    1146,1162; 
and  ovarian  tumors,  diagnosis  of,  1 153 

Uterus,  cancer  of,  1165  ;  cervix,  amputation  of, 
1 1 66;  laceration  of,  1168;  extirpation  of, 
1 166;  tumors  of,  1 1 59 


Vagina,  affections  of,  1 1 68 

Vaginal  hydrocele,  1139 

Valsalva,  method  of  inflating  ear,  797 

Varicocele,  1 138  ;  diagnosis  of,  11 26  ;  operation 
for,  1 1 39:  in  syphilis,  102;  and  wasting  of 
testis,  1 138 

Varicose  ulcer,  229  ;  vein,  227 

Varioloid  eruption  in  syphilis,  100 

Varix,  aneurysmal,  217  ;  arterial,  221  ;  of  in- 
ternal saphena,  227  ;  of  lymphatics,  290 

Varus,  spurious,  328,  335 

Vascular  growth  of  urethra,  1122,  1 168 


Vault  of  skull,  fracture  of,  634  ;  sypliilitic,  causes 
of,  466 

Veins:  diseases  of,  227  ;  entry  of  air  into,  219  ; 
injury  of,  218  ;  ligature  of  artery  and,  218  ; 
ligature  in  pyamia,  669  ;  ruptured,  in  frac- 
tures, 367 ;  varicose,  227 

Velpeau,  dislocation  of  clavicle,  507,  508 

Venereal  wart,  198 

Venous  angeiomata,  220;  hemorrhage,  201  ; 
hemorrhoids,  960 ;  noevi,  143,  220 ;  pulsation 
in  glaucoma,  733;  obstruction,  231 

Ventral  hernia,  909 

Verneuil,  958 

Verrucse,  loi,  143  ;  necrogenic,  189 

Vertebrae,  rotation  of,  in  curvature,  713 

Vertebral  artery,  ligature  of,  268;  wound,  215, 
816;  column.     6"^!?  Spine. 

Vesical  calculus,  1041  ;  ha^maturia,  1020 

Vesico- vaginal  fistula,  11 23 

Vesicular  eruptions  after  nerve  section,  294 

Vessels,  formation  of,  29  ;  injuries,  201 ;  occlu- 
sion, 206;  of  neck,  wounds  of,  815 

Villous  cancer,  127;  growths,  143;  tumor  of 
bladder,  1064;  of  rectum,  986 

Virus  of  hydrophobia,  123 

Viscera,  abdominal,  rupture  of,  870  ;  wounds, 
872 

Visceral  changes  in  rickets,  477  ;  congestion  in 
burns,  180 

Volvulus,  912;  after  hernia,  895  ;  treatment  of, 
920 

Vomiting  in  anesthesia,  187;  in  hernia,  887, 
916;  after  herniotomy,  895  ;  in  obstruction, 
926 

Vulcanite  splints  in  fracture  of  jaw,  384 

Vulva,  affections  of,  1168 


W 

Wall  of  thorax,  injuries  of,  853 

Walsham's  shoe,  337 

Walton-Wells  cot,  1208 

Wardrop's  method  of  ligature,  245 

Waring  in  ununited  fracture,  359;  of  jaw,  384 

Warmth  in  arthritis,  551 ;  in  inflammation,  36 

Warts,  198 

Washing  out  bladder,  1039;  in  enlarged  prostate, 
1079  ;  urethra,  1099 

Wasting  after  ligature  of  arteries  215  ;  after  in- 
flammation of  joints,  551,  571,  593 

Water  cushion  in  fracture  of  femur,  417 

Watson's  canula,  1080 

Wax  in  ear,  799 

Weakness  as  a  cause  of  spinal  curvature,  713 

Webbed  fingers,  324 

Webbing  straps  for  fracture  of  jaw,  383 

Wedges  in  reduction  of  dislocated  jaw,  505 

Wet-cupping  in  inflammation,  37 

Wharton's  duct,  cyst  from,  126 

Wheelhouse's  perineal  section,  I117;  on  pro- 
lapse, 968 

Whip  bougies,  I  no 

Whitehead  :  on  excision  of  tongue,  787  ;  on  piles, 
965 ;  tracheotomy,  828 

Whitehead's  varnish,  790 

White  swelling,  606 

Whitlow,  313;  after  nerve-section,  293 

Wilson's  cystometer,  679 


I23S 


INDEX. 


Wire,  introduction  of,  in  aneurysm,  246  ;  splint 

for  fracture  of  jaw,  3S4 
Wirin>j  in  fracture  of  jaw,  384 ;  in  delayed  union, 

359 

Wolffian  cysts,  127 

WoUler's  method  of  grafting,  162 

Wood's  operation  for  ectopia  vesicie,  1024 ;  pads, 
880 

Wood-wool,  168 

Wool-sorter's  disease,  84 

Wool  truss  for  inguinal  hernia,  882 

Wounds  of  abdomen,  872;  air-passages,  815; 
arteries,  207 ;  brain,  647 ;  chest,  855  ;  cord, 
698;  cellulitis  after  jioisoned,  70 ;  decom- 
position in,  162;  drainage  of,  171  ;  dressings 
for,  167  ;  of  the  eye,  726;  face,  745  ;  in  con- 
nection with  fractures,  378;  of  heart,  857; 
infected,  165,  171 ;  inflammation  in,  159,  162; 


inoculated  by  tubercle,  92  ;  of  joints,  492 ;  of 
kidney,  992;  lung,  856;  of  nerves,  292;  neck, 
814;  palate,  762;  protection  of,  173;  repair 
of,  158;  of  scalp,  632  ;  of  spinal  cord,  698; 
treatment  of,  164;  varieties  of,  157,  174;  of 
veins,  218;  of  viscera,  841 

Wrenches  of  back,  685  ;  Thomas's  600 

Wrist,  dislocation  of,  524;  excision  of,  623; 
fracture  into,  410;  tubercular  disease  of,  613 

Writer's  cramp,  310 

Wry-neck,  824;  and  spinal  caries,  601  ;  as  a 
cause  of  scoliosis,  713 


Zygoma,  fracture  of,  282 


¥^ 


.';';»>v>.^\A',:,*.vv'.'A'.- ,•?.•>•-..".. -.1 


i 


II 


•,-!■■. -v-nn.--^  1 


■;>:•;•  s\. •■■v.;;  ';  \ 


